Individualised, perioperative open-lung ventilation strategy during one-lung ventilation (iPROVE-OLV): a multicentre, randomised, controlled clinical trial.

BACKGROUND: It is uncertain whether individualisation of the perioperative open-lung approach (OLA) to ventilation reduces postoperative pulmonary complications in patients undergoing lung resection. We compared a perioperative individualised OLA (iOLA) ventilation strategy with standard lung-protective ventilation in patients undergoing thoracic surgery with one-lung ventilation. METHODS: This multicentre, randomised controlled trial enrolled patients scheduled for open or video-assisted thoracic surgery using one-lung ventilation in 25 participating hospitals in Spain, Italy, Turkey, Egypt, and Ecuador. Eligible adult patients (age ≥18 years) were randomly assigned to receive iOLA or standard lung-protective ventilation. Eligible patients (stratified by centre) were randomly assigned online by local principal investigators, with an allocation ratio of 1:1. Treatment with iOLA included an alveolar recruitment manoeuvre to 40 cm H2O of end-inspiratory pressure followed by individualised positive end-expiratory pressure (PEEP) titrated to best respiratory system compliance, and individualised postoperative respiratory support with high-flow oxygen therapy. Participants allocated to standard lung-protective ventilation received combined intraoperative 4 cm H2O of PEEP and postoperative conventional oxygen therapy. The primary outcome was a composite of severe postoperative pulmonary complications within the first 7 postoperative days, including atelectasis requiring bronchoscopy, severe respiratory failure, contralateral pneumothorax, early extubation failure (rescue with continuous positive airway pressure, non-invasive ventilation, invasive mechanical ventilation, or reintubation), acute respiratory distress syndrome, pulmonary infection, bronchopleural fistula, and pleural empyema. Due to trial setting, data obtained in the operating and postoperative rooms for routine monitoring were not blinded. At 24 h, data were acquired by an investigator blinded to group allocation. All analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT03182062, and is complete. FINDINGS: Between Sept 11, 2018, and June 14, 2022, we enrolled 1380 patients, of whom 1308 eligible patients (670 [434 male, 233 female, and three with missing data] assigned to iOLA and 638 [395 male, 237 female, and six with missing data] to standard lung-protective ventilation) were included in the final analysis. The proportion of patients with the composite outcome of severe postoperative pulmonary complications within the first 7 postoperative days was lower in the iOLA group compared with the standard lung-protective ventilation group (40 [6%] vs 97 [15%], relative risk 0·39 [95% CI 0·28 to 0·56]), with an absolute risk difference of -9·23 (95% CI -12·55 to -5·92). Recruitment manoeuvre-related adverse events were reported in five patients. INTERPRETATION: Among patients subjected to lung resection under one-lung ventilation, iOLA was associated with a reduced risk of severe postoperative pulmonary complications when compared with conventional lung-protective ventilation. FUNDING: Instituto de Salud Carlos III and the European Regional Development Funds.

Automating weighing of faces and voices based on cue saliency in trustworthiness impressions.

When encountering people, their faces are usually paired with their voices. We know that if the face looks familiar, and the voice is high-pitched, the first impression will be positive and trustworthy. But, how do we integrate these two multisensory physical attributes? Here, we explore 1) the automaticity of audiovisual integration in shaping first impressions of trustworthiness, and 2) the relative contribution of each modality in the final judgment. We find that, even though participants can focus their attention on one modality to judge trustworthiness, they fail to completely filter out the other modality for both faces (Experiment 1a) and voices (Experiment 1b). When asked to judge the person as a whole, people rely more on voices (Experiment 2) or faces (Experiment 3). We link this change to the distinctiveness of each cue in the stimulus set rather than a general property of the modality. Overall, we find that people weigh faces and voices automatically based on cue saliency when forming trustworthiness impressions.

Improving the performance of the Cleveland Clinic Score for predicting acute kidney injury after cardiac surgery: a prospective multicenter cohort study.

BACKGROUND: Cardiac surgery-associated acute kidney injury (CSA-AKI) is associated with high short- and long-term mortality rates. The prediction of CSA-AKI is crucial for early detection and treatment. Current predictive models may be improved by potentially useful preoperative and intraoperative information. METHODS: This multicenter prospective cohort study recruited 261 consecutive patients at high risk for developing CSA-AKI, based on a Cleveland Clinical Score (CCS) of ≥4 points from July to December 2017 in 14 hospitals in Spain and the UK. Postoperative AKI occurred in 145 (55.5%) patients. The receiver operating characteristics curve (AUC) of a base model including only the CCS was compared with models including additional preoperative and intraoperative variables such as the estimated glomerular filtration rate (eGFR) instead of plasmatic creatinine, intraoperative urine output, baseline hemoglobin, nadir hemoglobin, and glycosylated hemoglobin (HbA1c) instead of diabetes mellitus. The performance of each model for AKI was compared. RESULTS: The CCS alone gave an AUC of 0.67 (95% CI, 0.56-0.78) for postoperative AKI. None of the single variables added to the base model CCS improve discrimination. The AUC for postoperative AKI was improved when baseline hemoglobin, eGFR instead of plasmatic creatinine, HbA1c, and nadir hemoglobin were added to the CCS (AUC=0.77; 95% CI, 0.67-0.87; P=0.02). CONCLUSIONS: The addition of baseline hemoglobin, eGFR, HbA1c, and nadir intraoperative hemoglobin may be useful for improving the discrimination of the clinical predictive risk scores for AKI.

CARDIAC OUTPUT IN CRITICALLY ILL PATIENTS CAN BE ESTIMATED EASILY AND ACCURATELY USING THE MINUTE DISTANCE OBTAINED BY PULSED-WAVE DOPPLER.

ABSTRACT: Background: Cardiac output (CO) assessment is essential for management of patients with circulatory failure. Among the different techniques used for their assessment, pulsed-wave Doppler cardiac output (PWD-CO) has proven to be an accurate and useful tool. Despite this, assessment of PWD-CO could have some technical difficulties, especially in the measurement of left ventricular outflow tract diameter (LVOTd). The use of a parameter such as minute distance (MD) which avoids LVOTd in the PWD-CO formula could be a simple and useful way to assess the CO in critically ill patients. Therefore, the aim of this study was to evaluate the correlation and agreement between PWD-CO and MD. Methods: A prospective and observational study was conducted over 2 years in a 30-bed intensive care unit (ICU). Adult patients who required CO monitoring were included. Clinical echocardiographic data were collected within the first 24 h and at least once more during the first week of ICU stay. PWD-CO was calculated using the average value of three LVOTd and left ventricular outflow tract velocity-time integral (LVOT-VTI) measurements, and heart rate. Minute distance was obtained from the product of LVOT-VTI × heart rate. Pulsed-wave Doppler cardiac output was correlated with MD using linear regression. Cardiac output was quantified from the MD using the equation defined by linear regression. Bland-Altman analysis was also used to evaluate the level of agreement between CO calculated from MD (MD-CO) and PWD-CO. The percentage error was calculated. Results: A total of 98 patients and 167 CO measurements were analyzed. Sixty-seven (68%) were male, the median age was 66 years (interquartile range [IQR], 53-75 years), and the median Acute Physiology and Chronic Health Evaluation II score was 22 (IQR, 16-26). The most common cause of admission was shock in 81 patients (82.7%). Sixty-nine patients (70.4%) were mechanically ventilated, and 68 (70%) required vasoactive drugs. The median CO was 5.5 L/min (IQR, 4.8-6.6 L/min), and the median MD was 1,850 cm/min (IQR, 1,520-2,160 cm/min). There was a significant correlation between PWD-CO and MD-CO in the general population ( R2 = 0.7; P < 0.05). This correlation improved when left ventricular ejection fraction (LVEF) was less than 60% ( R2 = 0.85, P < 0.05). Bland-Altman analysis showed good agreement between PWD-CO and MD-CO in the general population, the median bias was 0.02 L/min, the limits of agreement were -1.92 to +1.92 L/min. The agreement was better in patients with LVEF less than 60% with a median bias of 0.005 L/min and limits of agreement of -1.56 to 1.55 L/min. The percentage error was 17% in both cases. Conclusion: Measurement of MD in critically ill patients provides a simple and accurate estimate of CO, especially in patients with reduced or preserved LVEF. This would allow earlier cardiovascular assessment in patients with circulatory failure, which is of particular interest in difficult clinical or technical conditions.

Conceptual representations of uncertainty predict risky decision-making.

Decisions made under uncertainty often are considered according to their perceived subjective value. We move beyond this traditional framework to explore the hypothesis that conceptual representations of uncertainty influence risky choice. Results reveal that uncertainty concepts are represented along a dimension that jointly captures probabilistic and valenced features of the conceptual space. These uncertainty representations predict the degree to which an individual engages in risky decision-making. Moreover, we find that most individuals have two largely distinct representations: one for uncertainty and another for certainty. In contrast, a minority of individuals exhibit substantial overlap between their representations of uncertainty and certainty. Together, these findings reveal the relationship between the conceptualization of uncertainty and risky decisions.

Uncertainty aversion predicts the neural expansion of semantic representations.

Correctly identifying the meaning of a stimulus requires activating the appropriate semantic representation among many alternatives. One way to reduce this uncertainty is to differentiate semantic representations from each other, thereby expanding the semantic space. Here, in four experiments, we test this semantic-expansion hypothesis, finding that uncertainty-averse individuals exhibit increasingly differentiated and separated semantic representations. This effect is mirrored at the neural level, where uncertainty aversion predicts greater distances between activity patterns in the left inferior frontal gyrus when reading words, and enhanced sensitivity to the semantic ambiguity of these words in the ventromedial prefrontal cortex. Two direct tests of the behavioural consequences of semantic expansion further reveal that uncertainty-averse individuals exhibit reduced semantic interference and poorer generalization. Together, these findings show that the internal structure of our semantic representations acts as an organizing principle to make the world more identifiable.

Inhaled Nitric Oxide in Acute Severe Pulmonary Hypertension and Severe Acute Respiratory Distress Syndrome Secondary to COVID-19 Pneumonia: A Case Report.

BACKGROUND Inhaled nitric oxide (iNO) is used as a treatment for pulmonary arterial hypertension (PAH). Severe hypoxia with hypoxic vasoconstriction caused by severe acute respiratory distress syndrome (ARDS) can induce pulmonary hypertension with hemodynamic implications, mainly secondary to right ventricle (RV) systolic function impairment. We report the case of the use of iNO in a critically ill patient with bilateral SARS-CoV-2 pneumonia and severe ARDS and hypoxemia leading to acute severe PAH, causing a ventilation/perfusion mismatch, RV pressure overload, and RV systolic dysfunction. CASE REPORT A 36-year-old woman was admitted to the Intensive Care Unit with a severe ARDS associated with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. Severe hypoxia and hypoxic vasoconstriction developed, leading to an acute increase in pulmonary vascular resistance, severe to moderate tricuspid regurgitation, RV pressure overload, RV systolic function impairment, and RV dilatation. Following 24 h of treatment with iNO at 15 ppm, significant oxygenation and hemodynamic improvement were noted, allowing vasopressors to be stopped. After 24 h of iNO treatment, echocardiography showed very mild tricuspid regurgitation, a non-dilated RV, no impairment of transverse free wall contractility, and no paradoxical septal motion. iNO was maintained for 7 days. The dose of iNO was progressively decreased with no adverse effects and maintaining an improvement of oxygenation and hemodynamic status, allowing respiratory weaning. CONCLUSIONS Sustained acute hypoxia in ARDS secondary to SARS-CoV-2 pneumonia can lead to PAH, causing a ventilation/perfusion mismatch and RV systolic impairment. iNO can be considered in patients with significant PAH causing hypoxemia and RV dysfunction.

Is political extremism supported by an illusion of understanding?

Polarization is rising in most countries in the West. How can we reduce it? One potential strategy is to ask people to explain how a political policy works-how it leads to consequences- because that has been shown to induce a kind of intellectual humility: Explanation causes people to reduce their judgments of understanding of the issues (their "illusion of explanatory depth"). It also reduces confidence in attitudes about the policies; people become less extreme. Some attempts to replicate this reduction of polarization have been unsuccessful. Is the original effect real or is it just a fluke? In this paper, we explore the effect using more timely political issues and compare judgments of issues whose attitudes are grounded in consequentialist reasoning versus protected values. We also investigate the role of social proof. We find that understanding and attitude extremity are reduced after explanation but only for consequentialist issues, not those based on protected values. There was no effect of social proof.

European association of cardiothoracic anesthesiology and intensive care (EACTAIC) fellowship curriculum: second edition

Abstract Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

European association of cardiothoracic anesthesiology and intensive care pediatric cardiac anesthesia fellowship curriculum: first edition

ABSTRACT: Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

European Association of Cardiothoracic Anesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum: First Edition.

Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

Acute kidney injury after cardiac surgery: Sustained low efficiency compared to continuous renal replacement therapy.

STUDY OBJECTIVE: Sustained low efficiency dialysis (SLED) has been introduced as a mode of renal replacement therapy (RRT) for treating severe cardiac surgery-associated acute kidney injury (CSA-AKI) at some hospitals; SLED is performed using intermittent hemodialysis (IHD) devices but differs from conventional IHD in its duration and intensity. However, there are limited data comparing SLED against more conventional continuous RRT methods. We conducted a retrospective cohort study to compare outcomes of patients with severe CSA-AKI after an institutional transition from continuous RRT to SLED. DESIGN: Following research ethics approval, we conducted a retrospective cohort study of patients with severe CSA-AKI requiring RRT. SETTING: Cardiac Intensive Care Unit at the Toronto General Hospital (Toronto, Ontario, Canada) from 1 January 1999 to 31 December 2011. PATIENTS: 351 consecutive patients with severe CSA-AKI requiring RRT after cardiac surgery. INTERVENTIONS: The RRT mode was continuous RRT before 31 March 2008, and SLED after 1 April 2008. MEASUREMENTS: The primary outcome was low-cardiac output syndrome (LCOS) and the main secondary outcome was associated costs. Propensity score matched-pairs analyses were used to compare the outcomes of patients in the continuous RRT period versus the SLED period. MAIN RESULTS: There were 268 patients treated with continuous RRT and 83 patients treated with SLED. The SLED group had a higher weight, higher baseline hemoglobin concentration, and higher prevalence of obstructive lung disease. In propensity score match-pairs analysis (n = 148), the SLED group experienced similar odds of low cardiac output syndrome (odds ratio [OR] 1.06, 95% CI 0.68 to 1.67), death (OR 1.09, 0.94 to 1.28), acute stroke (OR 0.97, 0.83 to 1.13), myocardial infarction (OR 0.92, 0.84 to 1.01). The use of SLED was associated with a reduced cost compared to continuous RRT. The cost differential for 83 treated patients was CAD$130,974 (CAD$178,159.50 vs CAD$309,133.50) in favor of SLED. CONCLUSIONS: An institutional transition from continuous RRT to SLED, was associated with a significant lower cost with the use of SLED, while maintaining comparable postoperative outcomes in CSA-AKI patients.

Hydroxyethyl starch and acute kidney injury in high-risk patients undergoing cardiac surgery: A prospective multicenter study.

BACKGROUND: Hydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients admitted to intensive care unit (ICU) for medical indications. We conducted a cohort study to evaluate the renal safety of modern 6% HES solutions in high-risk patients having cardiac surgery. METHOD: In this multicentre prospective cohort study, we recruited 261 consecutive patients at high-risk for developing cardiac surgery-associated AKI, based on a Cleveland score ≥ 4 points, from July to December 2017th in 14 hospitals in Spain and the United Kingdom. Multivariable logistic regression modeling and propensity-score matched-pairs analysis were used to determine the adjusted association between administration of HES and AKI. RESULTS: Of the cohort, 95 patients (36.4%) received 6% HES 130/0.4 either intraoperatively or postoperatively. Postoperative AKI occurred in 145 patients (55.5%). The unadjusted odds of AKI was significantly higher in the HES group, when compared to those not receiving HES (OR 2.22, 95% CI 1.30-3.80, p = 0.003). In multivariable logistic regression models, modern HES was not associated with significantly increased risk of AKI (adjusted OR 0.84, 95% CI 0.41-1.71, p = 0.63). In propensity score match-pairs analysis of 188 patients, the HES group experienced similar adjusted odds of AKI (OR 1.05, CI 95% 0.87-1.27, p = 0.57) and RRT (OR 1.06, CI 95% 0.92-1.22, p = 0.36). CONCLUSIONS: The use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with an increased risk of AKI nor dialysis in this cohort of patients at elevated risk for developing AKI after cardiac surgery.

Lenience breeds strictness: The generosity-erosion effect in hiring decisions.

In recruitment processes, candidates are often judged one after another. This sequential procedure affects the outcome of the process. Here, we introduce the generosity-erosion effect, which states that evaluators might be harsher in their assessment of candidates after grading previous candidates generously. Generosity is defined as giving a candidate the lowest possible grade required to progress in the hiring process. Analyzing a high-stake hiring process, we find that for each candidate graded generously, the probability for subsequent candidates to pass decreased by 7.7% (experiment 1; N = 11,281). Testing the boundary conditions of the generosity-effect, we explore a hiring process that, in contrast to the previous process, was very selective, because candidates were more likely to fail than to pass. In this scenario, no evidence is found for the generosity-erosion effect (experiment 2; N = 3171). Practical implications and mechanisms underlying the generosity-erosion effect are further discussed.

Multicenter International Survey on Cardiopulmonary Bypass Perfusion Practices in Adult Cardiac Surgery

OBJECTIVES: To assess current practice in adult cardiac surgery during cardiopulmonary bypass (CPB) across European and non-European countries. DESIGN: International, multicenter, web-based survey including 28 multiple choice questions addressing hemodynamic and tissue oxygenation parameters, organ protection measures, and the monitoring and usage of anesthetic drugs as part of the anesthetic and perfusion practice during CPB. SETTING: Online survey endorsed by the European Association of Cardiothoracic Anesthesiologists. PARTICIPANTS: Representatives of anesthesiology departments in European and non-European adult cardiac surgical centers. INTERVENTIONS: None. Measurements and Main Results: The survey was distributed via e-mail to European Association of Cardiothoracic Anesthesiologists members (n = 797) and kept open for 1 month. The response rate was 34% (n = 271). After exclusion of responses from the same centers and of incomplete answers, data from 202 cardiac centers in 56 countries, of which 67% of centers were university hospitals, were analyzed. Optimization of pump flows and tissue oxygenation parameters during CPB were applied by the majority of centers, with target flow rates of >2.2 L/min/m2 in 93% (n = 187) of centers and mean arterial blood pressures between 51 and 90 mmHg in 85% (n = 172). Hemoglobin transfusion triggers were either individualized or between 7 and 8 g/dL in 92% (n = 186) of centers. Mixed venous oxyhemoglobin saturations were assessed routinely in 59% (n = 120) and lactate in 88% (n = 178) of cardiac surgery units. Noninvasive cerebral saturation monitoring was used in a subgroup of patients or routinely in 84% (n = 169) of sites, and depth-of-anesthesia monitoring was used routinely in 53% (n = 106). Transesophageal echocardiography and pulmonary artery catheters were used routinely or in subgroups of patients in 97% (n = 195) and 71% (n = 153) of centers, respectively. The preferred site for temperature monitoring was the nasopharynx in 66% (n = 134) of centers. Anesthetic techniques were variable, with 26% of centers (n = 52) using low-tidal-volume ventilation and 28% (n = 57) using continuous positive airway pressure during CPB. Volatile agents were used routinely as the only agent during CPB in 36% sites (n = 73) and propofol in 47% (n = 95). Other drugs routinely administered included magnesium in 45% (n = 91), steroids in 18% (n = 37), tranexamic acid in 88% (n = 177), and aprotinin in 15% (n = 30) of the centers. CONCLUSION: This international CPB survey revealed that techniques for optimization of pump flow and oxygenation during CPB usually were applied. Furthermore, cerebral and hemodynamic monitoring devices were frequently used during CPB. However, most CPB-related anesthetic techniques and medications were more variable. More high-quality randomized controlled trials are needed to assess anesthetic techniques and organ protection.