Transaminase levels in ventilated children with respiratory syncytial virus bronchiolitis

Eisenhut, Michael; Thorburn, Kentigern; Ahmed, Tageldin

doi:10.1007/s00134-004-2236-2

Cited by 39 publications

(35 citation statements)

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“…Elevated transaminase levels have been found in 46 to 49% of ventilated children with RSV bronchiolitis [35,36]. Severe hepatitis with alanine aminotransferase levels of nearly 3,000 IU/l has been noted and this was associated with coagulopathy [35].…”

Section: Resultsmentioning

confidence: 99%

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Eisenhut

2006

Crit Care

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IntroductionRespiratory syncytial virus (RSV) bronchiolitis is the most important cause for admission to the paediatric intensive care unit in infants with lower respiratory tract infection. In recent years the importance of extrapulmonary manifestations of RSV infection has become evident. This systematic review aimed at summarizing the available evidence on manifestations of RSV infection outside the respiratory tract, their causes and the changes in clinical management required.MethodsDatabases searched were Medline (1950 to present), EMBASE (1974 to present), PubMed and reference lists of relevant articles. Summarized were the findings of articles reporting on manifestations of RSV infection outside the respiratory tract in patients of all age groups.ResultsExtrapulmonary manifestations reported in previous observational studies included cardiovascular failure with hypotension and inotrope requirements associated with myocardial damage as evident from elevated cardiac troponin levels (35–54% of ventilated infants), cardiac arrhythmias like supraventricular tachycardias and ventricular tachycardias, central apnoeas (16–21% of admissions), focal and generalized seizures, focal neurological abnormalities, hyponatraemia (33%) associated with increased antidiuretic hormone secretion, and hepatitis (46–49% of ventilated infants). RSV or its genetic material have been isolated from cerebrospinal fluid, myocardium, liver and peripheral blood.ConclusionThe data summarized indicate a systemic dissemination of RSV during severe disease. Cerebral and myocardial involvement may explain the association of RSV with some cases of sudden infant death. In infants with severe RSV infection cardiac rhythm, blood pressure and serum sodium need to be monitored and supportive treatment including fluid management adjusted accordingly.

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Section: Resultsmentioning

confidence: 99%

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Eisenhut

2006

Crit Care

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170

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“….02 a Duration of MV, days, median (IQR) 5 (4-6) 4 (2.8-4.3) 5 (4.5-5) 6 (5.5-9) Ͻ.01 a Duration of PICU stay, days, median (IQR) 6 (4-8.8) 5 (3.5-6.8) 6 (4.5-8) 9 (7)(8)(9)(10)(11)(12) . tween measurements.…”

Section: Discussionmentioning

confidence: 99%

“…We used length of ventilation and PICU stay as our outcome measures. ALT was used as a marker of bronchiolitis severity (7). We do not use the Pediatric Logistic Organ Dysfunction score as an outcome measure because of the large gaps in predicted risk of mortality and our concerns about its clinical applicability (8).…”

Section: Methodsmentioning

confidence: 99%

Glycemic level in mechanically ventilated children with bronchiolitis*

Branco

Tasker²

2007

Pediatric Critical Care Medicine

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“…Previous studies found that patients with acutely elevated intrapulmonary pressure resulting from bronchospasm [2] and severe respiratory syncytial viral lung disease leading to hyperinflation [3] exhibited evidence of myocardial injury, such as elevated cardiac troponin levels; this was probably due to strain imposed on the right ventricle by pulmonary hypertension. Ventricular strain has previously also been associated with elevated hyaluronate levels [4].…”

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Myocardial injury associated with hyperinflation of the lung

Eisenhut

2007

Crit Care

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A recent study [1], conducted in an animal model of acute lung injury, compared a ventilation strategy in which lungs were inflated by brief application of 50 cmH 2 O pressure followed by increased positive end-expiratory pressure (recruitment strategy) versus conventional ventilation. The study identified an increased inflammatory reaction in liver sinusoids, and increased serum aspartate aminotransferase (AST) and hyaluronate levels with the recruitment strategy. The authors speculated that deficient oxygen delivery and increased sinusoidal pressures may have caused liver injury. The findings of the study suggest an origin of AST outside the liver because there was no elevation in alanine aminotransferase levels, hepatocellular necrosis, or liver dysfunction. Animals in the group receiving the recruitment strategy required volume support and had temporarily reduced cardiac output. This indicated that the origin of AST elevation was a myocardial injury.Previous studies found that patients with acutely elevated intrapulmonary pressure resulting from bronchospasm [2] and severe respiratory syncytial viral lung disease leading to hyperinflation [3] exhibited evidence of myocardial injury, such as elevated cardiac troponin levels; this was probably due to strain imposed on the right ventricle by pulmonary hypertension. Ventricular strain has previously also been associated with elevated hyaluronate levels [4]. The increase in hepatic neutrophils may be due to a hyperoxia-induced increased inflammatory response found in patients with increased positive end-expiratory pressure and fractional inspired oxygen (FiO 2 ) [5]. Future studies need to use specific markers for myocardial injury such as cardiac troponin T in order to discriminate between myocardial and hepatic injury associated with the various ventilation strategies. Letter Myocardial injury associated with hyperinflation of the lung Authors' response Markus Kredel and Christian WunderWe thank Dr Eisenhut for his comments. He raises the issue of whether myocardial injury was the origin of the increased serum AST levels observed in animals treated with the recruitment manoeuvre (RM). Although we did not measure troponin T levels, there was no evidence for myocardial injury during the performed RM. Haemodynamic variables, as shown in Table 1 of our report [1], and mixed venous oxygen saturation (data not shown) were comparable in the two groups at all time points. In addition, the expected and observed increase in central venous pressure and decrease in cardiac output during the RM did not result in differences in pulmonary artery pressure. This casts right ventricular strain into doubt.In addition to nonspecific transaminases and hyaluronic acid, bilirubin was also elevated in the systemic circulation in the group undergoing the RM. High positive end-expiratory pressure is known to be an independent risk factor for liver dysfunction, as indicated by hyperbilirubinemia [6].Regarding the histologic examination, Dr Eisenhut speculates that the increase in liver ...

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Transaminase levels in ventilated children with respiratory syncytial virus bronchiolitis

Abstract: RSV disease in ventilated children was more severe if transaminase levels were elevated. Transaminase level elevation was due to hepatitis in the majority of patients. In patients with congenital heart disease we also detected myocardial involvement.

Cited by 39 publications

References 10 publications

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Glycemic level in mechanically ventilated children with bronchiolitis*

Myocardial injury associated with hyperinflation of the lung

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