Pediatr Crit Care Med. 2006 May 31; [Epub ahead of print] 

Extracorporeal membrane oxygenation after stage I reconstruction for hypoplastic
left heart syndrome*

Ravishankar C, Dominguez TE, Kreutzer J, Wernovsky G, Marino BS, Godinez R,
Priestley MA, Gruber PJ, Gaynor WJ, Nicolson SC, Spray TL, Tabbutt S.

From the Division of Cardiology (CR, GW, BSM, ST), Department of Pediatrics;
Division of Cardiothoracic Surgery (PJG, WJG, TLS), Department of Surgery; and
Department of Anesthesiology and Critical Care Medicine (TED, BSM, RG, MAP, SCN,
ST), The Children's Hospital of Philadelphia and University of Pennsylvania
School of Medicine; and the Division of Cardiology (JK), Department of
Pediatrics, The Children's Hospital of Pittsburgh.

OBJECTIVE:: Although extracorporeal membrane oxygenation (ECMO) is an acceptable
strategy for children with refractory cardiac dysfunction after cardiac surgery,
its role after stage I reconstruction for hypoplastic left heart syndrome and
its variants is controversial. Our objective is to describe the outcome of
"nonelective" ECMO after stage I reconstruction. 

DESIGN:: Retrospective case
series. 

SETTING:: Pediatric cardiac intensive care unit. PATIENTS:: Infants
placed on ECMO after stage I reconstruction from January 1998 to May 2005.

INTERVENTIONS:: None. 

MEASUREMENTS AND MAIN RESULTS:: Of the 382 infants who
underwent stage I reconstruction during the study period, 36 (9.4%) required
ECMO in the postoperative period. There were 22 infants with hypoplastic left
heart syndrome. Indications for ECMO included inability to separate from
cardiopulmonary bypass in 14 and cardiac arrest in 22. Fourteen infants (38.8%)
survived to hospital discharge. Nonsurvivors had longer cardiopulmonary bypass
time (150.1 +/- 70.0 mins vs. 103.9 +/- 30.0 mins, p =. 01). 9/14 infants (64%)
supported with ECMO> than 24 hrs after stage I reconstruction survived while
only 5/22 infants (22%) requiring ECMO< 24 hrs of stage I reconstruction
survived (p =. 02). Of note, all five infants diagnosed with an acute shunt
thrombosis were early survivors. Mean duration of ECMO was 50.1 +/- 12.5 hrs for
survivors and 125.2 +/- 25.0 for nonsurvivors (p =. 01). 7/14 early survivors
are alive at a median follow-up of 20 months (2-78 months). 

CONCLUSIONS:: In our experience, ECMO after stage I reconstruction can be life saving in about a
third of infants with otherwise fatal conditions. It is particularly useful in
potentially reversible conditions such as acute shunt thrombosis and transient
depression of ventricular function.

Pediatr Crit Care Med. 2006 May 31; [Epub ahead of print] 

Hyperglycemia is a marker for poor outcome in the postoperative pediatric
cardiac patient*

Yates AR, Dyke PC 2nd, Taeed R, Hoffman TM, Hayes J, Feltes TF, Cua CL.

From the Department of Pediatrics, The Ohio State University College of Medicine
and Public Health and Columbus Children's Hospital Heart Center, Columbus, OH.

OBJECTIVE:: Hyperglycemia in critical care populations has been shown to be a
risk factor for increased morbidity and mortality. No data exist in
postoperative pediatric cardiac patients. The goal of this study was to
determine whether hyperglycemia in the postoperative period was associated with
increased morbidity or mortality. 

DESIGN:: Retrospective chart review. 

SETTING:: Tertiary care, free-standing pediatric medical center with a dedicated cardiac
intensive care unit. 

PATIENTS:: We included 184 patients <1 yr of age who underwent cardiac surgery requiring 
cardiopulmonary bypass from October 2002 to August 2004. Patients with a weight <2 kg, 
a preoperative diagnosis of diabetes, preoperative extracorporeal membrane oxygenation 
 support, solid organ transplant recipients, and preoperative renal or liver insufficiency were excluded.

INTERVENTIONS:: None. 

MEASUREMENTS AND MAIN RESULTS:: Age was 4.3 +/- 3.2 months
and weight was 4.9 +/- 1.7 kg at surgery. Duration of hyperglycemia was
significantly longer in patients with renal insufficiency (p = .029), liver
insufficiency (p = .006), infection (p < .002), central nervous system event (p
= .038), extracorporeal membrane oxygenation use (p < .001), and death (p <
.002). Duration of hyperglycemia was also significantly associated with
increased intensive care (p < .001) and hospital (p < .001) stay and longer
ventilator use (p < .001). Peak glucose levels were significantly different in
patients with renal insufficiency (p < .001), infection (p = .002), central
nervous system event (p = .01), and mortality (p < .001). 

CONCLUSIONS::
Hyperglycemia in the postoperative period was associated with increased
morbidity and mortality in postoperative pediatric cardiac patient. Strict
glycemic control may improve outcomes in this patient population.

J Cardiothorac Surg. 2006 May 31;1(1):14 [Epub ahead of print] 

Preoperative calculation of risk for prolonged intensive care unit stay
following coronary artery bypass grafting.

Ghotkar SV, Grayson AD, Fabri BM, Dihmis WC, Pullan MD.

OBJECTIVE: Patients who have prolonged stay in intensive care unit
(ICU) are associated with adverse outcomes. Such patients have cost implications
and can lead to shortage of ICU beds. We aimed to develop a preoperative risk
prediction tool for prolonged ICU stay following coronary artery surgery (CABG).

METHODS: 5,186 patients who underwent CABG between 1st April 1997 and 31st March
2002 were analysed in a development dataset. Logistic regression was used with
forward stepwise technique to identify preoperative risk factors for prolonged
ICU stay; defined as patients staying longer than 3 days on ICU. Variables
examined included presentation history, co-morbidities, catheter and demographic
details. The use of cardiopulmonary bypass (CPB) was also recorded. The
prediction tool was tested on validation dataset (1197 CABG patients between 1st
April 2003 and 31st March 2004). The area under the receiver operating
characteristic (ROC) curve was calculated to assess the performance of the
prediction tool. 

RESULTS: 475(9.2%) patients had a prolonged ICU stay in the
development dataset. Variables identified as risk factors for a prolonged ICU
stay included renal dysfunction, unstable angina, poor ejection fraction,
peripheral vascular disease, obesity, increasing age, smoking, diabetes,
priority, hypercholesterolaemia, hypertension, and use of CPB. In the validation
dataset, 8.1% patients had a prolonged ICU stay compared to 8.7% expected. The
ROC curve for the development and validation datasets was 0.72 and 0.74
respectively. 

CONCLUSIONS: A prediction tool has been developed which is
reliable and valid. The tool is being piloted at our institution to aid resource
management.

Eur J Cardiothorac Surg. 2006 May 24; [Epub ahead of print] 

Hyporesponsiveness of T cell subsets after cardiac surgery: a product of altered
cell function or merely a result of absolute cell count changes in peripheral
blood?

Franke A, Lante W, Kurig E, Zoller LG, Weinhold C, Markewitz A.

Department of Cardiovascular Surgery, Bundeswehr Central Hospital, Rubenacher
Str. 170, D 56072 Koblenz, Germany.

OBJECTIVE: The activity of the specific immune system and especially the
function of T helper (TH) cells are reduced after cardiac surgery. This decrease
is followed by an increase in TH2 cell activity and a delayed recovery of TH1
cell function (TH1/TH2 shift). Neither the underlying cause nor the relationship
between the absolute numbers of T lymphocyte subpopulations, the state of
activation of these cells and cytokine synthesis in cell culture has been
clarified. We conducted a prospective study in order to test the hypothesis that
the decrease in specific immunity is not caused by dilution effects but by
functional alterations in T cell subsets. 

METHODOS: Blood samples were obtained from 40 patients undergoing elective 
cardiac surgery with cardiopulmonary bypass (CPB) preoperatively (d0), immediately 
after surgery (dx), and on the 1st (d1), 3rd (d3) and 5th (d5) postoperative days. 
The samples were stimulated for 24h with staphylococcal enterotoxin B and lipopolysaccharide. 
Interferon (IFN)-gamma, interleukin (IL)-2, IL-4, and IL-5 concentrations were measured by
flow cytometry using a cytokine bead array kit. We determined white blood cell
counts, analysed lymphocyte populations, and assayed human leukocyte antigen
(HLA)-DR expression on cluster of differentiation (CD)4+ and CD8+ lymphocytes.
Cytokine concentrations were corrected to preoperative absolute numbers of T
helper cells. 

RESULTS: Leukocyte counts were elevated during the entire
postoperative course with a maximum on dx. Absolute lymphocyte counts and
especially the T cell subpopulations significantly increased immediately after
surgery, then decreased to a minimum on d1 and increased again until they
returned to preoperative levels on d3. The release of IFN-gamma, IL-2 and IL-4
was significantly reduced from dx to d5 with a minimum on d1. IL-5 was
significantly reduced on dx and d1. When the concentrations were corrected to
preoperative TH lymphocyte levels, IL-2 and IL-5 synthesis was significantly
reduced only on dx and IL-4 release only on dx and d1. By contrast, IFN-gamma
synthesis decreased postoperatively and remained suppressed until d5 with a
minimum on d1. Only on d1 did an increase in HLA-DR expression give evidence of
a change in the state of TH cell activation. 
 
 CONSCLUSIONS: The number of immune cells of the specific and the non-specific 
 immune system is not reduced in the immediate postoperative period. Haemodilution 
 thus has no detectable effect on immune function at this time point. Beginning on d1, 
 the function of specific immune cells, especially TH lymphocytes, is severely suppressed. 
 This functional alteration appears not to be preceded by T cell activation during CPB. Although
TH cell activity begins to increase on d1, cytokine synthesis is reduced. When
cytokine synthesis is corrected to the absolute number of TH cells in culture,
there is strong evidence for an increase in TH2 cell activity. On the whole,
these results corroborate the hypothesis of a TH1/TH2 shift that is primarily
caused by an alteration of TH1 function. Neither haemodilution nor a preceding
activation plays a major role.

Eur J Cardiothorac Surg. 2006 May 22; [Epub ahead of print] 

IL-10 and TNF-beta gene polymorphisms have no major influence on lactate levels
after cardiac surgery.

Riha H, Hubacek JA, Poledne R, Kellovsky P, Brezina A, Pirk J.

Department of Anaesthesiology and Intensive Care Medicine, Institute for
Clinical and Experimental Medicine, Videnska 1958/9, 140 21 Prague, Czech
Republic; Cardiovascular Research Centre, Prague, Czech Republic.

OBJECTIVE: Lactate levels after cardiac surgery are influenced by different
proinflammatory (TNF, IL-6, IL-8) and anti-inflammatory (IL-10) cytokines. The
goal of the study was to determine the relationship between polymorphism in the
IL-10 (-1082G/A) and TNF-beta (+252G/A) genes and lactate levels in patients
after cardiac surgery. 

METHODS: We performed prospective observational study in
168 consecutive adult patients without left ventricle dysfunction undergoing
elective coronary artery bypass grafting. Lactic acid levels were documented at
five different time points: 10min after beginning of cardiopulmonary bypass,
40min after cardiopulmonary bypass termination, and 30min, 8h, and 16h after the
surgery. Genetic analysis for polymorphism was performed by mismatched
polymerase chain reaction and restriction analysis. 

RESULTS: No association was found between single polymorphism in IL-10 or 
TNF-beta gene and lactate levels, but the carriers of IL-10/TNF-beta genotype 
combination +A/GG had significantly different course of lactate levels in time with 
decrease in lactate (in comparison with increase in other groups) at 8h after the surgery. 

CONCLUSIONS: IL-10 (-1082G/A) and TNF-beta (+252G/A) gene polymorphisms have a little, yet
measurable influence on the time course of changes in lactate levels after
cardiac surgery.

Eur J Anaesthesiol. 2006 May 24;:1-6 [Epub ahead of print] 

Core and skin surface temperature course after normothermic and hypothermic
cardiopulmonary bypass and its impact on extubation time.

Pezawas T, Rajek A, Plochl W.

Medical University of Vienna, Department of Cardiology, Vienna, Austria.

BACKGROUND AND OBJECTIVE: Cardiopulmonary bypass is associated with
temperature pertubations that influence extubation time. Common extubation
criteria demand a minimum value of core temperature only. The aim of this
prospective study was to test the hypothesis that changes in core and skin
surface temperature are related to extubation time in patients following
normothermic and hypothermic cardiopulmonary bypass. 

METHODS: Forty patients undergoing cardiac surgery were studied; 28 patients had normothermic
cardiopulmonary bypass (nasopharyngeal temperature >35.5 degrees C) and 12 had
hypothermic cardiopulmonary bypass (28-34 degrees C). In the intensive care
unit, urinary bladder temperature and skin surface temperature gradient (forearm
temperature minus fingertip temperature: >0 degrees C =vasoconstriction, </=0
degrees C =vasodilatation) were measured at 30-min intervals for 10 h
postoperatively. At the same intervals, the patients were evaluated for
extubation according to common extubation criteria. 

RESULTS: On arrival in the intensive care unit the mean urinary bladder temperature was 36.8 +/- 0.5
degrees C in the normothermic group and 36.4+/-0.3 degrees C in the hypothermic
group ( P = 0.014). The skin surface temperature gradient indicated severe
vasoconstriction in the both groups. The shift from vasoconstriction to
vasodilatation was faster in normothermic cardiopulmonary bypass patients
(138+/-65 min) than in patients after hypothermic cardiopulmonary bypass
(186+/-61 min, P = 0.034). There was a linear relation between the time to reach
a skin surface temperature gradient = 0 degrees C and extubation time (r2 =
0.56, normothermic group; r2 = 0.82, hypothermic group). 

CONCLUSIONS: The transition from peripheral vasoconstriction to vasodilatation is related to
extubation time in patients following cardiac surgery under normothermic as well
as hypothermic cardiopulmonary bypass.

Anesth Analg. 2006 Jun;102(6):1623-9. 

Increased interleukin-6 after cardiac surgery predicts infection.

Sander M, von Heymann C, Dossow V, Spaethe C, Konertz WF, Jain U, Spies CD.

Department of Anesthesiology and Intensive Care Medicine, Charite University
Medicine Berlin, Charite Campus Mitte, Schumannstr. 20/21, 10117 Berlin,
Germany.

Early diagnosis and treatment of infection after cardiac surgery with
cardiopulmonary bypass (CPB) improves outcome. Conventional laboratory tests,
such as C-reactive protein and white blood cell count can not distinguish
patients with early infection from those with systemic inflammatory response
syndrome but without infection. After CPB, there is a systemic release of
proinflammatory and antiinflammatory cytokines, including tumor necrosis
factor-alpha, interleukin (IL)-6, and IL-10. We investigated the predictive
ability of these variables for infection after cardiac surgery. Forty-six
patients with impaired left ventricular ejection fraction (<60%), scheduled for
cardiac surgery, were included. Plasma samples were drawn 1 day before and
immediately before surgery, on admission to the intensive care unit, and on days
1, 3, and 7 after surgery. Infection was identified according to the criteria of
the Centers for Disease Control and Prevention. After surgery 13 patients
developed an infection. In patients with infection, confirmed a median of 4 days
after surgery, all measurements of IL-6, and IL-10 on postoperative day 3 were
significantly increased. Tumor necrosis factor-alpha, leukocytes, and C-reactive
protein were not increased in these patients. Immediately after surgery blood
glucose was significantly increased in patients with infection. Increased IL-6
after CPB is predictive of infection after cardiac surgery in patients with
impaired left ventricular function.

Intensive Care Med. 2006 Jun;32(6):881-7. Epub 2006 Apr 28. 

Procalcitonin kinetics in pediatric patients with systemic inflammatory response
after open heart surgery.

Celebi S, Koner O, Menda F, Balci H, Hatemi A, Korkut K, Esen F.

Anesthesiology and Intensive Care Department, Istanbul University, Cardiology
Institute, Istanbul, Turkey, sdrcelebi@yahoo.com.

OBJECTIVE: To evaluate procalcitonin and C-reactive protein as markers of
inflammation severity and their value in predicting development of organ failure
after pediatric open heart surgery. 

DESIGN: Prospective, observational, clinical study. 

SETTING: Single university hospital. 

PATIENTS: Thirty-three pediatric patients with systemic inflammatory response syndrome
 (SIRS; n[Symbol: see text]=[Symbol: see text]19) and SIRS+organ failure (SIRS+OF; n[Symbol: see
text]=[Symbol: see text]14) following open heart surgery were included.

MEASUREMENTS AND RESULTS: Plasma procalcitonin and C-reactive protein levels
were measured before and after the operation, and 1, 2, 3, and 4 days after
surgery. Patients were evaluated daily to assess organ failure. Postoperative
procalcitonin levels in the SIRS+OF group were significantly higher than in the
SIRS group. C-reactive protein levels were similar between the groups throughout
the study period. Peak procalcitonin levels were found to be positively
correlated with aortic cross-clamp and cardiopulmonary bypass times, duration of
mechanical ventilation, intensive care unit and hospital stay, mortality and
organ failure development. Peak procalcitonin was found to be a good predictor
of postoperative organ failure development and mortality. However, the
predictive value of peak C-reactive protein for organ failure and mortality was
found to be weak. Double-peak procalcitonin curves were observed in SIRS+OF
patients with infection during the intensive care unit stay. 

CONCLUSION: In the SIRS+OF group peak procalcitonin levels were found to be highly predictive for
mortality and organ failure development, whereas C-reactive protein levels were
not. Daily procalcitonin measurements in SIRS+OF patients may help identify the
postoperative infection during the follow-up period.

Kidney Int. 2006 May 17; [Epub ahead of print] 

Urinary IL-18 is an early predictive biomarker of acute kidney injury after
cardiac surgery.

Parikh CR, Mishra J, Thiessen-Philbrook H, Dursun B, Ma Q, Kelly C, Dent C,
Devarajan P, Edelstein CL.

1Section of Nephrology, Yale University, New Haven, Connecticut, USA.

Acute kidney injury (AKI) is a frequent complication of cardiopulmonary bypass
(CPB). The lack of early biomarkers for AKI has impaired our ability to
intervene in a timely manner. Urinary neutrophil gelatinase-associated lipocalin
(NGAL) is recently demonstrated as an early biomarker of AKI after CPB,
increasing 25-fold within 2 h and declining 6 h after surgery. In the present
study, we tested whether interleukin-18 (IL-18) is a predictive biomarker for
AKI in the same group of patients following CPB. Exclusion criteria included
pre-existing renal insufficiency and nephrotoxin use. Serial urine samples were
analyzed by enzyme-linked immunosorbent assay for IL-18 in 20 patients who
developed AKI (defined as a 50% or greater increase in serum creatinine after
CPB) and 35 controls (age, race, and gender-matched patients who did not develop
AKI after CPB). Using serum creatinine, AKI was detected only 48-72 h after CPB.
In contrast, urine IL-18 increased at 4-6 h after CPB, peaked at over 25-fold at
12 h, and remained markedly elevated up to 48 h after CPB. The performance of
IL-18 as demonstrated by area under the receiver operating characteristics curve
for diagnosis of AKI at 4, 12, and 24 h after CPB was 61, 75, and 73%
respectively. Also, on multivariate analysis, both IL-18 and NGAL were
independently associated with number of days in AKI among cases. Our results
indicate that IL-18 is an early, predictive biomarker of AKI after CPB, and that
NGAL and IL-18 are increased in tandem after CPB. The combination of these two
biomarkers may allow for the reliable early diagnosis and prognosis of AKI at
all times after CPB, much before the rise in serum creatinine.Kidney
International advance online publication, 17 May 2006;
doi:10.1038/sj.ki.5001527.

Heart Lung Circ. 2006 May 11; [Epub ahead of print] 

Evaluation of Epsilon Amino-Caproic Acid (EACA) and Autologous Blood as Blood
Conservation Strategies in Patients Undergoing Cardiac Surgery.

Sharma V, Talwar S, Choudhary SK, Lakshmy R, Kale S, Kumar AS.

Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi,
India.

BACKGROUND: To evaluate the effects of autologous blood and Epsilon
amino-caproic acid on intra-operative and post-operative blood loss and
homologous blood product requirements in patients undergoing cardiac surgery.

METHODS: Patients were randomly allocated to two groups of 30 each. In the
Epsilon amino-caproic acid (EACA) group, the drug was administered in a loading
dose of 100mg/kg before skin incision followed by an infusion of 1/5th the
loading dose hourly and terminated 3h after heparin neutralization. In the
autologous transfusion (AT) group, 10% of the calculated whole blood volume was
collected intra-operatively before cardiopulmonary bypass and re-infused after
its termination. 

RESULTS: Haemoglobin values were comparable pre-operatively, on
cardiopulmonary bypass, off cardiopulmonary bypass and post-operatively on day
two in both groups. Intra-operative blood loss was not significantly different
(643.3+/-129.14ml in group EACA versus 710+/-145.5ml in group AT, p=0.66).
Although the chest drainage was more in group AT during 0-3h (71.3+/-54.3ml
versus 112.6+/-79.3.6ml, p=0.006) it was comparable amongst in the first 24h
(231.1+/-98.3ml in group AT versus 235+/-101.4ml in group EACA, p=0.88).
Homologous blood product requirements were similar in both groups. 

CONCLUSION: Autologous blood is as efficacious as Epsilon amino-caproic acid for blood
conservation in cardiac surgery.