Monitoring anesthesia depth with patient state index during pediatric surgery.

BACKGROUND: Monitoring anesthesia depth in children is challenging. Pediatric anesthesiologists estimate general anesthesia depth using indirect methods such as pharmacokinetic models and neurovegetative reflexes. The application of processed electroencephalography may help to identify the correct anesthesia depth (i.e., patient state index between 25 and 50). AIMS: To determine the median values of patient state index and spectral edge frequency 95% in children undergoing general anesthesia conducted according to indirect evaluation of depth. The relationships between patient state index and spectral edge frequency 95% and indirect monitoring of anesthesia depth, type of anesthesia, age subgroups, and postoperative delirium were also assessed. METHODS: A prospective observational study on children (aged 1-18 years) undergoing surgery longer than 60 min. The SedLine monitor and the novel SedLine pediatric sensors (Masimo Inc., Irvine California) were applied. Patient state index levels were recorded for the duration of the anesthesia until the discharge to the ward at predefined time points. RESULTS: In the 111 enrolled children, median patient state index level at the end of anesthesia induction was 25 (22-32) and ranged from 26 (23-34) to 28 (25-36) in the maintenance phase. Patient state index at extubation was 48 (35-60) and 69 (62-75) at discharge from the operatory room. Median right/left spectral edge frequency 95% values at the end of induction were 10 (6-14)/9 (5-14) Hz and median right/left spectral edge frequency 95% values in the maintenance phase ranged from 10 (6-14) to 12 (11-15) Hz in both hemispheres. At extubation, right/left spectral edge frequency 95% levels were 18 (15-21)/17 (15-21) Hz. We observed 39 episodes of burst suppression in 20 patients (19%). Median patient state index levels were not different between patients undergoing inhalational and intravenous anesthesia and between those undergoing general anesthesia and general anesthesia added to locoregional anesthesia. Children <2 years displayed significantly higher patient state index levels than older patients (p = .0004). The presence of a burst suppression episode was not associated with PAED levels (OR 1.58, 95% CI 0.14-16.74, p` = .18). CONCLUSIONS: NonpEEG-guided anesthesia in children led to median patient state index levels at the low range of recommended unconsciousness values with frequent episodes of burst suppression. Patient state index levels were generally higher in children below 2 years.

Multisystem Inflammatory Syndrome in Children and Acute Kidney Injury: Retrospective Study of Five Italian PICUs.

OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) manifests with heart dysfunction and respiratory failure some weeks after a severe acute respiratory syndrome coronavirus disease 2 infection. The aim of our study was to explore the prevalence, severity, timing, and duration of acute kidney injury (AKI) in MIS-C patients. Furthermore, we evaluated which clinical variables and outcomes are associated with AKI. DESIGN: Multicenter retrospective study. SETTING: Five tertiary hospital PICUs in Italy. Data were collected in the first 7 days of PICU admission and renal function was followed throughout the hospital stay. PATIENTS: Patients less than 18 years old admitted to the PICU for greater than 24 hours with MIS-C. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We collected the following data, including: demographic information, inflammatory biomarkers, lactate levels, Pa o2 /F io2 , ejection fraction, N-terminal pro-B-type natriuretic peptide (NT-proBNP), renal function (serum creatinine, urinary output, fluid balance, and percentage fluid accumulation), Vasoactive-Inotropic Score (VIS), pediatric Sequential Organ Failure Assessment (pSOFA), and Pediatric Index of Mortality 3. AKI was diagnosed in eight of 38 patients (21%) and severe AKI was present in four of eight patients. In all cases, AKI was present at PICU admission and its median (interquartile range) duration was 3.5 days (1.5-5.7 d). We did not identify differences between AKI and no-AKI patients when not making correction for multiple comparisons, for example, in weight, ejection fraction, pSOFA, Pa o2 /F io2 , and lactates. We failed to identify any difference in these groups in urine output and fluid balance. Exploratory analyses of serial data between no-AKI and AKI patients showed significant differences on lymphocyte count, NT-proBNP value, ejection fraction, pSOFA, Pa o2 /F io2 , and VIS. CONCLUSIONS: In this multicenter Italian PICU experience, MIS-C is associated with AKI in one-in-five cases. In general, AKI is characterized by an associated reduction in glomerular filtration rate with a self-limiting time course.

Risk prediction of contrast-induced nephropathy by ACEF score in patients undergoing coronary catheterization.

AIMS: To explore the ability of the ACEF score to predict the incidence of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography with or without percutaneous coronary intervention. METHODS: A total of 706 patients undergoing coronary angiography ±â€Špercutaneous coronary intervention (PCI) between March 2011 and October 2011 were analyzed. CIN using different definitions was termed as CINnarrow (rise in serum creatinine ≥0.5 mg/dl) and CINbroad (rise in serum creatinine ≥0.5 mg/dl and/or ≥25% increase in baseline serum creatinine). RESULTS: The mean ACEF score was 1.5 ±â€Š0.6. Overall incidences of CINnarrow and CINbroad were 5.5% and 13.6%, respectively. There was a significant gradient in the incidence of CINnarrow (2.9%, 3.9%, 10.6% in the I, II, and III tertiles, respectively, P < 0.001) and CINbroad (9.1%, 14.2%, 17.9% in the I, II, and III tertiles, respectively, P = 0.021) across increasing ACEF tertiles. The ACEF score was independently associated with the risk of CINnarrow (adjusted odds ratio [OR] 1.6, 95% confidence interval [CI] 1.0-2.7; P = 0.047). Discrimination was more satisfactory when using the ACEF as a predictor of CINnarrow (c-statistic 0.71, 95% 0.63-0.79). CONCLUSION: The ACEF score is an independent and potentially useful predictor of CIN defined as rise in serum creatinine ≥0.5 mg/dl.

Volume-to-creatinine clearance ratio in patients undergoing coronary angiography with or without percutaneous coronary intervention: implications of varying definitions of contrast-induced nephropathy.

OBJECTIVES: Whether predicting the risk of early serum creatinine rise using the ratio of the volume of contrast media administered to the estimated creatinine clearance (V/CrCl) is applicable to the broader definition of contrast-induced nephropathy (CIN) (≥0.5 mg/dL absolute and/or 25% relative increase from baseline serum creatinine) is unknown. BACKGROUND: A V/CrCl ≥4 has been proven to predict the risk of ≥0.5 mg/dL postprocedural absolute rise in serum creatinine. METHODS: A total of 722 patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) between March 2011 and October 2011 with paired serum creatinine determinations at preprocedure and within 72-hr postprocedure were analyzed. The V/CrCl ratio was calculated by dividing the volume of contrast received by the patient's creatinine clearance. CIN using different definitions was termed as CINnarrow (rise in serum creatinine ≥0.5 mg/dL) and CINbroad (rise in serum creatinine ≥0.5 mg/dL and/or ≥25% increase in baseline serum creatinine). RESULTS: The mean age was 66 ± 11 years and the mean baseline serum creatinine was 1.1 ± 0.8 mg/dL. Patients with V/CrCl ≥4 were significantly older and more frequently underwent ad hoc PCI compared with those with V/CrCl <4. CINnarrow and CINbroad were observed in 13 versus 3% (P < 0.001) and 23 versus 11% (P < 0.001) of patients with or without V/CrCl ≥4, respectively. After statistical adjustment, a V/CrCl ratio ≥4 remained significantly associated with the risk of both CINnarrow [adjusted OR 3.5, 95% confidence intervals (95% CI) 1.7-7.3; P < 0.001] and CINbroad (adjusted OR 2.5, 95% 1.6-3.9; P < 0.001). CONCLUSIONS: A volume-to-creatinine clearance ratio ≥4 significantly predicts the risk of early postprocedural rise in serum creatinine regardless of the CIN definition adopted.