Nutritional assessment and surgical risk makers in children submitted to cardiac surgery

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H e ito r P o n s L e ite , M a u ro F is b e rg , N e il F e rre ira N o v o , E lia n a B o rg e s R o d rig u e s N o g u e ira , Iv e te K o to m i U e d a

N u tr itio n a l a s s e s s m e n t a n d s u r g ic a l r is k m a k e r s in c h ild r e n

s u b m itte d to c a r d ia c s u r g e r y

Pediatrics Department,

Escola Paulista de Medicina -

S liD

Paulo, Brazil

In o rd e r to a sse ss th e n u tritio n a l sta tu s o f ch ild re n w ith h e a rt d ise a se s a n d to e va lu a te n u tritio n a l p a ra m e te rs fo r p re d ictin g p o sto p e ra tive co m p lica tio n s, 5 0 ch ild re n u n d e rg o in g to ca rd ia c su rg e ry a n d cla ssifie d in h ig h a n d lo w su rg ica l risk

p ro sp e ctive ly e va lu a te d . A sse ssm e n t p a ra m e te rs in clu d e d a n th ro p o m e try a n d p la sm a p ro te in s a lb u m in , tra n sfe rrin a n d p re a lb u m in .

T h e n u tritio n a l cla ssifica tio n a cco rd in g to W a te rlo w 's m o d ifie d crite ria sh o w e d a h ig h p re va le n ce o f'm a ln u tritio n in th e p o p u la tio n stu d ie d (7 8 % ). T h e m e a su re s o f a rm circu m fe re n ce w h e n lo ca te d b e lo w th e 5 th p e rce n tile sh o w e d a sig n ifica n t a sso cia tio n w ith

g e n e ra l p o sto p e ra tive co m p lica tio n s in th e h ig h risk g ro u p (a rm circu m fe re n ce , p= 0 ,0 0 1 9 ; a rm m u scle circu m fe re n ce , p= 0 ,0 4 1 9 ). T h e p e rce n ta g e o f w e ig h t p e r h e ig h t, se ru m a lb u m in a n d tra n sfe rrin h a s n o t p la ye d a p ro g n o stic ro le co n c~ rn in g p o sto p e ra tive m o rb id ity. T h e m e a n va lu e o f p re a lb u m in w a s sig n ifica n tly lo w e r in h ig h risk g ro u p p a tie n ts d e ve lo p in g p o sto p e ra tive

in fe ctio n s (p< 0 ,0 1 ) co m p a re d to th o se w h o d id n o t. T h e se n sitivity-sp e cificity a n a lysis o f p re a lb u m in a s risk in d ica to r fo r p o sto p e ra tive in fe ctio n w a s 8 7 .5 % a n d 5 9 % re sp e ctive ly.

T h e n u tritio n a l risk cla ssifica tio n se e m s to b e a g o o d w a y to id e n tify th e su b g ro u p s o f ch ild re n w ith a d d itio n a l p o sto p e ra tive su rg ica l risk. H o w e ve r, m o re sp e cific a n d se n sitive te sts a re d e sira b le to p ro vid e a n in d ivid u a l id e n tifica tio n o f th e se ch ild re n .

U N IT E R M S : N u tritio n a l a sse ssm e n t. M a ln u tritio n . C a rd ia c su rg e ry. P re a lb u m in .

C

h a r a c t e r i s t i c sr e t a r d a t i o n a r e f r e q u e n t l ys u c h a s m a l n u t r i t i o na s s o c i a t e d t o c o n g e n i t a la n d g r o w t h c a r d i o p a t h i e s c o n s i d e r i n g f a c t o r s t h a t m a y h a v e c o n t r i b u t e d f o r t h i s c o n d i t i o n , b e s i d e s a p o o r c a l o r i c n u t r i t i o n ( 1 4 , 2 0 ) , l o w v i t a m i n a n d o l i g o e l e m e n t s ( 1 0 ) , o t h e r r e a s o n s h a v e b e e n o u t l i n e d s u c h a s h y p e r m e t a b o l i s m , c e l l u l a r h y p o x e m i a ( 1 8 , 1 9 ) a n d r e d u c t i o n o f t h e i n t e s t i n a l a b s o r p t i o n o f t h e n u t r i e n t s .

A d d re s s fo r c o rre s p o n d e n c e : H e ito r P o n s L e ite

R u a R io G ra n d e , 5 0 - A p to . 8 4

S a o P a u lo - S P - B ra s il - C E P 0 4 0 1 8 -0 0 0

I n c a r d i o p a t h i c c h i l d r e n , m a l n u t r i t i o n e f f e c t s m a y b e c l i n i c a l l y m u c h m o r e i m p o r t a n t i n s i t u ~ t i o n s o f m e t a b o l i c s t r e s s , a s 'i t o c c u r s w h e n t h e y a r e s u b m i t t e d t o g r e a t s u r g e r i e s . T h e s u r g i c a l s t r e s s a d d e d u p t o a p r e c e d e n t h a z a r d o u s n u t r i t i o n a l s t a t u s m a y b e c o m e e v e n m o r e p r o b l e m a t i c , c a u s i n g s e r i o u s c o n s e q u e n c e s

tq

t h e p a t i e n t ( 1 5 ) . T h i s s i t u a t i o n i n f l u e n c e s d i r e c t l y t h e h o s p i t a l e v o l u t i o n p a r a m e t e r s , c a u s i n g d e l a y i n c i c a t r i z a t i o n ( 2 6 ) , i n c r e a s e o f p o s t o p e r a t i v e i n f e c t i o n r a t e s ( 1 6 ) , l o n g e r c o n f i n e m e n t p e r i o d a n d m o r b i d i t y r a t e s i n c r e a s e ( 6 ) .

T h e r e a r e v e r y f e w w o r k s p u b l i s h e d r e g a r d i n g c a r d i o s u r g e r y ( 1 , 3 ) a n d l i t e r a t u r e d o e s n o t p r e s e n t s p e c i f i c s t u d i e s b e a r i n g p e d i a t r i c a g e d p a t i e n t s . B a s e d o n e v i d e n c e s u p o n w h i c h m a l n u t r i t i o n s t a t u s m a y a f f e c t p r o g n o s t i c o f

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•

patients undergoing to surgery, it seem s reasonable to believe that identification of patients w ith tendency to com plications due to m alnutrition, m ay enable a m ore approxim ate estim ative of the surgical risk and help in his

recuperation. W e have considered opportune a study 9f

the nutritional status of cardiopathic children selected for cardiosurgery and the param eters of nutritional evaluation as being risk indicators of postoperativ~ com plications of these children.

CASUISTIC AND METHODS

T his study w as approved by the ethics com m ittee of the E scola Paulista de M edicina.

Sketch of the study

In a prospective study m ade during the period of

O ctober 90 till O ctober 92, 50 cardiopathic children, chosen for a selective cardiosurgery at the H ospital Sao Paulo, w ere evaluated. B efore surgery, each patient has been subm itted to a nutritional evaluation and has been follow ed regarding his postoperative evolution till leaving hospital. N utritional assessm ent com prised anthropom etric and plasm atic protein dosage.

Patients

Patients w ere classified in tw o groups of surgical risk (high and low ) according evaluation during pre, intra and postoperative periods, perform ed by the C ardiology D ept. of the E scola Paulista de M edicina, based on cardiopathies, clinical status and kind of surgery, based on the w ork of K IR K L IN

&

B A R R A T T -B O Y E S (11). C hildren identified w ith at least one of the item s below w ere considered as pertaining to high surgical risk group:

- Presence of previous cardiac insufficiency. - Presence of outstanding lung hypertension, defined as a relation betw een the systolic pressure of the pulm onary trunk and the aortic pressure of m ore than 0.6, or a relation of the systolic pressure of the right ventricle over the left, higher than 0.6.

- E xtracorporeal circulation presenting long perfusion tim e (m ore than 70 m inutes).

- U nstableness of haem odynam ic during intra or

postoperati ve: shock, cardioinsufficiency, persistent arrhythm ia or cardiac arrest during surgery.

C hildren not identified w ith at least one of these item s, w ere classified as pertaining to low surgical risk

group. T he follow ing w ere excluded from the study:

patients born w ith less than 2.500 gr. w eight, presenting

renal and hepatic insufficiency, central paralysis,

congenital im m unology deficiency or infective process, and those w ho w ere subm itted to blood transfusion during the last 30 days period.

H igh risk group, a total of 30 children, w as m ainly com posed by patients presenting cyanotic cardiopathies and other cardiac diseases associated to significan~ lung hypertension. T he low risk group, form ed by 20 children, w as m ainly com posed by patients presenting acyanotic cardiopathies w ith pulm onary overflow . T able 1 show s

children according cardiopathies and type of surgery

perform ed. A control group w as form ed, com posed by 20 eutrophic children subm itted to a selective iniguinal or um bilical herniorraphy, w ho w ere laboratorie evaluated

exactly according the sam e patterns as the children

pertaining to the study group w ere subm itted to.

Anthropometric parameters

A nthropom etric param eters considered w eight,

height, cutaneous triciptal plica, arm circum ference and arm m uscle circum ference. For classification of nutritional condition, m odified criteria of W ater low w ere used (25,2).

A s reference for m easures of w eight, height and

correspondent relation, standards adopted by the

W O R L D W ID E H E A L T H O R G A N IZ A T IO N w ere used (7). T he percentage of w eight per height located below percentile 10 w as considered indicative of postoperative com plications risk. A nthropom etric m easures of arm and

calculation of brachial m uscle circum ference w ere

obtained according procedures indicated in literature (8). C utaneous triciptal plica w as obtained using the L ange's plicom eter. M easures of the cutaneous triciptal plica, brachial circum ferences and adipose and m uscle areas of the arm in children less than 1 year old, w ere com pared to FR ISA N C H O (8) standards, considering percentile less than 5 ~s postoperative m orbidity risk indicator. A ll the anthropom etric m easures w ere taken by the sam e exam iner.

Plasmic proteins

Serum uria dosage w as obtained through green

brom ocresol (7) m ethod. Prealbum in and transferrin

dosages w ere m ade through the single radial

im m unodiffusion m ethod (12) using, respectively, M

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n D ia g n o s e

Table 1

Children according diagnose and surgery performed

S u rg e ry

4

3

2 2

2

1

1 1 1

1

1 1

1

1 . 1

1

P .C .A .

F a llo t T e tra lo g y

C .I.V . a n d H .P .

C .I.A .

C .I.V . a n d im p o rta n t H .P .

O .A .V .C ., P .C .A . a n d im p o rta n t H .P .

F a llo t T . a n d O .A .V .C .

P .C .A .,C .I.V .,C .I.A . a n d I.C .C .

C .I.V . a n d E .M .

D .V .E .V .E ., D .V .S .V .D ., V D H y p o p la s ia

D .V .S .V .D ., C .I.A ., a n d im p o rta n t H .P .

D .V .S .V .D .,E .P .,tric u s p id in s u ffic ie n c y

T .G .V .B .

C .I.V .,C .I.V .A .,P .C .A . a n d im p o rta n t H .P .

C .I.V .,C .I.A . a n d H .P .

O .A .V .C .,P .C .A .,C .I.V . a n d im p o rta n t H .P .

1 0 M .d u e rh e u m a tic d is e a s e

I.M . a n d I.A o . d u e rh e u m a tic d is e a s e

S u b a o rtic C .I.V . a n d im p o rta n t H .P .

D .V .S .V .D .

A n o m a lo u s o rig in o f th e p u lm o n a ry a rte ria

in th e a o rta , P .C .A . a n d im p o rta n t H .P .

C .I.V . a n d H .P .

I.M . d u e rh e u m a tic d is e a s e

S u p ra d ia p h ra g m a tic D .V .A .P . a n d C .I.V .

M u ltip le (3 ) C .I.V .

P .C .A . a n d I.C .C .

R ig h t c o ro n a ry fis tu le

P .C .A . a n d im p o rta n t H .P

V a lv u la r E .A o .

A .T ., C .I.A . a n d C .I.V .

C .I.V . a n d P .C .A .

C .I.A . a n d P .C .A .

A .P . a n d v e n tr.tric u s p id d is p la s y

H y p e rtro p h ic s u b a o rtic s te n o s is

A n o m a lo u s V D m u s c le 's b a n d

C .I.A .,C .I.V . a n d tric u s p id a tre s ia

L ig a tu re o f th e a rte ria l c h a n n e l

B la lo c k T a u s s ig

C .I.V . c lo s u re

T o ta l c o rre c tio n

A th rio s e p to p la s ty

T o ta l c o rre c tio n a n d lig a tu re o f th e a rte ria l c h a n n e l

B la lo c k T a u s s ig

L ig a tu re o f th e a rte ria l c h a n n e l a n d c lo s in g o f th e C IV a n d C IA

C lo s in g o f th e C .I.V .

T o ta l c o rre c tio n

B ip u lm o n a ry -c a v a a n a s to m o s e

C IV c lo s u re ; a o rta -V E tu n n e lin g

V e n tric u lo p la s ty a n d a o rta -V E tu n n e lin g

S u rg e ry o f S e n n in g

C lo s in g o f C IV ,C IA :lig a tu re o f th e

a rte ria l c h a n n e l

C lo s in g o f C .I.V . a n d C .I.A .

T o ta l c o rre c tio n o f O A V C a n d lig a tu re

o f th e a rte ria l c h a n n e l

M itra l v a lv e p la s ty a

M itra l p la s ty a a n d c h a n g e o f th e a o rtic v a lv e

C .I.V .c lo s u re

A o rta -V E tu n n e lin g , C .I.V . a n d C .I.A . c lo s u re

Im p la n ta tio n o f p u lm o n a ry a rte ria in th e

p u lm o n a ry tru n k a n d lig a tu re o f th e a rte ria l c h a n n e l V e n tri c u lo s e p to p Ia s ty

M itra l p la s ty

T o ta l c o rre c tio n .o f th e a n o m a lo u s d ra in a g e

L ig a tu re o f th e fis tu le a n d th e a n e u ry s m a l s a c c u s

A o rtic c o m m is s u ro to m y

A trio s e p to p la s ty a n d lig a tu re o f th e a rte ria l c h a n n e l

B la lo c k ,T a u s s ig

T ra n s a o rtic m y o m e c to m y

R e s s e c tio n o f m u s c le 's b a n d

C .I. V .: in tra v e n tric u la r c o m m u n ic a tio n P .C .A .: a rte ria l c h a n n e l p e rs is te n c e

D .A .V .P .: a n o m a lo u s d ra in a g e o f p u lm o n a ry v e in E .M .: m itra l s te n o s is

H .P .: p u lm o n a ry h y p e rte n s io n

O .A .V .C .: c o m m o n o s te o :-a trio v e n tric u la r T .G .V .B .: tra n s p o s itio n o f th e g re a t b a s e v a s e s

C .I.A .: in tra a rte ria l c o m m u n ic a tio n

D .V .S .V .D .: d o u b le o u tle t o f th e rig h t v e n tric le E .A o .: a o rtic s te n o s is

I.M .: m itra l in s u ffic ie n c y E . P .: p u lm o n a ry s te n o s is

D .V .E .V .E .: d o u b le in le t o f th e le ft v e n tric le

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P a r tig e n @ P r e a lb u m in a n d N o r - P a r tig e n @ T r a n s f e r r in

( B e h r in g ) p la q u e s . F o r th e a n a ly s is o f th e s e p r o te in s , a

c u r v e w a s o u tlin e d u s in g th r e e p r o g r e s s iv e d ilu tio n s o f a

s ta n d a r d s e r u m .

Definition of postoperative complications

P o s to p e r a tiv e m o r b id ity w a s d e s c r ib e d a s th e

p r e s e n c e o f c o m p lic a tio n s r e q u ir in g a s p e c if ic th e r a p y ;

m o d e l o f p r o c e d u r e p r o p o s e d b y B U Z B I e t a l. ( 5 ) w a s

u s e d f o r th e d e f in itio n o f p o s to p e r a ti v e c o m p lic a tio n s . F o r

th e e v a lu a tio n o f n u tr itio n a l p a r a m e te r s a s p o s to p e r a tiv e

m o r b id ity in d ic a to r s , in f e c tio u s c o m p lic a tio n s w e r e

c o n s id e r e d b o th , s e p a r a te ly a n d to g e th e r w ith o th e r

c o m p lic a tio n s a s w e ll.

Statistic method

P a r a m e tr ic a n d n o n - p a r a m e tr ic te s ts w e r e u s e d f o r

th e a n a ly s is o f r e s u lts , ta k in g in to c o n s id e r a tio n

d is tr ib u tio n a l n a tu r e o f th e v a lu e s o f v a r ia b le s s tu d ie d :

F o llo w in g te s ts w e r e a p p lie d .

1 . A n a ly s is o f th e v a r ia n c e o f c r ite r ia ( 2 2 ) to c o m p a r e

th e th r e e g r o u p s s tu d ie d , in w h a t r e f e r s to th e p r o te in v a lu e s

m e a s u r e d d u r in g th e p r e o p e r a tiv e p e r io d . W h e n a n

o u ts ta n d in g d if f e r e n c e s h o w e d u p , a n a ly s is w a s

c o m p le m e n te d b y th e S c h e f f 6 ( 2 2 ) c o n tr a s tin g te s t.

2 . S tu d e n ts " T " te s t f o r tw o in d e p e n d e n t s a m p le s

( 2 2 ) , w h e n c o m p a r e d to g r o u p s o f p a tie n ts p r e s e n tin g o r

n o t p o s to p e r a ti v e c o m p lic a tio n s , in w h a t r e f e r s to th e

p r o te in v a lu e s .

3 . E x a c t F is h e r ( 2 1 ) te s t w ith th e p u r p o s e o f

c o m p a r in g g r o u p s w ith a n d w ith o u t p o s to p e r a tiv e

c o m p lic a tio n s in w h a t r e f e r " s to th e p e r c e n tile s o f

a n th r o p o m e tr ic p a r a m e te r s s tu d i~ d .

A 0 .0 5 % o r 5 % le v e l w a s f ix e d f o r a ll th e te s ts , in

c a s e o f p a r ity th e o r y r e je c tio n . P r o te in p la s m ic e v a lu a tio n s

a s in d ic a ti v e o f p o s to p e r a ti v e s u r g ic a l r is k w e r e b a s e d o n

a p r e v io u s s e n s ib ility a n d s p e c if ic ity a n a ly s is ( 9 ) .

S e n s ib ility w a s d e f in e d a s th e p e r c e n ta g e o f p a tie n ts

p r e s e n tin g v e r y h ig h p o s to p e r a tiv e r is k , s e le c te d a c c o r d in g

a h ig h r is k in d ic a to r o f p o s to p e r a tiv e p r o b le m s , a m o n g

th o s e w h o ~ a v e s u f f e r e d c o m p lic a tio n s . S p e c if ic ity w a s

d e f in e d a s th e p e r c e n ta g e o f p a tie n ts s e le c te d a c c o r d in g a

lo w r is k in d ic a to r o f p o s to p e r a tiv e p r o b le m s , a m o n g a ll

w h o h a v e n o t s h o w n c o m p lic a tio n s . F o llo w in g w e r e th e

v a lu e s c o n s id e r e d a s b e in g a b n o r m a l: a lb u m in p r e s e n tin g "

c o n c e n tr a tio n b e lo w 3 .5 g /d l a n d tr a n s f e r r in p r e s e n tin g

c o n c e n tr a tio n lo w e r th a n 2 0 0 m g /d l. I n w h a t r e f e r s to .

p r e a lb u m in , m e d iu m c o n c e n tr a tio n o f th e h ig h s u r g ic a l

r is k g r o u p w a s c o n s id e r e d a s b e in g th e lim it ( 1 9 .6 m g /d l) .

R E S U L T S

T h e m a in c h a r a c te r is tic s o f th e tw o s u r g ic a l r is k

g r o u p s a n d f r e q u e n c y o f p o s to p e r a tiv e c o m p lic a tio n s a r e

s h o w n o n ta b le s 2 a n d 3 r e s p e c tiv e ly .

C la s s if ic a tio n o f th e n u tr itio n a l s ta tu s m a y b e

o b s e r v e d o n ta b le 1 , s h o w in g th e n u tr itio n a l c o n d itio n o f

c h ild r e n p r e s e n tin g , r e s p e c tiv e ly , h ig h a n d lo w s u r g ic a l

r is k . P r e v a le n c e o f m a ln u tr itio n w a s o f 7 8 % , 9 0 %

p e r ta in in g to th e h ig h r is k g r o u p a n d 6 0 % to th e lo w r is k

g r o u p . I n th e h ig h r is k g r o u p 8 3 .3 % o f th e p a tie n ts

p r e s e n te d h e ig h t x a g e b e lo w p e r c e n tile 1 0 a n d s a m e

T a b le 2

M a in ch a ra cte ristics o f h ig h a n d lo w su rg ica l risks

A G E S E X (M /F )

C O N F IN E M E N T T IM E C .E .C .

U S E O F V A S O A C T IV E D R U G S C O M P L IC A T IO N S

IN F E C T IO N M O R T A L IT Y

C .E .C .: E xtra -co rp o re a l circu la tio n

H IG H R IS K (N = 3 0 )

M i: 1 2 m (3 -1 3 4 )

1 5 /1 5

M i: 1 1 d a ys (6 -3 6 ) 2 6 p a tie n ts

M i: 6 6 .5 h 6 3 .3 0 /0 2 6 .6 %

2

L O W R IS K (n = 2 0 )

M i: 4 2 m (3 -1 4 0 ) 8 /1 2 x: 7 d a ys (4 -9 )

9 p a tie n ts

o

1 5 %

o

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Table 3

H igh and low surgical risk children according the postoperative types of com plication

s itu a tio n w a s o b s e rv e d in 4 5 % o f p a tie n ts p e rta in in g to

th e lo w ris k g ro u p . U n d e r p a th o lo g ic lo w h e ig h t c o n d itio n ,

lo c a te d b e lo w p e rc e n tile 3 , 6 3 .3 % o f h ig h ris k c h ild re n

a n d

350/0

o f lo w ris k c h ild re n w e re id e n tifie d .

P re o p e ra tiv e a v e ra g e c o n c e n tra tio n s o f p la s m ic

p ro te in s s tu d ie d in th e th re e g ro u p s a re fo u n d o n ta b le 4 .

M e d iu m c o n c e n tra tio n s o f p re a lb u m in in c a rd io p a th ic

c h ild re n w e re s ig n ific a n tly lo w e r th a n th e c o n c e n tra tio n s

C ardioarrithm ia 7

H ypotension 2

C ardiogenic shock 6

.C ongestive cardio insufficiency 3

C ardiac "buffer" 1

Lobar atelectasis 2

Pneum othoracic 1

H aem othorax 2

Pneum onia 5

M ediastinitis 1

Sepsis 1

Incision infection 1

Acute otitis m edia 1

H aem orrhagic disturb 4

H ydroelectric disturb 8

M etabolic acidosis 3

S.disfunction of m ultiple organs 3

R enal insufficiency 1

C om plications H igh risk Low risk

o

1

o

fo u n d in th e c o n tro l. g ro u p . H o w e v e r, 6 o f th e p a tie n ts

w ith w e ig h t x h e ig h t lo c a te d b e lo w p e rc e n tile 2 .5 ,

p re s e n te d n o rm a l le v e ls . M e d iu m a lb u m in v a lu e s in

c a rd io p a th ic p a tie n ts s h o w e d s ig n ific a n tly lo w e r in

c o m p a ris o n to th e c o n tro l g ro u p , b e in g th e v a lu e o b s e rv e d

in th e h ig h ris k g ro u p s ig n ific a n tly lo w e r in c o m p a ris o n

to th e v a lu e o b s e rv e d in th e lo w ris k g ro u p . N o s ig n ific a n t

v a ria tio n w a s o b s e rv e d b e tw e e n th e th re e g ro u p s in w h a t

re fe rs to th e tra n s fe rrin p o s to p e ra tiv e v a lu e s . It w a s a ls o

o b s e rv e d th a t, fro m th e 3 3 c h ild re n s tu d ie d n o t p re s e n tin g

c y a n o tic c a rd io p a th ie s , 2 7 .8 2 % s h o w e d h e m o g lo b in ra te s

le s s th a n 1 1 g /d l.

B ra c h ia l c irc u m fe re n c e m e a s u re s a n d a rm m u s c le

c irc u m fe re n c e w h e n lo c a te d b e lo w p e rc e n tile 5 , s h o w e d

a s s o c ia tio n w ith g e n e ra l c o m p lic a tio n s in th e h ig h ris k

g ro u p d u rin g th e p o s to p e ra tiv e p e rio d , a s it m a y b e

o b s e rv e d o n ta b le 6 . T h is a s s o c ia tio n w a s n o t o b s e rv e d

w h e n o n ly in fe c tio u s c o m p lic a tio n s w e re c o n s id e re d .

W e ig h t x h e ig h t ra tio , w h e n lo c a te d b e lo w p e rc e n tile 1 0 ,

w a s n o t a s s o c ia te d to a n y s ig n ific a n t p o s to p e ra tiv e

m o rb id ity . P re o p e ra tiv e p la s m ic p ro te in v a lu e s d id n o t

s h o w a s s o c ia tio n w ith g e n e ra l p o s to p e ra tiv e

c o m p lic a tio n s . M e d iu m c o n c e n tra tio n o f p re a lb u m in w a s

s ig n .ific a n tly lo w e r in p a tie n ts w h o d e v e lo p e d

p o s to p e ra tiv e in fe c tio n , th e s a m e b e in g n o t o b s e rv e d in

w h a t re fe rs to a lb u m in a n d tra n s fe rrin . P la s m a tic p ro te in

p re o p e ra tiv e v a lu e s in th e h ig h ris k g ro u p , in th e p re s e n c e

o r n o t o f in fe c tio u s c o m p lic a tio n s d u rin g p re o p e ra tiv e

p e rio d a re s h o w n o n ta b le 7 .. R e s u lts o f th e s e n s itiv ity

-s p e c ific ity a n a ly s is o f p la s m ic p ro te in a s ris k in d ic a to rs

fo r p o s to p e ra tiv e m o rb id ity w e re re s p e c tiv e ly : a lb u m in

6 3 .3 % a n d 3 7 .5 % , tra n s fe rrin z e ro a n d 1 0 0 % ; p re a lb u m in

5 9 .1 % a n d 6 2 .5 % . C o n s id e rin g o n ly in fe c tio u s

Table 4

Preoperative average values of pre-album ine (m g/dl), transferrin (m g/dl), and album in (g/dl) in the high risk group, low risk group and control group

PR EALBU M IN

AVER AG E D .P.

TR AN SFER R IN

AVER AG E D .P.

ALBU M IN

AVER AG E D .P.

H IG H R ISK LO W R ISK C O N TR O L

1 9 .1

18.3 22.0*

4 .0

3 .8

2 .7

327.2 328.8

333.3

5 9 .9

51.4

3 5 .6

3.38 3.68t 4.02*

0 .4 1

0 .4 6

0 .2 5

Analysis of variance - Scheffe test

*control> high risk and low risk

t

low risk> high risk

(6)

T a b le 5

B ra c h ia l c irc u m fe re n c e p e rc e n tile in c h ild re n o f h ig h ris k g ro u p in th e p re s e n c e o f p o s to p e ra tiv e

c o m p lic a tio n s

T a b le 6

e e rc e n tile o f b ra c h ia l m u s c le c irc u m fe re n c e in c h ild re n o f h ig h ris k g ro u p in th e p re s e n c e o f

p o s to p e ra tiv e c o m p lic a tio n s

C O M P L IC A T IO N S P E R C E N T IL E T O T A L C O M P L IC A T IO N P E R C E N T IL E T O T A L

> 5 < 5 > 5 < 5

Y E S 0 9 9 Y E S 4 5 9

N O 5 1 6 N O 6 0 6

T O T A L 5 1 0 1 5 T O T A L 1 0 5 1 5

E x a c t F is h e r T e s t E x a c t F is h e r T e s t

p = 0 ,0 0 1 9 p = 0 ,0 4 1 9 5

c o m p lic a tio n s , fo llo w in g re s u lts w e re o b ta in e d : a lb u m in

6 2 .5 % a n d 3 6 .6 % ; tra n s fe rrin z e ro a n d 1 0 0 % a n d

p re a lb u m ~ n 8 7 .5 % a n d 5 9 % .

D IS C U S S IO N

firm ly re g is te re d , it is lim ite d in s itu a tio n s o f fe rru m

d e fic ie n c y , w h e n its c o n c e n tra tio n is in c re a s e d . In th is

s tu d y , 8 2 % o f th e c a rd io p a th ic c h ild re n c a rry in g n o

c y a n o tic c a rd io p a th ie s , p re s e n te d h e m o g lo b in v a lu e s

b e lo w n o rm a l le v e ls , fa c t th a t m a y e x p la in th e n o rm a l

s e ru m tra n s fe rrin v a lu e .

4 0 %

H IG H S U R G IC A L R IS K L O W S U R G IC A L R IS K

P re g re s s iv e D is e a s e

A c u te D is e a s e

E u tro p h ic

[l]] C h ro n ic D is e a s e

D

P re g re s s iv e D is e a s e

- A c u te D is e a s e

III

E u tro p h ic

[l]] C h ro n ic D is e a s e

D

[ I

I I

7 %

F ig u re 1 - N u tritio n a l c o n d itio n a c c o rd in g W a te rlo w .s c rite rio n

b a s e d o n th e s u rg ic a l ris k T h e h ig h p re v a le n c e o f m a ln u tritio n in c h ild re n

s tu d ie d a re in a c c o rd a n c e w ith lite ra tu re d a ta o n p ro te in

-c a lo ri-c m a ln u tritio n in c a rd io p a th ic c h ild re n (1 3 ). T h e

p re v a le n c e o f m a ln u tritio n in th e h ig h ris k g ro u p in

c o m p a ris o n to th e o b s e rv e d in th e lo w ris k g rl)u p m a y b e

e x p la in e d b y th e fa c t th a t th e firs t g ro u p w a s c o m p o s e d

b y c h ild re n w ith m o re s e rio u s c a rd io p a th ie s a n d th e h ig h e r

h a e m o d y n a m ic c o n s e q u e n c e s . A n o th e r im p o rta n t fa c to r

d is tin g u is h in g m a ln u tritio n s itu a tio n b e tw e e n c h ild re n o f

b o th g ro u p s w a s th e p re v a il o f lo w h e ig h t in c h ild re n

s h o w in g h ig h s u rg ic a l ris k . T h e s e d a ta , in a d d itio n to th e

h ig h e r c h ro n ic m a ln u tritio n fre q u e n c y , in c lin e fa v o ra b ly

fo r a p re v io u s a n d m o s t in te n s iv e n u tritio n a l in v o lv e m e n t

in c h ild re n p re s e n tin g h ig h s u rg ic a l ris k s , p ro b a b ly

a s s o c ia te d to th e c a rd io p a th ic s e rio u s n e s s .

S e ru m a lb u m in ra te s in b o th s u rg ic a l ris k g ro u p s ,

a lth o u g h in fe rio r to th e c o n tro l g ro u p , a p p e a re d w ith in

n o rm a l ra te s . S e ru m a lb u m in , h a v in g a lo n g life tim e a n d

d u e to e x tra v a s c u la r " p o o l" re d is trib u tio n , d o e s n o t re fle c t

a d e q u a te ly th e p ro te in /c a lo ric m a ln u tritio n , u n le s s v e ry la te

a n d 'w h e n th e p ro te in o ffe r is a lm o s t n o n e .

P re o p e ra ti v e c o n c e n tra tio n s o f tra n s fe rrin a p p e a re d

b e tw e e n n o rm a l le v e ls in a ll th e c h ild re n s tu d ie d

(c a rd io p a th ie s a n d c o n tro l g ro u p ). A lth o u g h th e v a lu e o f

th is p a ra m e te r fo r th e m a ln u tritio n d e te rm in a tio n h a s b e e n

(7)

M e d iu m c o n c e n tra tio n s o f p re a lb u m in , sim ila r in

b o th o f th e su rg ic a l risk g ro u p s, w e re lo w e r th a n th e

sh o w e d in th e c o n tro l g ro u p .' S A L Z E R e t a l. (2 0 ), stu d y in g

1 6 c h ild re n p re se n tin g c o n g e n ita l c a rd io p a th ie s, o b se rv e d

th a t a lth o u g h p re se n tin g a sh o rta g e in w e ig h t x h e ig h t a n d

h e ig h t x a g e , p re a lb u m in v a lu e s w e re w ith in n o rm a l ra te s.

In th e p re se n t stu d y , m e d iu m c o n c e n tra tio n o f a lb u m in in

c a rd io p a th ic c h ild re n w a s lo w e r th a n th e o b se rv e d in th e

c o n tro l g ro u p , n e v e rth e le ss so m e o f th e c h ild re n sh o w in g

w e ig h t d e fic ie n c y in c o m p a riso n to th e ir h e ig h t, p re se n te d

n o rm a l v a lu e s o f th is p ro te in . T h is re su lt, in a d d itio n to

th e stu d y p re v io u sly re p o rte d , su g g e sts th a t th e p re a lb u m in

re le v a n c e in th e in d iv id u a l n u tritio n a l a sse ssm e n t is a lre a d y

p e n d in g o n a d e fin itio n .

In th e p re se n t stu d y , p a ra m e te rs o f th e e x p e c te d

w e ig h t x h e ig h t h a s n o t p la y e d a p ro g n o stic ro le c o n c e rn in g

p o sto p e ra tiv e m o rb id ity . A lth o u g h a sig n ific a n t a sso c ia tio n

b e tw e e n th e m e a su re s o f b ra c h ia l a n d th e b ra c h ia l m u sc le

c irc u m fe re n c e s, m o d ifie d , a n d th e p o sto p e ra tiv e m o rb id ity ,

th is c a lls fo r a v e ry c a re fu l u n d e rsta n d in g . A n th ro p o m e tric

a rm m e a su re s w e re o n ly p e rfo rm e d in c h ild re n o ld e r th a n

1 y e a r, in a to ta l o f 1 5 c h ild re n o f th e h ig h risk g ro u p , a

n u m b e r th a t m a y n o t b e e n o u g h fo r c o n sid e rin g th e

a sso c ia tio n o b se rv e d a s c lin ic a lly sig n ific a n t.

It w a s n o t p o ssib le to se p a ra te c h ild re n stu d ie d b y

th e u su a l a n th ro p o lo g ic a l p a ra m e te rs b a se d o n w e ig h t a n d

h e ig h t, in g ro u p s o f h ig h e r m o rb id ity risk . T h is c a n b e

d u e , p ro b a b ly , to th e fa c t th a t h ig h risk g ro u p w a s

c o m p o se d , q u ite a ll, b y c h ild re n su b m itte d to p o o r d ie t.

A s fe w p a tie n ts sh o w e d n o rm a l ra te s, th e se p a ra m e te rs

h a v e p ro b a b ly lo st th e ir d iffe re n tia l p u rp o se .

S tu d ie s v a ry in w h a t re fe rs to p ro g n o stic c a p a b ility

o f n u tritio n a l p a ra m e te rs in su rg ic a l p a tie n ts. S Y M R E N G

e t a l. (2 4 )" stu d y in g a d u lt p a tie n ts su b m itte d to se le c tiv e

su rg e rie s, o f d iffe re n t se rio u sn e ss a n d risk s, fo u n d lo w e r

a lb u m in a n d p re a lb u m in ra te s in th e p re o p e ra tiv e p e rio d

in th o se w h o d e v e lo p e d p o sto p e ra tiv e c o m p lic a tio n s, th e

sa m e b e in g n o t o b se rv e d in w h a t c o n c e rn s to th e

a n th ro p o m e tric p a ra m e te rs. B R O D E N e t a l. (4 ), stu d y in g

a d u lt p a tie n ts, d e m o n stra te d a p re d ic tiv e v a lu e o f a lb u m in

a n d tra n sfe rrin in p o sto p e ra tiv e c o m p lic a tio n s. H is

c a su istic re fe rre d to se le c tiv e a n d to u rg e n t su rg e rie s,

in c lu d in g a h ig h n u m b e r o f p a tie n ts c a rry in g th e m o st

d iffe re n t tra u m a s, situ a tio n c lo se ly a sso c ia te d to th e p ro te in

ra te s d e c re a se .

R e g a rd in g c a rd io su rg e ry , stu d y o f A B E L e t a l. (1 ),

p e rfo rm e d in a d u lt p a tie n ts w ith isc h e m ic c a rd io p a th ie s

m a y b e p o in te d o u t a s a re fe re n c e . A u th o rs d id n o t fin d

a n y c o rre la tio n b e tw e e n m a ln u tritio n p ro b le m s a n d

p o sto p e ra tiv e c o m p lic a tio n s. T h e y su g g e st th a t

c h a ra c ~ e ristic s o f th e g ro u p stu d ie d m a y h a v e c o n trib u te d

. fo r th is re su lt, a s th e m o st p a rt o f th e se p a tie n ts sh o w e d

a rte rio sc le ro sis, slig h t o v e rw e ig h t, b e in g th e

a n th ro p o m e tric m e a su re s, te sts o f im m u n o lo g ic fu n c tio n

a n d p la sm a tic p ro te in s w ith in th e n o rm a l ra te s. It is v e ry

d iffic u lt to c o m p a re th e re su l.ts o f th is stu d y w ith th o se

fo u n d in lite a tu re , o n c e in th e p re v io u s w o rk s su b m itte d ,

c a su istic w a s h e te ro g e n e o u s a n d c o n stitu te d b y a d u lts,

b e in g m a ln u tritio n p r~ v a le n c e in fe rio r to th e o b se rv e d in

th is stu d y .

A n a ly sis o f se n sitiv ity a n d sp e c ific ity o f th e

p re o p e r.a tiv e p la sm a tic p ro te in le v e ls a s in d ic a to rs o f

p o sto p e ra ti v e c o m p lic a tio n s su g g e st th a t a lb u m in is a v e ry

fe w se n sib le a n d sp e c ific p a ra m e te r a n d tra n sfe rrin h a s

n o v a lu e fo r th is, o n c e v a lu e s w e re n o rm a l in a ll o f th e

c h ild re n . P re a lb u m in w a s a se n sib le p a ra m e te r, a lth o u g h

Table 7

P reoperative values of prealbum in (m g/dl), tranferrin (m g/dl) and album in (g/dl) in the high risk group in w hat refers to postoperative com plications incidence

PR EALBU M IN

AVER AG E D .P..

TR AN SFER R IN

AVER AG E D .P.

ALBU M IN

AVER AG E D .P.

W ITH IN FEC TIO N W ITH O U T IN FEC TIO N

15.4*

2 0 .4

3.1

3 .5

325.9

3 2 7 .8

6 2 .0

6 0 .6

3.23

3.46

0.52

0.33

* Student "T" Test for no-parity values

p <0,01

(8)

little specific in the prognostic of infectious complications

in children pertaining to high surgical risk,' during the

postoperati ve cardiosurgeries period.

Assessment based on well defined clinical

parameters, anthropometric and biochemical, may

positively perform the malnutrition diagnose. More

important, however, is identification of the nutritional

parameters associated to the morbidity increase. This could

enable a correct nutritional support to these children during

a certain period before the surgery, improving their

nutritional conditions so that they may face surgical trauma

in more favorable conditions. In this study, the nutritional

assessment enabled identification, within a group of

patients basically malnutritioned and under high surgical

risk, a subgroup of children with an additional

postoperative morbidity risk. Need persists, however, in

the identification of a parameter sufficiently sensitive ~nd

specific, to characterize these patients individually.

ACKNOWLEDGEMENT

Authors thank to Prof. Dr. Antonio Carlos de

Camargo de Carvalh~, of the Cardiology Discipline, to

Prof. Dr. Miguel Angel Maluf, of the Cardiovascular

Discipline of the E.P.M. and to HOECHST do Brasil

-Behring Diagnosis Division, for the support given.

(9)

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