The effect on intermediary metabolism of open-heart surgery with deep hypothermia and circulatory arrest in infants of less than 10 kilograms body weight. A preliminary study

Abstract

The effects of hypothermic open-heart surgery with circulatory arrest upon intermediary metabolism and endocrine function in small children are still poorly understood. This report presents data obtained in a preliminary study in which seven children of <10 Kg body weight were investigated during and after such procedures. Frequent blood samples were taken from one day preoperatively to seven days postoperatively for estimation of hormone concentrations (insulin, growth hormone, glucagon, cortisol), and intermediary metabolites (glucose, lactate, pyruvate, alanine, glycerol, and 3- hydroxybutyrate).

Marked hyperglycaemia (34·8 ±3·3 mmol/L) was observed during cardiopulmonary bypass probably as a result of the glucose content of the pump prime. Moderate hyperglycaemia persisted for at least seven days postoperatively. A significant increase in lactate concentrations (p < 0·02) was observed during circulatory arrest and peak concentrations of 6·77 +0.87 mmol/L were measured at the end of the operation. Very high blood lactate concentrations were observed at the end of cardiopulmonary bypass in two patients who subsequently died. Peak insulin concentrations (20·7 ± 5·2 mU/L) were lower than those (30-40 mU/L) reported in adults undergoing similar procedures. Glucagon concentrations were significantly elevated during bypass (p<0·05) to approximately twice the levels reported in adults. Unlike the other hormones, growth hormone concentrations revealed remarkably uniform change, similar to those reported in 'high responding' adults with peak values of 124 ± 26 mU/L, observed during cardiopulmonary bypass. Cortisol concentrations showed no significant changes throughout the study.

Thus, the response of small infants to these procedures differed both qualitatively and quantitatively from that reported in adults. The results suggest that the nature of the prime fluid may be of major importance in the metabolic consequences of such surgery and that glucose and lactate may be better avoided in the pump prime.

Get full access to this article

View all access options for this article.

References

Stark J , de Leval M eds. Surgery for congenital heart defects. London, New York; Grune and Stratton, 1983.

Cuthbertson DP Second annual Jonathan E Rhoades lecture. The metabolic response to injury and its nutritional implications: retrospective and prospect. J Parent Ent Nutr 1979; 3: 1081-1129.

Yokota H. , Kawashima Y. , Takao T. , Hashimoto S. , Manabe H. Carbohydrate and lipid metabolism in open heart surgery. J Thorac Cardiovasc Surg 1977; 73: 5435-49.

Elliott MJ Aspects of the metabolic response to open-heart surgery. MD thesis , University of Newcastle upon Tyne, 1983.

Soeldner JS , Slone D. Critical variables in the radioimmunoassay of serum insulin using the double antibody technic. Diabetes 1965 ; 14: 771-79.

Seth S. , Brown LM A simple radioimmunoassay for plasma cortisol. Clin Chem Acta 1978; 86: 109-20.

Ørskov H. , Thomsen HG , Yde H. Wick-chromatography for rapid and reliable immunoassay of insulin, glucagon and growth hormone. Nature 1968; 219: 193.

Lloyd B. , Burrin J. , Smythe P, Alberti KGMM. Simple automated fluorimetric assays for blood glucose, lactate, pyruvate, alanine, glycerol and 3-hydroxybutyrate. Clin Chem 1978; 24: 1724-29.

Benzing G. , Francis PD , Kaplan S. , Helmsworth JA , Sperling JA Glucose and insulin changes in infants and children undergoing hypothermic open heart surgery. Am J Cardiol 1983; 52: 133-36.

10.

Baum D. , Dillard DH , Mohri H. , Crawford EW Metabolic aspects of deep surgical hypothermia in infancy. Pediatrics 1968; 42: 93-105.

11.

Baum D. , Dillard DH , Porter D.

Inhibition of insulin release in infants undergoing deep hypothermic cardiovascular surgery. New England

J Med 1968; 279: 1309-14.

12.

Rittenhouse EA , Mohri H. , Mevendino KA Studies of carbohydrate metabolism and serum electrolytes during surface induced hypothermia with prolonged circulatory occlusion. Surgery 1970 ; 67: 995-1005.

13.

Baum D. , Gale CC , Dillard DH , Porter D. Plasma growth hormone in the infant undergoing deep hypothermic cardiovascular surgery. Proc Soc Exp Biol Med 1968; 128: 70-75.

14.

Bickford AF , Mottram RF Glucose metabolism during induced hypothermia in rabbits. Clin Sci 1960; 19: 345-59.

15.

Blackard WG , Nelson NC , Labat JA Insulin secretion in hypothermic dogs. Am J Physiol 1967; 212: 1185-87.

16.

Fuhrman GJ , Fuhrman FA Utilization of glucose by the hypothermic rat. Am J Physiol 1963; 205: 181-83.

17.

Wood M. , Shand DG , Wood AJ The sympathetic response to profound hypothermia and circulatory arrest in infants. Can Anaesth Soc J 1980; 27: 125-31.

18.

Elliott MJ , Alberti KGMMA. Carbohydrate metabolism: effect of preoperative starvation and trauma. Clin Anaesth 1983; 1: 527-30.

19.

McKnight CK , Elliott MJ , Holden MP , Pearson DT, Alberti KGMM. Continuous monitoring of blood glucose in open-heart surgery. Br J Anaesth 1985; 57: 595-601.

20.

Friedenberg GR , Kosuik EJ , Sotos JF Hyperglycemic coma after suprasellar surgery . N Engl J Med 1980; 303: 863-65.

21.

Seelye ER , Harris EA , Squire AW , Barratt-Boyes BH Metabolic effects of deep hypothermia and circulatory arrest in infants during cardiac surgery. Br J Anaesth 1971; 43: 449-58.

22.

Carpentier YA , Nordenstrom J. , Robin A. , Kinney JM Glycerol turnover and kinetics of exogenous fat in surgical patients. In: Wright PD and Elliott MJ eds Symposia 2nd European Congress on Parenteral and Enteral Nutrition. Acta Chir Scand 1981; Suppl 507: 226-37.

23.

McDonald RG , Buckler Jmh , Deverall PB , Watson DA , Ballant M. Growth hormone and blood glucose concentrations during cardiopulmonary bypass. Br J Anaesth 1975; 47: 713-17.

24.

Uozumi T. , Manabe H. , Kawashima Y. , Hamanaka Y. , Monden Y. , Matesumoto K. Plasma cortisol, corticosterone and non-protein-bound cortisol in extracorporeal circulation. Acta Endocrinol 1972; 69: 517-25.

25.

Yokota H. , Kawashima Y. , Hashimoto S. et al. Plasma cortisol, luteinizing hormone (LH) and prolactin secretory responses to cardiopulmonary bypass. J Surg Res 1977; 23: 196-200.

26.

Taylor KM , Jones JV , Walker MS , Rao S. , Bain WH The cortisol response during cardiac surgery. Circulation 1976; 54: 20-25.

27.

Zilva JF , Pannall PR Clinical chemistry in diagnosis and treatment. London: Lloyd Luke, 1971.

28.

Wells FC , Coghill S. , Caplan HL , Lincoln C. Duration of circulatory arrest does influence the psychological development of children after cardiac operation in early life. J Thorac Cardiovasc Surg 1983; 86: 823-31.

29.

McKnight CK , Elliott MJ , Pearson DT , Holden MP, Alberti KGMM. The effects of four different crystalloid bypass pump-priming fluids upon the metabolic response to open-heart surgery . J Thorac Cardiovasc Surg 1985; 90: 97-111.

30.

Teramoto T. , Fukukei I. , Okamura E. et al. Changes of serum gastrin, amylase, insulin and glucagon during and after open heart surgery with cardiopulmonary bypass. J Jap Ass Thor Surg 1980; 28: 23-29.

31.

Kobayashi M. , Irisawa T. , Nakamura C. et al. The study of glucose metabolism, pancreatic exocrine and endocrine in cardiopulmonary bypass . J Jap Ass Thor Surg 1980; 28: 1085-89.

32.

Baca I. , Bieger W. , Mittman V. et al. Comparative studies on pulsatile and continuous flow during extracorporeal circulation. Chirurgishes Forum fur Experimentalle und Klinische Forshung 1979; 49: 43.