Clinical profile of systemic inflammatory response after pediatric cardiac surgery with cardiopulmonary bypass

Soares, Leonardo Cavadas da Costa; Ribas, Denise; Spring, Regine; Silva, Jean Marcelo Ferreira da; Miyague, Nelson Itiro

doi:10.1590/S0066-782X2010000100019

Abstracts

BACKGROUND: the postoperative period of congenital cardiomyopathies correction is frequently accompanied by systemic inflammatory response. OBJECTIVE: To assess the frequency of occurrence and clinical manifestations of the systemic inflammatory response syndrome after cardiopulmonary bypass (SIRS-CPB) in children submitted to cardiac surgery. METHODS: Historical cohort study including patients up to 3 years old that were submitted to elective corrective surgeries for congenital cardiopathies with cardiopulmonary bypass (CPB). A total of 101 patients were assessed by means of clinical criteria of organ dysfunction through score tests, as comparing predisponent factors and aggregated morbidity to the presence of SIRS-CPB. RESULTS: Twenty-two patients (21.9%) fulfilled the criteria for SIRS-CPB. The sex or type of cardiopathy did not differ between groups (p = NS). Patients diagnosed with SIRS-CPB (compared to patients without SIRS-CPB) presented lower mean age (6.8 ± 5.5 versus 10.8 ± 5.1 months, p < 0.05), lower weight (5.3 ± 1.9 versus 6.9 ± 2.0 kg, p < 0.05), and longer CPB duration (125.1 ± 49.5 versus 93.9 ± 33.1 minutes, p < 0.05). Longer median duration of mechanical ventilation (120.0 versus 13.0 hours, p < 0.05), longer stay in Intensive Care Unit (ICU) (265.0 versus 107.0 hours, p < 0.05) and in hospital (22.0 versus 10.0 days, p < 0.05) were observed. In the multivariate analysis, higher weight (OR = 0.68, p = 0.01) was identified as a protection factor. CONCLUSION: The adopted clinical criteria identified a risk group for SIRS-CPB, which presented lower weight and longer CPB duration as predisponent factors. Patients with SIRS-CPB remain in mechanical ventilation, in ICU and in hospitalization for a longer period of time.

Systemic inflammatory response syndrome; thoracic surgery; cardiopulmonary bypass

FUNDAMENTO: O pós-operatório de correção de cardiopatias congênitas frequentemente é acompanhado por resposta inflamatória sistêmica. OBJETIVO: Avaliar a frequência e as manifestações clínicas da síndrome de resposta inflamatória sistêmica após circulação extracorpórea (SRIS-CEC) em crianças submetidas à cirurgia cardíaca. MÉTODOS: Coorte histórico incluindo pacientes com até 3 anos de idade, submetidos à correção cirúrgica eletiva de cardiopatias congênitas com utilização de circulação extracorpórea (CEC). Foram analisados 101 pacientes por meio de critérios clínicos de disfunção de órgãos sob forma de escore, comparando-se fatores predisponentes e morbidade agregada à presença de SRIS-CEC. RESULTADOS: Foram identificados 22 pacientes (21,9%) que preencheram os critérios estabelecidos para SRIS-CEC. O sexo ou tipo de cardiopatia não diferiu entre os grupos (p =NS). Pacientes com SRIS-CEC (comparados aos pacientes sem SRIS-CEC) apresentavam idade média menor (6,8 ± 5,5 vs. 10,8 ± 5,1 meses, p < 0,05), menor peso (5,3 ± 1,9 vs. 6,9 ± 2,0 quilogramas, p < 0,05), maior tempo CEC (125,1 ± 49,5 vs. 93,9 ± 33,1 minutos, p < 0,05). Observou-se respectivamente maior tempo em mediana de ventilação mecânica (120,0 vs. 13,0 horas, p < 0,05), maior tempo de internação em unidade de cuidados intensivos (UCI) (265,0 vs. 107,0 horas, p < 0,05) e internação hospitalar (22,0 vs. 10,0 dias, p < 0,05). Em análise multivariada, maior peso (OR = 0,68, p = 0,01) foi identificado como fator de proteção. CONCLUSÃO: Os critérios clínicos adotados identificaram um grupo de risco para SRIS-CEC. Esse grupo tem como fatores predisponentes: menor peso e maior tempo de CEC. Pacientes com SRIS-CEC permanecem maior tempo em ventilação mecânica, internados em unidade de cuidados intensivos e em hospital.

Síndrome de resposta inflamatória sistêmica; cirurgia cardíaca; circulação extracorpórea

FUNDAMENTO: El postoperatorio de corrección de cardiopatías congénitas está acompañado frecuentemente por una respuesta inflamatoria sistémica. OBJETIVO: Evaluar la frecuencia y las manifestaciones clínicas del síndrome de respuesta inflamatoria sistémica tras la circulación extracorpórea (SRIS-CEC) en niños sometidos a una cirugía cardiaca. MÉTODOS: Cohorte histórica de pacientes con hasta 3 años de edad, sometidos a la corrección quirúrgica electiva de cardiopatías congénitas con utilización de circulación extracorpórea (CEC). Fueron analizados 101 pacientes mediante criterios clínicos de disfunción de órganos bajo forma de escore, comparando factores predisponentes y morbilidad agregada a la presencia de SRIS-CEC. RESULTADOS: Fueron identificados 22 pacientes (21,9%) que cumplieron los criterios establecidos para el SRIS-CEC. El sexo o tipo de cardiopatía no difirió entre los grupos (p =NS). Pacientes con SRIS-CEC (comparados a los pacientes sin SRIS-CEC) presentaban un menor promedio de edad (6,8 ± 5,5 vs 10,8 ± 5,1 meses, p < 0,05), menor peso (5,3 ± 1,9 vs 6,9 ± 2,0 kilogramos, p < 0,05), mayor tiempo de CEC (125,1 ± 49,5 vs 93,9 ± 33,1 minutos, p < 0,05). Se observó respectivamente mayor tiempo promedio de ventilación mecánica (120,0 vs 13,0 horas, p < 0,05), mayor tiempo de internación en unidad de cuidados intensivos (UCI) (265,0 vs 107,0 horas, p < 0,05) e internación hospitalaria (22,0 vs 10,0 días, p < 0,05). En el análisis multivariado, el mayor peso (OR = 0,68, p = 0,01) fue identificado como factor de protección. CONCLUSIÓN: Los criterios clínicos adoptados identificaron un grupo de riesgo para SRIS-CEC. Ese grupo tiene como factores predisponentes: menor peso y mayor tiempo de CEC. Pacientes con SRIS-CEC permanecen mayor tiempo en ventilación mecánica, internados en unidad de cuidados intensivos y en hospital.

Síndrome de respuesta inflamatoria sistémica; cirugía cardiaca; circulación extracorpórea

ORIGINAL ARTICLE

^IHospital Infantil Pequeno Príncipe, PR - Brazil

^IIUniversidade Federal do Paraná Curitiba, PR - Brazil

Mailing address

ABSTRACT

BACKGROUND: The postoperative period of congenital cardiomyopathies correction is frequently accompanied by systemic inflammatory response.

OBJECTIVES: To assess the frequency of occurrence and clinical manifestations of the systemic inflammatory response syndrome after cardiopulmonary bypass (SIRS-CPB) in children submitted to cardiac surgery.

METHODS: Historical cohort study including patients up to 3 years old that were submitted to elective corrective surgeries for congenital cardiopathies with cardiopulmonary bypass (CPB). A total of 101 patients were assessed by means of clinical criteria of organ dysfunction through score tests, as comparing predisponent factors and aggregated morbidity to the presence of SIRS-CPB.

RESULTS: Twenty-two patients (21.9%) fulfilled the criteria for SIRS-CPB. The sex or type of cardiopathy did not differ between groups (p = NS). Patients diagnosed with SIRS-CPB (compared to patients without SIRS-CPB) presented lower mean age (6.8 ± 5.5 versus 10.8 ± 5.1 months, p < 0.05), lower weight (5.3 ± 1.9 versus 6.9 ± 2.0 kg, p < 0.05), and longer CPB duration (125.1 ± 49.5 versus 93.9 ± 33.1 minutes, p < 0.05). Longer median duration of mechanical ventilation (120.0 versus 13.0 hours, p < 0.05), longer stay in Intensive Care Unit (ICU) (265.0 versus 107.0 hours, p < 0.05) and in hospital (22.0 versus 10.0 days, p < 0.05) were observed. In the multivariate analysis, higher weight (OR = 0.68, p = 0.01) was identified as a protection factor.

CONCLUSION: The adopted clinical criteria identified a risk group for SIRS-CPB, which presented lower weight and longer CPB duration as predisponent factors. Patients with SIRS-CPB remain in mechanical ventilation, in ICU and in hospitalization for a longer period of time.

Key-Words: Systemic inflammatory response syndrome; thoracic surgery; cardiopulmonary bypass.

Introduction

After the introduction of cardiopulmonary bypass (CPB) as a supportive tool in cardiac surgery, the benefits to patients with congenital and acquired cardiopathies increased, as it was possible to modify these diseases' natural course and significantly increase the survival rates¹.

CPB is a modality of controlled circulation that is crucial to the majority of corrective cardiac surgeries and may, together with the tissular injury due to surgical incision, trigger a series of inflammatory processes through cellular activation and liberation of inflammatory mediators^2-4. In this context, there is a stimulation of leukocytes, monocytes, macrophages, basophils, endothelial cells, myocytes and hepatocytes. There is an increase in the circulation of complement fractions (mainly C3a, C4a and C5a)^5,6, citokynes (mainly tumor necrosis factor-alpha, class 1, 6, 8 and 10 interleukins)^7-9, histamine¹⁰ and adhesion molecules^11.

The inflammatory cascade is then amplified and may be associated with clinical manifestations by fever occurrences^12,13, myocardial dysfunction (due to mechanical, ischemic and immunological injury)^14,15 and/or vasoplegy^16,17, with occurrence of hypotension; signs of low cardiac output with hyperperfusion and tissular hypoxia; acute renal insufficiency^18,19; acute pulmonary lesion²⁰, acute respiratory distress syndrome²¹; blood dyscrasia²², neurological symptoms^23,24 and liquid retention with weight gain down to endothelial lesion²⁵. When present, these manifestations may prolong the period of stay in ICU and in general hospital due to aggregated morbidity. In extreme cases, multiple organs failure syndrome or even rare and severe clinical status with syndromes similar to septic shock may be observed.

Diagnosis criteria for SIRS-CPB are still in need of a consensus, and studies are made based on isolated variables or non-uniform clinical criteria. The frequency of SIRS-CPB clinical manifestations varies from 22 to 27.5%, even though it has been evaluated by means of different methods^5,6.

The present study was developed with the objective of evaluating the occurrence of SIRS-CPB clinical manifestations in pediatric patients submitted to cardiac surgery with CPB for correction of congenital cardiopathies and of relating them to clinical outcomes. In order to do that, the study of clinical variables was proposed, for they could reflect the dysfunction of organs and subsystems in the precocious postoperative period or, in group, they could represent SIRS-CPB and become applicable to clinical recognition.

Methods

This is a historical cohort study carried out through analyses of the records of children submitted to surgical correction due to congenital cardiopathies and admitted in the intensive cardiac care unit at Hospital Infantil Pequeno Príncipe from January 1^st till December 31^st, 2003. The study was approved by the Humana Research Ethics Committee of Hospital das Clínicas, Universidade Federal do Paraná, and of Hospital Infantil Pequeno Príncipe.

Selected patients were up to 3 years old (141 individuals). The choice of younger children for the research is justified by the fact that SIRS-CPB occurs more frequently in children than in adults⁵.

Forty patients were excluded from the study according to the following criteria:

a) mechanical ventilation during more than 48 hours before surgery;

b) preoperative infection;

c) death during surgical intervention or in the first 48 hours after surgery;

d) precocious postoperative infection within the first five days;

e) record with incomplete data. The exclusion criteria were applied with the purpose of eliminating other known causes of deflagration of inflammatory process, specially prolonged mechanical ventilation and other infectious processes.

After the exclusion, defined by the abovementioned criteria, data from 101 patients were assessed.

In the whole sample, mean age was 9.9 ± 5.4 months, mean weight 6.6 ± 2.1 kg. The sex distribution was homogeneous, with 50% each.

The mean CPB duration was 100.7 ± 39.2 minutes and aortic clamping duration was 68.2 ± 27.6 minutes. Median time of stay in intensive care unit (ICU) was 133.0 hours (varying from 33 to 1,162 hours) and of general hospitalization was 12.0 days (varying from 0 to 756 hours).

Clinical criteria for SIRS-CPB

Clinical variables associated with SIRS-CPB were assessed in the first five days of the postoperative period, which corresponds to a period of intense inflammatory activity: (a) fever (if higher than or equal to 38 degrees Celsius); (b) hemodynamic dysfunction (inotropic score-²⁶); (c) pulmonary dysfunction (PaO₂/FiO₂ relation smaller than 300); (d) renal dysfunction (increase of more than 20% in creatinine); (e) clinical endothelial dysfunction and (f) radiologic endothelial dysfunction.

Endothelial dysfunction was evaluated in clinical and radiologic aspects. With regard to clinical aspect, the volume of liquid collected by drains that were set during surgical intervention was measured. Groups were considered as altered when drainage was above the third quartile in comparison to the whole sample. Concerning the radiologic aspect, interstitial thickness was measured by means of a radiologic index⁷ in the preoperative period and in two postoperative moments: admittance of the patient in ICU and after 48 hours of permanence. Increase of 50% in interstitial thickness was considered to be significant alteration (Figure 1).

According to the quantity of altered variables (with one attributed point each), it was possible to divide the sample into two groups. In Group I were gathered the patients who presented three or more points, considered as the presence of SIRS-CPB. Group II were composed by the patients who did not present SIRS-CPB and presented up to two points.

Assessment of predisponent factors

The association between type of cardiopathy (acyanotic or cynotic), age, weight, duration of CPB and of aortic occlusion was assessed.

Assessement of hospital outcome

Hospital outcome was analyzed through a comparison between groups with regard to duration of ventilation, duration of stay in intensive care unit, total period of time of hospitalization and death.

Statistical analysis

Variables are presented as proportions (when categorical), mean and standard deviation (when continuum and normally distributed) or mean and inter-quartile interval (when continuum and asymmetric).

The predisponent factors for SIRS-CPB were compared through Pearson's chi-square test (χ²) and Student's t-test. Additionally, relative risks with respective 95% confidence interval were calculated for categorical variables.

Logistic regression was made as considering SIRS-CPB a dependent variable.

With regard to outcomes among patients with and without SIRS-CPB, Pearson's χ² and Mann-Whitney tests were used.

Multiple linear models were also used for continuum outcomes, and Spearman's correlation was used for the assessment of SIRS-CPB by means of continuum score. The score was elaborated with the attribution of one point of the following altered criteria: fever, hemodynamic dysfunction, pulmonary dysfunction, renal dysfunction and endothelial dysfunction (clinical and radiologic). In this manner, the score varied from 0 to 6.

Results

Twenty-two (21,9%) patients who fulfilled the criteria indicative of SIRS-CPB were identified (Group I) during the first five days of the postoperative period.

From the whole sample, 12.9% of the patients presented fever. Hemodynamic dysfunction was present in 15.8%, pulmonary and renal dysfunction in 22.8%, interstitial edema in 28.7% and volume of drainage in 25.7% of the sample (Figure 2).

The presence of one isolated clinical factor (except for fever) was significantly associated with a higher frequency of identification of SIRS-CPB among these patients.

In face of the altered variable, the diagnosis for SIRS-CPB was significantly more frequent, while in the absence of alterations, the diagnosis became unprovable. When a hemodynamic dysfunction was characterized, SIRS-CPB was diagnosed in 81.3% of the patients. This diagnosis was present in 10.6% of the patients without hemodynamic dysfunction (Figure 3).

Assessment of predisponent factors

After the formation of groups based on clinical criteria, a similar frequency o SIRS-CPB was observed when the analysis was made according to sex or type of cardiopathy.

Patients of Group I had lower age (6.8 ± 5.5 versus 10.8 ± 5.1 months, p < 0.05), lower weight (5.3 ± 1.9 versus 6.9 ± 2.0 kg, p < 0.05), longer exposition to CPB (125.1 ± 49.5 versus 93.9 ± 33.1 minutes, p < 0.05) and aortic clamping (82.3 ± 34.0 versus 64.2 ± 24.3 minutes, p < 0.05), all occurrences that led to SIRS-CPB (Table 1).

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Even in a multivariate model, time of CPB and weight were still considered as significant predisponent factors for SIRS-CPB. The variables weight and age, as well as time of CPB and time of aortic occlusion, are connected and interfere with each other. Therefore, only weight and time of CPB were assessed in the multivariate model.

Assessment of clinical outcomes

Patients of Group I were submitted to mechanical ventilation during longer periods of time (mean 120.0 versus 13.0 hours, p < 0.05), stayed longer in the ICU (mean 265.0 versus 107.0 hours, p < 0.05) and in hospitalization (mean 22.0 versus 10.0 days, p < 0.05) (Table 2). The difference between groups concerning death occurrences (13.6 versus 2.5%, respectively) was not statistically significant (p = 0.068).

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Discussion

SIRS-CPB was present in 21.9% of the patients in a young population (up to 3 years old) submitted to elective cardiac surgery, and the majority of other predisponent preoperative causes that could provoke SIRS were excluded.

Seghaye et al⁶, in 1993, found an incidence of 27.5% of SIRS in a study with children in which the diagnostic criteria was adapted from SIRS manifestations in clinical patients. The use of SIRS criteria in this case has high sensibility, however, there is still a necessity of specificity for the vital signs, neurological and laboratorial data are strongly influenced by factors that are intrinsic to the procedure or to specific care given in the ICU during the postoperative period.

In the studied sample, isolated organ dysfunction occurred with frequently between in 15.8 to 28.7% of the patients. Kirklin et al⁵ studied adult and pediatric patients in 1983 and found recurrent organ failure associated with global morbidity in 22% of the sample. Cardiac (23%), pulmonary (35%), renal (21%) and haemostatic dysfunctions (18%) were present and related to high levels of C3a within three hours after the intervention as much as to age inferior to 1 year old.

With the exception of renal dysfunction, all other complications were associated with prolonged CPB.

The frequency of hemodynamic dysfunction in patients was of 16%. Among these patients, 81% presented SIRS-CPB, and such diagnosis occurred in only 11% of the patients without hemodynamic dysfunction. These facts may lead to the adoption of higher-influence criteria for the hemodynamic variable concerning the SIRS-CPB diagnosis.

Unlikely the shock in adults, the shock in children presents a singularity: in 80% of occurrences it is associated with myocardial dysfunction²⁷. Postoperatively, the low cardiac output syndrome is described in approximately 24% of newborns submitted to Jatene procedure and is characterized by myocardial dysfunction and decrease in cardiac output, both associated with an increase in peripheral vascular resistence²⁶.

CPB is followed by acute respiratory distress in a 0.4% frequency in the adult population with associated mortality²¹. During CPB, there is activation and migration of neutrophils to the pulmonary endothelium, which may initiate a local lesion by means of a phenomenon called pulmonary leukocyte sequestration⁵. This may explain the acute pulmonary lesion associated with surgery for cardiac correction with CPB. In the studied patients, a frequency of 22.8% for acute pulmonary lesion was observed, but not cases of acute respiratory distress syndrome. The acute pulmonary lesion accompanied by pulmonary dysfunction and decrease in PaO₂/FiO₂ relation may have been responsible for prolonged mechanical ventilation observed in patients diagnosed with SIRS-CPB.

The analysis of renal function after surgical procedure has been difficult with regard to the determination of frequency, for the different groups have different diagnostic criteria. In adults, Tuttle et al²⁸, in 2003, assessed a group of patients submitted to CPB with a renal failure criterion similar to the one herein stated (increase of 25% in creatinine) and observed a 42% incidence. In the present study, a 22.8% frequency was registered, which is an important criterion for SIRS-CPB score, because 81% of the patients with renal failure presented SIRS-CPB and only 7% of the group which had normal renal function were diagnosed with SIRS-CPB.

Through the radiologic index, it was shown that a high frequency of interstitial edema (28.7%) would identify, during the surgical procedure, the patients who would present liquid extravasations, besides intravascular space, in the immediate postoperative period. The inflammatory process after CPB has its final lesion characterized by an increase of diffuse capillary permeability with significant liquid extravasation towards the interstitial tissue^7-25. This finding could be partially explained by the presence of what is currently called endothelial dysfunction. In these case, the endothelium is the target for the inflammatory chain and, when it expresses adhesion molecules, it also adheres and activates leukocytes, causing lesion in this barrier and permits a free liquid flow from the intra-vascular space to the interstitial tissue^3,29. It is believed that this radiologic data may be explored in a prospective study, for it could represent a precocious diagnostic tool for SIRS-CPB in this group of patients.

Carriers of SIRS-CPB present independent lower age and weight, hence there is a protective factor when older patients are treated. The biggest surgical technique complexity in neonatal period, together with the biggest surface of relative exposition of CPB circuits, could explain the frequent occurrences of SIRS-CPB in children and its protective effect in young adults.

In this paper, mean CPB duration was significantly longer in Group I than Group II. The same result was observed with regard to time of aortic occlusion. Both groups presented Odds Ratio equal to 1.02. Kirklin et al⁵, in 1983, observed that CPB's increase from 60 to 120 minutes would also increase postoperative morbidity in all age groups.

The group with SIRS-CPB patients had a worse outcome concerning the time period of hospitalization. These patients are kept for longer periods in mechanical ventilation, which could be explained by two reasons. The first one would be that CPB may unleash a pulmonary injury comprised in the inflammatory chain, in which pulmonary leukocyte sequestration and endothelial injury happen⁵. The second reason may be directly related to the first one, for patients who are kept for longer periods of time in mechanical ventilation are exposed to a higher risk of pneumonia and direct pulmonary injury (barotrauma, volutrauma and injury by O₂)

Despite the fact that cases of infection in the immediate postoperative period were retrospectively rejected, dosages of serum procalcitonin could be useful for these patients as a means of excluding infections^30,31. These factors were minimized through a selection criterion, in which patients that underwent elective surgeries and that presented no preoperative factors that could unleash SIRS were chosen. Patients who presented clinical status compatible with infection and whose evolvement and hemoculture results confirmed these initial impression were not selected.

Recently, the hypothesis that the utilization of corticosteroids in the postoperative period would minimize the inflammatory process and that their reposition would diminish hemodynamic dysfunction, which is common in this period, have been considered, since adrenal failure is very common in severely sick patients^32,33.

The present study shows limitations in its final conclusions, for it deals with a retrospective analysis in which the clinical variables could not be controlled. There were no available quantitative data concerning measures of hemodynamic dysfunction, like invasive procedures of cardiac output, which could precisely define a situation of hemodynamic dysfunction.

Conclusions

Based on clinical criteria established for this retrospective study, it was possible to identify that patients with lower weight and prolonged CPB belong to a risk population for development of SIRS-CPB. These individuals remain for longer periods in mechanical ventilation, in intensive care units and in general hospital.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This article is part of the thesis of master submitted by Leonardo Cavadas da Costa Soares, from Universidade Federal do Paraná.

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