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ARTIGO ORIGINAL

Injúria orgânica da circulação extracorpórea nos três primeiros meses de vida

Décio O Elias; Maria Helena L Souza; Bernardo S Lacerda; Francisco Eduardo S Fagundes; Francisco J. S Lino; Márcio Tiraboshi

DOI: 10.1590/S0102-76381990000100001

RESUMO

Diversos fatores contribuíram para aumentar o número de procedimentos com circulação extracopórea para neonatos e lactentes. Esses pacientes necessitam procedimentos especiais de perfusão, fundamentos em sua fisiologia particular, nas características do seu metabolismo e na sua resposta aos desvios da homeostase, principalmente a acidose lática. São analisados os protocolos de perfusão em 110 procedimentos com parada circulatória total, para a realização da correção intracardíaca, durante a qual diversos mecanismos de injúria ao sangue foram identificados. A injúria mecânica, por ação das forças desenvolvidas na circulação artificial do sangue e nas trocas gasosas, pode danificar os elementos figurados e as proteínas do plasma sangüíneo. O contato com as superfícies do circuito extracorpóreo pode ativar os sistemas das cininas, da coagulação, da fibrinólise e do complemento, por ativação inicial do fator XII e produzir uma reação inflamatória generalizada. A produção de ácido lático pode modificar o pH ideal para a função enzimática e celular, e o superaquecimento do sangue, durante o reaquecimento, pode produzir dano ao sangue semelhante àquele causado pelos fatores físicos da circulação extracorpórea. A perfusão neonatal e de pequenos lactentes é um continuado exercício de atenção aos detalhes e respeito aos aspectos particulares da fisiologia, do metabolismo e da resposta à injúria.

ABSTRACT

Newborns and small infants require special procedures of extracorporeal circulation for open heart surgery, which must be based on their specific physiological and metabolic patterns, as well as on the response to deviations of their homeostasis. The authors reviewed the protocols of cardiopulmonary bypass utilized during 100 procedures with total circulatory arrest and discuss some mechanisms by which the blood components may be damaged or injured during perfusion. Mechanical injury of solid blood components and plasma proteins are discussed; the activation of certain plasmatic systems as the coagulation, fibrinolytic and complement by the Hageman factor, which can produce a generalized inflammatory reaction is also identified; deviations of acid-base balance by excessive lactic acid production may impair enzymatic and cellular functions which can cause injury of a metabolic nature. Thermal injury may also be produced by overheating blood during rewarming if the dynamic nature of heat exchangers function is not adequately monitored. The conclusion is that neonatal perfusion represents a continuing exercise of attention to detail and must be performed with a profound respect to their specific physiology, metabolism and response to injury.
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REFERÊNCIAS

1. BACKER, C. L.; ILBAWI, M. N.; OHTAKE, S.; DE LEON, S.; MUSTER, A. J.; PAUL, M. H.; BENSON Jr., D. W.; IDRISS, F. S. - Transposition of the great arteries: a comparison of results of the Mustard procedure versus the arterial switch. Ann. Thorac. Surg., 48: 10-14, 1989. [MedLine]

2. BARRAT-BOVES, B. G.; NEUTZE, J. M.; SEELYE, E. R.; SIMPSON, M. - Complete correction of cardiovascular malformations in the first year of life. Progr. Cardiovasc. Dis., 15: 229-234, 1972.

3. BAUM, D.; DILLARD, D. H.; MOHRI, H.; CRAWFORD, E. W. - Metabolic aspects of deep surgical hypothermia in infancy. Pediatrics, 42: 93-105, 1968. [MedLine]

4. BERRYESSA, R.; HYDRICK, D.; McCORMICK, J.; TYNDALL, C. M.; PETERSON, D.; TORNABENE, M.;TORNABENE, S.; WILLIAMS, W.; PAPPAS, G.; CAMPBELL, D.; CLARKE, D. R. - Refinements in infant/pediatric perfusion. J. Extracorp. Technol., 18: 140-144, 1986.

5. BUCKBERG, G. D. - Strategies and logic of cardioplegic delivery to prevent, avoid, and reverse ischemic and reperfusion damage. J. Thorac. Cardiovasc. Surg., 93: 127-139, 1987. [MedLine]

6. BUCKBERG, G. D.; STEEED, D.; BECKER, H.; ROSENKRANZ, E. R. - Myocardial protection during paediatric cardiac surgery. In: MARCELLETTI, C.; ANDERSON, R. H.; BECKER, A. E.; CORNO, A.; Di CARLO, D.; MAZZERA, E. (eds.) Paediatric Cardiology. London, Churchill Livingstone, 1986. p. 39-52.

7. BULL, C.; COOPER, J.; STARK, J. - Cardioplegic protection of the child's heart. J. Thorac. Cardiovasc. Surg., 88: 287-293, 1984. [MedLine]

8. CASTAÑEDA, A. R.; LAMBERTI, J.; SADE, R. M.; WILLIAMS, R. G.; NADAS, A. S. - Open-heart surgery during the first three months of life. J. Thorac. Cardiovasc. Surg., 68: 719-723, 1974.

9. CLARKE, D. R. - Pediatric perfusion: an evolving science. J. Extracorp. Technol., 21: 18-20, 1989.

10. DAVIES, G. C.; SOBEL, M.; SALZMAN, E. W. - Elevated plasma fibrinopeptide A and thromboxane B2 levels during cardiopulmonary bypass. Circulation, 61: 808-814, 1980. [MedLine]

11. DE LEVAL, M. - Perfusion techniques for paediatric cardiac surgery. In: TAYLOR, K. M. Cardiopulmonary bypass: principles and management. Baltimore, Williams & Wilkins, 1986. p. 115-123.

12. DILLARD, D. H.; MOHRI, H.; HESSEL II, E. A.; ANDERSON, H. N.; NELSON, R. J.; CRAWFORD, E. W.; MORGAN, B. C.; WINTERSCHEID, L. C.; MERENDINO, K. A. - Corrections of total anomalous pulmonary venous drainage in infancy utilizing deep hypothermia with total circulatory arrest. Circulation, 105 (Supl. 1): 35-36, 1967.

13. EDMUNDS Jr., L. H. & ADDONIZIO Jr., V. P. - Platelet physiology during cardiopulmonary bypass. In: UTLEY, J. R. (ed.) Pathophysiology and techniques of cardiopulmonary bypass. Baltimore, Williams & Wilkins, 1982. p. 106-119.

14. FAYMONVILLE, M. E.; DEBY-DUPONT, G.; LARBUISSON, R.; DEBY, C.; BODSON, L.; LIMET, R.; LAMY, M. - Prostaglandin E2, prostacyclin, and thromboxane changes during nonpulsatile cardiopulmonary bypass in humans. J. Thorac. Cardiovasc. Surg., 91 (6): 858-866, 1986. [MedLine]

15. FRIEDMAN, W. F. - Physiological properties of the developing heart. In: MARCELLETTI, C.; ANDERSON, R. H.; BECKER, A. E.; CORNO, A.; Di CARLO, D.; MAZZERA, E. (eds.) Paediatric Cardiology. London, Churchill Livingstone, 1986. p. 3-12.

16. GRAHAM, G. - A personal review of over 20 years' experience in ECC in infants. In: HAGL, S.; KLOVEKORN, W. P.; MAYR, N.; SEBENING, F. Thirty years of extracorporeal circulation. Munich, Carl Gerber, 1984. p. 65-73.

17. HAMMERSCHMIDT, D. E.; STRONCEK, D. F.; BOWERS, T. K. - Complement activation and neutropenia during cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., 86: 845-957, 1983.

18. KEMPSFORD, R. D. & HEARSE, D. J. - Protection of the immature heart: temperature-dependent beneficial or detrimental effects of multidose crystalloid cardioplegia in the neonatal rabbit heart. J. Thorac. Cardiovasc. Surg., 99: 269-279, 1990. [MedLine]

19. KIRKLIN, J. K. - Low flow perfusion and the damaging effects of cardiopulmonary bypass. In: MARCELLETTI, C.; ANDERSON, R. H.; BECKER, A. E.; CORNO, A.; Di CARLO, D.; MAZZERA, E. (eds.). Paediatric Cardiology, London, Churchill Livingstone, 1986. p. 53-58.

20. KIRKLIN, J. K.; WESTABY, S.; BLAKSTONE, E. H.; KIRKLIN, J. W.; CHENOWETH, D. E.; PACIFICO, A. D. - Complement and the damaging effects of cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., 86: 845-857, 1983. [MedLine]

21. LAKS, H.; MILLIKEN, J.; HASS, G. - Myocardial protection in the neonatal heart. In: MARCELLETTI, C.; ANDERSON, R. H.; BECKER, A.E.; CORNO, A.; Di CARLO, D.; MAZZERA, E. (eds.) Paediatric Cardiology, London, Churchill Livingstone, 1986. p. 13-27.

22. LAKS, H. - The arterial switch procedure for the neonate: coming of age. Ann. Thorac. Surg., 48: 3-4, 1989. [MedLine]

23. LINDBERG, H.; OVRUM, E.; HOLEN, E. A.; ABDELNOOR, M. ; SOMMERFELT, S. C. - Changes in colloid oncotic pressure during and after cardiopulmonary bypass. Perfusion, 3: 47-53, 1988.

24. MARATH, A.; MAN, W.; TAYLOR, K. M. - Paediatric extracorporeal priming procedures: does low temperature priming promote histamine release? Perfusion, 3: 287-293, 1988.

25. MILNE, E. G.; ELLIOTT, M. J.; PEARSON, D. T.; HOLDEN, M. P.; ORSKOV, H.; ALBERTI, K. G. M. M. - 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. Perfusion, 1: 29-40, 1986.

26. NICOLAS, F.; BRUNIAUX, J.; PLANCHE, C.; BINET, J. P. - Recent techniques of cardiopulmonary bypass in infancy. In: HAGL, S.; KLOVEKORN, W. P.; MAYR, N.; SEBENING, F. (eds.). Thirty years of extracorporeal circulation. Munich, Carl Gerber, 1984. p. 75-85.

27. NORWOOD, W. I.; DOBELL, A. R.; FREED, M. D.; KIRKLIN, J. W.; BLAKSTONE, E. H. - Intermediate results of the arterial switch repair: a 20th Institution study. J. Thorac. Cardiovasc. Surg., 96: 854-863, 1988. [MedLine]

28. OEVEREN, W. & WILDEVUUR, C. R. H. - Blood compatibility of cardiopulmonary bypass circuits. Perfusion, 2: 237-244, 1987.

29. PLANCHE, C.; BRUNIAUX, J.; LACOUR-GAYET, F.; KACHANER, J.; BINET, J. P.; SIDI, D.; VILLAIN, E. - Switch operation for transposition of the great arteries in neonates: a study of 120 patients. J. Thorac. Cardiovasc. Surg., 96: 354-363, 1988. [MedLine]

30. SADE, R. M.; STROUD, M. R.; CRAWFORD Jr., F. A.; KRATZ, J. M.; DEARING, J. P.; BARTLES, D. M. - A prospective randomized study of hydroxyethyl starch, albumin, and lactated Ringer's solution as priming fluid for cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., 89: 713-722, 1985. [MedLine]

31. THARION, J.; JOHNSON, D. C.; CELEMAJER, J. M. - Profound hypothermia with circulatory arrest: nine years' clinical experience. J. Thorac. Cardiovasc. Surg., 84: 66-72, 1982. [MedLine]

32. UTLEY, J. R. - Early development of cardiopulmonary bypass. Perfusion, 1:1-14, 1986.

33. WELLS, F. C.; COGHILL, S.; CAPLAN, H. L.; LINCOLN, C.; KIRKLIN, J. W. - Duration of circulatory arrest does influence the psychological develpment of children after cardiac operations in early life. J. Thorac. Cardiovasc. Surg., 86: 823-831, 1983. [MedLine]

34. WILLIAMS, G. D.; SEIFEN, A. B.; LAWSON, N. W.; NORTON, J. B.; READINGER, R. I.; DUNGAN, T. W.; CALLAWAY, J. K. - Pulsatile perfusion versus conventional high-flow nonpulsatile perfusion for rapid core cooling and rewarming of infants for circulatory arrest in cardiac operations. J. Thorac. Cardiovasc. Surg., 78: 667-674, 1979.

35. WRIGHT, G. - Blood cell trauma. In: TAYLOR, K. M. (ed.). Cardiopulmonary bypass: principles and management. Baltimore, Williams & Wilkins, 1986. p. 249-276.

36. WRIGHT, G. - The hydraulic power outputs of pulsatile and nonpulsatile cardiopulmonary bypass pumps. Perfusion, 3: 251 -262, 1988.

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