Influence of left ventricular unloading on pediatric post-cardiotomy veno-arterial extracorporeal life support outcomes.

Background: The effectiveness of veno-arterial extracorporeal life support (V-A ECLS) in treating neonatal and pediatric patients with complex congenital heart disease (CHD) and requiring cardio-circulatory assistance is well-known. Nevertheless, the influence of left ventricle (LV) distension and its countermeasure, namely LV unloading, on survival and clinical outcomes in neonates and children treated with V-A ECLS needs still to be addressed. Therefore, the aim of this study was to determine the effects of LV unloading on in-hospital survival and complications in neonates and children treated with V-A ECLS. Methods: The clinical outcomes of 90 pediatric patients with CHD under 16 years of age supported with V-A ECLS for post-cardiotomy cardiogenic shock (CS) were retrospectively reviewed in relationship with the presence or absence of an active LV unloading strategy. Results: The patient cohort included 90 patients (age 19.6 ± 31.54 months, 64.4% males), 42 of whom were vented with different techniques (38 with atrial septostomy (AS) or left atria cannula, two with cannula from LV apex, 1 with intra-aortic balloon pump (IABP), and one with pigtail across the aortic valve). The LV unloading strategy significantly increased the in-hospital survival (odds ratio [OR] = 2.74, 95% CI 1.06-7.08; p = 0.037). On the contrary, extracorporeal cardiopulmonary resuscitation decreased the related survival (OR = 0.32, 95% CI 1.09-0.96; p = 0.041). The most common complications were infections (28.8%), neurological injury (26%), and bleeding (25.6%). However, these did not differently occur in venting and no-venting groups. Conclusion: In pediatric patients with CHD supported with V-A ECLS for post-cardiotomy CS, the LV unloading strategy was associated with increased survival.

Complexity of nursing care at 24 h from admission predicts in-hospital mortality in medical units: a cohort study.

BACKGROUND: The Informative System of Nursing Performance was developed to measure complexity of nursing care based on the actual interventions performed by nurses at the point of care. The association of this score with in-hospital mortality was not investigated before. Having this information is relevant to define evidence-based criteria that hospital administrators can use to allocate nursing workforce according to the real and current patients' need for nursing care. The aim of this study is to assess the association between complexity of nursing care and in-hospital mortality. METHODS: Register-based cohort study on all patients admitted to acute medical wards of a middle-large hospital in the North of Italy between January 1, 2014, to December 31, 2015 and followed up to discharge. Out of all the eligible 7247 records identified in the Hospital Discharge Register, 6872 records from 5129 patients have been included. A multivariable frailty Cox model was adopted to estimate the association between the Informative System of Nursing Performance score, both as continuous variable and dichotomized as low (score < 50) or high (score ≥ 50), and in-hospital mortality adjusting for several factors recorded at admission (age, gender, type of admission unit, type of access and Charlson Comorbidity Index). RESULTS: The median age of the 5129 included patients was 76 [first-third quartiles 64-84] and 2657(52%) patients were males. Over the 6872 admissions, there were 395 in-hospital deaths among 2922 patients at high complexity of nursing care (13.5%) and 74/3950 (1.9%) among those at low complexity leading to a difference of 11.6% (95% CI: 10.3-13.0%). Adjusting by relevant confounders, the hazard rate of mortality in the first 10 days from admission resulted 6 times significantly higher in patients at high complexity of nursing care with respect to patients at low complexity (hazard ratio, HR 6.58, 95%CI: 4.50;9.62, p < 0.001). The HR was lower after 10 days from admission but still significantly higher than 1. By considering the continuous score, the association was confirmed. CONCLUSION: Complexity of nursing care is strongly associated to in-hospital mortality of acute patients admitted to medical departments. It predicts in-hospital mortality better than widely used indicators, such as comorbidity.

Histology-guided proteomic analysis to investigate the molecular profiles of clear cell Renal Cell Carcinoma grades.

Renal Cell Carcinoma (RCC) is the most frequent form of kidney cancer and approximately 80% of cases are defined as clear cell RCC (ccRCC). Among the histopathological factors, tumour grade represents one of the most important parameters to evaluate ccRCC progression. Nonetheless, the molecular processes associated with the grading classification haven't been deeply investigated thus far. Therefore, the aim of this study was to uncover protein alterations associated with different ccRCC grade lesions. Formalin-fixed paraffin-embedded samples from ccRCC patients were analysed by histology-guided MALDI-MSI and shotgun proteomics in order to study the biological processes implicated in ccRCC. MALDI-MSI data highlighted signals able to discriminate among different grades (AUC > 0.8). The ion at m/z 1428.92 was identified as Vimentin and was overexpressed in grade 4 lesions, whereas ions at m/z 944.71, m/z 1032.78 and m/z 1325,99 were identified as histones H2A, H3, and H4, respectively. nLC-ESI-MS/MS analysis provided a further list of proteins and their abundances, showing a difference in protein content among the four grades. Moreover, the obtained molecular profiles showed a correspondence with the different Cancer-Specific Survival rate at 10 years post-surgery, as reported in literature. SIGNIFICANCE: Despite the generally accepted role of tumour grade in ccRCC diagnosis, the proteomic processes associated with the different tumour grades has not been extensively studied and doing so may provide insights into the development of the disease. In the current study, data obtained using MALDI-MSI was integrated with that obtained using nLC-ESI-MS/MS to highlight the proteomic alterations underlying the different ccRCC grades. The combined approach identified vimentin and three histones (H2A, H3 and H4) that were able to discriminate among the four grades whilst the nLC-ESI-MS/MS analysis alone provided a further list of proteins with an altered abundance. Furthermore, there was a good correlation between the molecular profiles generated for each grade and the different Cancer-Specific Survival rate at 10 years post-surgery. Such findings could be a valuable starting point for further studies aimed at clarifying the molecular events that occur during the development of ccRCC.

Validation of renal-risk models for the prediction of non-renal replacement therapy cardiac surgery-associated acute kidney injury.

BACKGROUND: Cardiac surgery-associated acute kidney injury (AKI) is a serious complication of cardiac surgery, even when renal replacement therapy (RRT) is not required. The existing risk models for cardiac surgery associated AKI are designed to predict AKI requiring RRT (RRT-AKI). The aim of this study is to validate three risk models for the prediction of RRT-dependent and non-RRT AKI after cardiac surgery. METHODS: Retrospective analysis on 7675 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for stage 1 and 2. RRT AKI and non-RRT AKI were defined according to the need for RRT. Three risk models were validated separately for RRT and non-RRT AKI: the Cleveland Risk Score, the Bedside Risk Score, and the Simplified Renal Index Scoring Scheme. Discrimination power was assessed with Receiver Operating Characteristics analysis and c-statistics. RESULTS: There were 502 (6.5%) non-RRT AKI events, 128 (1.7%) RRT-AKI events, and 7045 (91.8%) no-events. The three models performed well for predicting RRT-AKI (c-statistics 0.75-0.79) and poorly for predicting non-RRT AKI (c-statistics 0.54-0.59). The models had an excellent calibration for RRT-AKI but not for non-RRT AKI. Preoperative serum creatinine and estimated glomerular filtration rate were associated with RRT AKI but not with non-RRT AKI. Mortality was 12.2% in non-RRT AKI and 46.9% in RRT-AKI, significantly (P = 0.001) higher than in patients without AKI (1.3%). CONCLUSIONS: The existing risk models are inadequate for predicting non-RRT AKI following cardiac surgery, both in terms of discrimination and calibration.

Jugular vs femoral vein for central venous catheterization in pediatric cardiac surgery (PRECiSE): study protocol for a randomized controlled trial.

BACKGROUND: Placement of central venous catheters (CVCs) is essential and routine practice in the management of children with congenital heart disease. The purpose of the present protocol is to evaluate the risk for infectious complications in terms of catheter colonization, catheter line-associated bloodstream infections, and catheter-related bloodstream infections (CRBSIs), and the mechanical complications from different central venous access sites in infants and newborns undergoing cardiac surgery. METHODS: One hundred sixty patients under 1 year of age and scheduled for cardiac surgery will be included in this randomized controlled trial (RCT); patients will be randomly allocated to the jugular or femoral vein arms. CVC insertion will be performed by one of three selected expert operators. DISCUSSION: The choice of the insertion site for central venous catheterization can influence the incidence and type of infectious complications in adults but this is not unanimously evidenced in the pediatric setting. The experimental hypothesis of this RCT is that the jugular insertion site is less likely to induce catheter colonization and CRBSI than the femoral site. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03282292 . Registered on 12 September 2017.

Determinants of early discharge from the intensive care unit after cardiac operations.

BACKGROUND: The length of stay in the intensive care unit is one of the factors limiting operating room utilization in cardiac surgery. We investigated the impact of a goal-oriented program aimed at discharging the patients from the intensive care unit the morning after the operation within a comprehensive model including other explanatory variables. METHODS: A multivariable predictive model for early discharge from the intensive care unit was established using a stepwise forward logistic regression. The analysis was retrospectively conducted on 9120 consecutive patients undergoing cardiac surgical procedures at our institution. RESULTS: A total of 1874 patients were discharged early from the intensive care unit. Factors associated with early discharge were ejection fraction, lowest hematocrit on cardiopulmonary bypass, lowest temperature on cardiopulmonary bypass, and the presence of the goal-oriented strategy (odds ratio, 5.5; 95% confidence interval, 4.8 to 6.3). Factors associated with late discharge were age, preoperative serum creatinine value, unstable angina, congestive heart failure, redo operation, combined operation, and cardiopulmonary bypass duration. An extubation time of 4 hours after the arrival in the intensive care unit was associated with the peak rate of early discharge. Patients being early discharged according to the goal-oriented strategy did not demonstrate a different complication rate compared with patients treated with a standard strategy. CONCLUSIONS: Early discharge from the intensive care unit depends on a combination of preoperative and intraoperative factors, but most of all on the presence of a goal-oriented strategy. A very early extubation is not required for an early discharge from the intensive care unit.

Lowest hematocrit on cardiopulmonary bypass impairs the outcome in coronary surgery: An Italian Multicenter Study from the National Cardioanesthesia Database.

Severe hemodilutional anemia on cardiopulmonary bypass increases morbidity and mortality after coronary surgery. The present study focuses on the lowest hematocrit values during extracorporeal circulation and on allogenic blood transfusions as mortality and morbidity risk factors. The records of 1,766 consecutive adult patients undergoing isolated coronary artery bypass graft surgery at 3 institutions have been analyzed retrospectively for in-hospital mortality and adverse outcomes. Clinical data were from the Italian National Cardioanesthesia Database. Multivariate analysis and analysis of receiver operating characteristic curves were applied. The lowest hematocrit value on cardiopulmonary bypass was an independent risk factor for postoperative low-output syndrome and renal failure. The hematocrit cutoff values were similar for renal failure (23%) and low-output syndrome (24%). Blood transfusions were significantly associated with both renal failure and low-output syndrome. The risk of renal failure doubled when the nadir-on-cardiopulmonary-bypass hematocrit occurred in transfused patients. Anemia upon cardiopulmonary bypass was not associated with death. Our findings confirm that both severe anemia and blood transfusions were significantly associated with renal failure and low-output syndrome.

The antithrombin III-saving effect of reduced systemic heparinization and heparin-coated circuits.

OBJECTIVE: To investigate the perioperative changes of antithrombin III (AT-III) activity using reduced systemic heparinization and the possible role of AT-III in determining a better postoperative outcome. DESIGN: Prospective randomized study. SETTING: University hospital. PARTICIPANTS: Patients undergoing elective coronary revascularization with cardiopulmonary bypass (n = 90). INTERVENTIONS: Of patients, 30 were treated with heparin-coated circuits and reduced systemic heparinization; 30, with heparin-coated circuits and full systemic heparinization; 30, with conventional circuits and full systemic heparinization. MEASUREMENTS AND MAIN RESULTS: Heparin-coated circuits with full systemic heparinization did not exert any effect on coagulation parameters. Low systemic heparinization resulted in a significantly (p < 0.01) higher hematocrit value on arrival in the intensive care unit and in significantly higher values of AT-III activity during cardiopulmonary bypass (66 +/- 12% v 57.4 +/- 13% and 59.1 +/- 12% in the full systemic heparinization groups; p < 0.05), on arrival in the intensive care unit (69.7 +/- 13% v 60.7 +/- 13% and 60.8 +/- 11% in the full systemic heparinization groups; p < 0.01), and on the first postoperative day (81.3 +/- 15% v 67.4 +/- 13% and 70.2 +/- 12% in the full systemic heparinization groups; p < 0.01). No differences were observed in the clinical outcome. CONCLUSION: Reducing systemic heparinization determines an AT-III-saving effect that could be responsible for the decrease in thromboembolic complications already observed by other authors. It induces higher hematocrit levels immediately after the operation, probably reducing the unmeasurable intraoperative blood loss.

Different patterns of heparin resistance: therapeutic implications.

Heparin resistance (HR) during cardiac operations is a common feature. Its aetiology often recognizes a decrease in circulating antithrombin III (AT III) due to a preoperative heparin treatment. Nevertheless, some papers highlighted the existence of HR in patients with normal values of AT III. This paper was designed in order to identify this subgroup of AT III-independent heparin-resistant patients. Five hundred consecutive patients scheduled for coronary revascularization with cardiopulmonary bypass were enrolled in this prospective trial. HR was identified in 104 (20.8%) patients. Thirty-six of them (7.2% of the total population) had a preoperative AT III activity > or = 100%, and were defined as AT III-independent heparin-resistant patients. This subgroup significantly differs from the AT III-dependent heparin-resistant group being affected by a less severe degree of HR and including less patients pretreated with heparin. Unlike the other heparin-resistant patients, these subjects do not respond to AT III supplementation aimed at reaching supranormal AT III activity values.