Andersons pediatric cardiology 2260
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FIG.88.3 Severelyemaciatedchildwithalargeventricularseptaldefect
recoveringaftersurgicalcorrection.Thebabyweighed2.56kgat6
months;hisbirthweightwas2.1kg.
Althoughundernutritioniswidelyacknowledgedasanimportantcomorbidity
inchildrenwithheartdiseases,opinionsaredividedonitsimpacton
postoperativeoutcomes.26,54,55Notwithstandingimportanttheoreticalconcerns
onhowundernutritioncouldimpactpostoperativeoutcomes(Fig.88.4),
satisfactoryoutcomeshavebeenreportedfollowingmostcongenitalheart
operationsonundernourishedchildrenfrompediatricheartprogramsinLMICs.
InastudyfromSouthernIndiaon100consecutiveinfantsundergoingsurgical
closureoftheVSD,46%hadweightz-scoresof−3orlower,butthisdidnot
affectpostoperativemortalityormorbidity(durationofmechanicalventilation,
lengthofstayintheintensivecareunitorhospital).55Amorerecentprospective
studyof1028infantsfromthesamecenterstudiedtheimpactofpreoperative
factorsonpostoperativeoutcomesaftercongenitalheartsurgery,weightz-score
lessthan−3andlowbirthweight(<2.5kg)didnotadverselyaffectmortalityor
morbidity.26TheseresultsreinforcethestrategyofearlycorrectionofCHD
irrespectiveofnutritionalstatus.Preoperativeoptimizationofnutritionalstatus
throughaggressivefeedingisnotnecessaryinmostpatients,butitmaymake
sensetousethistechniqueifthereareongoingdelaysinaccesstosurgical
repair.54
FIG.88.4 Hypercatabolicstateaftersurgery:mechanismsandspecific
considerationsinchildrenwithundernutrition.
Postoperatively,nutritionalsupportiscriticalandprotocolsneedtobe
aggressivelyimplemented.IntheLMICenvironmentthereisgreateremphasis
onearlyinstitutionofenteralfeeding.Itisnecessarytodevelopastructured
systemwithinthecardiaccareenvironmenttoensureappropriaterecognitionof
theparticularroleofnutritioninaspecificchild;repeatedandaccurate
measurementofgrowthparameterstogetherwithdetailedattentiontonutritional
intakeandtolerance.Itmakeslittlesensetoinvestintheexpenseofcardiac
surgeryandthenignorethenutritionalchallenges.54
FollowingsuccessfulrepairoftheCHD,nutritionalrecoverymaybedelayed
andsuboptimal.Inonestudy,suboptimalnutritionalrecoverywithpersistent
weightz-scorelessthan−2wasobservedin27.3%ofpatients,andthiswas
predictedbylowerweightz-scoreatsurgery,lowerbirthweight,andlower
parentalanthropometry.56Althougheffortsatmaintainingadequatedietary
intakeshouldcontinueaftersurgery,itisalsoimportanttoidentifypatientsat
riskofsuboptimalrecovery(thosewithlowergrowthpotential)before
interventionsothattargetednutritionalrehabilitationmaybeprovidedon
follow-up.
Infections
Infectionsposeaseriousadditionalchallengetochildrenwithheartdiseasein
LMICsandcontributesubstantiallytotheirmorbidity,mortality,andcostof
care.ThecommoninfectionsthatoccurinLMICsettingsarelistedinTable
88.4.Selectedconditionswillbediscussedingreaterdetailhere.
Table88.4
CommonInfectionsinAffectingChildrenWithHeartDiseaseinLow-andMiddle-Income
Countries
Category
Respiratory
infections
Prevalence
Bacterialpneumoniaisacommon
comorbidityincommonleft-to-right
shuntlesionstogetherwith
undernutrition
Virallowerrespiratorytractinfections
andbronchiolitis(respiratorysyncytial
virus)arealsoimportantinselected
temperateregionsandtendtobe
seasonal
Bloodstream Especiallycommonamongneonateswith
sepsisin
congenitalheartdisease;gram-negative
newborns
organisms(extendedspectrumβlactamase–producingbacteria,e.g.,
Klebsiella,Acinetobacter)predominate;
multidrugresistanceiswidelyprevalent
fungalsepsis,especiallynon-albicans
Candidaanemergingthreat
Postoperative Prevalenceishigherinlow-andmiddlenosocomial incomecountryenvironments;multidrug
infections
resistanceiscommonandemergingasthe
singlemostimportantthreat
Hepatitisand Prevalentisselectregions;preoperative
HIV
screeningismandatedtoprotecthealth
carepersonnelandtoavoidoperatingon
patientswithevolvinghepatitis
Dengue
Widelyprevalentduringspecificseasons;
routinescreeningnotfeasible
Impact
Associatedwithpreoperativemortalityandmorbidity;
postoperativemorbidityfromprolongedmechanical
ventilation,lowcardiacoutputstateandsepsis
Seriouslyimpactspostoperativecourse;strongly
associatedwithpostoperativemortalityandmorbidity
intheformofthedurationofpostoperative
mechanicalventilation,aswellassepsis,septicshock,
acutelunginjury,capillaryleak,andmultiorgan
dysfunction.Fungalinfectionshaveahigh
recrudescencerate;potentialforinfectionof
prostheticimplantsandpatches
Stronglyassociatedwithpostoperativemortalityand
morbidity
Subclinicalhepatitismayworsenaftersurgery;
occasionalcasesoffulminanthepatitisandhepatic
failurecanoccur;associatedwithveryhighmortality
Occasionallymanifestsafteropen-heartsurgery;
seriousthrombocytopeniacanresult
postoperatively
Dangerofsurgicalsiteandvitalorganbleeding
(e.g.,intracranialbleeds),uncontrolledcapillary
leakandacutelunginjurycontributetomortality
Malaria
Prevalentisspecificregions
Recentmalariamaycomplicatepostoperativecourse
byresultinginhemolysis,seriousrapidlyevolving
acutekidneyinjuryandoccasionally,cerebralmalaria
Tuberculosis Widelyprevalentinselectedregions,
Recentandpastpulmonarytuberculosisand
multidrugresistanttuberculosisisaserious secondarybronchiectasisposepostoperative
emergingthreat
ventilationchallenges
