Complicaciones neurológicas en el postoperatorio inmediato de cirugía cardiaca: todavía un largo camino por recorrer / Acute neurological complications after pediatric cardiac surgery: still a long way to go

Introducción: Existe una creciente preocupación por las complicaciones neurológicas asociadas a las cardiopatías congénitas y a la cirugía cardiaca infantil. Material y métodos: Estudio observacional retrospectivo de casos y controles de las cirugías cardiacas infantiles y su postoperatorio en cuidados intensivos durante un período de 10 años. Se seleccionaron dos controles por cada caso, ajustados por el mismo grado de complejidad quirúrgica. Resultados: Se estudiaron 900 cirugías. Se detectaron 38 complicaciones neurológicas (4,2%), de las cuales 21 (55,3%) implicaban al sistema nervioso periférico y 17 (44,7%) al sistema nervioso central. Las complicaciones del sistema nervioso central (1,9% del total) fueron 8 convulsiones, 4 accidentes cerebrovasculares, 4 encefalopatías hipóxico-isquémicas y un déficit neurológico reversible. Un 35,3% mostró afectación al alta y un 17,6% falleció. Se encontró una diferencia estadísticamente significativa en el tiempo de circulación extracorpórea (p=0,009), el tiempo de isquemia (p=0,12), los días de estancia en cuidados intensivos (p=0,001), días de ventilación mecánica (p=0,004) y días de soporte inotrópico (p=0,001). Conclusiones: La incidencia de complicaciones neurológicas en nuestra serie es similar a la descrita previamente. Las convulsiones son la manifestación clínica más común. Las complicaciones del sistema nervioso central se asocian con un aumento de la morbilidad, una mayor estancia hospitalaria y un mayor consumo de recursos. Es necesario establecer medidas en el pre y post-operatorio, así como durante la cirugía, encaminadas a su prevención y diagnóstico precoz(AU)

Introduction: There has been an increasing concern over the neurological complications associated with congenital heart disease and cardiac surgery. Material and methods: We performed a retrospective, case-control, observational review of the postoperative period in the intensive care unit of patients undergoing cardiac surgery over the past 10 years. We selected 2 control patients for each case, matched for surgical complexity. Results: A total of 900 patients were reviewed. We found 38 neurological complications (4.2%), of which 21 (55.3%) were in the peripheral nervous system and 17 (44.7%) in the central nervous system. The complications involving the central nervous system (1.9% of total) consisted of 8 seizures, 4 cerebrovascular accidents, 4 hypoxic-ischemic encephalopathy events, and 1 reversible neurological deficit. At the time of discharge, 35.3% were symptomatic and 17.6% had died. Patients with neurological complications had a longer bypass time (P=.009), longer aortic cross time (P=.012), longer hospitalization in intensive care (P=.001), longer duration of mechanical ventilation (P=.004) and an increased number of days under inotropic support (P=.001). Conclusions: Our incidence of neurological complications after cardiac surgery is similar to that previously described. Clinical seizures are the most common complication. Central nervous system complications are associated with a higher morbidity and hospitalization time. Units caring for patients with congenital heart disease must implement neurological monitoring during and after cardiac surgery to prevent and to detect these complications earlier(AU)

[Acute neurological complications after pediatric cardiac surgery: still a long way to go]. / Complicaciones neurológicas en el postoperatorio inmediato de cirugía cardiaca: todavía un largo camino por recorrer.

INTRODUCTION: There has been an increasing concern over the neurological complications associated with congenital heart disease and cardiac surgery. MATERIAL AND METHODS: We performed a retrospective, case-control, observational review of the postoperative period in the intensive care unit of patients undergoing cardiac surgery over the past 10 years. We selected 2 control patients for each case, matched for surgical complexity. RESULTS: A total of 900 patients were reviewed. We found 38 neurological complications (4.2%), of which 21 (55.3%) were in the peripheral nervous system and 17 (44.7%) in the central nervous system. The complications involving the central nervous system (1.9% of total) consisted of 8 seizures, 4 cerebrovascular accidents, 4 hypoxic-ischemic encephalopathy events, and 1 reversible neurological deficit. At the time of discharge, 35.3% were symptomatic and 17.6% had died. Patients with neurological complications had a longer bypass time (P=.009), longer aortic cross time (P=.012), longer hospitalization in intensive care (P=.001), longer duration of mechanical ventilation (P=.004) and an increased number of days under inotropic support (P=.001). CONCLUSIONS: Our incidence of neurological complications after cardiac surgery is similar to that previously described. Clinical seizures are the most common complication. Central nervous system complications are associated with a higher morbidity and hospitalization time. Units caring for patients with congenital heart disease must implement neurological monitoring during and after cardiac surgery to prevent and to detect these complications earlier.

[Early extubation with caudal morphine after pediatric heart surgery]. / Extubación precoz con morfina caudal tras cirugía cardíaca pediátrica.

OBJECTIVES: To analyze the viability of immediate extubation of children after corrective surgery for congenital heart defects with extracorporeal membrane oxygenation using an anesthetic technique involving caudal morphine, and to study the effect on length of stay in the pediatric intensive care unit (PICU) or elsewhere in the hospital. MATERIAL AND METHODS: Twenty-nine ASA I-II patients without coagulation alterations undergoing surgery to correct simple heart defects were selected for extubation after surgery. Anesthesia was provided with with sevoflurane, midazolam, rocuronium, fentanil (maximum dose 10 micrograms/Kg) and a bolus of caudal morphine (50-60 micrograms/Kg) after anesthetic induction. Patient characteristics, type of surgery, times of extracorporeal circulation and of ischemia, arterial blood gases upon arrival in the PICU, postoperative complications and quality of analgesia were the variables analyzed. We also compared length of stay in the PICU and hospital for the study group and for a historical control group of 23 patients who had no received caudal morphine or been selected for early extubation. RESULTS: All patients were extubated satisfactorily in the operating room. None required reintubation or reoperation. Postoperative pain was controlled with metamizol alone for 79.3%. No episodes of respiratory depression or neurological complications were observed. PICU and hospital stays were significantly shorter in the study group than in the control group. CONCLUSIONS: Of patients undergoing simple corrective heart surgery with extracorporeal membrane oxygenation immediate extubation did not increase postoperative morbimortality and shortened the hospital stay. A single dose of caudal morphine provided optimum conditions for extubation and good control of postoperative pain. Strict measures must be taken, however, to avoid postpuncture bleeding.

Extubación precoz con morfina caudal tras cirugía cardíacapediátrica / Early exttubation with caudal morphine after pediatric heart surgery

OBJETIVO: Analizar la viabilidad y la influencia en la estancia en la Unidad de Cuidados Intensivos Pediátricos (UCIP) y en el hospital de la extubación inmediata de niños sometidos a corrección de cardiopatías congénitas bajo circulación extracorpórea (CEC) utilizando una técnica anestésica basada en la administración de morfina caudal. MATERIAL Y MÉTODOS: 29 pacientes ASA I-II, sin alteraciones de la coagulación y sometidos a corrección de una cardiopatía simple, fueron seleccionados para ser extubados tras la intervención. La anestesia se realizó con sevoflurano, midazolam, rocuronio, fentanilo (dosis máxima de 10 µg/Kg) y bolo de morfina caudal (50-60 µg/Kg) tras la inducción anestésica. Se analizaron las variables demográficas, tipo de cirugía, tiempo de CEC y de isquemia, gasometría arterial a su llegada a UCIP, complicaciones postoperatorias y grado de analgesia. Asimismo se compararon las estancias en la UCIP y en el hospital con las de un grupo control histórico de 23 pacientes a los que no se administró morfina caudal ni hubo intencionalidad de conseguir su extubación precoz. RESULTADOS: Todos los pacientes fueron extubados satisfactoriamente en quirófano. Ninguno requirió reintubación o reintervención. En el 79,3 por ciento de los casos el dolor se controló sólo con metamizol durante el postoperatorio. No se registraron episodios de depresión respiratoria ni complicaciones neurológicas. La estancia en UCIP y hospitalaria fueron significativamente más bajas que en el grupo control. CONCLUSIONES: La extubación inmediata de pacientes intervenidos por cardiopatía simple bajo CEC no aumentó la morbimortalidad postoperatoria y acortó la estancia hospitalaria. La morfina caudal en dosis única proporcionó unas condiciones óptimas para la extubación y un buen control del dolor postoperatorio, aunque deben extremarse las precauciones para prevenir un sangrado postpunción (AU)

[Corticoid-resistant rejection and humoral rejection. The diagnostic criteria and therapeutic management]. / Rechazo corticorresistente y rechazo humoral. Criterios diagnósticos y manejo terapéutico.

The standard treatment of rejection episodes post-heart transplantation is based on high dose of steroids followed by monoclonal or policlonal antibodies directed against T lymphocytes like ATG or OKT3. When this treatment is insufficient it can be used other drugs like metothrexate, ciclofosfamide and another procedures such as total lymphoid irradiation, plasmapheresis or photopheresis. Cardiac allograft rejection is defined by histologic features that include the presence of lymphocytic infiltration of the myocardium with or without necrosis and this histologic pattern is termed cellular rejection. However there is a second form of acute rejection, associated with capillary injury, usually mediated by humoral immune response and without interstitial infiltrates which has been named vascular or humoral rejection. Vascular allograft rejection is commonly resistant to standards forms of immunosuppressive therapy and may result in irreversible allograft dysfunction and reduced patient survival.