PubMed · 6978091
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J W Chapin, P Nance, J W Yarbrough. 1982. Facial paleness.. https://doi.org/10.1213/00000539-198205000-00018
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BACKGROUND: Treatment of congenital heart disease has entered a new era of healthcare delivery and cost containment. Critical pathway method (CPM) has been previously demonstrated by us to produce a significant reduction in average length of stay (ALOS) in hospital of -44%. A new approach, radical outcome method (ROM), has produced comparable results that appear to improve over time. The dynamic nature is examined. METHODS AND RESULTS: Two hundred consecutive patients with congenital heart disease were treated by a single surgeon at a single health maintenance organization (HMO) facility. ROM was used in all patients. This method uses seven critical moments at which shortening rather than confirmation of the ALOS is possible. This process is completed by the second post-operative day. Overall mortality was 1%. The 200 patients were divided into two consecutive groups of 100 patients to determine the effectiveness of ROM over time. Fifty sets were matched. ALOS hospital decreased by 29 days (mean, 0.6 d/set), P < .003. Thirty sets who underwent cardiopulmonary bypass had a 16% decrease (P < .03), and 20 sets in whom nonbypass procedures were performed had a decrease of 16% (P < .02). ALOS in hospital for the 50 sets decreased from 3.7 to 3.1 days (-16%, P < .003). Outcome data demonstrated no significant difference. CONCLUSIONS: ROM, a proactive approach to hospital stay, is a dynamic process that reduces ALOS in hospital. This is achieved by both reducing negative variation in the standard CPM and allowing for positive variation. Outcome data confirm that this approach can reduce ALOS in hospital while providing optimal patient care and family satisfaction, a standard for the new era of healthcare delivery.
BACKGROUND: Interleukin-8 (IL-8), the major neutrophil chemoattractant factor, contributes to inflammatory tissue injury by activating neutrophils and promoting their migration into tissue. IL-8 levels increase in serum of patients undergoing cardiopulmonary bypass (CPB). The purpose of this study was to determine if IL-8 gene expression is activated in tissues subjected to CPB with or without hypothermic arrest. METHODS AND RESULTS: IL-8 transcript levels were measured by ribonuclease protection in samples of human atrium and skeletal muscle from children before and after CPB for repair of congenital heart defects. Results were quantified by PhosphorImager. Atrial IL-8 mRNA levels increased during CPB in 14 of 16 patients tested (median increase, 2.9-fold; P = .0029). In skeletal muscle, IL-8 mRNA increased in 11 of 12 patients (median, 12-fold; P = .012). Degree of IL-8 induction in atrium and muscle was not directly associated with total support time or cross-clamp time. Transcript increase in skeletal muscle occurred with or without a period of circulatory arrest, suggesting that the stimulus of CPB alone was sufficient to induce message production. Baseline values for IL-8 mRNA varied widely among patients in atrium and skeletal muscle. In situ hybridization analysis revealed diffuse increase in IL-8 mRNA throughout the tissue after CPB, with striking increase in some small veins. CONCLUSIONS: We conclude that production of IL-8 mRNA occurs in most patients during CPB in both myocardium and skeletal muscle. This may result in high local IL-8 concentrations, contributing to the tissue injury after CPB.
BACKGROUND: Peripheral vasodilation, a potentially adverse effect of warm heart surgery, may be mediated by the perioperative release of cytokines. Corticosteroids may abolish cytokine production and vasodilation. We investigated cytokine production and its inhibition by steroids in patients undergoing elective coronary bypass surgery. METHODS AND RESULTS: Twenty-five patients undergoing coronary bypass surgery with normothermic cardiopulmonary bypass received either preoperative steroid (Solumedrol 250 mg IV, n = 16) or no steroid (n = 9, control group). Blood samples were obtained serially for 24 hours and assayed for interleukin-6 (IL-6), tumor necrosis factor (TNF), and interleukin-8 (IL-8). In the control patients, the IL-6, TNF, and IL-8 levels were elevated postoperatively and peaked between 3 and 6 hours after surgery (IL-6, 1330 +/- 295 [mean +/- SEM] pg/mL; TNF, 18.4 +/- 9.8 pg/mL; and IL-8, 150 +/- 51 pg/mL). Cytokine release was abolished in patients receiving preoperative corticosteroid (IL-6, 75 +/- 38 pg/mL; TNF, 2.6 +/- 0.5 pg/mL; and IL-8, 33 +/- 6.7 pg/mL; P < .05). Patients receiving steroid premedication had higher arterial pressure, lower cardiac index, and higher systemic vascular resistance, indicating less vasodilation. CONCLUSIONS: Our findings demonstrate that cytokine production occurs after normothermic cardiopulmonary bypass. Preoperative administration of steroids abolishes cytokine release and vasodilation.