The Role of Prophylactic Postoperative Steroids in Pediatric Cardiac Operations.
The Role of Prophylactic Postoperative Steroids in Pediatric Cardiac Operations.
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预防性术后类固醇在小儿心脏手术中的作用。
DOI：
10.1097/pcc.0000000000000465
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发表时间：
2015
期刊：
影响因子：
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通讯作者：
Graham,EricM
中科院分区：
文献类型：
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作者：
Graham,EricM
众所周知，体外循环(CPB)会引发炎症级联反应，从而导致术后并发症的发生。因此，经验性地使用类固醇作为预防性抗炎治疗已成为儿科心脏手术的一种常见做法。大多数研究类固醇和儿科心脏手术的早期工作都围绕着术前和/或麻醉诱导时或CPB期间的类固醇应用展开。在21世纪初，几个不同类型、剂量和手术前激素时机的小儿科随机对照试验显示，尽管血液动力学变量或临床结果有不同程度的改善，但炎症标志物的减少。最近，文献已经让位于更大的试验(3，4)、荟萃分析(5)和大型观察性研究(6，7)，这些研究表明预防性类固醇没有好处，可能与发病率增加有关，特别是在手术风险较低的人群中。因此，先发制人的术前和术中类固醇激素在儿科心脏手术中的应用仍然备受争议。相比之下，很少有文献探讨类固醇在术后期间的风险和益处。在大多数这些研究中，类固醇被选择性地应用于患有儿茶酚胺抵抗低血压的外科(有时是非手术)患者(9-11)。这些研究表明，与选择性应用类固醇前相比，血流动力学有所改善，肌力需求减少。尽管令人鼓舞，但研究的局限性阻碍了它们的推广。在本期《儿科重症监护医学》杂志上，Robert等人(12人)对接受体外循环心脏手术的婴儿进行了术后氢化可的松与安慰剂的双盲随机对照试验，以确定预防性氢化可的松是否可以降低低心输出量综合征(LCOS)的发生率。研究的主要结果是，与安慰剂相比，预防性连续5天输注氢化可的松降低了LCOS的发生率，改善了液体平衡和尿量，并减轻了炎症。这项研究的优势包括一个经过深思熟虑的实验设计，并得到了很好的执行。此外，这是当代最大的评价儿童心脏手术术后类固醇的随机对照试验。事实上，只有另外两个儿科随机对照试验专门检查术后类固醇(13，14)。40年前，托莱多-佩雷拉等人(13人)对95名接受体外循环的儿童进行了一项双盲随机对照试验。患者被随机分为6个剂量的甲基强的松龙(30 mg/kg/剂量)或安慰剂，从术前1小时开始到术后24小时每6小时持续一次。与目前的研究相反，他们发现两组之间在测量的任何血流动力学变量上没有差异。然而，作者确实观察到类固醇组的住院存活率有所改善，他们发现很难解释这一点，因为两组之间没有其他差异。最近，Ando等人(14)随机选择了20名接受双侧脑室修补术的新生儿，术后7天持续输注氢化可的松或安慰剂，以确定体外循环后是否存在肾上腺功能不全。因此，它不是用来检测临床结果的，但与目前的研究类似，他们发现类固醇治疗与改善液体平衡和尿量有关，但与其他重要的临床结果无关。与这些发现一致的是，最近的一项荟萃分析(15…
Cardiopulmonary bypass (CPB) is known to incite an inflammatory cascade that is believed to contribute to postoperative morbidity. As a result, the empiric use of steroids as prophylactic anti-inflammatory therapy has become a common practice in pediatric cardiac surgery. Most of the early work investigating steroids and pediatric cardiac surgery revolved around steroid administration preoperatively and/or at the induction of anesthesia or in the CPB prime. In the early 2000s, several small pediatric randomized controlled trials of varying type, dose, and timing of preoperative steroids demonstrated a reduction in inflammatory markers albeit with variable improvement in hemodynamic variables or clinical outcomes (1, 2). More recently, the literature has given way to larger trials (3, 4), meta-analysis (5), and large observational studies (6, 7) that suggest no benefit with prophylactic steroids and possibly an association with increased morbidity particularly in lower surgical risk groups. As such, the utility of preemptive preoperative and intraoperative steroids in pediatric cardiac operations remains highly debated (8). By contrast, there is a paucity of literature that has explored the risks and benefits of steroids in the postoperative period. In the majority of these studies, steroids were administered selectively to surgical (and sometimes nonsurgical) patients with catecholamine-resistant hypotension (9–11). These studies suggest an improvement in hemodynamics and a reduction in inotropic requirements when compared with the time preceding selective steroid administration. Although encouraging, study limitations hinder their generalizability. In this issue of Pediatric Critical Care Medicine, Robert et al (12) performed a double-blind randomized controlled trial of postoperative hydrocortisone versus placebo in infants undergoing cardiac operations with CPB to determine if prophylactic hydrocortisone could decrease the prevalence of low cardiac output syndrome (LCOS). The main findings of the study are that a prophylactic continuous 5-day infusion of hydrocortisone reduced the prevalence of LCOS, improved fluid balance and urine output, and attenuates inflammation after CPB compared with placebo. The strengths of this study include an experimental design that was thoughtfully conceived and was well executed. In addition, it is the largest contemporary randomized controlled trial to evaluate postoperative steroids in pediatric cardiac surgery. In fact, there are only two other pediatric randomized controlled trials specifically examining postoperative steroids (13, 14). Four decades ago, Toledo-Pereyra et al (13) performed a double-blind randomized controlled trial of 95 children undergoing CPB. Patients were randomized to six doses of methylprednisolone (30 mg/kg/dose) or placebo beginning 1 hour preoperatively and continuing every 6 hours for 24 hours postoperatively. In contrast to the current study, they found no difference between groups in any hemodynamic variables measured. The authors did, however, observe an improved hospital survival in the steroid group that they found difficult to explain given no other differences between groups. More recently, Ando et al (14) randomized 20 neonates undergoing biventricular repair to a postoperative 7-day continuous hydrocortisone infusion or placebo to determine if adrenal insufficiency exists after CPB. As such, it was not powered to detect clinical outcomes, but similar to the current study they found that steroid treatment was associated with an improved fluid balance and urine output but was not associated with other important clinical outcomes. Consistent with these findings, a recent meta-analysis (15 …