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.

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.

Can Transesophageal Echocardiography Be Performed Safely Using a Laryngeal Mask Airway During Atrial Fibrillation Ablation?

OBJECTIVE: To investigate the feasibility and safety of using a laryngeal mask airway (LMA) compared with a cuffed oral endotracheal tube (COETT) for atrial fibrillation (AF) ablation with transesophageal echocardiography (TEE). DESIGN: Prospective, cohort study. SETTING: A single-center inner-city hospital. PARTICIPANTS: The study comprised adult patients undergoing elective AF ablation with periprocedural TEE over a 3-year period. INTERVENTIONS: Patients were treated with either an LMA or a COETT before undergoing a standardized protocol for TEE and AF ablation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the need for conversion from an LMA to a COETT. Between January 2014 and January 2017, 346 patients underwent AF ablation. Of those, 126 procedures were performed with a COETT (36.4%) and 220 (63.6%) with an LMA. There were no differences between groups in terms of baseline characteristics, including age, sex, body mass index, and American Society of Anesthesiologists grade. An adequate airway seal was unable to be maintained in 3 patients in the LMA group (1.4%), and those patients were converted to a COETT. No episodes of airway complications occurred in either group. No difference was found in mean propofol (2%) dose between COETT and LMA (385 mg/h v 374 mg/h; p = 0.127). However, the mean remifentanil dose (100 µg/mL) was reduced significantly in the LMA group compared with the COETT group at 355 µg/h and 939 µg/h, respectively (p < 0.001). CONCLUSIONS: LMA use is safe and feasible in the vast majority of patients undergoing AF ablation with TEE and is an acceptable alternative to COETT. A significantly reduced rate of remifentanil was required to maintain anesthesia in the LMA group.

A randomized trial of cardiopulmonary resuscitation training for medical students: voice advisory mannequin compared to guidance provided by an instructor.

INTRODUCTION: Current European Resuscitation Guidelines 2010 recommend the use of prompt/feedback devices when training for cardiopulmonary resuscitation (CPR). We aimed to assess the quality of CPR training among second-year medical students with a voice advisory mannequin (VAM) compared to guidance provided by an instructor. METHODS: Forty-three students received a theoretical reminder about CPR followed by a 2-minute pretest on CPR (compressions/ventilations cycle) with Resusci Anne SkillReporter (Laerdal Medical). They were then randomized into a control group (n = 22), trained by an instructor for 4 minutes per student, and an intervention group (n = 21) trained individually with VAM CPR mannequin for 4 minutes. After training, the students performed a 2-minute posttest, with the same method as the pretest. RESULTS: Participants in the intervention group (VAM) performed more correct hand position (73% vs. 37%; P = 0.014) and tended to display better compression rate (124 min vs. 135 min; P = 0.089). In a stratified analyses by sex we found that only among women trained with VAM was there a significant improvement in compression depth before and after training (36 mm vs. 46 mm, P = 0.018) and in the percentage of insufficient compressions before and after training (56% vs. 15%; P = 0.021). CONCLUSIONS: In comparison to the traditional training method involving an instructor, training medical students in CPR with VAM improves the quality of chest compressions in hand position and in compression rate applied to mannequins. Only among women was VAM shown to be superior in compression depth training. This technology reduces costs in 14% in our setup and might potentially release instructors' time for other activities.