Low Turnover Renal Osteodystrophy With Abnormal Bone Quality and Vascular Calcification in Patients With Mild-to-Moderate CKD.

Introduction: Limited information is available on renal osteodystrophy (ROD) and vascular calcification (VC) during early chronic kidney disease (CKD). This study was designed to evaluate ROD and VC in 32 patients with CKD stages II to IV. Methods: Patients underwent dual-energy X-ray absorptiometry (DXA) for assessment of bone mineral density (BMD) and trabecular bone score (TBS), thoracic computed tomography for VC scoring using the Agatston method, and anterior iliac crest bone biopsy for mineralized bone histology, histomorphometry, and Fourier transform infrared spectroscopy (FTIR). Classical and novel bone markers were determined in the blood. Results: Mean estimated glomerular filtration rate (eGFR) was 44 ± 16 ml/min per 1.73 m2. Of the patients, 84% had low bone turnover. In Whites, eGFR correlated negatively with the turnover parameter activation frequency (Ac.f) (r -0.48, P = 0.019) and with parameters of bone formation. Most patients had VC (>80%) which correlated positively with levels of phosphorus, c-terminal fibroblast growth factor-23, and activin. Aortic calcifications (ACs) correlated negatively with bone formation rate (BFR) and Ac.f (rho -0.62, -0.61, P < 0.001). TBS correlated negatively with coronary calcification (rho -0.42, P = 0.019) and AC (rho -0.57, P = 0.001). These relationships remained after adjustment of age. The mineral-to-matrix ratio, an FTIR metric reflecting bone quality, was negatively related to Ac.f and positively related to AC. Conclusion: Low bone turnover and VC are predominant in early stages of CKD. This is the first study demonstrating mineral abnormalities indicating reduced bone quality in these stages of CKD.

Cisatracurium Continuous Infusion Versus No Neuromuscular Blockade for Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation.

The benefit of continuous infusion neuromuscular blockade concurrently with venovenous (VV) extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome who are receiving mechanical ventilation remains unclear. Adult patients with severe acute respiratory distress syndrome requiring VV ECMO were analyzed in 2 groups: continuous infusion neuromuscular blockade with cisatracurium vs no neuromuscular blockade. Similar mechanical ventilation strategies were used. The primary end point was duration of VV ECMO. This single-center, retrospective observational cohort included a total of 47 patients, 28 of whom received continuous infusion cisatracurium and 19 patients who did not receive neuromuscular blockade. There was no difference in the duration of VV ECMO in patients who received cisatracurium, 226.5 hours (interquartile range, 119-362.3) vs 187.0 hours (interquartile range, 108-374) in the group who did not receive a paralytic (P = .64). There were no differences in secondary outcomes of days in the hospital, days free of organ dysfunction, ECMO survival, or discharged alive. Among patients with severe ARDS who were managed with VV ECMO, patients who received continuous infusion cisatracurium had no difference in the duration of VV ECMO compared to the nonparalytic comparator group.

Extracorporeal Membrane Oxygenation Complicated by an Interrupted Inferior Vena Cava.

Heterotaxy refers to a congenital disorder in which there is a disruption of the normal left-right axis, resulting in duplication of one laterality, and can affect all of the thoracic and abdominal organs. Findings include atrial isomerism, vascular abnormalities affecting the great vessels, ciliary dyskinesia, polysplenia or asplenia, biliary atresia, and gut malrotation. These anomalies can present unique challenges in the critical care setting, particularly in those requiring mechanical circulatory support. Here, we present a patient with acute respiratory distress syndrome requiring venovenous extracorporeal oxygenation which was complicated by a persistent impedance of flow. She was subsequently discovered to have an interrupted inferior vena cava, where lower limb venous drainage returned to the heart via the azygos and hemiazygos systems. We use this case to also highlight other manifestations of heterotaxy which may affect critical care.

Enteral Guanfacine to Treat Severe Anxiety and Agitation Complicating Critical Care After Cardiac Surgery.

This article is the first reported case describing the off-label use of enteral immediate-release guanfacine, a long-acting α-2 adrenergic agonist most commonly used in the treatment of attention-deficit hyperactivity disorder, for sedation in a patient with severe anxiety and agitation limiting mechanical ventilation weaning several days after cardiac surgery. In this case, after several days of unsuccessful attempts to control his agitation and anxiety with conventional therapies, guanfacine therapy was initiated, and the patient was rapidly weaned from all other sedatives and mechanical ventilation shortly thereafter. The patient was weaned from guanfacine therapy without evidence of bradycardia, hypotension, or rebound syndrome. Enteral guanfacine therapy should be further studied as a potentially useful and cost-effective sedative therapy for patients with severe anxiety and/or agitation in the intensive care unit following cardiac and thoracic surgical procedures.

Ultrasound Skill and Application of Knowledge Assessment using an Innovative OSCE Competition-Based Simulation Approach.

BACKGROUND: Despite Point-of Care Ultrasound (PoC US) rapidly becoming an important tool in perioperative medicine structured education, PoC US is currently rarely integrated into the anesthesiology residency curriculum. The aim of this project was to assess the current ultrasound skills of anesthesiology residents at one institution and evaluate the needs for development of a formal ultrasound curriculum. METHODS: A event containing 6 different OSCE PoC US stations was developed with following stations: vascular, peripheral nerve block, lung ultrasound, transthoracic echocardiography (TTE) human model, pathologic TTE (simulator), and inferior vena cava (IVC) evaluation (simulator). The ability to obtain an US image or to interpret the US information was evaluated using a checklist and global rating scale. After IRB approval, anesthesiology residents participated in this event (n=30; PGY 2-4). RESULTS: All residents were able to identify vascular structures and demonstrated sufficient ultrasound skill for lung anatomy IVC assessment. The lowest scores were observed for performing and interpreting TTE. There were no differences in resident ultrasound skills for all OSCE stations except minor differences between PGY 2 and PGY 4 in TTE pathology station. While more advanced residents had more clinical exposure to ultrasound for procedures and point-of-care diagnosis, we did not find growth in ultrasound skill level. Despite performing sufficient ultrasound guided peripheral nerve blocks, PGY 4 residents were not able to consistently identify common nerve block targets. CONCLUSIONS: Our findings indicate that exposure and clinical use of ultrasound for procedures and point-of-care diagnosis is not sufficient for developing competency in PoC US and that a formal curriculum throughout the entire anesthesiology residency is needed to ensure PoC US competency.

Death by late-presenting Bochdalek hernia in infant soon after congenital cardiac repair.

Congenital diaphragmatic hernia (CDH) presenting beyond the neonatal period is commonly perceived to be rare. With reported frequencies of 2.6% to 20% of all CDH, it may be an overlooked cause of mortality. Variable symptomatology makes its diagnosis challenging. We report the sudden death of a 3-month-old patient shortly after hospital discharge following congenital heart surgery. Autopsy findings associated the patient's demise with migrated abdominal contents in the chest through a Bochdalek hernia defect. No indications of CDH existed before hospital discharge. Relevant issues pertaining to congenital heart disease, CDH, and importance of autopsy in this context are discussed.