Fudulu Daniel P, Gibbison Ben, Upton Thomas, Stoica Serban C, Caputo Massimo, Lightman Stafford, Angelini Gianni D
Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom.
Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom.
Front Pediatr. 2018 Apr 20;6:112. doi: 10.3389/fped.2018.00112. eCollection 2018.
Corticosteroids have been administered prophylactically for more than 60 years in pediatric heart surgery, however, their use remains a matter of debate. There are three main indications for corticosteroid use in pediatric heart surgery with the use of cardiopulmonary bypass (CPB): (1) to blunt the systemic inflammatory response (SIRS) induced by the extracorporeal circuit; (2) to provide perioperative supplementation for presumed relative adrenal insufficiency; (3) for the presumed neuroprotective effect during deep hypothermic circulatory arrest operations. This review discusses the current evidence behind the use of corticosteroids in these three overlapping areas. We conducted a structured research of the literature using PubMed and MEDLINE databases to November 2017 and additional articles were identified by cross-referencing. The evidence suggests that there is no correlation between the effect of corticosteroids on inflammation and their effect on clinical outcome. Due to the limitations of the available evidence, it remains unclear if corticosteroids have an impact on early post-operative outcomes or if there are any long-term effects. There is a limited understanding of the hypothalamic-pituitary-adrenal axis function during cardiac surgery in children. The neuroprotective effect of corticosteroids during deep hypothermic circulatory arrest surgery is controversial. The utility of steroid administration for pediatric heart surgery with the use of CPB remains a matter of debate. The effect on early and late outcomes requires clarification with a large multicenter randomized trial. More research into the understanding of the adrenal response to surgery in children and the effect of corticosteroids on brain injury is warranted.
在小儿心脏手术中，预防性使用皮质类固醇已有60多年历史，然而，其使用仍存在争议。在小儿心脏手术中使用体外循环（CPB）时，使用皮质类固醇主要有三个指征：（1）减轻体外循环引起的全身炎症反应（SIRS）；（2）为推测的相对肾上腺功能不全提供围手术期补充；（3）在深低温停循环手术中发挥推测的神经保护作用。本综述讨论了在这三个重叠领域使用皮质类固醇背后的当前证据。我们使用PubMed和MEDLINE数据库对截至2017年11月的文献进行了结构化研究，并通过交叉引用确定了其他文章。证据表明，皮质类固醇对炎症的作用与其对临床结局的作用之间没有相关性。由于现有证据的局限性，尚不清楚皮质类固醇是否对术后早期结局有影响，以及是否有任何长期影响。对儿童心脏手术期间下丘脑-垂体-肾上腺轴功能的了解有限。皮质类固醇在深低温停循环手术中的神经保护作用存在争议。在小儿心脏手术中使用CPB时给予类固醇的效用仍存在争议。对早期和晚期结局的影响需要通过大型多中心随机试验加以阐明。有必要对儿童肾上腺对手术的反应以及皮质类固醇对脑损伤的影响进行更多研究。
