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BACKGROUND: Delayed sternal closure is used to prevent low cardiac output syndrome in selected newborns shortly after cardiac surgery for congenital cardiac defects. Sternal closure itself often causes haemodynamic and ventilatory instability that cannot be entirely assessed by standard monitoring means. Therefore, we used transpulmonary thermodilution technique for an exact evaluation of the haemodynamic changes. PATIENTS AND METHODS: Between April, 2006, and December, 2008, 23 neonates aged from 1 to 30 days, with a median of 7 days, and weighing from 1.9 to 4.2 kilograms, with a median of 3.25 kilograms, were studied after biventricular corrections. Residual intracardiac shunts were excluded by echocardiography. Haemodynamic and ventilatory parameters, along with those obtained by the transpulmonary thermodilution technique, were recorded before and immediately after the sternal closure, and then at 0.5, 1, 2, 6, 12, 24, and 48 hours. RESULTS: Chest closure caused significant decrease in systolic arterial pressure from 80.04 +/- 11.48 to 69.48 +/- 9.63 mmHg (p < 0.001), cardiac index from [median (25th/75th centile)] 2.640 (2.355/2.950) to 2.070 (1.860/2.420) l/min/m2 (p < 0.001), stroke volume index from 18.50 (16.00/20.00) to 14.00 (11.00/17.00) ml/m2 (p < 0.001), and dynamic lung compliance from 2.45 (2.31/3.00) to 2.30 (2.14/2.77) ml/cmH2O (p = 0.007). Stroke volume variation increased from 14.00 (9.25/16.75) to 18.00 (15.00/21.00) % (p < 0.001). The oxygenation index transitorily increased from 2.50 (2.14/3.15) to 3.36 (2.63/4.29) (p < 0.001). Serum lactate decreased from 1.40 (1.12/2.27) to 1.0 (0.8/1.3)mmol/l, p < 0.001 in coincidence with a haemodynamic stabilisation at a later time after chest closure. Cardiopulmonary instability caused by the sternal closure necessitated therapeutic intervention in 18 of 23 patients (78.3%). CONCLUSION: Delayed sternal closure causes a significant transitory decrease in stroke volume, cardiac output and arterial blood pressure. Also lung compliance and blood oxygenation are temporarily significantly compromised.

Výzkumná zpráva

Vliv sekundárního uzávěru hrudníku na hemodynamiku novorozenců po operaci komplexní vrozené srdeční vady

Vojtovič, Pavel
Autor Autorita
Chaloupecký, Václav, 1950-
Autor Autorita
Hostaša, Jiří
Autor Autorita
Matějka, Tomáš
Autor Autorita
Gebauer, Roman
Autor Autorita
Reich, Oleg, 1954-
Autor Autorita
Gabriel, Otakar
Autor Autorita
Fakultní nemocnice v Motole (Praha, Česko)
Autor Autorita

Praha : Iga MZ ČR, 2009

Závěrečná zpráva o řešení grantu Interní grantové agentury MZ ČR

Přeruš. str. : tab., il. ; 30 cm

Odložený uzávěr sternotomické rány po kardiochirurgické operaci u novorozenců vrozenou srdeční vadou je metodou, která umožní překlenutí kritického hemodynamického stavu bezprostředně po operačním zákroku a nebo v časném pooperačním období. Spolehlivá, pohotová a kontinuální monitorace hemodynamického stavu pacienta je důležitá pro snížení rizika oběhového zhroucení při definitivním (sekundárním) uzávěru hrudníku. Kontinuální invazivní monitorace hemodynamiky metodou PiCCO by umožnila okamžitě reagovatna změny způsobené uzávěrem hrudníku a předcházet kritickým situacím, které mohou v důsledku změněné hemodynamiky či ventilace nastat. Metoda PiCCO (pulse contour cardiac output)- méně invazivní kontinuální hemodynamické monitorování, je metoda plně srovnatelná a méně riziková oproti termodiluční technice, s možností bezpečné aplikace i v nejnižších věkových kategoriích.; The delayed sternal closure of the sternotomic wound after the cardiosurgery operation in newborns with congenital heart defect is a method allowing to get over the critical hemodynamic condition after the operation or in the postoperative period. Reliable, fast and continuous hemodynamic monitoring is an important subject to decrease the risk of circulatory and ventilatory failure during and after secondary sternal closure. Continuous invasive monitoring of the hemodynamics by a PiCCO method would allow an immediate therapeutic intervention to changes caused by chest closure and would percede critical situations caused by changed hemodynamic or ventilation. The PiCCO method (pulse contour cardiac output)-less invasive continuous hemodynamic monitoringis comparable and less risky method against the termodilution technique, with safety application in youngest patients.