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The Comparison of Clinical Study of Off Pump and On Pump CABG (On Pump-CABG와 Off Pump-CABG의 임상적 고찰에 관한 비교연구)

  • 유경종;임상현;송석원;김치영;홍유선;장병철
    • Journal of Chest Surgery
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    • v.35 no.4
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    • pp.261-266
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    • 2002
  • In an attempt to avoid the adverse effects of the cardiopulmonary bypass, off pump coronary artery bypass grafting(Off pump CABG) that has recently been rediscovered and refined. We compared the preoperative risk factors and in-hospital outcomes of patients done Off pump with those done On pump CABG. Material na Method: One hundred seventy eight patients was underwent CABG between January 2001 and July 2001 12 patients whom underwent associated valvular or left ventricular volume reduction surgery were excluded in this study Data were collected for 52 Off pump CABG and 114 On pump CABG for patient and disease risk factors, extent of coronary disease, and in-hospital outcomes. Result: Off pump CABG and On pump CABG groups did not show any differences in their patient and disease risk factors, and extent of coronary disease. Off pump CABG group had significantly lower mean operation time(234 $\pm$ 37 min vs 290 $\pm$ 48 min, p<0.001), lower mean CK-MB level(10.1 $\pm$ 13.5 IU/L vs 33.1 $\pm$ 18.2 IU/L, p<0.001) and mean ventilation time(14.8 $\pm$ 3.5 hours vs 16.2 $\pm$ 4.9 hours, p=0.048) than On pump CABG groups. On pump CABG group had significantly more distal grafts(3.4 $\pm$ 0.9 vs 2.6 $\pm$ 0.8, p<0.001) than Off pump CABG groups. There were no operative mortality in two groups. Off pump) CABG and On pump CABG groups did not show any differences in their postoperative complications and outcomes including perioperative myocardial infarction, stroke, respiratory failure, renal failure, reoperation, the amount of bleeding, the need of intraaortic balloon pump, the need of inotropics, and the stay of intensive care unit and hospital. Two patients were converted to On pump CABG. Conclusion: This study showed that patients having Off pump CABG are not exposed to a greater risks of adverse outcomes and also provided evidence that patients having Off pump CABG have significantly lower operation time, CK-MB, ventilation time and less distal grafts. Although there may be potential benefits to Off pump CABG, further studies must be directed to determine those patients who would benefit from Off pump CABG.

Mid- and Long Term Outcome of Fontan Procedure: Extracardiac Conduit Fontan versus Lateral Tunnel Fontan (폰탄 술식의 중장기 성적: 심장외 도관 술식과 가측터널 술식의 비교)

  • Kwak, Jae-Gun;Kim, Dong-Jung;Kim, Yong-Jin
    • Journal of Chest Surgery
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    • v.40 no.12
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    • pp.805-810
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    • 2007
  • Background: This paper reviews our experience retrospectively to examine the clinical results and effectiveness of lateral tunnel (LT) and extracardiac conduit (ECC) Fontan procedures at a single institution. Material and Method: One hundred and sixty five Fontan procedures were performed (67 LT and 98 ECC) between January 1996 and December 2006. Preoperative and postoperative hemodynamic values, arrhythmia, hospital and intensive care unit stay, chest tube drain, morbidity and mortality were reviewed. Result: The overall operative mortality in the LT and ECC groups was 4.5% (3) and 2.0% (2), respectively. There was a significant difference in the immediate postoperative transpulmonary gradient (LT $8.5{\pm}2.5$ vs ECC $6.6{\pm}2.4$, p-value<0.001) and central venous pressure (LT $18.3{\pm}3.8$ vs ECC $15.6{\pm}2.4$, p-value=0.001) between the two groups. The mean follow-up in the LT and ECC groups was $74.1{\pm}31.5$ and $38.1{\pm}29.1$ months, respectively. There was one late death. The actuarial survival at 10 years in the LT and ECC groups was 92% and 89%, respectively. In arrhythmia, the ECC patients showed a slightly low incidence but the difference was not statistically significant. Conclusion: Both the LT and ECC Fontan procedures showed comparable early and mid-term outcomes in terms of the surgical morbidity and mortality, postoperative hemodynamics, and mid-term survival. The ECC Fontan procedure reduces the risk of arrhythmia in the follow up period.

Surgical Closure of the Patent Ductus Arteriosus in Premature Infants by Axillary Minithoracotomy (액와 소개흉술에 의한 미숙아 동맥관 개존증의 외과적 치료)

  • Cho, Jung-Soo;Yoon, Yong-Han;Kim, Joung-Taek;Kim, Kwang-Ho;Hong, Yung-Jin;Jun, Yong-Hoon;Shinn, Helen Ki;Baek, Wan-Ki
    • Journal of Chest Surgery
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    • v.40 no.12
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    • pp.837-842
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    • 2007
  • Background: Closure of the ductus arteriosus is often delayed in premature infants, which creates a hemodynamically significant left to right shunt that exerts an adverse effect on the normal development and growth of these babies. We reviewed out experience on surgical closure of patent ductus arteriosus via axillary minithoracotomy in premature infants. Material and Method: From April 2002 to October 2006, 20 premature infants whose gestation was under 37 weeks underwent surgical closure of patent ductus arteriosus as a result of complications or contra-indications for the use of indomethacin. Their mean gestational age was 28.8+3.4 weeks, ranging from 25+3 to 34+6 weeks, and the average age at operation was $15.6{\pm}6.3$ days. The mean body weight at operation was $1,174{\pm}416\;g$, ranging from 680 to 2,100g; 16 infants were under 1,500 and 9 infants were under 1,000 g. The procedures were performed in the newborn intensive care unit via $2{\sim}3\;cm$ long axillary minithoracotomy with the infant in the lateral position with left arm abduction. The mean size of the patent ductus arteriosus was $3.8{\pm}0.3\;mm$. For the most part, the ductus was closed with clips; 2 infants in whom the ductus was ruptured while dissection was being performed underwent ductal division. Result: Ten of twelve infants who had been ventilator dependent preoperatively could be successfully weaned from the ventilator at a mean duration of 9.7 days after the operation. There was no procedure-related complication or death. Two infants eventually died of the conditions not related to the operation; one from sepsis at postoperative 131 days and the other from pneumonia at postoperative 41 days, respectively. Conclusion: Surgical closure of the patent ductus arteriosus improved the hemodynamic instability and so promoted the successful growth and normal development of premature infants. Considering the low surgical risk along with the reduced invasiveness, early and aggressive surgical intervention is highly recommended.

End Point Temperature of Rewarming and Afterdrop After Hypothermic Cardiopulmonary Bypass in Pediatric Patients (소아에서의 저체온 심폐바이패스후 재가온 종료온도와 후하강)

  • Kim, Won-Gon;Lee, Hae-Won;Lim, Cheong
    • Journal of Chest Surgery
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    • v.30 no.2
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    • pp.125-130
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    • 1997
  • Separating the patient from hypothermic cardiopulmonary bypass(CPB) before achieving adequate rewarming often results in afterdrop, which can predispose to electrolyte disturbances, arrhythmia, hemodynamic alterations, and shivering-induced increase of oxygen consumption. In an attempt to find an adequate end point temperature of rewarming after hypothermic CPB, 50 pediatric cardiac surgical patients were r ndomly assigned for end point temperature of rewarming of 35.5$^{\circ}C$ (Group 1) or 37t (Group 2), rectal temperature. Thereafter the rectal temperature was measured half, one, four, eight, and 16 hour after arrival to the intensive care unit(ICU), with heart rate and blood pressure. Additionally the rectal temperature was compared with esophageal temperature during CPB, and axillary temperature luring stay in the ICU. Nonpulsatile perfusion with a roller pump was used in all patients and a membrane or bubble oxygenator was used for oxygenation. Both groups were comparable with respect to age, sex, body surface area, total bypass time, and rewarming time. There was no afterdrop in both groups, and there were no statistical differences in the rectal temperatures between two groups. There were also no statistical dilyerences with respect to the heart rate and blood pressure between two groups. At the end of rewarming the esophageal temperature was higher than the rectal temperature. The axil ary temperature measured in ICU was always lower than the rectal temperature. No shivering was noted in all patients. In conclusion, with restoration of rectal temperature above 35.5$^{\circ}C$ at the end of CPB in pediatric patients, we did not observe an afterdrop.

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Clinical characteristics and risk factors for staphylococcal infections in neonatal intensive care unit (신생아 중환자실에서 포도알균 감염에 대한 임상적 고찰과 위험 요인 조사)

  • Chung, Min Kook;Choi, Jeong Ho;Chang, Jin Keun;Chung, Sung Hoon;Bae, Chong Woo;Cha, Sung Ho
    • Clinical and Experimental Pediatrics
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    • v.49 no.12
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    • pp.1287-1295
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    • 2006
  • Purpose : The importance of staphylococcal infections in NICU has been emphasized in terms of increased resistant strains and increased incidence of morbidity and mortality. In this study, we inrestignted the clinical characteristics and risk factors for staphylococcal infections, and looked into sensitivity trends of antibiotics in the era of a high rate of methicillin-resistant staphylococcus aureus (MRSA) in our society. Methods : This study included 240 neonates with positive blood, urine and other sites cultures for staphylococci who were admitted to NICU of Hanil General Hospital and Kyunghee University Hospital from January 2000 to December 2004. The analyses included clinical characteristics of staphylococcal infections and the relationship of incidence rate among various factors, including invasive procedures. Results : For 5 years, 3,593 patients were hospitalized in the NICU and 7,481 specimens were cultured from blood, urine, and other sites. During the study period, staphylococci were isolated from 240 patients, of whom 88 patients had MRSA, 41 patients methcillin sensitive staphylococcus aureus (MSSA), 63 patients S. epidermidis, 48 patients coagulase-negative staphylococcus (CNS) except S. epidermidis infections. The risk factors associated with staphylococcal infections were less than 37 weeks of gestational age, less than 7 on a 5 minutes Apgar score, receiving TPN, applied mechanical ventilation, use of central venous catheters and other tubes. The sensitivity to vancomycin was 100 percent. A relatively high sensitivity against teicoplanin, trimethoprim-sulfamethoxazole, chloramphenicol, clindamycin and low sensitivity against gentamicin and erythromycin were shown. Conclusion : To reduce staphylococcal infections in NICU, we need to monitor and manage premature neonates from the beginning of the birth process and to avoid as many invasive procedures as possible in NICU. Considering MRSA, control of preceding factors and early use of appropriate antibiotics is expected to reduce the morbidity and mortality caused by MRSA infections.

Intrauterine Intraventricular Hemorrhage in Premature Infants (태아기 신생아 뇌실내 출혈)

  • Jin, Hyun-Seung;Park, Kyeng-Ah;Goo, Hyun-Woo;Yoon, Jong-Hyun;Kim, Ai-Rhan;Kim, Ki-Soo;Pi, Su-Young
    • Clinical and Experimental Pediatrics
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    • v.48 no.1
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    • pp.27-33
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    • 2005
  • Purpose : To determine incidence, characteristics and risk factors associated with intrauterine intraventricular hemorrhage(IU-IVH) among premature infants. Methods : The medical records of infants with intraventricular hemorrhage(IVH) admitted to the neonatal intensive care unit of Asan Medical Center from January 1999 to June 2003 were reviewed retrospectively. Infants whose IVH with cystic change were detected within five days of life were defined as the IU-IVH group. The control group included those without any IVH. Various maternal and neonatal factors were evaluated between the IU-IVH and control groups, and risk factors for IU-IVH were identified using multiple logistic regression analysis. Results : The incidence of IU-IVH was 49/1024(15.9%). Mothers who are younger, primiparous, use less antenatal steroid, and neonates with greater incidence of neonatal respiratory distress syndrome, had higher incidences of IU-IVH compared to neonates with normal neurosonography. Risk factors associated with IU-IVH included neonatal respiratory distress syndrome and placenta infarct by placenta biopsy. Most infants with IU-IVH were ${\geq}1,501g$, ${\geq}34$ weeks gestational age and had low grade IVH. The size of the cysts associated with IU-IVH remained the same or disappeared in 96 %. IU-IVH does not seem to affect short-term neurodevelopmental outcome although a longer period of follow-up is needed. Conculusion : IU-IVH occurred mostly in ${\geq}1,501g$, ${\geq}34$ weeks infants with grade I IVH without developmental delays. However, the high incidence of total IVH merits more attention in terms of awareness of its existence as an unusual IVH among premature infants.

Clinical aspects of an outbreak of Serratia marcescens infections in neonates (신생아 중환자실에서 Serratia marcescens에 의한 집단 감염 발생에 대한 고찰)

  • Sung, Min-Jung;Chang, Chul-Hun;Yoon, Yeon-Kyong;Park, Su-Eun
    • Clinical and Experimental Pediatrics
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    • v.49 no.5
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    • pp.500-506
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    • 2006
  • Purpose : We evaluated an outbreak of Serratia marcescens infections in 24 neonates in a neonatal intensive care unit(NICU). Methods : From January to August, 2004 a nosocomial outbreak of S. marcescens occurred in our NICU. We describe the clinical characteristics of the outbreak and analyse the risk factors for infections with S. marcescens. After the outbreak stopped, 7 isolates from blood were typed using rapid amplified polymorphic DNA analysis(RAPD). Results : S. marcescens was isolated from 24 neonates, 19 infected and 5 colonized. Seven out of nineteen neonates had bacteremia, 4 had ventilator associated pneumonia, 4 had purulent conjunctivitis, 2 had UTI, 1 had meningitis and 1 had a wound infection. Three neonates died due to S. marcescens infection, 2 of 3 had ventilator associated pneumonia, 1 had meningitis complicated with abscess. The mortality rate of S. marcescens infection was 15.8%. Factors associated with S. marcescens infections were previous antibiotic therapy, indwelling catheter and use of ventilators. The isolated strains were resistant to most antibiotics, but frequently sensitive to imipenem, bactrim and amikacin. RAPD typing results show that at least 3 epidemic strains were related with this outbreak. But one genotype was predominant type in this outbreak. The control measures were instituted and the outbreak stopped within 2 months. Conclusion : S. marcescens can cause rapidly spreading outbreaks associated with fatal infections in neonates. If S. marcescens is isolated from clinical specimens, meticulous infection control measures and epidemiologic investigations should be done at an early stage of the outbreak.

Clinical characteristics of severe meconium aspiration syndrome (중증 태변흡입증후군의 임상적 특성)

  • Choi, Chang Won;Kim, Beyong Il;Lee, Hyun Ju;Joung, Kyoung Eun;Shim, Gyu Hong;Lim, In Suk;Lee, Jin-A;Kim, Ee-Kyung;Kim, Han-Suk;Choi, Jung-Hwan
    • Clinical and Experimental Pediatrics
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    • v.51 no.7
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    • pp.713-721
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    • 2008
  • Purpose : This study aims to describe the clinical characteristics of severe meconium aspiration syndrome (MAS) which required mechanical ventilation over 48 h and to delineate the progress of respiratory failure and radiographic findings in severe MAS. Methods : Twelve infants admitted to the Neonatal Intensive Care Unit (NICU) of the Seoul National University Bundang Hospital diagnosed with severe MAS from January 2004 to July 2007 were analyzed retrospectively. Results : The presence of persistent pulmonary hypertension of the newborn (PPHN) is the only independently significant risk factor for a longer hospital stay and longer duration of mechanical ventilation. Surfactant replacement therapy (SRT) was not randomized but only performed in infants with radiographic findings for respiratory distress syndrome (RDS). In the presence of radiographic findings for RDS, the duration of high-frequency oscillatory ventilation was significantly longer. PPHN developed in 8 infants (75%). The PPHN group had a significantly longer duration of mechanical ventilation. All infants who received SRT showed radiographic improvement within 12 h, but there was no significant change in the severity score during the same period. Infants without the PPHN complications showed significant decrease in the severity score within 12 h after SRT, whereas infants with PPHN complications did not. Conclusion : The clinical course of severe MAS differed significantly depending on the development of PPHN. SRT conferred radiographic improvement in infants who showed radiographic findings for RDS, but did not influence the clinical course of MAS significantly.

Association between Ureaplasma urealyticum Colonization and Adverse Outcomes in Premature Infants (출생 시 Ureaplasma urealyticum 집락이 조산아의 임상 양상에 미치는 영향)

  • Yun, Jin-Sang;Chang, Sun-Jung;Jo, Heui-Seung;Lee, Kyu-Hyung
    • Neonatal Medicine
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    • v.16 no.1
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    • pp.47-54
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    • 2009
  • Purpose: Present evidences suggest that Ureaplasma urealyticum is a cause of pneumonia, septicemia, and bronchopulmonary dysplasia (BPD) in newborn infants, particularly those born prematurely. The purpose of this work was to examine the relationship between Ureaplasma urealyticum in the tracheal aspirates and adverse outcomes, such as BPD and early onset neonatal sepsis in premature infants. Methods: A polymerase chain reaction (PCR) was performed on tracheal aspirates collected within 24 hour after birth in 176 premature infants less than 35 weeks of gestation and admitted to the neonatal intensive care unit of Bundang CHA Hospital. Results: U. urealyticum was detected in 37 of 176 preterm infants (21.0%). Gestational age ($29^{+5}{\pm}2^{+5}$ wk vs. $30^{+6}{\pm}2^+{-5}$ wk, P=0.0l3) and birth weight (1.39${\pm}$0.44 kg vs. 1.59${\pm}$0.55 kg, P=0.037) were lower in the U urealyticum-positive group compared to the control group. The incidence of early onset neonatal sepsis (16.2% vs. 6.5%, P=0.045) and BPD (45.9% vs. 29.5%, P=0.047) was higher in the U urealyticum-positive group compared to the control group, but the severity of BPD was not different between two groups. However, multiple logistic regression analysis revealed that the presence of U. urealyticum was not independently related to the development of early onset neonatal sepsis and BPD. Conclusion: The results suggest that colonization of the lower respiratory tract by U. urealyticum might not be related to the development of neonatal sepsis and BPD directly in preterm infants.

Transpulmonary Sequestration of Leukocyte and Changes of Peripheral Leukocyte Counts with Card iopu Imonary Bypass (체외순환에 따른 백혈구의 폐내정체와 말초혈액내 숫적 동태에 관한 연구)

  • Kim, Yun-Gyu;Kim, Yang-Won;Choe, Seok-Cheol;Jo, Gwang-Hyeon
    • Journal of Chest Surgery
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    • v.29 no.7
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    • pp.700-712
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    • 1996
  • Transpulmonary sequestration of leukocyte following cardiopulmonary bypass(CPB) has been recognized as one of main causes of postoperative pulmonary dysfunction. The purpose of this study is to investigate the effect of a single dose of prebypass corticosteroid on pulmonary leukostasis and postoperative pulmonary dysfunction. The study was performed prospectively in randomized-blind fas ion for 50 patients from January 1995 to June 1995. All patients were divided into two groups; In the steroid group(n=25), corticosteroid(Solu-Medrol 30mg1kg) was injected prior to CPB and in the placebo group (n=25), normal saline was injected before CPB. The results were summarized as follows. 1. Total peripheral leukocyte counts decreased significantly at 5 minutes of CPB in all patients(P<0.01), and began to increase progressively at later periods of CPB with neutrophilia. The significant rise remained at postoperative 7th day. 2. During partial CPB, transpulmonary leukostasis occurred in placebo group(P< 0.001), whereas it was prevented in steroid group. 3. In both groups, peripheral Lymphocyte counts were stable during CPB, but began to reduce at time of intensive care unit(ICV) and the Iymphocytopenia remained until postoperative )rd day. The Iympho- cyte counts recovered on postoperative 7th day. 4. In both groups, peripheral counts of monocyte were relatively stable in the e rly peroid of CPB, and increased gradually in the later periods of CPB. This significant monocytosis remained throughout postoperative periods(P< 0.05). 5. The mean value of postoperative PaOa was lower than that of pre-CPB In placebo group(P=0.01), but in steroid group, there was no significant difference(P=0. 90) and fever was higher in placebo group compared to steroid group(P=0.001).

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