Brain Damage in Children after Deep Hypothermia for Open-heart Surgery

Björk, Viking Olov; Hultquist, Gösta T.

doi:10.1136/thx.15.4.284

Cited by 130 publications

(20 citation statements)

References 2 publications

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“…These studies, which were performed at temperatures below 30°C, sug gest that hypothermia results in a reduction in the rate of degradation of brain energy metabolism dur ing the onset of hypothermic ischemia as well as a reduced level of brain tissue acidosis compared with normothermic ischemia. However, the clinical application of hypothermia is limited by adverse ef fects associated with level as well as the duration of hypothermia (Popovic, 1960;Michenfelder and Milde, 1977;Bjork and Hultquist, 1960;Brunberg et aI., 1974;Connolly et aI., 1962;Olesen et aI., 1971).…”

Section: Discussionmentioning

confidence: 99%

The Metabolic Effects of Mild Hypothermia on Global Cerebral Ischemia and Recirculation in the Cat: Comparison to Normothermia and Hyperthermia

Chopp

Knight

Tidwell

et al. 1989

J Cereb Blood Flow Metab

219

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Summary:The metabolic effects of graded whole body hypothermia on complete global cerebral ischemia and recirculation was investigated in the cat. Hypothermia was induced to one of three levels prior to ischemia; T = 26.8° ± OSC (n = 4), T = 32.1° ± 0.2°C (n = 5), and T = 34.6° ± 0.3°C (n = 6), and maintained constant throughout 16 min of ischemia and 1.5-2 h of recircula tion. Intracellular cerebral pH and relative concentrations of high-energy phosphate metabolites were continuously monitored, using in vivo 31p nuclear magnetic resonance (NMR) spectroscopy. Except for the first 4 min of isch emia, no significant differences were detected in the re sponse of adenylate intensities and intracellular pH to ischemia and recirculation between the hypothermic groups. The three hypothermic groups were then pooledThe effect of whole body hypothermia on cere bral metabolism has a long history (Field et aI., 1944). The possible beneficial effects of hypother mia on cerebral pathophysiological conditions have also been explored (see Siesj6, 1978). Whole body hypothermia, when applied judiciously, can curtail metabolic changes and lessen cerebral edema and neuropathologic damage associated with hypoxia (Carlsson et aI., 1976;Rosomoff 1959), and head injury (Shapiro et aI., 1974 141into one group, and the data compared to previously pub lished data from a normothermic group, T = 38.4° ± 0.6°C (n = 14), and a hyperthermic group, T = 40.6° ± 0.2°C (n = 9), subjected to the identical ischemic and NMR measurement protocols. The hypothermic animals exhibited a statistically significant reduction of cerebral intracellular acidosis, both during ischemia and recircu lation, as well as a more rapid return of adenylate inten sities during recirculation, compared to the normothermic or hyperthermic groups. The data thus suggest that mild hypothermia has an ameliorative affect on brain energy metabolism and intracellular pH under conditions of com plete global cerebral ischemia and recirculation. Key Words: 31p NMR spectroscopy-Cerebral ischemia Hypothermia-Body temperature, and cerebral ischemia. emia, including circulatory arrest, with recircula tion (Marshal et aI., 1956; Kramer et aI., 1968; Ber ing, 1974; Perna et aI., 1973; Wolin et aI., 1973;Hickey, 1985) and without recirculation (Stocker et aI., 1986); the isolated perfused brain (Norwood et aI., 1979); and focal cerebral ischemia (Simeone et aI., 1979;Rosomoff, 1957). These studies, which were performed at temperatures below 30°C, sug gest that hypothermia results in a reduction in the rate of degradation of brain energy metabolism dur ing the onset of hypothermic ischemia as well as a reduced level of brain tissue acidosis compared with normothermic ischemia. However, the clinical application of hypothermia is limited by adverse ef fects associated with level as well as the duration of hypothermia (Popovic, 1960;Michenfelder and Milde, 1977;Bjork and Hultquist, 1960; Brunberg et aI., 1974; Connolly et aI., 1962; Olesen et aI., 1971).

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Section: Discussionmentioning

confidence: 99%

The Metabolic Effects of Mild Hypothermia on Global Cerebral Ischemia and Recirculation in the Cat: Comparison to Normothermia and Hyperthermia

Chopp

Knight

Tidwell

et al. 1989

J Cereb Blood Flow Metab

219

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“…No brain injury occurred in a subsequent comparable series of patients operated on at 24-30°C. Björk and Hultquist [2] reported brain damage including choreoathetosis in children undergoing hypothermia of 5.8-16°C with or without circulatory arrest. Cortical ischemia, degeneration of cells of the basal ganglia and thalamus, and disappearance of Purkinje cells and myelin sheath were noted.…”

Section: Commentsmentioning

confidence: 98%

Experimental Evidence of Cerebral Injury from Profound Hypothermia During Cardiopulmonary Bypass

et al. 1998

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Choreoathetosis, seizures, and impaired mental development continue to occur in children undergoing cardiopulmonary bypass (CPB) and profound hypothermia with or without circulatory arrest. Although there is some evidence that the hypothermia itself may be causing these neurologic problems, skepticism remains because of lack of evidence from experimental studies simulating the clinical setting. In this experimental study, we examined the effect of profound and moderate hypothermia on the brain while maintaining normal flow rates during CPB. Ten adult mongrel dogs equally divided into two groups were anesthetized and subjected to CPB and varying levels of hypothermia (group 1, < or = 15 degreesC; group 2, < or = 2 degreesC). Both groups were kept at the desired temperature for 1 hour prior to rewarming and discontinuation of CPB. The dogs were euthanized 4-6 weeks later and neuropathologic studies were performed. The mean CPB flow rates during cooling and at the desired rectal temperature were comparable in both groups: group 1, 108 +/- 10 ml/kg/min versus 106 +/- 7 ml/kg/min in group 2 (p = NS) and 95 +/- 12 ml/kg/min in group 1 versus 101 +/- 5 ml/kg/min in group 2 (p = NS). Because of the difference in temperature between the two groups, the mean cooling time (onset of CPB to desired rectal temperature) was longer in group 1 (70 +/- 14 minutes) than in group 2 (28 +/- 11 minutes, p = 0.007). Hence, the total mean CPB time was also longer in group 1 (198 +/- 25 minutes) than in group 2 (143 +/- 13 minutes, p = 0.002). The lowest mean blood and rectal temperature achieved in group 1 were 11 +/- .9 degreesC and 12 +/- 1 degreesC versus 29 +/- .4 degreesC (p < 0.001) and 30 +/- .6 degreesC (p = 0.001), respectively, in group 2 (p = 0.001). Neuronal loss and degeneration was noted in all dogs in group 1 ranging from 2 to 8 cells per 1000 cells counted compared to none in group 2 (p = 0.05). These lesions occurred in both the basal ganglia and the cortex, although they were more marked in the caudate when compared to the cortex and cerebellum. Both in the cortex and in the caudate, neuronal loss was more marked around the capillaries. We conclude that the use of profound hypothermia of < or =15 degreesC and maintenance of normal flow rates during cooling at this temperature for 1 hour produces neuronal loss and degeneration in the brain. These lesions being more marked around capillaries points to the vulnerability of the neurons, probably because of their high lipid content to injury from the cold perfusate.

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“…It was first introduced to decrease homologous blood use [26], thereby avoiding the ''homologous blood syndrome'' [18]. Later the effects of hemodilution in counteracting the deleterious rheological consequences of deep hypothermia, such as increased viscosity and red cell rigidity, came to be considered important in minimizing brain injury associated with deep hypothermic circulatory arrest [7]. However, hemodilution reduces the oxygen carrying capacity of blood.…”

Section: Optimal Hematocrit During Cardiopulmonary Bypassmentioning

confidence: 99%

Neurological Protection During Cardiopulmonary Bypass/Deep Hypothermia

Jonas

1998

Pediatr Cardiol

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Brain Damage in Children after Deep Hypothermia for Open-heart Surgery

Cited by 130 publications

References 2 publications

The Metabolic Effects of Mild Hypothermia on Global Cerebral Ischemia and Recirculation in the Cat: Comparison to Normothermia and Hyperthermia

The Metabolic Effects of Mild Hypothermia on Global Cerebral Ischemia and Recirculation in the Cat: Comparison to Normothermia and Hyperthermia

Experimental Evidence of Cerebral Injury from Profound Hypothermia During Cardiopulmonary Bypass

Neurological Protection During Cardiopulmonary Bypass/Deep Hypothermia

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