Postoperative Pulmonary Hemodynamics and Systemic Inflammatory Response in Pediatric Patients Undergoing Surgery for Congenital Heart Defects

There is scarce information about the relationships between postoperative pulmonary hemodynamics, inflammation, and outcomes in pediatric patients with congenital cardiac communications undergoing surgery. We prospectively studied 40 patients aged 11 (8–17) months (median with interquartile range) with a preoperative mean pulmonary arterial pressure of 48 (34–54) mmHg who were considered to be at risk for postoperative pulmonary hypertension. The immediate postoperative pulmonary/systemic mean arterial pressure ratio (PAP/SAPIPO, mean of first 4 values obtained in the intensive care unit, readings at 2-hour intervals) was correlated directly with PAP/SAP registered in the surgical room just after cardiopulmonary bypass ( r = 0.68 , p < 0.001 ). For the entire cohort, circulating levels of 15 inflammatory markers changed after surgery. Compared with patients with PAP / SA P IPO ≤ 0.40 ( n = 22 ), those above this level ( n = 18 ) had increased pre- and postoperative serum levels of granulocyte colony-stimulating factor ( p = 0.040 ), interleukin-1 receptor antagonist ( p = 0.020 ), interleukin-6 ( p = 0.003 ), and interleukin-21 ( p = 0.047 ) (panel for 36 human cytokines) and increased mean platelet volume ( p = 0.018 ). Using logistic regression analysis, a PAP / SA P IPO > 0.40 and a heightened immediate postoperative serum level of macrophage migration inhibitory factor (quartile analysis) were shown to be predictive of significant postoperative cardiopulmonary events (respective hazard ratios with 95% CIs, 5.07 (1.10–23.45), and 3.29 (1.38–7.88)). Thus, the early postoperative behavior of the pulmonary circulation and systemic inflammatory response are closely related and can be used to predict outcomes in this population.

Microcirculatory Response to Blood vs. Crystalloid Cardioplegia During Coronary Artery Bypass Grafting With Cardiopulmonary Bypass

Background: Blood cardioplegia attenuates cardiopulmonary bypass (CPB)-induced systemic inflammatory response in patients undergoing cardiac surgery, which may favorably influence the microvascular system in this cohort. The aim of this study was to investigate whether blood cardioplegia would offer advantages over crystalloid cardioplegia in the preservation of microcirculation in patients undergoing coronary artery bypass grafting (CABG) with CPB.Methods: In this prospective observational cohort study, 20 patients who received crystalloid (n = 10) or blood cardioplegia (n = 10) were analyzed. The microcirculatory measurements were obtained sublingually using incident dark-field imaging at five time points ranging from the induction of anesthesia (T0) to discontinuation of CPB (T5).Results: In the both crystalloid [crystalloid cardioplegia group (CCG)] and blood cardioplegia [blood cardioplegia group (BCG)] groups, perfused vessel density (PVD), total vessel density (TVD), and proportion of perfused vessels (PPV) were reduced after the beginning of CPB. The observed reduction in microcirculatory parameters during CPB was only restored in patients who received blood cardioplegia and increased to baseline levels as demonstrated by the percentage changes from T0 to T5 (%Δ)T0−T5 in all the functional microcirculatory parameters [%ΔTVDT0−T5(CCG): −10.86 ± 2.323 vs. %ΔTVDT0−T5(BCG): 0.0804 ± 1.107, p &lt; 0.001; %ΔPVDT0−T5(CCG): −12.91 ± 2.884 vs. %ΔPVDT0−T5(BCG): 1.528 ± 1.144, p &lt; 0.001; %ΔPPVT0−T5(CCG): −2.345 ± 1.049 vs. %ΔPPVT0−T5(BCG): 1.482 ± 0.576, p &lt; 0.01].Conclusion: Blood cardioplegia ameliorates CPB-induced microcirculatory alterations better than crystalloid cardioplegia in patients undergoing CABG, which may reflect attenuation of the systemic inflammatory response. Future investigations are needed to identify the underlying mechanisms of the beneficial effects of blood cardioplegia on microcirculation.

A Dynamic Approach for Early Risk Prediction of Gram-Negative Bloodstream Infection and Systemic Inflammatory Response Syndrome in Febrile Pediatric Hemato-Oncology Patients

The aim of this paper was to evaluate the usefulness of C-Reactive Protein (CRP), Procalcitonin (PCT) and Interleukine 6 (IL6) biomarkers in predicting the existence of Gram negative bloodstream infections (Gr-BSI) or the development of Systemic Inflammatory Response Syndrome (SIRS) during the first 24 hours of fever in pediatric cancer patients. The present study included a total of 103 consecutive fever episodes in 44 hemato-oncological pediatric patients, from whom samples for biomarkers CRP, PCT and IL6 were taken upon initial evaluation and then between 12 and 24 hours after.An IL6 value at the first evaluation (IL6-1) higher than 164 pg/ml and an increase in CRP higher than 291% between the first and subsequent samples (CRP-2vs1) showed a statistically significant OR of 26.03 and 19.62, respectively, in multivariate analysis.Conclusion: IL6-1 and CRP-2vs1 showed a strong, independent correlation with Gr-BSI and SIRS episodes and, therefore, could be used as reliable predictors of these kinds of severe episodes. The approach taken in our study, using biomarker variations over time as a variable, has shown itself to be an improvement in the predictive model.

Acute Heart Failure After Reperfused Ischemic Stroke: Association With Systemic and Cardiac Inflammatory Responses

Patients with acute ischemic stroke (AIS) present an increased incidence of systemic inflammatory response syndrome and release of Troponin T coinciding with cardiac dysfunction. The nature of the cardiocirculatory alterations remains obscure as models to investigate systemic interferences of the brain-heart-axis following AIS are sparse. Thus, this study aims to investigate acute cardiocirculatory dysfunction and myocardial injury in mice after reperfused AIS. Ischemic stroke was induced in mice by transient right-sided middle cerebral artery occlusion (tMCAO). Cardiac effects were investigated by electrocardiograms, 3D-echocardiography, magnetic resonance imaging (MRI), invasive conductance catheter measurements, histology, flow-cytometry, and determination of high-sensitive Troponin T (hsTnT). Systemic hemodynamics were recorded and catecholamines and inflammatory markers in circulating blood and myocardial tissue were determined by immuno-assay and flow-cytometry. Twenty-four hours following tMCAO hsTnT was elevated 4-fold compared to controls and predicted long-term survival. In parallel, systolic left ventricular dysfunction occurred with impaired global longitudinal strain, lower blood pressure, reduced stroke volume, and severe bradycardia leading to reduced cardiac output. This was accompanied by a systemic inflammatory response characterized by granulocytosis, lymphopenia, and increased levels of serum-amyloid P and interleukin-6. Within myocardial tissue, MRI relaxometry indicated expansion of extracellular space, most likely due to inflammatory edema and a reduced fluid volume. Accordingly, we found an increased abundance of granulocytes, apoptotic cells, and upregulation of pro-inflammatory cytokines within myocardial tissue following tMCAO. Therefore, reperfused ischemic stroke leads to specific cardiocirculatory alterations that are characterized by acute heart failure with reduced stroke volume, bradycardia, and changes in cardiac tissue and accompanied by systemic and local inflammatory responses.

REVOLUTION (Routine EValuatiOn of people LivIng with caNcer)—Protocol for a prospective characterisation study of patients with incurable cancer

Introduction There is a pressing need for a holistic characterisation of people with incurable cancer. In this group, where quality of life and improvement of symptoms are therapeutic priorities, the physical and biochemical manifestations of cancer are often studied separately, giving an incomplete picture. In order to improve care, spur therapeutic innovation, provide meaningful endpoints for trials and set priorities for future research, work must be done to explore how the tumour influences the clinical phenotype. Characterisation of the host-tumour interaction may also provide information regarding prognosis, allowing appropriate planning of investigations, treatment and referral to palliative medicine services. Methods Routine EValuatiOn of people LivIng with caNcer (REVOLUTION) is a prospective observational study that aims to characterise people with incurable cancer around five key areas, namely body composition, physical activity, systemic inflammatory response, symptoms, and quality of life by developing a bio-repository. Participants will initially be recruited from a single centre in the UK and will have assessments of body composition (bio-impedance analysis [BIA] and computed tomography [CT]), assessment of physical activity using a physical activity monitor, measurement of simple markers of inflammation and plasma cytokine proteins and three symptom and quality of life questionnaires. Discussion This study aims to create a comprehensive biochemical and clinical characterisation of people with incurable cancer. Data in this study can be used to give a better understanding of the ‘symptom phenotype’ and quality of life determinants, development of a profile of the systemic inflammatory response and a detailed characterisation of body composition.

Evolving Definition and Diagnostic Criteria of Sepsis

For many years, the Systemic Inflammatory Response Syndrome (SIRS) criteria were primarily considered for the diagnosis of sepsis, promoting the importance of inflammation. The definition and dia gnostic criteria of sepsis has undergone a sizeable metamorphosis from the inception of standardized definitions of sepsis in 1991. In 1991, the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) convened in Chicago and emphasized that sepsis is an ‘ongoing process’ of infection and considered SIRS score of two or more for diagnosis of sepsis. SOFA scoring system is an easily calculated system using parameters that are usually obtained during routine care of patients. This ensures that delays are avoided from requirement of any special investigations, making it reproducible in any number of healthcare settings.