Parental Presence during Induction of Anesthesia and Emergence Delirium Influence the Incidence of Postoperative Maladaptive Behavioral Changes.

OBJECTIVE: Surgical intervention in pediatric patients can cause variable degrees of psychological stress with potential consequences in the perioperative period and even in the long term, after hospital discharge in the form of behavioral changes days and months later. The aim of our study was to determine which preoperative preparation strategy reduces postoperative maladaptive behavioral changes in children undergoing ambulatory pediatric surgery. MATERIALS AND METHODS: This prospective observational study included 638 pediatric American Society of Anesthesiologists physical status I or II patients who underwent ambulatory pediatric surgery. They were grouped into four preoperative preparation groups: not premedicated (NADA), premedicated with midazolam (MDZ), parental presence during induction of anesthesia (PPIA), and parental presence during induction of anesthesia and premedicated with midazolam (PPIA + MDZ). All patients included in the study were contacted by telephone during 1 year posthospital discharge to assess the postoperative maladaptive behavioral changes using the Posthospitalization Behavior Questionnaire (PHBQ). We performed a multivariate analysis to evaluate the influence of type of preparation and behavioral changes. RESULTS: Patients in the PPIA and PPIA + MDZ preparation groups presented less postoperative maladaptive behavioral changes compared to patients in the NADA and MDZ groups (odds ratio [OR]: 1.8 [1.1-2.8] and OR 2.2 [1.03-4.49]) during the first week and first month. The intensity of emergence delirium measured by the Pediatric Anesthesia Emergence Delirium (PAED) scale increases the probability of postoperative maladaptive behavioral changes (OR: 1.05 [1.006-1.103]). CONCLUSION: The presence of parents during induction of anesthesia (PPIA and PPIA + MDZ) is a very effective strategy in reducing postoperative behavioral changes. These benefits are more significant in children under 5 years of age.

Respiratory mechanics in late COVID-19 ARDS - a restrictive pattern is strongly associated with death. A cohort study.

INTRODUCTION: COVID-19 is associated with severe respiratory distress and high mortality. We investigated the evolution of the respiratory mechanics in COVID-19 acute respiratory distress syndrome (ARDS) and the occurrence of a restrictive respiratory pattern. MATERIAL AND METHODS: A retrospective, single-centre study including patients admitted to the ICU during the first wave of the pandemic (March-April 2020). RESULTS: A total of 141 consecutive patients were included. Many patients developed a restrictive pattern of respiratory mechanics during the course of the disease. Fifty-two patients died in the hospital (36.8%). In 29 cases (58% of the deceased) death was associated with a pattern of pulmonary mechanics, indicating a restrictive evolution of ARDS. Other diagnoses related to death were pulmonary embolism (n = 7, 14%), septic shock (n = 17, 33%), and other causes (n = 10, 20%), with some patients combining at least 2 of these diagnoses. In a multivariate analysis, age (OR = 1.06; 95% CI: 1.01-1.12; P = 0.029) and the administration of steroid pulses (OR = 2.7; 95% CI: 1.1-6.8; P = 0.03) were associated with the development of a restrictive pulmonary pattern and a higher level of plasmatic interleukin-6. CONCLUSIONS: COVID-19 ARDS is associated with high mortality associated with a specific pattern of respiratory mechanics and sustained activation of innate immunological response. Age and administration of high-dose steroid pulses are associated with this clinical picture.

Parental Presence during Induction of Anesthesia Improves Compliance of the Child and Reduces Emergence Delirium.

INTRODUCTION: Preoperative stress and anxiety in pediatric patients are associated with poor compliance during induction of anesthesia and a higher incidence of postoperative maladaptive behaviors. The aim of our study was to determine which preoperative preparation strategy improves compliance of the child during induction and decreases the incidence and intensity of emergence delirium (ED) in children undergoing ambulatory pediatric surgery. MATERIALS AND METHODS: This prospective observational study included 638 pediatric American Society of Anesthesiologists I-II patients who underwent ambulatory pediatric surgery, grouped into four preoperative preparation groups: NADA (not premedicated), MDZ (premedicated with midazolam), PPIA (parental presence during induction of anesthesia), and PPIA + MDZ. The results were subsequently analyzed in four age subgroups: Group 1 (0-12 months), Group 2 (13-60 months), Group 3 (61-96 months), and Group 4 (> 96 months). Preoperative anxiety (modified Yale Preoperative Anxiety Scale [m-YPAS]), compliance of the child during induction (Induction Compliance Checklist [: ICC]), and ED (Pediatric Anesthesia Emergence Delirium scale) were analyzed in each group. RESULTS: Eighty-one percent of patients in the PPIA + MDZ preparation group presented a perfect compliance during the induction of anesthesia (ICC = 0), less preoperative anxiety (mean score m-YPAS = 26), less probability of ED (odds ratio: 10, 5 [3-37.5]; p < 0.05), and less ED intensity compared with the NADA group (1.2 vs. 5.8; p = 0.001). CONCLUSION: PPIA associated with midazolam premedication improves compliance during induction and decreases the incidence and intensity of ED.

Successful systemic fibrinolysis in a patient with Covid-19: Case report / Fibrinólisis sistémica exitosa en un paciente con Covid- 19: Reporte de Caso

Abstract The new coronavirus 2019-nCov or SARS-Cov-2 is responsible for the most important pandemic in the 21st century: the coronavirus disease (COVID-19). The 2019-nCov infection elicits a hyper-coagulable state, conditioning a worse outcome in these patients. The pathophysiology of the exaggerated coagulation activation in these patients is still unknown, and probably involves several mechanisms, different from those involved in sepsis-associated coagulopathy. This article discusses the case of a patient with no remarkable medical history, who after 7 days of fever, diarrhea and epigastric pain was diagnosed with COVID-19 bilateral pneumonia, further aggravated by severe Acute Respiratory Distress Syndrome. In this context, the patient experienced a massive acute pulmonary thromboembolism accompanied by an acute thrombus in the heart's right ventricle, leading to hemodynamic instability. For the first time in our center in these patients, systemic fibrinolysis was successfully performed, with resolution of the intracavitary thrombus and the acute hemodynamic shock.

Resumen El nuevo coronavirus 2019-nCov o SARS-Cov-2 es responsable de la pandemia más importante del siglo XXI: la enfermedad del coronavirus (COVID-19). La infección por 2019-nCov produce un estado de hipercoagulabilidad, que promueve peores desenlaces en estos pacientes. La fisiopatología de la exagerada activación de la coagulación en estos pacientes aún se desconoce y posiblemente involucre varios mecanismos, diferentes a los participan en la coagulopatía asociada a sepsis. El presente artículo presenta el caso de un paciente sin antecedentes médicos y quien luego de 7 días de fiebre, diarrea y dolor epigástrico, fue diagnosticado con neumonía bilateral por COVID-19, agravada por la presencia de Síndrome de Dificultad Respiratoria Aguda. En este contexto, el paciente desarrolla un tromboembolismo pulmonar agudo masivo, acompañado de un trombo agudo en el ventrículo derecho, produciéndole inestabilidad hemodinámica. Por primera vez en nuestro centro, se realizó exitosamente una fibrinólisis sistémica, con resolución del trombo intracavitario y del shock hemodinámico agudo.

Preoperative clinical model to predict myocardial injury after non-cardiac surgery: a retrospective analysis from the MANAGE cohort in a Spanish hospital.

OBJECTIVES: To determine preoperative factors associated to myocardial injury after non-cardiac surgery (MINS) and to develop a prediction model of MINS. DESIGN: Retrospective analysis. SETTING: Tertiary hospital in Spain. PARTICIPANTS: Patients aged ≥45 years undergoing major non-cardiac surgery and with at least two measures of troponin levels within the first 3 days of the postoperative period. All patients were screened for the MANAGE trial. PRIMARY AND SECONDARY OUTCOME MEASURES: We used multivariable logistic regression analysis to study risk factors associated with MINS and created a score predicting the preoperative risk for MINS and a nomogram to facilitate bed-side use. We used Least Absolute Shrinkage and Selection Operator method to choose the factors included in the predictive model with MINS as dependent variable. The predictive ability of the model was evaluated. Discrimination was assessed with the area under the receiver operating characteristic curve (AUC) and calibration was visually assessed using calibration plots representing deciles of predicted probability of MINS against the observed rate in each risk group and the calibration-in-the-large (CITL) and the calibration slope. We created a nomogram to facilitate obtaining risk estimates for patients at pre-anaesthesia evaluation. RESULTS: Our cohort included 3633 patients recruited from 9 September 2014 to 17 July 2017. The incidence of MINS was 9%. Preoperative risk factors that increased the risk of MINS were age, American Status Anaesthesiology classification and vascular surgery. The predictive model showed good performance in terms of discrimination (AUC=0.720; 95% CI: 0.69 to 0.75) and calibration slope=1.043 (95% CI: 0.90 to 1.18) and CITL=0.00 (95% CI: -0.12 to 0.12). CONCLUSIONS: Our predictive model based on routinely preoperative information is highly affordable and might be a useful tool to identify moderate-high risk patients before surgery. However, external validation is needed before implementation.

Pulmonary vascular proliferation in patients with severe COVID-19: an autopsy study.

Diffuse alveolar damage and thrombi are the most common lung histopathological lesions reported in patients with severe COVID-19. Although some studies have suggested increased pulmonary angiogenesis, the presence of vascular proliferation in COVID-19 lungs has not been well characterised. Glomeruloid-like microscopic foci and/or coalescent vascular proliferations measuring up to 2 cm were present in the lung of 14 out of 16 autopsied patients. These lesions expressed CD31, CD34 and vascular endothelial cadherin. Platelet-derived growth factor receptor-ß immunohistochemistry and dual immunostaining for CD34/smooth muscle actin demonstrated the presence of pericytes. These vascular alterations may contribute to the severe and refractory hypoxaemia that is common in patients with severe COVID-19.

Nosocomial infections associated to COVID-19 in the intensive care unit: clinical characteristics and outcome.

Bacterial and fungal co-infection has been reported in patients with COVID-19, but there is limited experience on these infections in critically ill patients. The objective of this study was to assess the characteristics and ouctome of ICU-acquired infections in COVID-19 patients. We conducted a retrospective single-centre, case-control study including 140 patients with severe COVID-19 admitted to the ICU between March and May 2020. We evaluated the epidemiological, clinical, and microbiological features, and outcome of ICU-acquired infections. Fifty-seven patients (40.7%) developed a bacterial or fungal nosocomial infection during ICU stay. Infection occurred after a median of 9 days (IQR 5-11) of admission and was significantly associated with the APACHE II score (p = 0.02). There were 91 episodes of infection: primary (31%) and catheter-related (25%) bloodstream infections were the most frequent, followed by pneumonia (23%), tracheobronchitis (10%), and urinary tract infection (8%) that were produced by a wide spectrum of Gram-positive (55%) and Gram-negative bacteria (30%) as well as fungi (15%). In 60% of cases, infection was associated with septic shock and a significant increase in SOFA score. Overall ICU mortality was 36% (51/140). Infection was significantly associated with death (OR 2.7, 95% CI 1.2-5.9, p = 0.015) and a longer ICU stay (p < 0.001). Bacterial and fungal nosocomial infection is a common complication of ICU admission in patients with COVID-19. It usually presents as a severe form of infection, and it is associated with a high mortality and longer course of ICU stay.