RESUMO
BACKGROUND: We have developed a new clinical research approach for the quantification of cellular proliferation in human infants to address unanswered questions about tissue renewal and regeneration. The approach consists of oral 15N-thymidine administration to label cells in S-phase, followed by Multi-isotope Imaging Mass Spectrometry for detection of the incorporated label in cell nuclei. To establish the approach, we performed an observational study to examine uptake and elimination of 15N-thymidine. We compared at-home label administration with in-hospital administration in infants with tetralogy of Fallot, a form of congenital heart disease, and infants with heart failure. METHODS: We examined urine samples from 18 infants who received 15N-thymidine (50 mg/kg body weight) by mouth for five consecutive days. We used Isotope Ratio Mass Spectrometry to determine enrichment of 15N relative to 14N (%) in urine. RESULTS/FINDINGS: 15N-thymidine dose administration produced periodic rises of 15N enrichment in urine. Infants with tetralogy of Fallot had a 3.2-fold increase and infants with heart failure had a 4.3-fold increase in mean peak 15N enrichment over baseline. The mean 15N enrichment was not statistically different between the two patient populations (p = 0.103). The time to peak 15N enrichment in tetralogy of Fallot infants was 6.3 ± 1 hr and in infants with heart failure 7.5 ± 2 hr (mean ± SEM). The duration of significant 15N enrichment after a dose was 18.5 ± 1.7 hr in tetralogy of Fallot and in heart failure 18.2 ± 1.8 hr (mean ± SEM). The time to peak enrichment and duration of enrichment were also not statistically different (p = 0.617 and p = 0.887). CONCLUSIONS: The presented results support two conclusions of significance for future applications: (1) Demonstration that 15N-thymidine label administration at home is equivalent to in-hospital administration. (2) Two different types of heart disease show no differences in 15N-thymidine absorption and elimination. This enables the comparative analysis of cellular proliferation between different types of heart disease.
Assuntos
Insuficiência Cardíaca , Tetralogia de Fallot , Humanos , Tetralogia de Fallot/tratamento farmacológico , Isótopos de Nitrogênio , Administração Oral , Boca , Insuficiência Cardíaca/tratamento farmacológicoAssuntos
Oclusão da Artéria Retiniana , Tetralogia de Fallot , Humanos , Tetralogia de Fallot/complicações , Tetralogia de Fallot/tratamento farmacológico , Oclusão da Artéria Retiniana/complicações , Oclusão da Artéria Retiniana/diagnóstico , Oclusão da Artéria Retiniana/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Administração Intravenosa , Terapia TrombolíticaAssuntos
Antagonistas Adrenérgicos beta/farmacologia , Citocinese/efeitos dos fármacos , Miócitos Cardíacos/efeitos dos fármacos , Tetralogia de Fallot/fisiopatologia , Animais , Criança , Coração/anatomia & histologia , Coração/fisiologia , Humanos , Lactente , Camundongos , Camundongos Transgênicos , Miócitos Cardíacos/citologia , Propranolol/farmacologia , Tetralogia de Fallot/tratamento farmacológicoRESUMO
OBJECTIVES: The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. DESIGN: Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. SETTING: Five children's hospitals. PATIENTS: A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. CONCLUSIONS: The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.
Assuntos
Extubação/métodos , Anestésicos/administração & dosagem , Coartação Aórtica/cirurgia , Hipnóticos e Sedativos/administração & dosagem , Guias de Prática Clínica como Assunto , Tetralogia de Fallot/cirurgia , Analgesia/métodos , Analgésicos Opioides/administração & dosagem , Coartação Aórtica/tratamento farmacológico , Benzodiazepinas/administração & dosagem , Procedimentos Cirúrgicos Cardíacos/métodos , Dexmedetomidina/administração & dosagem , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Masculino , Cuidados Pós-Operatórios , Tetralogia de Fallot/tratamento farmacológicoRESUMO
The role of antibiotic prophylaxis for prevention of infective endocarditis is unknown. Endocarditis prophylaxis is recommended for certain high-risk individuals prior to dental procedures. To our knowledge, this is the first case reported in the literature of a patient with complex congenital heart disease developing endocarditis in the period immediately following otherwise uncomplicated intrauterine device insertion.
Assuntos
Endocardite Bacteriana/diagnóstico , Próteses Valvulares Cardíacas/microbiologia , Dispositivos Intrauterinos/microbiologia , Infecções Relacionadas à Prótese/diagnóstico , Tetralogia de Fallot/tratamento farmacológico , Adulto , Antibioticoprofilaxia , Procedimentos Cirúrgicos Cardiovasculares , Assistência Odontológica , Assistência Odontológica para Doentes Crônicos/normas , Endocardite Bacteriana/terapia , Feminino , Humanos , Dispositivos Intrauterinos/efeitos adversos , Infecções Relacionadas à Prótese/terapia , Fatores de Risco , Tetralogia de Fallot/complicações , Resultado do TratamentoRESUMO
BACKGROUND: Measures of left ventricular (LV) systolic and diastolic function are known predictors of mortality after repair of tetralogy of Fallot. We aimed to characterise LV reverse remodelling achievable with ramipril therapy. METHODS AND RESULTS: A blinded post-hoc analysis of baseline and 6-month follow-up echocardiograms from the APPROPRIATE (ISRCTN: 97515585) randomised double-blinded placebo-controlled trial of ramipril therapy was performed in 64 patients: 32 in ramipril and 32 in placebo group. Tissue Doppler systolic and diastolic myocardial velocities, mitral inflow velocities and time intervals were measured. Left atrial area and left atrial emptying fraction were calculated. There was significant increase in long axis shortening mean (standard deviation); MAPSE [1.9 (4.2) mm vs -0.2 (3.7) mm; pâ¯=â¯0.030], peak lateral systolic velocity; S' lateral [1.0 (2.0) cm/s vs -0.3 (2.2) cm/s; pâ¯=â¯0.025], peak lateral early diastolic velocity; E' lateral [0.57 (2.4) cm/s vs -3.3 (3.9) cm/s; pâ¯<â¯0.001], transmitral to lateral mitral annular early diastolic velocity ratio; E/E' lateral [-0.7 (1.9) vs 1.5 (1.9); pâ¯<â¯0.001] over the study period in the ramipril compared to the placebo group. Significantly higher measurements were observed in the ramipril arm of the subgroup of patients with right ventricular restrictive physiology in terms of peak late diastolic velocity; A [5.9 (13.5) cm/s vs -5.8 (12.5) cm/s; pâ¯=â¯0.041] and early to late diastolic transmitral velocity ratio; E/A [-0.18 (0.42) vs 0.23 (0.48); pâ¯=â¯0.037]. CONCLUSION: Six months' ramipril treatment appears to limit progression of both diastolic and systolic LV function in adults late after tetralogy of Fallot repair. With increased appreciation that even subtle LV disease predicts tetralogy of Fallot outcomes, further clinical trials of drug therapies are justified.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Complicações Pós-Operatórias/tratamento farmacológico , Insuficiência da Valva Pulmonar/tratamento farmacológico , Ramipril/uso terapêutico , Tetralogia de Fallot/tratamento farmacológico , Função Ventricular Esquerda/efeitos dos fármacos , Adulto , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/epidemiologia , Ramipril/farmacologia , Método Simples-Cego , Tetralogia de Fallot/diagnóstico por imagem , Tetralogia de Fallot/cirurgia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/epidemiologia , Disfunção Ventricular Esquerda/prevenção & controle , Função Ventricular Esquerda/fisiologia , Adulto JovemRESUMO
BACKGROUND: The effect of angiotensin II receptor blockers on right ventricular (RV) function is still unknown. Angiotensin II receptor blockers are beneficial in patients with acquired left ventricular dysfunction, and recent findings have suggested a favorable effect in symptomatic patients with systemic RV dysfunction. The current study aimed to determine the effect of losartan, an angiotensin II receptor blocker, on subpulmonary RV dysfunction in adults after repaired tetralogy of Fallot. METHODS: The REDEFINE trial (Right Ventricular Dysfunction in Tetralogy of Fallot: Inhibition of the Renin-Angiotensin-Aldosterone System) is an investigator-initiated, multicenter, prospective, 1:1 randomized, double-blind, placebo-controlled study. Adults with repaired tetralogy of Fallot and RV dysfunction (RV ejection fraction [EF] <50%) but without severe valvular dysfunction were eligible. Patients were randomly assigned between losartan (150 mg daily) and placebo with target treatment duration between 18 and 24 months. The primary outcome was RV EF change, determined by cardiovascular MRI in intention-to-treat analysis. RESULTS: Of 95 included patients, 47 patients received 150 mg losartan daily (age, 38.0±12.4 years; 74% male), and 48 patients received placebo (age, 40.6±11.4 years; 63% male). Overall, RV EF did not change in patients allocated to losartan (n=42) (44.4±5.1% to 45.2±5.0%) and placebo (n=46) (43.2±6.3% to 43.6±6.9%). Losartan did not significantly improve RV EF in comparison with placebo (+0.51%; 95% confidence interval, -1.0 to +2.0; P=0.50). No significant treatment effects were found on secondary outcomes: left ventricular EF, peak aerobic exercise capacity, and N-terminal pro-brain natriuretic peptide (P>0.30 for all). In predefined subgroup analyses, losartan did not have a statistically significant impact on RV EF in subgroups with symptoms, restrictive RV, RV EF<40%, pulmonary valve replacement, or QRS fragmentation. However, in a post hoc analysis, losartan was associated with improved RV EF in a subgroup (n=30) with nonrestrictive RV and incomplete remodeling (QRS fragmentation and previous pulmonary valve replacement) (+2.7%; 95% confidence interval, +0.1 to +5.4; P=0.045). CONCLUSIONS: Losartan had no significant effect on RV dysfunction or secondary outcome parameters in repaired tetralogy of Fallot. Future larger studies may determine whether there might be a role for losartan in specific vulnerable subgroups. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02010905.
Assuntos
Losartan/uso terapêutico , Tetralogia de Fallot/tratamento farmacológico , Disfunção Ventricular Direita/tratamento farmacológico , Adulto , Fator Natriurético Atrial/análise , Pressão Sanguínea , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Losartan/efeitos adversos , Masculino , Pessoa de Meia-Idade , Efeito Placebo , Estudos Prospectivos , Precursores de Proteínas/análise , Tetralogia de Fallot/patologia , Resultado do Tratamento , Disfunção Ventricular Direita/patologiaRESUMO
PURPOSE: This retrospective cohort study aimed to identify the early postoperative kinetics of C-reactive protein (CRP) and procalcitonin (PCT) in children undergoing tetralogy of Fallot (ToF) correction. The ability of these inflammatory markers to guide rational antibiotic usage was also determined. MATERIALS AND METHODS: All consecutive children who underwent ToF correction in 2009-2016 in our referral pediatric cardiac surgery clinic in Gdansk, Poland and did not exhibit infection signs on early postoperative days (POD) were identified. All patients received 48h antibiotic prophylaxis. Antibiotic treatment was extended or empirical antibiotic therapy was introduced if the clinician considered it necessary. CRP and PCT levels were measured on POD1-4 and 1-3, respectively. RESULTS: Of the 60 eligible children, 44 underwent CRP testing only. The remaining 16 patients underwent both CRP and PCT testing. All patients had abnormally high CRP values after surgery. All patients who also underwent PCT testing also displayed elevated PCT levels. The CRP and PCT levels peaked on POD2 (median=99.8mg/L) and POD1 (median=4.08ng/mL), respectively. In the CRP-alone patients, antibiotic prophylaxis was prolonged or empirical antibiotic therapy was started in 59%; in the CRP and PCT group, this was 25% (p<0.05). CONCLUSIONS: The children had elevated CRP and PCT levels after ToF correction, with peaks observed on POD2 and POD1, respectively. Monitoring both CRP and PCT in the early postoperative period may guide antibiotic therapy, thus reducing unnecessary treatment, additional toxicity, and adverse drug interactions without increasing treatment failure. Rational antibiotic treatment may also reduce antibiotic resistance.
Assuntos
Antibacterianos/uso terapêutico , Proteína C-Reativa/metabolismo , Calcitonina/sangue , Tetralogia de Fallot/sangue , Tetralogia de Fallot/cirurgia , Antibioticoprofilaxia , Criança , Demografia , Feminino , Humanos , Cinética , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Tetralogia de Fallot/tratamento farmacológicoRESUMO
Realizar uma revisão sistemática da literatura, discutindo e conceituando os aspectos clínicos da Tetralogia de Fallot, entendendo seu diagnóstico e formas de tratamento atuais. Métodos: Trata-se de um estudo qualitativo, realizado através de revisões sistemáticas, com busca nas bases de dados eletrônicos da SCIELO, Bireme, Google acadêmico, LILACS, e também em livros, utilizando-se como descritores: Tetralogia de Fallot, Cardiopatias Congênitas e Defeito do septo ventricular. Foram selecionados 9 artigos sobre o assunto, utilizando os descritores mencionados, sendo selecionados as referências publicadas de 2010 a 2017, com apenas um artigo publicado em 2003, cujas informações eram relevantes para a elaboração do trabalho, além de 9 livros sobre o assunto. Foi realizada uma pesquisa quanto a fisiopatologia, sintomatologia, diagnóstico, tipos de tratamento e acompanhamento da criança em relação aos riscos da TF. Resultados: A Tetralogia de Fallot é uma cardiopatia congênita cianótica, composta por quatro defeitos, sendo eles: a CIV, a dextroposição da aorta, hipertrofia do ventrículo direito e a estenose pulmonar. A gravidade da Tetralogia vai depender do grau de obstrução da saída do ventrículo direito. Os sintomas incluem cianose, dispneia, dificuldade de ganho de peso, crises de hipóxia e baqueteamento digital. O exame diagnóstico mais eficaz é a ecocardiografia, evidenciando com êxito os defeitos da cardiopatia. A principal terapêutica recomendada é a cirurgia reparatória definitiva, que apresenta poucas complicações e proporciona aos pacientes uma melhor qualidade de vida.
Assuntos
Tetralogia de Fallot/diagnóstico , Tetralogia de Fallot/tratamento farmacológicoRESUMO
We present the use of pulmonary vasodilators in three adult patients with unrepaired tetralogy of Fallot, pulmonary atresia, aortopulmonary collaterals, and segmental pulmonary arterial hypertension. Patients improved by 1-2 NYHA classes with modest exercise-tolerance increase, and remained stable without side effects during 2.5, 10, and 14 years. Literature review revealed five studies with pulmonary vasodilators in heterogeneous, mostly repaired patient populations.
Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão Pulmonar/tratamento farmacológico , Atresia Pulmonar/tratamento farmacológico , Sulfonamidas/uso terapêutico , Tetralogia de Fallot/tratamento farmacológico , Vasodilatadores/uso terapêutico , Adulto , Bosentana , Circulação Colateral/efeitos dos fármacos , Angiografia Coronária , Tolerância ao Exercício/efeitos dos fármacos , Feminino , Humanos , Masculino , Adulto JovemRESUMO
Renin-angiotensin-aldosterone system (RAAS) inhibition with angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors is beneficial in patients with acquired left ventricular dysfunction. Adult patients with tetralogy of Fallot (TOF) with right ventricular (RV) dysfunction are at high risk for heart failure, arrhythmias, and sudden cardiac death. However, the efficacy of RAAS inhibition has not been established in these patients. METHODS: The REDEFINE is an investigator-initiated, multicenter, prospective, randomized, double-blind, placebo-controlled trial to study the effects of the angiotensin II receptor blocker losartan (target dosage of 150 mg once daily) in adult patients with TOF. Patients with RV dysfunction in the absence of severe valvular dysfunction are eligible for inclusion. The primary end point is the change in RV ejection fraction after 18 to 24 months, as measured by cardiovascular magnetic resonance imaging. In addition, laboratory measurements, echocardiography, and cardiopulmonary exercise testing are performed. CONCLUSION: The REDEFINE trial will study the effects of RAAS inhibition with losartan in TOF patients with RV dysfunction.
Assuntos
Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Losartan/uso terapêutico , Sistema Renina-Angiotensina/efeitos dos fármacos , Tetralogia de Fallot/tratamento farmacológico , Tetralogia de Fallot/fisiopatologia , Disfunção Ventricular Direita/tratamento farmacológico , Disfunção Ventricular Direita/fisiopatologia , Adulto , Método Duplo-Cego , Feminino , Humanos , Masculino , Estudos Prospectivos , Tetralogia de Fallot/diagnóstico , Disfunção Ventricular Direita/diagnósticoRESUMO
BACKGROUND: Tetralogy of Fallot (TOF) is one of the common congenital heart diseases (CHD) in implantable cardioverter defibrillator (ICD) recipients, but few studies have reported the long-term outcomes of and the anti-tachycardia pacing (ATP) efficacy in repaired TOF.MethodsâandâResults:Twenty-one repaired TOF patients with an ICD implanted between April 2003 and March 2015 were investigated retrospectively. ICD therapy and clinical outcome were analyzed. Mean patient age was 39±11 years; 62% were male; and mean age at repair surgery was 9.4±6.8 years. During a median follow-up of 5.6 years (range, 2.6-8.4 years), no patients died. Appropriate ATP were delivered in 11 patients (52%), with appropriate shocks in 5 patients (24%) and inappropriate shocks in 5 patients (24%). The success rate of ATP was 98% for fast ventricular tachycardia (VT; cycle length ≤320 ms) and 98% for slow VT (cycle length >320 ms). ATP effectiveness increased from 81.5% with the first ATP attempt to 93.7% with the second ATP attempt, to 97.5% with the third ATP attempt, and to 98.6% with the fourth or successive ATP attempt (P<0.0001, Cochran-Armitage trend test). CONCLUSIONS: ATP was highly effective in repaired TOF regardless of VT cycle length. Multiple ATP attempts could have an important role in VT termination, and the novel subcutaneous ICD without ATP capability should be used carefully.
Assuntos
Desfibriladores Implantáveis/normas , Tetralogia de Fallot/cirurgia , Trifosfato de Adenosina/uso terapêutico , Adulto , Estimulação Cardíaca Artificial , Estudos de Casos e Controles , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taquicardia Ventricular/fisiopatologia , Tetralogia de Fallot/tratamento farmacológico , Resultado do TratamentoRESUMO
Tetralogy of fallot (TOF) is one of the most common congenital heart disease (CHD) in children. With the development of pediatric surgery and intensive care units, increasing number of grown-up CHD patients are presenting for non-cardiac surgeries. Non-operated TOF patients suffer from chronic hypoxia and decreased pulmonary blood flow resulting in considerable alteration in the physiology. The optimal management of these patients, therefore, require a thorough understanding of the pathophysiology of the uncorrected TOF. We hereby report a case of successful management of a 10-year-old child with an uncorrected TOF posted for tibial external fixation device (AU)
La tetralogía de Fallot (TF) es una de las cardiopatías congénitas más habituales en niños. Con el desarrollo de la cirugía pediátrica y las unidades de cuidados intensivos cada vez se presentan más casos de pacientes adultos con cardiopatías congénitas para cirugías no cardíacas. Los pacientes con TF no operada padecen hipoxia crónica y un flujo sanguíneo pulmonar reducido, lo que supone una alteración considerable de la fisiología. El manejo óptimo de estos pacientes requiere, por tanto, un profundo conocimiento de la fisiopatología de la TF no corregida. El presente artículo expone el caso de tratamiento exitoso de un paciente de 10 años con TF no corregida intervenido con dispositivo de fijación externa tibial (AU)
Assuntos
Humanos , Masculino , Criança , Tetralogia de Fallot/diagnóstico , Tetralogia de Fallot/tratamento farmacológico , Hipóxia/complicações , Período Perioperatório/métodos , Anestesia , Isoflurano/uso terapêutico , Fenilefrina/uso terapêutico , Norepinefrina/uso terapêutico , Anestesia Endotraqueal/instrumentação , Anestesia Endotraqueal/métodos , Cardiopatias Congênitas/complicações , Tetralogia de Fallot/complicações , Cardiopatias Congênitas/tratamento farmacológico , Cardiopatias Congênitas/prevenção & controle , Tetralogia de Fallot/fisiopatologia , Ketamina/uso terapêuticoRESUMO
BACKGROUND: Pathophysiologic changes in children with congenital heart disease may alter the effect of drugs by influencing the pharmacokinetics (PK). Considering the limited literature that describes the PK of etomidate in pediatric patients, especially in those with tetralogy of Fallot (TOF), our aim was to characterize the PK of etomidate and explore the effects of TOF. METHODS: Twenty-nine pediatric patients (15 with TOF and 14 with normal cardiac anatomy) scheduled to undergo elective surgery under general anesthesia were recruited in the study. All children received etomidate 60 µg/kg/min intravenously until a bispectral index of ≤50 was reached for 5 seconds during anesthesia induction. Arterial blood samples were drawn and analyzed. Population analysis was performed by using NONMEM to define PK characteristics. The estimates were standardized to a 70-kg adult using a per-kilogram model. RESULTS: Data consisting of 244 samples from 29 children with a mean age of 236 days (range, 86-360 days) were used, including a TOF group with a mean age of 250 days (range, 165-360 days) and a normal cardiac anatomy group with a mean age of 221 days (range, 86-360 days). A 3-compartment disposition model was best fitted to describe the PK of etomidate. The introduction of TOF as a covariate for systemic clearance (Cl1) improved the model and resulted in a significant reduction of objective function (Δobjective function = -7.33; P = .0068), which means that TOF was a significant covariate of Cl1, and the etomidate Cl1 in children with TOF (1.67 × (weight [WT]/70 kg) L/min) was lower than those with normal cardiac anatomy (2.28 × (WT/70 kg) L/min). Other PK parameter values were as follows: V1 = 8.05 × (WT/70 kg) L; V2 = 13.7 × (WT/70 kg) L; V3 = 41.3 × (WT/70 kg) L; Cl2 = 3.35 × (WT/70 kg) L/min; Cl3 = 0.563 × (WT/70 kg) L/min. CONCLUSIONS: A decreased systemic clearance for etomidate in children with TOF resulted in a lower required infusion rate and variation with time to achieve the same plasma concentration and maintain an equivalent target concentration or have longer sedation and recovery times after bolus or continuous infusion than normal children.
Assuntos
Etomidato/sangue , Hipnóticos e Sedativos/sangue , Taxa de Depuração Metabólica/fisiologia , Tetralogia de Fallot/sangue , Tetralogia de Fallot/fisiopatologia , Etomidato/administração & dosagem , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Lactente , Infusões Intravenosas , Masculino , Taxa de Depuração Metabólica/efeitos dos fármacos , Tetralogia de Fallot/tratamento farmacológicoRESUMO
BACKGROUND: The optimal dose of methylprednisolone during pediatric open heart surgical procedures is unknown. This study compared the antiinflammatory and cardioprotective effects of high and lower doses of methylprednisolone in children undergoing cardiac operations. METHODS: Thirty children, between 1 and 18 months old and undergoing total correction of tetralogy of Fallot, were randomized in double-blind fashion to receive either 5 or 30 mg/kg of intravenous methylprednisolone after anesthesia induction. Plasma concentrations of methylprednisolone, interleukin-6 (IL-6), IL-8, and IL-10, troponin T, and glucose were measured at anesthesia induction before administration of the study drug, at 30 minutes on cardiopulmonary bypass (CPB), just after weaning from CPB, and at 6 hours after CPB. Troponin T and blood glucose were also measured on the first postoperative morning. RESULTS: Significantly higher methylprednisolone concentrations were measured in patients receiving 30 mg/kg of methylprednisolone at 30 minutes on CBP, after weaning from CPB and at 6 hours after CPB (p < 0.001). No differences were detected in IL-6, IL-8, IL-10, or troponin concentrations at any time point. Blood glucose levels were significantly higher in patients receiving 30 mg/kg of methylprednisolone at 6 hours after CPB (p = 0.04) and on the first postoperative morning (p = 0.02). CONCLUSIONS: Based on the measured concentrations of interleukins or troponin T, a 30 mg/kg dose of methylprednisolone during pediatric open heart operations does not offer any additional antiinflammatory or cardioprotective benefit over a 5 mg/kg dose. Higher dose of methylprednisolone exposes patients more frequently to hyperglycemia.
Assuntos
Metilprednisolona/administração & dosagem , Tetralogia de Fallot/tratamento farmacológico , Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Citocinas/sangue , Método Duplo-Cego , Feminino , Humanos , Lactente , Masculino , Metilprednisolona/sangue , Metilprednisolona/farmacologia , Tetralogia de Fallot/cirurgiaRESUMO
The objective of this study was to investigate whether the α agonist dexmedetomidine has the ability to attenuate hypoxemia in pediatric patients undergoing palliative pulmonary artery reconstruction.From January 2009 to January 2013, a total of 25 pediatric patients with Tetralogy of Fallot, pulmonary atresia (ventricular septal defect), or persistent truncus arteriosus (I) were enrolled in our study. Due to hypoplastic pulmonary arteries, all patients received palliative pulmonary artery reconstruction. During the perioperative period, they were allocated to receive either dexmedetomidine (bolus dose of 0.3 µg/kg followed by an infusion of 0.2-0.3 µg/kg/h, n = 15) or control drug (n = 10) intravenously. Any desaturation was recorded. Heart rate, mean arterial pressure, pulse oximetry, and arterial blood gas parameters were measured during the perioperative period.There were no significant differences between the groups in hemodynamic variables. The arterial oxygen saturation and arterial blood gas parameters increased in the dexmedetomidine groups (P < 0.05).These findings suggest that the injection of dexmedetomidine can attenuate hypoxemia during palliative pulmonary artery reconstruction in pediatric patients.
Assuntos
Agonistas de Receptores Adrenérgicos alfa 2/uso terapêutico , Dexmedetomidina/uso terapêutico , Hipóxia/prevenção & controle , Cuidados Paliativos , Artéria Pulmonar/cirurgia , Atresia Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Persistência do Tronco Arterial/cirurgia , Pressão Sanguínea , Procedimentos Cirúrgicos Cardíacos/métodos , Feminino , Frequência Cardíaca , Hemodinâmica , Humanos , Lactente , Masculino , Atresia Pulmonar/tratamento farmacológico , Atresia Pulmonar/fisiopatologia , Tetralogia de Fallot/tratamento farmacológico , Tetralogia de Fallot/fisiopatologia , Resultado do Tratamento , Persistência do Tronco Arterial/tratamento farmacológico , Persistência do Tronco Arterial/fisiopatologiaRESUMO
La tetralogía de Fallot es una cardiopatía congénita que representa el 11-13% de estas. La estenosis e hipoplasia de las arterias pulmonares aparecen en un alto porcentaje, debido a que esta enfermedad cursa con una estenosis nativa de la rama pulmonar y a que la cirugía previa la puede estenosar. Los stents intravasculares expandibles mediante balón son una técnica alternativa a la reintervención en pacientes con cardiopatías congénitas. Sin embargo, a pesar del progresivo incremento de su utilización, el limitado número de procedimientos asociado a la amplia variedad anatómica y diferentes características de estos pacientes hace que aun en manos expertas, la implantación de stents en estos pacientes asocie una incidencia no despreciable de complicaciones, las cuales no son siempre inocuas y obligan en ocasiones a realizar tratamientos quirúrgicos en enfermos ya multiintervenidos, lo que aumenta la complejidad y el riesgo (AU)
Tetralogy of Fallot is a congenital heart disease that accounts for 11-13% of the congenital cardiomyopathies. Stenosis and hyperplasia of the pulmonary arteries occur in a high proportion of them as this disease causes a native stenosis of the pulmonary branch, which can be surgically repaired with a stent. The use of balloon expandable intravascular stents is an alternative technique to further surgery in patients with congenital heart diseases. However, despite the gradual increase in their use, the limited number of procedures, combined with the wide anatomical variability and different characteristics of these patients, even in expert hands, stent implants are associated with a not inconsiderable incidence of complications. These are not always obvious and often require performing surgery in patients who have already had multiple interventions, thus increasing the complexity and the risk (AU)
Assuntos
Humanos , Masculino , Tetralogia de Fallot/cirurgia , Tetralogia de Fallot , Stents , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/tratamento farmacológico , Cardiopatias Congênitas/cirurgia , Estenose da Valva Pulmonar/complicações , Tetralogia de Fallot/tratamento farmacológico , Stents/efeitos adversos , Stents , Estenose da Valva Aórtica/complicações , Estenose da Valva Pulmonar/induzido quimicamente , Estenose da Valva Pulmonar/cirurgia , Estenose da Valva PulmonarRESUMO
Infantile hemangiomas (IHs) are the most common benign tumors of infancy and usually they don't require specific therapy. In 10-20% of cases IHs are able to generate complication and medical/surgical intervention is needed. For many decades standard treatment consisted in oral or intralesional corticosteroids until Leaute-Labreze and colleagues published the first report on the efficacy of propranolol for cutaneous infantile hemangiomas in 2008. IHs can be sometimes part of complex syndrome. Here we report the case of a patient with tetralogy of Fallot operated at 5 month of age who stopped propranolol treatment for hypoxic spells and unusually developed facial and subglottic IHs configuring the diagnosis of PHACES syndrome (posterior fossa brain malformations, hemangioma, arterial anomalies, cardiac defects and/or aortic coarctation, ocular anomalies and sternal defects). To our knowledge this is the first report in the international literature of a delayed appearance of an infantile hemangioma involving the skin and the airways (PHACES syndrome). The pathophysiological explanation relies on the mechanism of action of propranolol which seems to act initially with vasoconstriction, down-regulating proangiogenetic factors and inducing endothelial cell apoptosis. Many decades since their introduction ß-blockers are useful in a growing group of diseases. The pleiotropic effect of ß-adrenoceptors antagonists is not yet deeply understood, residing in neurohormonal regulation systems and angiogenesis and proving to be an effective treatment from cardiovascular to oncological illnesses.