6].0
KF,PORTS OF INVESTIGATION
Histamine release during cardiopulmonary bypass in neonates and infants
Davinia E. W i t h i n g t o n BM FP.CA MRCP (ur.), J a c o b V. A r a n d a MD PhD.
P u r p o s e : Histamine release has been previously documented in adults and children during cardiopulrnonary bypass (CPB). It has not been studied in neonates nor during deep hypothermic drculatory arrest (DHCA). Histamine dfe~s could explain many penoperatJve c o m p l i ~ of congenital cardiac surgery such as dysrhythmias and massive oedema. Therefore, documentation of histamine release in the perioperative period is of dinical importance. The source of histamine can be determined by measurement of tryptase which is released with histamine from mast cells but not basophils. M e t h o d s : Blood samples for histamine and ~ were taken before and after specific events eg. cross-damp removaJ, dunng anaesthesia and CP8 in 14 infants and seven neonates undergoing complex congenital heart repairs and were analysed by commercial radioimmunoassays. Haemodynamic vanables and pre and post-op weights were recorded to look for correlation between ~ y s i o b g i c a l events and histamine release. R~ts: Histamine concentration decreased at the start of bypass (0.69 to 0.38 ng'ml -~ at five minutes, (P < .005). There were no changes associated with DHCA and a small dse wi~ reven'dlatJon(P < 0.02). Histamine concentration was lower in neonates than in infants (P < 0.05) during CPB. Plasma histamine and t~/ptase concentrations did not correlate, suggesting histamine release was from basophils and not from mast cells. Haemodynamic variables did not correlate with histamine concentrations. C o n d u a i o n : Them was no major histamine release during CPB in infanls and neonates. There was no relationship between histamine concentrations and dinical variables. Histamine released dudr~ CPB appears to come from basophils and may be a function of age.
Objcctif: La liberation d'h~stamine a dEjA6t6 documentg,e chezdes enfantset des adultespendantla drculation extracorporelle (CEC), Ellen'a pas6t6 recherch6echez les nouveau-nEsou pendantl'arr6t circu~oire en hypothermieprofonde (ACHP). Les effetsde l'histaminepourraientexpliquer plusieursdes complicationspostop~r-atoiresde la chirurgie des cardiopathies cong6nitales comme les dys~/thmies et roedhme pulmonaire massif. II est done important du point de vue dinique de corroborer la lil~ration d ' h i ~ i n e A la l~dode pEdop&atoire. La source de l'histamine peut d6terrnin~ par le dosage de la ~ lib&de avec l'histarnine par les mastocytes mais non les basophiles. M6thodes : Des dchantillons sangums ont 6tE pr61ev6s pour le dosage de l'histamine et de la tr~ptase avant et apr~s des 6v6nements spdcifiques, per ex. le relrait du damp aortique, pendant ranesbhEsieet la CEC, chez 14 enfants et sept nouveau-r~ soumis ~ des corrections chirurgicalesde malformations congEnitalescompliqudes. Les Echarf0llons ont analys6s par dosage radioimmunologique. Les variables l - ~ i q u e s et les pes~s pr~- et postop&atoires ont enre~str6es pour rechercher une corr61afion entre les 6v6nements physiopathologiques et la lib6ration d'histamine. ]R~ultal~ : La concentration d'histamine a diminuE au debut de la CEC de 0,69 ~ 0,38 r~-mP' it la cinqui~me minute (P < 0,005). Aucun changement n'a dtd assodd ~ I'ACHP. Une tL,~re au~neni~ion est survenue a,~c la reprise de la ventJlation (P < 0,02). Pendant la CEC, les c o n c e ~ d'histamine des enfants ~aient infc~ieums ,~celles des nouveau-n& (P < 0,05). II n'y avait pas de corr61ation entre les concentrations de tO1gase et d'histamine, su~rant aimi que l'histamine dtait lib&6e ,~ partir des basophiles plut6t que des mastooltes. Les variables h~modynam~ue ne corr~laient pas avec les c o n c e n t ~ d'histamine. Conclusion : On n'a pas not6 de lil~ration importante d'histamine pendant la CEC chez les enfants et les nouveaur~s. l'histarnine lil~r6e semble provenir des basophiles et pounmit Etre en fonction de l'~:~e.
From the Departments of Anaesthesia, Montreal Children's Hospital and McGill University,2300 Tupper Street, Monu'Eal, Quebec H3H 1P3 and the Centre for Perinatal and Developmental Pharmacology Research," Lady Davis Institute, Jewish General Hospital, 3755, C6te Ste. Catherine, Montr6al, Qu6bec H3T IE2. Addrez correspond.mr.#to: Dr. D.E. Withington; Phone: 514-934-4463; Fax: 514-934-4341; E-mail:
[email protected] Supported by the Heart and Stroke Foundation of Qu6bec. Presented in part at the 5th International Congress of Cardiac, Thoracic and Vascular Anaesthesia, September 1995.
Acceptedfor publication 15 February 199Z
CAN J ANAESTH 1997 / 44:6 / pp 610-616
Withington & Aranda et al.: HISTAMINE RELEASEDURING PAEDIATRICCPB ISTAMINE release has been demonstrated at initiation o f cardiopulmonary bypass (CPB) in adults 1 and also on aortic cross-clamp removal and on reventilation o f the lungs in children aged over nine months. 2 Neonates have not been studied in this context and are particularly at risk from any destabilizing event since they show a more rapid and profound response to physiological stress. 3 The effect o f deep hypothermic circulatory arrest ( D H C A ) on plasma histamine concentrations has not been documented. This technique is frequently used to facilitate delicate procedures by providing bloodless conditions 4 in neonates and small infants. Reperfusion after D H C A may be anticipated to cause mediator release since myocardial reperfusion after coronary occlusion in animals has been demonstrated to provoke histamine release, s Histamine is the major mediator in systemic anaphylaxis, 6 producing effects ranging from urticaria to bronchospasm, capillary leak, cardiac dysrhythmias and haemodynamic collapse. 7,s Similar events are seen during and after congenital heart surgery: dysrhythmias are c o m m o n and capillary leak producing postoperative fluid overload with severe oedema is a major problem. Thus, histami.ne may play a rrle in the pathophysiology o f CPB. To be able to modulate histamine release, the source o f histamine must be known since mast cells can be stabilised by disodium cromoglycate whereas basophil degranulation is managed with receptor blockade. The cellular origin o f histamine can be determined by the simultaneous measurement o f plasma tryptase, 9 which is released along with histamine from mast cells but not from basophils. The objectives o f the present study were: 1) to measure plasma histamine concentrations during CPB in neonates and infants; 2) to examine the effect o f DHCA; 3) to determine the source o f histamine and 4) to describe any relationship between histamine release and pathophysiological changes during and after CPB.
H
Methods In our establishment D H C A may be used during the repair o f complex congenital heart disease in children o f less than one year o f age or
