The protocol of enhanced recovery after cardiac surgery in adult patients: A stepped wedge cluster randomized trial.

BACKGROUND: The enhanced recovery after cardiac surgery is a bundle of measurements from preoperative to postoperative phases to improve patients' recovery. METHODS: This study is a multicenter, stepwise design, cluster randomized controlled trial. About 3,600 patients presenting during control and intervention periods are eligible if they are aged from 18 to 80 years old awaiting elective cardiac surgery with cardiopulmonary bypass (CPB). About 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive ERAS strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI). DISCUSSION: This study aims to compare the application of ERAS management protocol and traditional management protocol in adult cardiac surgery under extracorporeal circulation.

Integrative proteomics and metabolomics data analysis exploring the mechanism of brain injury after cardiac surgery in chronic stress rats.

OBJECTIVE: Preoperative chronic stress (CS) is associated with postoperative brain injury in patients undergoing open heart cardiac surgery. This research is to explore the potential molecular biological mechanisms of brain damage following cardiac surgery in preoperative CS rats by the analyses combining proteomics and metabolomics. METHODS: We constructed the chronic unpredictable stress (CUS) and cardiac surgery models in adult rats. We proved the brain injury in CUS cardiac surgery rats by Hematoxylin-Eosin (H&E) staining, followed by separating the hippocampal tissue and investigating the potential mechanisms of brain injury by the methods of data-independent acquisition proteomics and untargeted metabolomics. RESULTS: The signaling pathways of glycoproteins and metabolism of amino acids were the main possible mechanisms of brain injury in CUS rats following cardiac surgery according to the proteomics and metabolomics. In addition, the pathways of animo acids metabolism such as the pathways of lysine degradation and ß-alanine metabolism may be the main mechanism of cardiac surgery related brain injury in preoperative CUS rats. CONCLUSIONS: The pathways of animo acids metabolism such as lysine degradation and ß-alanine metabolism may be the potential mechanisms of brain injury in CUS rats following cardiac surgery. We should focus on the varieties of bioproteins and metabolites in these pathways, and related changes in other signaling pathways induced by the two pathways.

Predictors of length of hospital stay after pediatric Ebstein anomaly corrective surgery: a retrospective cohort study.

BACKGROUND: The remarkable advancements in surgical techniques over recent years have shifted the clinical focus from merely reducing mortality to enhancing the quality of postoperative recovery. The duration of a patient's hospital stay serves as a crucial indicator in evaluating postoperative recovery and surgical outcomes. This study aims to identify predictors of the length of hospital stay for children who have undergone corrective surgery for Ebstein Anomaly (EA). METHODS: We conducted a retrospective cohort study on children (under 18 years of age) diagnosed with EA who were admitted for corrective surgery between January 2009 and November 2021 at Fuwai Hospital. The primary outcome was the Time to Hospital Discharge (THD). Cox proportional hazard models were utilized to identify predictors of THD. In the context of time-to-event analysis, discharge was considered an event. In cases where death occurred before discharge, it was defined as an extended THD, input as 100 days (exceeding the longest observed THD), and considered as a non-event. RESULTS: A total of 270 children were included in this study, out of which three died in the hospital. Following the Cox proportional hazard analysis, six predictors of THD were identified. The hazard ratios and corresponding 95% confidence intervals were as follows: age, 1.030(1.005,1.055); C/R > 0.65, 0.507(0.364,0.707); Carpentier type C or D, 0.578(0.429,0.779); CPB time, 0.995(0.991,0.998); dexamethasone, 1.373(1.051,1.795); and transfusion, 0.680(0.529,0.875). The children were categorized into three groups based on the quartile of THD. Compared to children in the ≤ 6 days group, those in the ≥ 11 days group were associated with a higher incidence of adverse outcomes. Additionally, the duration of mechanical ventilation and ICU stay, as well as hospital costs, were significantly higher in this group. CONCLUSION: We identified six predictors of THD for children undergoing corrective surgery for EA. Clinicians can utilize these variables to optimize perioperative management strategies, reduce adverse complications, improve postoperative recovery, and reduce unnecessary medical expenses.

The protocol of Enhanced Recovery After Cardiac Surgery (ERACS) in congenital heart disease: a stepped wedge cluster randomized trial.

BACKGROUND: The Enhanced Recovery After Cardiac Surgery (ERACS) programs are comprehensive multidisciplinary interventions to improve patients' recovery. The application of the ERAS principle in pediatric patients has not been identified completely. METHODS: This study is a multicenter, stepwise design, cluster randomized controlled trial. 3030 patients presenting during control and intervention periods are eligible if they are aged from 28 days to 6 years old and awaiting elective correction surgery of congenital heart disease with cardiopulmonary bypass. 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive a bundle strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive the usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI). DISCUSSION: This study aims to explore whether the bundle of ERAS measurements could improve patients' recovery in congenital heart surgery. TRIAL REGISTRATION: http://www. CLINICALTRIALS: gov . (NCT05914103).

Relationship between intra-operative urine output and postoperative acute kidney injury in paediatric cardiac surgery: A retrospective cohort study.

BACKGROUND: Intra-operative urine output (UO) has been shown to predict postoperative acute kidney injury (AKI) in adults; however, its significance in children undergoing cardiac surgery remains unknown. OBJECTIVE: To explore the association between intra-operative UO and postoperative AKI in children with congenital heart disease. DESIGN: A retrospective observational study. SETTING: A tertiary hospital. PATIENTS: Children aged >28 days and <6 years who underwent cardiac surgery at Fuwai Hospital from 1 April 2022 to 30 August 2022. MAIN OUTCOME MEASURES: AKI was identified by the highest serum creatinine value within postoperative 7 days using Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: In total, 1184 children were included. The incidence of AKI was 23.1% (273/1184), of which 17.7% (209/1184) were stage 1, 4.2% (50/1184) were stage 2, and others were stage 3 (1.2%, 14/1184). Intra-operative UO was calculated by dividing the total intra-operative urine volume by the duration of surgery and the actual body weight measured before surgery. There was no significant difference in median [range] intra-operative UO between the AKI and non-AKI groups (2.6 [1.4 to 5.4] and 2.7 [1.4 to 4.9], respectively, P  = 0.791), and multivariate logistic regression analyses showed that intra-operative UO was not associated with postoperative AKI [adjusted odds ratio (OR) 0.971; 95% confidence interval (CI), 0.930 to 1.014; P  = 0.182]. Regarding the clinical importance of severe forms of AKI, we further explored the association between intra-operative UO and postoperative moderate-to-severe AKI (adjusted OR 0.914; 95% CI, 0.838 to 0.998; P  = 0.046). CONCLUSIONS: Intra-operative UO was not associated with postoperative AKI during paediatric cardiac surgery. However, we found a significant association between UO and postoperative moderate-to-severe AKI. This suggests that reductions in intra-operative urine output below a specific threshold may be associated with postoperative renal dysfunction. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT05489263.

Monocytes to lymphocytes multiplying platelets ratio as an early indicator of acute kidney injury in cardiac surgery with cardiopulmonary bypass: a retrospective analysis.

OBJECTIVE: The monocyte-to-lymphocyte multiplying platelets ratio (MLPR) is a novel systemic inflammatory marker, deriving from the monocyte-to-lymphocyte ratio (MLR). However, the link between MLPR and acute kidney injury following cardiac surgery (CSA-AKI) with cardiopulmonary bypass (CPB) has not been investigated yet. We comprehensively explored the potential linear and nonlinear relationship between MLPR or MLR and CSA-AKI. METHODS: Data of patients who underwent cardiac surgery with CPB between December 2018 and April 2021 were retrospectively collected at Fuwai Hospital, Beijing, China. MLPR was defined as monocyte count (×109/L) × 1000/(lymphocyte count (×109/L) × platelets (×109/L)). MLR was defined as monocyte count (×109/L)/lymphocyte count (×109/L). Logistic regression and restricted cubic spline (RCS) were used for linear and nonlinear analysis. The primary outcome was postoperative AKI within 48 h of after cardiac surgery. RESULTS: Of the 2420 patients screened, 2387 eligible patients were enrolled in the final analysis; the mean age was 54.7 years, and 1501 [62.9%] were men. The incidence of AKI was 25.8%. Logistic regression showed that MLPR (odds ratio [OR] = 1.31, 95% confidence interval [CI]: 1.16-1.48, p < .001) and MLR (OR = 3.06, 95% CI: 1.29-7.29, p = .012) were independent risk factors for AKI. Moreover, in the RCS model with adjustment for age (median: 56), female sex, and history of diabetes, a significant statistical difference was detected between preoperative MLPR, MLR, and AKI (p for non-linearity <.001). The subgroup analyses revealed similar results. CONCLUSIONS: The study revealed a nonlinear relationship between MLPR and MLR with AKI. MLPR exhibited a J-shaped curve, and MLR showed a favorable S-shaped curve in relation to AKI. Particularly, MLPR emerges as a promising clinical composite index for early CSA-AKI prediction. These findings emphasize the significance of MLPR as a valuable tool in clinical practice for timely identification and management of CSA-AKI.

Early Postoperative Acetaminophen Administration and Severe Acute Kidney Injury After Cardiac Surgery.

RATIONALE & OBJECTIVE: Oxidative stress may contribute to the development of acute kidney injury (AKI) after cardiac surgery. Acetaminophen can be considered an antioxidant because it inhibits hemoprotein-catalyzed lipid peroxidation. We hypothesized that perioperative acetaminophen administration is associated with reduced AKI after cardiac surgery. STUDY DESIGN: Retrospective observational cohort study. SETTING & PARTICIPANTS: Patients aged≥18 years who had cardiac surgery were identified from 2 publicly available clinical registries: the Medical Information Mart for Intensive Care III (MIMIC-III) and the eICU Collaborative Research Database (eICU). EXPOSURE: Administration of acetaminophen in the first 48 hours after surgery. OUTCOME: Severe AKI in the first 7 days after surgery, defined as stage 2 or stage 3 AKI according to KDIGO criteria. ANALYTICAL APPROACH: Multivariable cause-specific hazards regression analysis. RESULTS: We identified 5,791 patients from the MIMIC-III and 3,840 patients from the eICU registries. The overall incidence of severe AKI was 58% (3,390 patients) in the MIMIC-III cohort and 37% (1,431 patients) in the eICU cohort. Acetaminophen was administered in the early postoperative period to 4,185 patients (72%) and 2,737 patients (71%) in these 2 cohorts, respectively. In multivariable regression models, early postoperative use of acetaminophen was associated with a lower risk of severe AKI in both the MIMIC-III (adjusted hazard ratio [AHR], 0.86 [95% CI, 0.79-0.94]) and eICU (AHR, 0.84 [95% CI, 0.72-0.97]) cohorts. The benefit was consistent across sensitivity and subgroup analyses. LIMITATIONS: No data on acetaminophen dose. CONCLUSIONS: Early postoperative acetaminophen administration was independently associated with a lower risk of severe AKI in adults recovering from cardiac surgery. Prospective trials are warranted to assess the extent to which the observed association is causal and estimate the extent to which acetaminophen administration might prevent or reduce the severity of AKI. PLAIN-LANGUAGE SUMMARY: There is uncertainty about whether antioxidant medications such as acetaminophen may protect against kidney injury. Therefore, we evaluated the associations between acetaminophen use and kidney outcomes in adults recovering from cardiac surgery in 2 large clinical registries. Acetaminophen treatment was significantly associated with a 14%-16% lower risk of severe and any-stage acute kidney injury but similar risks of kidney replacement therapy and in-hospital mortality. Our findings suggest that acetaminophen use may protect against kidney injury in adult patients recovering from cardiac surgery.

S-Ketamine Exerts Antidepressant Effects by Regulating Rac1 GTPase Mediated Synaptic Plasticity in the Hippocampus of Stressed Rats.

Clinical studies have found that ketamine has a rapid and lasting antidepressant effect, especially in the case of patients with major depressive disorder (MDD). The molecular mechanisms, however, remain unclear. In this study, we observe the effects of S-Ketamine on the expression of Rac1, neuronal morphology, and synaptic transmission function in the hippocampus of stressed rats. Chronic unpredictable mild stress (CUMS) was used to construct stressed rats. The rats were given a different regimen of ketamine (20 mg/kg, i.p.) and Rac1 inhibitor NSC23766 (50 µg, ICV) treatment. The depression-like behavior of rats was evaluated by sucrose preference test and open-field test. The protein expression of Rac1, GluA1, synapsin1, and PSD95 in the hippocampus was detected by Western blot. Pull-down analysis was used to examine the activity of Rac1. Golgi staining and electrophysiological study were used to observe the neuronal morphology and long-term potentiation (LTP). Our results showed that ketamine can up-regulate the expression and activity of Rac1; increase the spine density and the expression of synaptic-related proteins such as GluA1, Synapsin1, and PSD95 in the hippocampus of stressed rats; reduce the CUMS-induced LTP impairments; and consequently improve depression-like behavior. However, Rac1 inhibitor NSC23766 could have effectively reversed ketamine-mediated changes in the hippocampus of rats and counteracted its antidepressant effects. The specific mechanism of S-Ketamine's antidepressant effect may be related to the up-regulation of the expression and activity of Rac1 in the hippocampus of stressed rats, thus enhancing synaptic plasticity.

A simple-to-use nomogram for predicting prolonged mechanical ventilation for children after Ebstein anomaly corrective surgery: a retrospective cohort study.

BACKGROUND: Prolonged mechanical ventilation (PMV) after pediatric cardiac surgery imposes a great burden on patients in terms of morbidity, mortality as well as financial costs. Ebstein anomaly (EA) is a rare congenital heart disease, and few studies have been conducted about PMV in this condition. This study aimed to establish a simple-to-use nomogram to predict the risk of PMV for EA children. METHODS: The retrospective study included patients under 18 years who underwent corrective surgeries for EA from January 2009 to November 2021. PMV was defined as postoperative mechanical ventilation time longer than 24 hours. Through multivariable logistic regression, we identified and integrated the risk factors to develop a simple-to-use nomogram of PMV for EA children and internally validated it by bootstrapping. The calibration and discriminative ability of the nomogram were determined by calibration curve, Hosmer-Lemeshow goodness-of-fit test and receiver operating characteristic (ROC) curve. RESULTS: Two hundred seventeen children were included in our study of which 44 (20.3%) were in the PMV group. After multivariable regression, we obtained five risk factors of PMV. The odds ratios and 95% confidence intervals (CI) were as follows: preoperative blood oxygen saturation, 0.876(0.805,0.953); cardiothoracic ratio, 3.007(1.107,8.169); Carpentier type, 4.644(2.065,10.445); cardiopulmonary bypass time, 1.014(1.005,1.023) and postoperative central venous pressure, 1.166(1.016,1.339). We integrated the five risk factors into a nomogram to predict the risk of PMV. The area under ROC curve of nomogram was 0.805 (95% CI, 0.725,0.885) and it also provided a good discriminative information with the corresponding Hosmer-Lemeshow p values > 0.05. CONCLUSIONS: We developed a nomogram by integrating five independent risk factors. The nomogram is a practical tool to early identify children at high-risk for PMV after EA corrective surgery.

Effect of hemoglobin and oxygen saturation on adverse outcomes in children with tetralogy of fallot: a retrospective observational study.

BACKGROUND: Tetralogy of Fallot (TOF) is a common cyanotic congenital heart malformation that carries a high risk of right-to-left shunting. Anemia is characterized by decreased hemoglobin (Hb) levels that can affect tissue oxygen delivery and impact postoperative recovery in patients. Chronic hypoxia caused by right-to-left shunting of TOF could lead to compensatory increases in Hb to maintain systemic oxygen balance. This study aims to investigate whether preoperative Hb and blood oxygen saturation (SpO2) can predict adverse outcomes in children undergoing corrective surgery for TOF. METHODS: This retrospective study included patients under 18 years of age who underwent corrective surgery for TOF at Fuwai Hospital between January 2016 and December 2018. Adverse outcomes, including in-hospital death, extracorporeal membrane oxygenation implantation, ICU stay > 30 days, and severe complications, were considered as the primary outcome. Univariable and multivariable logistic analyses were performed to identify independent risk factors for adverse outcomes. Propensity score-matched (PSM) analysis was also conducted to minimize the confounding factors. RESULTS: A total of 596 children were included in the study, of which 64 (10.7%) experienced adverse outcomes. Hb*SpO2 < aaHb was identified as an independent risk factor for adverse outcomes (OR = 2.241, 95% CI = 1.276-3.934, P = 0.005) after univariable and multivariable logistic analyses. PSM analysis further confirmed the association between Hb*SpO2 < aaHb and adverse outcomes. Patients with Hb*SpO2 < aaHb had a significantly higher incidence of postoperative adverse outcomes, longer time of mechanical ventilation, and hospital stay, as well as higher in-hospital costs. CONCLUSIONS: Hb*SpO2 < aaHb is significantly associated with adverse outcomes in children undergoing corrective surgery for TOF. Clinicians can use this parameter to early identify high-risk children and optimize their postoperative management.

Intubation using video laryngeal mask airway SaCoVLM and laryngeal mask airway Ambu® Aura-i in anesthetized children with microtia: a randomized controlled study.

The Ambu Aura-i laryngeal mask is considered to be a device for blind intubation as well as for fiberoptic guided intubation. The novel video laryngeal airway mask SaCoVLM is a supraglottic airway device that allows intubation under direct vision. We hypothesized that success rates for device placement and tracheal intubation with the SaCoVLM would be comparable with the Ambu Aura-i mask. A prospective, randomized clinical trial was conducted from March 2021 to December 2021. One hundred and twenty patients were enrolled and randomized in the study. Direct intubation was performed with the SaCoVLM, and fiberoptic guided intubation was performed with the Ambu Aura-i mask. The primary outcome measure was the first success rate of LMA placement. Secondary outcome measures were the time from device placement and time from endotracheal intubation (as well as the time for LMA removal after successful intubation), differences in airway leak pressure, fiberoptic grade of the laryngeal view, and incidence of blood staining. The first success rate of LMA placement was similar for the two devices. There was no difference in the time for successful endotracheal intubation between the Ambu Aura-i and SaCoVLM groups (24.1 s ± 6.3 versus 25.7 s ± 2.1; p > 0.05). The time for removal was slower in the SaCoVLM group than in the Ambu Aura-i group (20.8 s ± 0.8 versus 14.7 s ± 6.1; p < 0.01). The airway leak pressure was higher in the SaCoVLM group than in the Ambu Aura-i group (27.0 s ± 1.0 versus 22.3 s ± 3.6; p < 0.01), and the incidence of blood staining was higher in the SaCoVLM group (16.7%). The SaCoVLM has an overall comparable performance to the Ambu Aura-i mask. However, the SaCoVLM is better relative to direct intubation without the assistance of a flexible intubation scope, which reduces the device's demand.

Ultrasound-guided Serratus Anterior Plane Block, Along with Improved Parasternal Block, is Superior to Serratus Anterior Plane Block Alone in Relieving Pain for Rhinoplasty with Autologous Costal Cartilage.

BACKGROUND: Rhinoplasty with autologous costal cartilage (ACC) is followed by severe pain in the chest. Ultrasound-guided (USG) serratus anterior plane block (SAPB), in combination with parasternal block (PSB), was earlier reported to be highly efficacious in relieving pain associated with thoracic anterior lateral surgery. However, it is unclear whether it is effective for pain relief after ACC harvest. METHODS: Sixty-four patients, aged 18 to 60, who received rhinoplasty with ACC, were randomly separated into a SAPB+PSB or SAPB group. The analyzed parameters of both groups included the rest and coughing numerical rating scale (NRS) pain scores of the chest and the NRS pain scores of the nose at postoperative 2, 4, 8, 12, 24, and 48 hours, oral rescue analgesic usage, side effect incidence and patient satisfaction, etc. RESULTS: Thirty patients per group were recruited for analysis. The rest and coughing NRS scores of the chest and the NRS scores of the nose at postoperative 2, 4, 8, 12 h were lower in the SAPB+PSB group, compared to the SAPB group (all P < 0.05). However, these scores were comparable between the two groups at postoperative 24 and 48 h (all P > 0.05). Additionally, relative to the SAPB group, the oral rescue analgesic usage was drastically lower (P < 0.05), the postoperative nausea and vomiting (PONV) incidence was diminished (P < 0.05), and the patient satisfaction was markedly higher (P < 0.001) in the SAPB+PSB group. CONCLUSION: USG-SAPB, in combination with improved PSB, is superior to SAPB alone in relieving pain after ACC harvest in rhinoplasty. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Suppression of Myocardial Hypoxia-Inducible Factor-1α Compromises Metabolic Adaptation and Impairs Cardiac Function in Patients With Cyanotic Congenital Heart Disease During Puberty.

BACKGROUND: Cyanotic congenital heart disease (CCHD) is a complex pathophysiological condition involving systemic chronic hypoxia (CH). Some patients with CCHD are unoperated for various reasons and remain chronically hypoxic throughout their lives, which heightens the risk of heart failure as they age. Hypoxia activates cellular metabolic adaptation to balance energy demands by accumulating hypoxia-inducible factor 1-α (HIF-1α). This study aims to determine the effect of CH on cardiac metabolism and function in patients with CCHD and its association with age. The role of HIF-1α in this process was investigated, and potential therapeutic targets were explored. METHODS: Patients with CCHD (n=25) were evaluated for cardiac metabolism and function with positron emission tomography/computed tomography and magnetic resonance imaging. Heart tissue samples were subjected to metabolomic and protein analyses. CH rodent models were generated to enable continuous observation of changes in cardiac metabolism and function. The role of HIF-1α in cardiac metabolic adaptation to CH was investigated with genetically modified animals and isotope-labeled metabolomic pathway tracing studies. RESULTS: Prepubertal patients with CCHD had glucose-dominant cardiac metabolism and normal cardiac function. In comparison, among patients who had entered puberty, the levels of myocardial glucose uptake and glycolytic intermediates were significantly decreased, but fatty acids were significantly increased, along with decreased left ventricular ejection fraction. These clinical phenotypes were replicated in CH rodent models. In patients with CCHD and animals exposed to CH, myocardial HIF-1α was upregulated before puberty but was significantly downregulated during puberty. In cardiomyocyte-specific Hif-1α-knockout mice, CH failed to initiate the switch of myocardial substrates from fatty acids to glucose, thereby inhibiting ATP production and impairing cardiac function. Increased insulin resistance during puberty suppressed myocardial HIF-1α and was responsible for cardiac metabolic maladaptation in animals exposed to CH. Pioglitazone significantly reduced myocardial insulin resistance, restored glucose metabolism, and improved cardiac function in pubertal CH animals. CONCLUSIONS: In patients with CCHD, maladaptation of cardiac metabolism occurred during puberty, along with impaired cardiac function. HIF-1α was identified as the key regulator of cardiac metabolic adaptation in animals exposed to CH, and pubertal insulin resistance could suppress its expression. Pioglitazone administration during puberty might help improve cardiac function in patients with CCHD.

Plasma metabolomics in the perioperative period of defect repair in patients with pulmonary arterial hypertension associated with congenital heart disease.

The quality of life and survival rates of patients with pulmonary arterial hypertension associated with congenital heart disease (CHD-PAH) have been greatly improved by defect-repair surgery and personalized treatments. However, those who survive surgery may remain at risk of persistent PAH, the prognosis may be considerably worse than those unoperated. Dynamic monitoring of clinical measures during the perioperative period of shunt correction is therefore indispensable and of great value. In this study, we explored the plasma-metabolite profiling in 13 patients with CHD-PAH during the perioperative period of defect repair. Plasma was harvested at four time points: prior to cardiopulmonary bypass (CPB) after anesthesia (Pre), immediately after CPB (T0), 24 h (T24), and 48 h (T48) after defect repair. Untargeted metabolomics strategy based on UPLC Q-TOF MS was used to detect the metabolites. A total of 193 distinguishing metabolites were determined at different time points, enriched in pathways such as oxidation of branched-chain fatty acids. We found that 17 metabolite alterations were significantly correlated with the reduction in mean pulmonary arterial pressure (MPAP) at T48 versus Pre. Gradients in diastolic pulmonary arterial pressure (DPAP), bicarbonate in radial artery (aHCO3), bicarbonate in superior vena cava (svcHCO3), and the partial pressure of dissolved CO2 gas in radial artery (aPCO2) were positively correlated with MPAP gradient. Notably, these clinical-measure gradients were correlated with alterations in shunt-correction-associated metabolites. In total, 12 out of 17 identified metabolites in response to defect repair were increased at both T24 and T48 (all P < 0.05, except propionylcarnitine with P < 0.05 at T24). In contrast, galactinol dihydrate, guanosine monophosphate, and hydroxyphenylacetylglycine tended to decline at T24 and T48 (only galactinol dihydrate with P < 0.05 at T48). In conclusion, 17 metabolites that respond to shunt correction could be used as suitable noninvasive markers, and clinical measures, including DPAP, aHCO3, svcHCO3, and aPCO2, would be of great value in disease monitoring and evaluating future therapeutic interventions.

Effect of Clemastine Fumarate on Perioperative Hemodynamic Instability Mediated by Anaphylaxis During Cardiopulmonary Bypass Surgery.

BACKGROUND Perioperative hemodynamic instability mediated by anaphylaxis is a life-threatening complication in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). This study aimed to evaluate the effect of clemastine fumarate in this specific patient population. MATERIAL AND METHODS We enrolled 100 participants who met the inclusion criteria and randomly allocated them to the treatment group and the placebo group. Participants in the treatment group and the placebo group were treated separately with an injection of clemastine fumarate and saline, respectively. Plasma histamine concentration and blood pressure were quantified at 5 timepoints during the perioperative period, and differences between the 2 groups were assessed by repeated-measures ANOVA. The postoperative complications and in-hospital mortality also were evaluated. All participants were followed up for 7 days after cardiac surgery. RESULTS Plasma histamine concentrations increased in both groups but were statistically significantly lower in the treatment group during the perioperative period (P=0.007). Diastolic blood pressure (P=0.014) and mean arterial pressure (P=0.024) in the treatment group were significantly higher than in the placebo group during the perioperative period. The coefficients of variation for systolic (13.9±4.2% vs 17.2±4.4%, P<0.01) and diastolic (12.9±4.9% vs 15.3±5.2%, P=0.02) blood pressure were significantly lower in the treatment group compared with the placebo group. CONCLUSIONS Pretreatment with clemastine fumarate restrains the increase in histamine concentration and provides safer hemodynamics in patients undergoing cardiac surgery with CPB.

Mild and moderate to severe early acute kidney injury following cardiac surgery among patients with heart failure and preserved vs. mid-range vs. reduced ejection fraction: A retrospective cohort study.

BACKGROUND: Patients with heart failure who undergo cardiac surgery have increased long-term mortality in which acute kidney injury (AKI) plays a role. However, little is known about whether the incidence of AKI differs according to stratified left ventricular ejection fraction (LVEF). OBJECTIVES: To assess the risks of mild AKI and moderate to severe AKI postcardiac surgery among patients with heart failure. DESIGN: Retrospective cohort analysis of patient data. Ejection fractions were categorised as LVEF less than 40%, heart failure with reduced ejection fraction (HFrEF); LVEF 40 to 49%, heart failure with mid-range ejection fraction (HFmrEF); and LVEF at least 50%, heart failure with preserved ejection fraction (HFpEF). PATIENTS AND SETTINGS: Patients who underwent cardiac surgery from 2012 to 2019 in Fuwai Hospital, Beijing, China, were consecutively enrolled. MAIN OUTCOME MEASURES: The primary endpoint was postoperative AKI staged either as mild AKI or moderate to severe AKI. The secondary outcome was the peri-operative composite adverse event of dialysis support, tracheotomy, intrasurgical and postsurgical mechanical cardiac support and in-hospital mortality. This study also assessed chronic renal dysfunction at follow-up. RESULTS: Of the 54 696 included patients, 18.9% presented with heart failure. Among these with HFpEF, HFmrEF and HFrEF, the incidence of postoperative mild AKI was 37.0, 33.4 and 37.6%, respectively. Patients with HFpEF and HFmrEF were characterised by numerically greater prevalence of moderate to severe AKI than HFrEF (8.5 vs. 9.1 vs. 5.8%). HFrEF and HFmrEF patients had comparable risks for mild AKI relative to HFpEF patients, odds ratio (OR) 0.885; 95% confidence interval CI 0.763 to 1.027 for HFmrEF vs. HFpEF; OR 1.083; 95% CI 0.933 to 1.256 for HFrEF vs. HFpEF. Patients with HFmrEF were more at risk for moderate to severe AKI than patients with HFpEF (OR, 1.368; 95% CI 1.066 to 1.742), but HFrEF and HFpEF did not differ significantly (OR 1.012; 95% CI 0.752 to 1.346). An increasing number of noncardiac comorbidities led to a higher risk of mild AKI and moderate to severe AKI in patients with heart failure; and its effect on AKI was almost equal among the three heart failure strata. The incidence of postoperative composite adverse outcome increased in a graded manner from HFpEF to HFmrEF to HFrEF. Information on the creatine concentrations at 3 months postoperatively and longer were retained for 5200 out of 10 347 (50.6%) heart failure patients in our charts.The AKI severity and the presence of HFmrEF contributed substantially to the development of renal dysfunction over a median [IQR] follow-up of 10 months [4.0 to 21.0]. CONCLUSIONS: Initiative programmes aimed at patients with HFrEF to prevent moderate to severe AKI and chronic kidney dysfunction should also include patients with HFmrEF.

Ultrasound-guided Bilateral Serratus Anterior Plane Block for Postoperative Analgesia in Ear Reconstruction after Costal Cartilage Harvest: A Randomized Controlled Trial.

BACKGROUND: Costal cartilages harvest for ear reconstruction is accompanied by severe pain in chest. However, there is no perfect solution for reducing this chest pain. OBJECTIVE: Evaluate the efficacy and safety of analgesia using ultrasound-guided bilateral serratus anterior plane block (SAPB) in children receiving costal cartilage harvest for ear reconstruction. METHODS: Sixty children undergoing ear reconstruction using costal cartilage were randomized to an SAPB group (SAPB with 3 mg/kg 0.25% ropivacaine) or an incision infiltration (II) group (II with 3 mg/kg 0.75% ropivacaine), and 29 in each group completed the study. All children received patient-controlled intravenous analgesia (PCIA). The primary outcomes were numerical rating scale (NRS) scores of pain while rest and coughing at 1, 6, 12, 24, and 48 h after surgery. The secondary outcomes were sufentanil use within 24 h, duration of analgesia, use of oral rescue analgesics, first time out of bed, and incidence of treatment-related adverse effects. RESULTS: The SAPB group had lower rest and coughing NRS scores at 6 and 12 h after surgery (all P < 0.001), but the scores were similar at other times. The SAPB group used less sufentanil within 24 h, but had a longer duration of analgesia (both P < 0.001). The II group used more oral rescue analgesics within 48 h, had a longer time until first time out of bed, and had more opioid-related side effects (all P < 0.01). There were no SAPB-related complications. CONCLUSION: Ultrasound-guided SAPB can provide safe and effective regional pain relief after costal cartilage harvest for ear reconstruction. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Comparison of the Sedative and Analgesic Effects of Dexmedetomidine-Remifentanil and Dexmedetomidine-Sufentanil for Liposuction: A Prospective Single-Blind Randomized Controlled Study.

BACKGROUND: Dexmedetomidine had sedative and analgesic effects and did not produce significant respiratory depression at therapeutic doses. AIMS: To compare the sedative and analgesic effects and safety of dexmedetomidine combined with remifentanil or sufentanil in patients undergoing liposuction. METHODS: A total of 100 subjects were randomized 1:1 to two groups: Group R and Group S. First, patients were administered midazolam 0.02 mg·kg-1. Anesthesia was induced with an intravenous infusion of dexmedetomidine 1 µg kg-1 (15 min) and remifentanil 0.1 µg kg-1 min-1 (Group R) or sufentanil 0.1 µg kg-1h-1 (Group S). Anesthesia was maintained with an intravenous infusion of dexmedetomidine 1.0 µg kg-1h-1, midazolam 0.015 mg kg-1h-1, remifentanil 0.1 µg kg-1min-1 (Group R), or sufentanil 0.1 µg kg-1h-1 (Group S). Hemodynamic and respiratory changes, modified OAA/S score and BIS values, postoperative Visual Analogue Scale pain scores, satisfaction of the patient and surgical team with the procedure, and adverse events and recovery time were recorded. RESULTS: Group R received significantly less midazolam and midazolam per hour compared to Group S (Group R vs. Group S: 3.4 ± 1.7 mg vs. 5.1 ± 2.0 mg, P < 0.0001; 1.5 ± 0.7 mg/h vs. 1.9 ± 0.6 mg/h, P = 0.002). The incidence of physical or verbal expressions of pain at the start of surgery was significantly lower in Group R compared to Group S (2 [4.3%] vs. 12 [26.7%], P = 0.003). Patient satisfaction with the procedure was significantly higher in Group R compared to Group S (3.9 ± 0.3 vs. 3.1 ± 0.3, P < 0.0001). CONCLUSION: Dexmedetomidine-remifentanil and dexmedetomidine-sufentanil were effective and safe sedative and analgesic agents for liposuction. Hemodynamic stability was maintained. Dexmedetomidine-remifentanil might be associated with improved analgesic effects compared to dexmedetomidine-sufentanil. LEVEL OF EVIDENCE II: Evidence was obtained from at least one properly designed randomized controlled trial. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The salutary effect of peritoneal dialysis catheters on enhanced recovery among high-risk pediatric patients undergoing the left coronary transfer procedure: a cohort study.

BACKGROUND: Evidence for peritoneal dialysis catheter (PDC) usage in pediatric patients undergoing surgery for deteriorating cardiac dysfunction is lacking. This investigation explored factors associated with PDC usage and its effectiveness in children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). METHODS: Eighty-four children undergoing left coronary artery transfer were retrospectively recruited. The primary endpoint was the postoperative ratio of the general ward/[intensive care unit (ICU)] length of stay. Univariable and multivariable analyses were fitted to assess factors related most strongly to PDC and the ratio of general ward/ICU length of stay. RESULTS: Of the 84 patients, 17 (20.2%) underwent postoperative PDC placement. Patients with extreme cardiac dysfunction [left ventricular ejection fraction (LVEF) ≤25%] were much more likely to require a PDC (OR, 9.88; 95% CI, 2.13-45.76; P = 0.003). Moreover, univariate analysis indicated that concomitant mitral repair significantly decreased the likelihood of PDC placement (OR, 0.25; 95% CI, 0.07-0.85; P = 0.026). In those with cardiac dysfunction (LVEF ≤50%), PDC use was associated with a reduced ratio of ward/ICU length of stay (B, - 1.62; 95% CI, - 2.77- -0.46; P = 0.008), as was age ≤ 12 months (B, - 1.57; 95% CI, - 2.88- -0.26; P = 0.02). At the 1-year follow-up, cardiac improvement was significantly greater in patients with PDC usage than in those without it (P <  0.001), and the number of mitral recoveries was comparable between the groups (64.2% vs. 53.3%, P = 0.434). CONCLUSION: In cohorts with ALCAPA, PDC placement following surgery may be necessary for patients with extreme cardiac compromise, while concomitant mitral repair can probably reduce their usage rate. PDC is beneficial in conferring an improvement in cardiac and mitral performance. Importantly, after patients are transferred from the ICU, recovery efficiency in the general ward can be enhanced by PDC placement, and hospital discharge can therefore be achieved early, especially for patients younger than 12 months or with LVEF ≤50%.

Incidence and Risk Factors for Silent Brain Infarction After On-Pump Cardiac Surgery: A Meta-analysis and Meta-regression of 29 Prospective Cohort Studies.

BACKGROUND: Silent brain infarction (SBI) happens at a considerable rate after on-pump cardiac surgery. Though termed silent, SBI is related to unfavorable clinical outcomes including higher incidence of future stroke and neurocognitive impairment in the general population. The risk factors of SBI have not been fully identified in both individual studies and several meta-analyses addressing the topic. In this meta-analysis, we aimed to conduct meta-regression analysis for the first time to explore risk factors for SBI after on-pump cardiac surgery. METHODS: This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Medline, Embase, Central, Web of Science, and Wiley databases were searched for relevant studies. Preoperative patient baseline characteristics and intraoperative surgical parameters were extracted from included studies. For meta-regression, a P value of less than 0.1 was considered statistically significant in both univariable and multivariable analyses. RESULTS: Twenty-nine studies with 1478 patients were included in this meta-analysis. The summarized SBI rate after on-pump cardiac surgery was 37% (95% CI 0.27-0.47, P < 0.0001). Heterogeneity between studies was significant (I2 = 94.9%, P < 0.0001). In multivariable meta-regression, we found that age (coefficient 0.014, 95% CI 0.001-0.029, P = 0.043), diabetes (coefficient 0.006, 95% CI - 0.001 to 0.013, P = 0.075), and proportion of CABG (coefficient - 0.001, 95% CI - 0.003 to 0.0003, P = 0.096) were significantly associated with SBI incidence. CONCLUSION: From the meta-regression, we concluded that advanced age and diabetes were related to increased SBI incidence after on-pump cardiac surgery, while CABG procedure alone was associated with less SBI onset. Studies with more accurate diagnoses of SBI are required to add more conclusive evidence to the field.