Evaluation on the early hemodynamic changes after cardiac surgery for congenital heart diseases in neonates / 中华儿科杂志

<p><b>OBJECTIVE</b>To accurately evaluate the early hemodynamic status of neonates who undergo complex neonatal cardiac surgery, through monitoring the cardiac index (CI), serum lactate (Lac), mixed venous oxygen saturation (SvO(2)).</p><p><b>METHODS</b>From January to November 2007, haemodynamic data of 80 patients who had open heart surgery for congenital heart disease were analyzed within 48 hours after operation. Of the 80 patients, 47 were neonates, their age ranged from 3 days to 29 days [mean (21.98 + or - 8.15) days] and weight ranged from 2.6 kg to 4.2 kg [mean (3.51 + or - 0.39) kg]. As the control group, 33 young infants at the age of 30 days to 180 days [mean (76.36 + or - 24.79) days] with body weight ranged from 3.1 kg to 6.0 kg [mean (4.59 + or - 0.59) kg] were also enrolled. The value of CI derived from pulse contour and was calculated by using the PiCCO system. Meanwhile, measurements of serum lactate level and SvO(2) were recorded. Serial measurements of the cardiac output were performed for the neonates.</p><p><b>RESULTS</b>CI in survivors of neonates (2.01 + or - 0.35) L/(min x m(2)) was lower than that of the infants (2.26 + or - 0.39) L/(min x m(2)) after cardiac surgery (P < 0.05) at 2 h, 6 h postoperatively. However, urine output remained normal. The value of pulse pressure in neonates was less than that in young infants. Serum lactate level in neonates was significantly higher than that of young infants during cardiac surgical procedures (P < 0.01) at 12 h postoperatively; the SvO(2) was more than 60% postoperatively in survived neonates, there was no significant difference (P > 0.05) in SvO(2) between neonates and young infants during preoperative and postoperative periods. There was a positive correlation between CI and SvO(2). Four neonates and 1 young infant died after surgical treatment, surgical mortality was 8.5% and 3.0%, respectively. The deaths of the neonates were related to the cardiocirculatory function decompensation, unrelieved severe acidosis preoperatively, and the transposition of great artery with coronary artery malformation and longer cardiopulmonary bypass. The patients with significantly high arterial blood lactate levels during the first 6 - 12 hours postoperatively had poor outcome. Lactate levels were higher than 10 mmol/L and SvO(2) less than 50% in neonates who developed multiple organ system failure. One young infant died of sudden arrhythmia after surgical treatment, whose death may be related the surgical procedure itself with pulmonary artery banding and blalock-taussig shunt leading to increased preload and afterload of the heart.</p><p><b>CONCLUSIONS</b>Elevated serum lactate level postoperatively may reflect intraoperative tissue hypoperfusion. Serial blood lactate level measurements may be an accurate predictor of clinical outcomes in children after pediatric open heart surgery. Mixed venous oxygen saturation changes more rapidly than other standard hemodynamic variables. The higher mortality of neonates with congenital heart disease is related to the malformation complexity itself and illness severity.</p>

Application of neurally adjusted ventilatory assist in infants who underwent cardiac surgery for congenital heart disease / 中国当代儿科杂志

<p><b>OBJECTIVE</b>Neurally adjusted ventilatory assist (NAVA) is a new mode of mechanical ventilation that delivers ventilatory assist in proportion to neural effort. This study aimed to compare the hemodynamic safety, oxygenation and gas exchange effects ventilated with NAVA and with pressure support ventilation (PSV) in infants who underwent open-heart surgery.</p><p><b>METHODS</b>Twenty-one infants who underwent open-heart surgery for congenital heart disease (mean age 2.9+/- 2.1 months and mean weight 4.2+/- 1.4 kg) were enrolled. They were ventilated with PSV and NAVA for 60 minutes respectively in a randomized order. The hemodynamic, oxygenation and gas exchange effects produced by the two ventilation modes were compared.</p><p><b>RESULTS</b>Three cases failed to shift to NAVA because of the bilateral diaphragmatic paralysis after operation. In the other 18 cases, there were no significant differences in the heart rate (HR), systolic blood pressure (BPs) and central venous pressure (CVP) in the two ventilation modes. The PaO2/FiO2 (P/F) ratio in NAVA was slightly higher than in PSV, but there was no statistical difference. PaCO2 did not show significant differences in the two modes. The peak inspiratory pressure (PIP) and electrical activity of the diaphragm (EAdi) in NAVA were significantly lower than in PSV. The EAdi signal after extubation was higher in infants who needed reintubation or intervention of noninvasive mechanical ventilation than in those who were extubated successfully (30.0+/- 8.4 microV vs 11.1+/- 3.6 microV; P<0.01).</p><p><b>CONCLUSIONS</b>As the first study of application of NAVA in infants in China, this study shows that NAVA has the same homodynamic effects as PSV. However the PIP for maintaining the same level of PaCO2 in NAVA is significantly lower than that in the traditional PSV. Monitoring the EAdi signal after extubation may show the risks of reintubation or intervention of noninvasive mechanical ventilation.</p>

Percutaneous radiofrequency ablation combined with transcatheter arterial chemoembolization and percutaneous ethanol injection for recurrent small hepatocellular carcinoma / 南方医科大学学报

<p><b>OBJECTIVE</b>To explore the value of percutaneous radiofrequency ablation (PRFA) combined with transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the management of recurrent small hepatocellular carcinoma.</p><p><b>METHODS</b>Between March 2001 and March 2005, 52 patients with recurrent hepatocellular carcinoma (tumor size< or =5 cm) underwent PRFA, and 14 of the patients (tumor size 3-5 cm) also received TACE and PEI, and their clinical data were analyzed retrospectively.</p><p><b>RESULTS</b>MRI or CT after PRFA revealed complete coagulative necrosis of the tumor in 38 cases (tumor size <3 cm). In the 14 patients (tumor size 3-5 cm) with also TACE and PEI, complete necrosis occurred in 11 cases (78.6%). In the patients involved in this study, the 1-, 2-, 3- and 4-year survival rates were 96.2%, 69.4%, 45.5% and 30.0%, respectively.</p><p><b>CONCLUSIONS</b>PRFA is an effective modality for local treatment of recurrent small hepatocellular carcinoma, capable of total elimination of tumors <3 cm. For tumors of 3-5 cm, combination with TACE and PEI may help increase the tumor necrosis rate following the ablation and raise the patients' survival rate.</p>