Pediatr Crit Care Me
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Pulmonary arterial hypertension in children contributes significantly to morbidity and mortality in diverse pediatric cardiac, lung, hematologic, and other diseases. Pulmonary arterial hypertension is generally a disease of small pulmonary arteries characterized by vascular narrowing due to high-tone and abnormal vasoreactivity, structural remodeling of the vessel wall, intraluminal obstruction, and decreased vascular growth and surface area. ⋯ Advances in basic pulmonary vascular biology over the last few decades have led directly to several novel therapies, which have significantly expanded therapeutic choices and have led to improved survival and quality of life of many children with pulmonary arterial hypertension. Despite these improvements, long-term outcomes in many settings remain guarded and substantial challenges persist, especially with regard to understanding mechanisms and approach to structural remodeling of severe pulmonary arterial hypertension.
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Pediatr Crit Care Me · Mar 2010
ReviewPathophysiology of right ventricular failure in pulmonary hypertension.
This review focuses on right ventricular anatomy and function and the significance of ventricular interdependence in the response of the right ventricle to an increase in afterload. This is followed by a discussion of the pathophysiology of right ventricular failure in pulmonary arterial hypertension as well as in other clinical syndromes of pulmonary hypertension. ⋯ Regardless of the etiology, an increase in right ventricular afterload leads to a number of compensatory changes in cardiovascular physiology. These changes are not altogether intuitive and require an understanding of right ventricular physiology and ventricular interdependence to optimize the care of these patients.
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Pediatr Crit Care Me · Mar 2010
ReviewPreoperative pulmonary hemodynamics and assessment of operability: is there a pulmonary vascular resistance that precludes cardiac operation?
Preoperative pulmonary vascular disease remains an important risk factor for death or right-heart failure in selected children undergoing two-ventricle repair, single-ventricle palliation, or heart transplantation. Preoperative criteria for poor outcome after operation remain unclear. The purpose of this review is to critically assess both the historic and current data and make recommendations where appropriate. ⋯ In children awaiting cardiac transplantation with elevated pulmonary vascular disease of >6 U.m and/or transpulmonary gradient of >15 mm Hg, heart transplantation is deemed feasible in most transplant centers if the administration of inotropes or vasodilators can decrease the pulmonary vascular disease to <6 U.m or transpulmonary gradient to <15 mm Hg. In patients with preoperative pulmonary vascular disease, there may be contributing factors to the pulmonary vascular disease, such as the specifics of the cardiac lesion (atrioventricular valve regurgitation, low cardiac output), parenchymal and/or airway issues, and/or individual genetic predisposition. Amelioration of any reversible factors before operation and optimization of their management in the preoperative and postoperative period are recommended.
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Lung and heart-lung transplantation are accepted treatments for children with end-stage pulmonary vascular disease. This is a review of the current literature and our own experience with lung and heart-lung transplantation for children with pulmonary hypertension of a variety of causes. I reviewed the pertinent literature and our lung transplant database to acquire information and data regarding this subject. ⋯ The major operative complications include those related to the surgical procedure itself (vascular and airway anastomotic stenoses) and those related to graft dysfunction. The 3- and 5-yr survival is approximately 60% and 50%, respectively, for children undergoing lung transplantation for pulmonary hypertension. Although these survival statistics are somewhat poor, transplantation remains the only viable alternative for children with end-stage pulmonary vascular disease failing to respond to medical therapy.
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Pediatr Crit Care Me · Mar 2010
Comparative StudyImpact of hypothermia in the rural, pediatric trauma patient.
Hypothermia is an independent predictor of mortality in adult trauma studies. However, the impact of hypothermia on the pediatric trauma population has not been described. The purpose of this study is to evaluate hypothermia as a cofactor to mortality, complications, and among survivors, hospital length of stay parameters in the pediatric trauma population. ⋯ Hypothermia is a common problem at admission among pediatric trauma patients. Hypothermia is associated with an increase in the odds of death and the development of a bleeding diathesis, while having decreased odds for developing pneumonia. While the length of stay indicators were longer in the hypothermic cohort among survivors, no significant association was noted with hypothermia for hospital, ICU, or ventilator days after controlling for confounders.