Department of Pediatric Critical Care, Lieutenant Commander, Medical Corps, United States Navy, Naval Medical Center Portsmouth, Portsmouth, VA.
Department of Pediatric Critical Care, Vanderbilt Children's Hospital, Nashville, TN.
Pediatr Crit Care Med. 2020 Jan;21(1):42-49. doi: 10.1097/PCC.0000000000002049.
Cardiopulmonary bypass-induced endothelial dysfunction has been inferred by changes in pulmonary vascular resistance, alterations in circulating biomarkers, and postoperative capillary leak. Endothelial-dependent vasomotor dysfunction of the systemic vasculature has never been quantified in this setting. The objective of the present study was to quantify acute effects of cardiopulmonary bypass on endothelial vasomotor control and attempt to correlate these effects with postoperative cytokines, tissue edema, and clinical outcomes in infants.
Single-center prospective observational cohort pilot study.
Pediatric cardiac ICU at a tertiary children's hospital.
Children less than 1 year old requiring cardiopulmonary bypass for repair of a congenital heart lesion.
None.
Laser Doppler perfusion monitoring was coupled with local iontophoresis of acetylcholine (endothelium-dependent vasodilator) or sodium nitroprusside (endothelium-independent vasodilator) to quantify endothelial-dependent vasomotor function in the cutaneous microcirculation. Measurements were obtained preoperatively, 2-4 hours, and 24 hours after separation from cardiopulmonary bypass. Fifteen patients completed all laser Doppler perfusion monitor (Perimed, Järfälla, Sweden) measurements. Comparing prebypass with 2-4 hours postbypass responses, there was a decrease in both peak perfusion (p = 0.0006) and area under the dose-response curve (p = 0.005) following acetylcholine, but no change in responses to sodium nitroprusside. Twenty-four hours after bypass responsiveness to acetylcholine improved, but typically remained depressed from baseline. Conserved endothelial function was associated with higher urine output during the first 48 postoperative hours (R = 0.43; p = 0.008).
Cutaneous endothelial dysfunction is present in infants immediately following cardiopulmonary bypass and recovers significantly in some patients within 24 hours postoperatively. Confirmation of an association between persistent endothelial-dependent vasomotor dysfunction and decreased urine output could have important clinical implications. Ongoing research will explore the pattern of endothelial-dependent vasomotor dysfunction after cardiopulmonary bypass and its relationship with biochemical markers of inflammation and clinical outcomes.
心肺旁路引起的内皮功能障碍可以通过肺血管阻力的变化、循环生物标志物的改变以及术后毛细血管渗漏来推断。全身血管内皮依赖性血管舒缩功能障碍在这种情况下从未被量化过。本研究的目的是量化心肺旁路对内皮血管舒缩控制的急性影响，并尝试将这些影响与婴儿的术后细胞因子、组织水肿和临床结果相关联。
单中心前瞻性观察队列初步研究。
一家三级儿童医院的儿科心脏 ICU。
需要心肺旁路修复先天性心脏病变的 1 岁以下儿童。
无。
激光多普勒灌注监测与乙酰胆碱（内皮依赖性血管扩张剂）或硝普钠（内皮非依赖性血管扩张剂）的局部离子电渗联合使用，以量化皮肤微循环中的内皮依赖性血管舒缩功能。测量在术前、心肺旁路分离后 2-4 小时和 24 小时进行。15 名患者完成了所有激光多普勒灌注监测（Perimed，Järfälla，瑞典）测量。与旁路前相比，旁路后 2-4 小时的反应，乙酰胆碱后峰值灌注（p = 0.0006）和剂量反应曲线下面积（p = 0.005）均降低，但硝普钠反应无变化。旁路后 24 小时，乙酰胆碱的反应性改善，但通常仍低于基线。内皮功能的一致性与术后前 48 小时内更高的尿量有关（R = 0.43；p = 0.008）。
婴儿在心肺旁路后立即出现皮肤内皮功能障碍，并且在一些患者中，24 小时内术后内皮依赖性血管舒缩功能显著恢复。内皮依赖性血管舒缩功能障碍持续存在与尿量减少之间的关联的确认可能具有重要的临床意义。正在进行的研究将探索心肺旁路后内皮依赖性血管舒缩功能障碍的模式及其与炎症的生化标志物和临床结果的关系。
