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Pubblicazioni recenti - cardiopulmonary
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The Influence of Atrial Strain on Functional Capacity in Patients with the Fontan Circulation.
Pediatr Cardiol2020 Aug;():. doi: 10.1007/s00246-020-02435-7.
Rato Joćo, Mendes Susana Cordeiro, Sousa Ana, Lemos Mariana, Martins Duarte Saraiva, Anjos Rui,
Abstract
Speckle-tracking echocardiography has been used to assess atrial function. This analysis is feasible in univentricular hearts. The aim of this study was to characterize the relationship between atrial strain and functional capacity in the Fontan circulation. Apical four-chamber echocardiographic loops of 39 Fontan patients were reviewed. The dominant atrium was assessed for active (?), conduit (?), and reservoir (?) strain and ?/? ratio. Cardiopulmonary exercise test was performed on the same day and oxygen uptake (VO) at ventilatory threshold (VT) and peak VO were chosen as the dependent variables. Statistical analysis was performed using SPSS version 23. Unpaired t test was used for binomial and continuous variable correlation; single and multivariable linear regression were used for continuous variable correlation. Statistical significance was defined as p value < 0.05. VO at VT as a percentage of predicted VO was 36.8% (SD 10.7). Peak VO was 64.7% (SD 18.9) of the predicted value. In univariate analysis, both were associated with age, atrioventricular regurgitation, ejection fraction, ?, ?, and ?/?. In multivariate regression, higher VO at VT and peak VO were associated with younger age (p = 0.003 and p = 0.001, respectively) and higher ? (p = 0.026 and p = 0.020). Evaluation of heart function is difficult in the Fontan circulation, hindered by complex ventricular morphology and lack of normative data. VO provides a good surrogate. Atrial strain parameters are compromised in these patients and associated with VO. Therefore, whenever possible, atrial strain should be measured as it may provide a new method of risk stratification.
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The effect of nebivolol on erectile function in the cases with coronary artery bypass surgery: A protocol for a systematic review and meta-analysis of randomized controlled trials.
Medicine (Baltimore)2020 Aug;99(32):e21588. doi: 10.1097/MD.0000000000021588.
Yang Yali, Yong Shanshan, Li Fuhao, Dong Liang, Chang Degui,
Abstract
BACKGROUND:
Erectile dysfunction is a common disease. It affects the quality of life of both husband and wife and its prevalence is higher in patients with overt cardiovascular disease or cardiovascular risk factors. In recent years, multiple studies confirm that nebivolol exerts protective effects on erectile function against the disruptive effects of cardiopulmonary bypass in patients undergoing coronary artery bypass grafting, but its quality and efficacy have not been systematically evaluated. Therefore, it is necessary to carry out a systematic review and meta-analysis to fully evaluate the efficacy and safety of nebivolol on erectile function in the cases with coronary artery bypass grafting.
METHODS AND ANALYSIS:
Chinese and English literature of nebivolol on erectile function in the cases with coronary artery bypass surgery published before August 31, 2020 will be comprehensive searched in PubMed, Cochrane Library, EMBASE, WANFANG, China National Knowledge Infrastructure, VIP Chinese Science and Technology Journal Database, Chinese biomedical document service system, and Clinicaltrials.gov. Only randomized controlled trials that meet the eligibility criteria will be included. Two researchers will independently complete literature screening, data extraction and assess the risk of bias, and the third investigator will handle disagreements. Our main evaluation includes 2 outcome indicators including the international index of erectile function 5 score and adverse events. RevMan 5.3 and Stata 14.0 will be used to conduct this systematic review. The preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P) statement is followed in this protocol and the PRISMA statement will be followed in the completed systematic review.
CONCLUSION AND DISSEMINATION:
The efficacy and safety of nebivolol on erectile function in the cases with coronary artery bypass grafting will be evaluated. We will publish the results of this systematic review in peer-reviewed journals to provide new evidence to clinicians.
ETHICS AND DISSEMINATION:
Ethical approval is not required as the review is a secondary study based on published literature. The results will be published in a public issue journal to provide evidence-based medical evidence for urologists and andrologists to make better clinical decisions.
REGISTRATION INFORMATION:
INPLASY202060110.
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Neonatal and Maternal Composite Adverse Outcomes Among Low-Risk Nulliparous Women Compared With Multiparous Women at 39-41 Weeks of Gestation.
Obstet Gynecol2020 Aug;():. doi: 10.1097/AOG.0000000000003951.
Chauhan Suneet P, Rice Madeline Murguia, Grobman William A, Bailit Jennifer, Reddy Uma M, Wapner Ronald J, Varner Michael W, Thorp John M, Caritis Steve N, Prasad Mona, Tita Alan T N, Saade George R, Sorokin Yoram, Rouse Dwight J, Tolosa Jorge E, ,
Abstract
OBJECTIVE:
To estimate whether the frequency of adverse maternal and neonatal outcomes differs between low-risk nulliparous and multiparous women at 39-41 weeks of gestation.
METHODS:
This is a secondary analysis of an observational obstetrics cohort of maternal-neonatal dyads at 25 hospitals. Low-risk women with nonanomalous singletons who delivered between 39 0/7 and 41 6/7 weeks of gestation were included. The composite neonatal adverse outcome included 5-minute Apgar score less than five, ventilator support or cardiopulmonary resuscitation, seizure, hypoxic ischemic encephalopathy, sepsis, bronchopulmonary dysplasia, persistent pulmonary hypertension, necrotizing enterocolitis, birth injury or perinatal death. The composite maternal adverse outcome included infection, third- or fourth-degree perineal laceration, thromboembolism, transfusion of blood products, or maternal death. Small for gestational age (SGA), large for gestational age (LGA), and shoulder dystocia requiring maneuvers were also evaluated. Multivariable regression was used to estimate adjusted relative risks (aRRs) and adjusted odds ratios (aORs) with 95% CIs.
RESULTS:
Of the 115,502 women in the overall cohort, 39,870 (34.5%) met eligibility criteria for this analysis; 18,245 (45.8%) were nulliparous. The risk of the composite neonatal adverse outcome (1.5% vs 1.0%, aRR 1.80, 95% CI 1.48-2.19), composite maternal adverse outcome (15.1% vs 3.3%, aRR 5.04, 95% CI 4.62-5.49), and SGA (8.9% vs 5.8%, aOR 1.45, 95% CI 1.33-1.57) was significantly higher in nulliparous than multiparous patients. The risk of LGA (aOR 0.65, 95% CI 0.60-0.71) and shoulder dystocia with maneuvers (aRR 0.68, 95% CI 0.60-0.77) was significantly lower in nulliparous rather than multiparous patients.
CONCLUSION:
The risk of composite adverse outcomes and SGA among low-risk nulliparous women at 39-41 weeks of gestation is significantly higher than among multiparous counterparts. However, nulliparous women had a lower risk of shoulder dystocia with maneuvers and LGA.
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Impact of bystander-focused public health interventions on cardiopulmonary resuscitation and survival: a cohort study.
Lancet Public Health2020 Aug;5(8):e428-e436. doi: S2468-2667(20)30140-7.
Blewer Audrey L, Ho Andrew Fu Wah, Shahidah Nur, White Alexander Elgin, Pek Pin Pin, Ng Yih Yng, Mao Desmond Renhao, Tiah Ling, Chia Michael Yih-Chong, Leong Benjamin Sieu-Hon, Cheah Si Oon, Tham Lai Peng, Kua Jade Phek Hui, Arulanandam Shalini, Ųstbye Truls, Bosworth Hayden B, Ong Marcus Eng Hock,
Abstract
BACKGROUND:
Bystander cardiopulmonary resuscitation (CPR) increases an individual's chance of survival from out-of-hospital cardiac arrest (OHCA), but the frequency of bystander CPR is low in many communities. We aimed to assess the cumulative effect of CPR-targeted public health interventions in Singapore, which were incrementally introduced between 2012 and 2016.
METHODS:
We did a secondary analysis of a prospective cohort study of adult, non-traumatic OHCAs, through the Singapore registry. National interventions introduced during this time included emergency services interventions, as well as dispatch-assisted CPR (introduced on July 1, 2012), a training programme for CPR and automated external defibrillators (April 1, 2014), and a first responder mobile application (myResponder; April 17, 2015). Using multilevel mixed-effects logistic regression, we modelled the likelihood of receiving bystander CPR with the increasing number of interventions, accounting for year as a random effect.
FINDINGS:
The Singapore registry contained 11 465 OHCA events between Jan 1, 2011, and Dec 31, 2016. Paediatric arrests, arrests witnessed by emergency medical services, and healthcare-facility arrests were excluded, and 6788 events were analysed. Bystander CPR was administered in 3248 (48%) of 6788 events. Compared with no intervention, likelihood of bystander CPR was not significantly altered by the addition of emergency medical services interventions (odds ratio [OR] 1·33 [95% CI 0·98-1·79]; p=0·065), but increased with implementation of dispatch-assisted CPR (3·72 [2·84-4·88]; p<0·0001), with addition of the CPR and automated external defibrillator training programme (6·16 [4·66-8·14]; p<0·0001), and with addition of the myResponder application (7·66 [5·85-10·03]; p<0·0001). Survival to hospital discharge increased after the addition of all interventions, compared with no intervention (OR 3·10 [95% CI 1·53-6·26]; p<0·0001).
INTERPRETATION:
National bystander-focused public health interventions were associated with an increased likelihood of bystander CPR, and an increased survival to hospital discharge. Understanding the combined impact of public health interventions might improve strategies to increase the likelihood of bystander CPR, and inform targeted initiatives to improve survival from OHCA.
FUNDING:
National Medical Research Council, Clinician Scientist Award, Singapore and Ministry of Health, Health Services Research Grant, Singapore.
Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.
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Sugammadex Neuromuscular Blockade Reversal Associated With Lower Postoperative Arterial Carbon Dioxide Levels After Congenital Cardiac Surgery.
J Cardiothorac Vasc Anesth2020 Jul;():. doi: S1053-0770(20)30711-4.
Bray Jacob P, Adams Douglas R, Phadke Aparna S, Adams Phillip S,
Abstract
OBJECTIVE:
To compare postoperative arterial blood gas samples and requirement for respiratory support between patients who received sugammadex versus neostigmine reversal before extubation after congenital cardiac surgery.
DESIGN:
Retrospective, cross-sectional study.
SETTING:
Single-center, university-based, tertiary care hospital.
PARTICIPANTS:
Patients with congenital heart disease undergoing surgery with cardiopulmonary bypass.
INTERVENTIONS:
Chart review.
MEASUREMENTS AND MAIN RESULTS:
The first postoperative arterial blood gas measurements were abstracted from electronic medical records, and reintubation or use of positive- pressure respiratory support within the first 24 postoperative hours was documented. Of the 237 charts reviewed, 111 (47%) patients received sugammadex reversal and 126 (53%) received neostigmine. Multivariate models showed that patients with 2-ventricle congenital heart disease who received sugammadex had lower postoperative arterial carbon dioxide partial pressure (PaCO) values (coefficient -3.1, 95% confidence interval [CI] -5.9 to -0.4; p?=?0.026) and required less- noninvasive positive- pressure ventilation (odds ratio 0.3, 95% CI 0.1-0.8; p?=?0.021). Single-ventricle congenital heart disease patients who received sugammadex had higher postoperative pH values (coefficient 0.04, 95% CI 0.01-0.06; p?=?0.01) and lower PaCO values (coefficient -5.2, 95% CI -9.6 to -0.8; p?=?0.021).
CONCLUSION:
Sugammadex reversal was associated with lower postoperative PaCO values. In addition, sugammadex reversal was associated with less need for noninvasive positive- pressure ventilation in 2-ventricle patients. The magnitude of the effect appears modest, therefore the clinical significance remains unclear. Additional studies focused on investigating particular patient populations, such as infants, single-ventricle congenital heart disease, or patients with pulmonary hypertension, are needed to identify whether these patients appreciate a greater benefit from sugammadex reversal.
Copyright © 2020 Elsevier Inc. All rights reserved.
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Ventilatory efficiency during ramp exercise in relation to age and sex in a healthy Japanese population.
J Cardiol2020 Aug;():. doi: S0914-5087(20)30249-5.
Ashikaga Kohei, Itoh Haruki, Maeda Tomoko, Itoh Hidetaka, Ichikawa Yuri, Tanaka Shiori, Ajisaka Ryuichi, Koike Akira, Makita Shigeru, Omiya Kazuto, Kato Yuko, Adachi Hitoshi, Nagayama Masatoshi, Tajima Akihiko, Harada Naomi, Akashi Yoshihiro J, ,
Abstract
BACKGROUND:
The current understanding of ventilator efficiency variables during ramp exercise testing in the normal Japanese population is insufficient, and the responses of tidal volume (VT) and minute ventilation (V?E) to the ramp exercise test in the normal Japanese population are not known.
METHODS:
A total of 529 healthy Japanese subjects aged 20-78 years underwent cardiopulmonary exercise testing using a cycle ergometer with ramp protocols. VT and V?E at rest, at anaerobic threshold, and at peak exercise were determined. The slope of V?E versus carbon dioxide (V?CO) (V?E vs. V?CO slope), minimum V?E/V?CO, and oxygen uptake efficiency slope (OUES) were determined.
RESULTS:
For males and females in their 20 s, peak VT (VTpeak) was 2192 ± 376 and 1509 ± 260 mL (p < 0.001), peak V?E (V?Epeak) was 80.6 ± 18.7 and 57.7 ± 13.9 L/min (sex differences p < 0.001), the V?E vs. V?CO slope was 24.4 ± 3.2 and 25.7 ± 3.2 (p = 0.035), the minimum V?E/V?CO was 24.2 ± 2.3 and 27.0 ± 2.8 (p < 0.001), and the OUES was 2452 ± 519 and 1991 ± 315 (p < 0.001), respectively. VTpeak and V?Epeak decreased with age and increased with weight and height. The V?E vs. V?CO slope and minimum V?E/V?CO increased with age, while conversely, the OUES decreased with age.
CONCLUSIONS:
We have established the normal range of VT and V?E responses, the V?E vs. V?CO slope, the minimum V?E/V?CO, and the OUES for a healthy Japanese population. Some of these parameters were influenced by weight, height, sex, and age. These results provide useful reference values for interpreting the results of cardiopulmonary exercise testing in cardiac patients.
Copyright © 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
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Evaluation of Microbiological Contamination of Dummies used in Cardio-pulmonary Resuscitation in Korea.
Curr Pharm Biotechnol2020 Aug;():. doi: 10.2174/1389201021666200807105136.
Cho Seung-Hak, Bak Young-Seok, Kim Cheorl-Ho, Kim Jung-Beom,
Abstract
OBJECTIVES:
In order to prevent infections through dummies used during Cardiopulmonary Resuscitation (CPR) training, we analyzed the microbiological contamination on dummies used in CPR institutions.
METHODS:
A total of 31 dummy samples were collected from 13 different institutions in Korea, and were evaluated for the number of contaminating bacteria and fungi on the surface. PCR and biochemical tests were performed to identify pathogenic bacteria and fungi, including methicillin-resistant Staphylococcus aureus (MRSA). Moreover, we further assessed the survival rate of microorganisms on the surface of the dummies.
RESULTS:
We assessed the total number of microorganisms on the surface to be 77,752 CFU/cm2 (±50,047 CFU), which is up to 188 times higher than the requirement surface contamination level. Gram-positive cocci such as Micrococcus spp. and Staphylococcus spp. accounted for the highest proportion (55.3%). Especially, we detected three MRSA strains. Considering the isolated fungi and yeast, Aspergillus spp. and Candidia spp. accounted for the highest proportion. Assessing the contamination level simulation and survival rate on humanoid surface showed that within two weeks of training, the level of contamination on the dummy's surface exceeded the standard, and artificially contaminated pathogenic strains on the surface of the dummy survived for at least 40 days.
CONCLUSION:
To minimize the possibility of secondary infections during CPR training, there is a requirement for a standardized protocol for proper microbiological management of dummies.
Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.
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Confounded by obesity and modulated by urinary uric acid excretion, sleep-disordered breathing indirectly relates to hyperuricaemia in males: A structural equation model.
J Sleep Res2020 Aug;():e13108. doi: 10.1111/jsr.13108.
Lai Ching-Hsiang, Huang Ren-Jing, Wong James Kok-Suh, Chang Shen-Wen, Chung Ai-Hui, Chi Yung-Chun, Yu Yi-Chen, Lee Shin-Da, Ting Hua,
Abstract
Sleep-disordered breathing (SDB) causes hypoxic stress and can trigger uric acid (UA) overproduction. We comprehensively investigated whether SDB, interacting with components of metabolic syndrome, hepatic and renal dysfunctions, low physical fitness, sedentary lifestyle, disrupted sleep, and chronic systemic inflammation (CSI), is directly associated with hyperuricaemia. In 528 community-based males (mean [SD] age 46.2 [7.4] years), we cross-sectionally analysed measures of anthropometry; self-reported lifestyle habits; overnight sleep polysomnography data; cardiopulmonary exercise tests; and biomarkers of cardiometabolic, hepatic, and renal functions; and CSI, using structural equation modelling. Objective disrupted sleep, C-reactive protein, low physical fitness, and sedentary lifestyle were not related to UA levels in univariate analysis and were excluded. The latent variables (with corresponding manifest variables) obesity (body mass index, waist-hip ratio), hypertension (post-sleep systolic, diastolic blood pressure), dyslipidaemia (total cholesterol, triglyceride/high-density lipoprotein cholesterol), hepatic dysfunction (alanine aminotransferase, aspartate transaminase), and renal dysfunction (blood urea nitrogen, serum creatinine) were positively; and hyperglycaemia (fasting glucose, glycated haemoglobin) was negatively associated with hyperuricaemia (serum UA), except for SDB (Apnea-Hypopnea Index, percentage of oxygen saturation <90% period against total sleep time, oxygen desaturation index) in the one-stage influence model. In the two-stage model, SDB, closely interacting with obesity, was positively indirectly associated with hyperuricaemia through directly linked renal dysfunction and obesity-linked hypertension, inverse hyperglycaemia, dyslipidaemia, and hepatic dysfunction. In conclusion, structural equation modelling reveals that SDB closely interacts with obesity and is positively but indirectly related to hyperuricaemia in males. This suggests that urinary UA excretion modulates and obesity confounds the SDB-hyperuricaemia relationship.
© 2020 European Sleep Research Society.
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Feasibility of studying the association between intraoperative regional cerebral oxygen saturation and postoperative functional decline (ReFUNCTION): a pilot sub-study of NeuroVISION-Cardiac Surgery.
Can J Anaesth2020 Aug;():. doi: 10.1007/s12630-020-01777-3.
Spence Jessica, Lamy Andre, Bosch Jackie, Thabane Lehana, Gagnon Stephanie, Power Patricia, Browne Austin, Murkin John, Devereaux P J,
Abstract
PURPOSE:
Function describes an individual's ability to perform everyday activities. In the context of cardiac surgery, functional changes quantify the effect of surgery on one's day-to-day life. Decreases in regional cerebral oxygen saturation (rScO) measured using near-infrared spectroscopy (NIRS) has been associated with postoperative cognitive decline but its relationship with function has not been studied. We sought to determine the feasibility of conducting a large observational study examining the relationship between decreases in rScO during cardiac surgery and postoperative functional decline.
METHODS:
We undertook a single-centre, pilot sub-study of the NeuroVISION-Cardiac Surgery pilot study, which included adults undergoing isolated coronary artery bypass grafting on cardiopulmonary bypass; all patients enrolled in NeuroVISION-Cardiac Surgery were included. Function was evaluated at baseline, 30 days, and three months using the Standardized Assessment of Global activities in the Elderly (SAGE) scale. Blinded NIRS monitors were affixed for the duration of surgery. Our feasibility outcomes were to recruit one patient per week, obtain complete NIRS data in ? 90%, obtain SAGE at all time-points in ? 90%, and determine the time required for NIRS data to be transcribed into case report forms.
RESULTS:
49/50 patients enrolled in NeuroVISION-Cardiac Surgery were recruited over 48 weeks (1.02 patients/week). Of the 49 included patients, 49 (100%) had complete NIRS data and 44 (90%) had complete SAGE data. The time required for NIRS data collection was a mean (standard deviation) of 5.5 (1.8) min per patient.
CONCLUSION:
This pilot study shows the feasibility of conducting a large observational study examining the relationship between decreases in cerebral saturation during cardiac surgery and postoperative functional decline.
TRIAL REGISTRATION:
www.clinicaltrials.gov (NCT04241289); registered 27 January 2020.
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Extracorporeal Membrane Oxygenation for Amniotic Fluid Embolism-Induced Cardiac Arrest in the First Trimester of Pregnancy: A Case Report.
Crit Care Explor2020 Jul;2(7):e0162. doi: 10.1097/CCE.0000000000000162.
Creel-Bulos Christina, Hassani Brian, Stentz Michael J, Budhrani Gaurav, Daneshmand Mani A, Jabaley Craig S, Groff Robert F,
Abstract
Amniotic fluid embolism is a rare obstetric emergency that can be accompanied by profound hypoxemia, coagulopathy, hemorrhage, and cardiogenic shock. Extracorporeal membrane oxygenation may provide a rescue strategy in amniotic fluid embolism with cardiopulmonary collapse. Approaches to anticoagulation must be balanced against the risk of hemorrhage with concomitant coagulopathy. Although extracorporeal membrane oxygenation has been described for cardiopulmonary collapse in the setting of amniotic fluid embolism, its initiation as a bridge to hemostasis and cardiopulmonary recovery in amniotic fluid embolism-induced hemorrhagic and cardiogenic shock remains a novel resuscitation strategy.
Design Subject and Intervention:
We present a case detailing the initiation of extracorporeal life support with veno-arterio-venous extracorporeal membrane oxygenation in a patient with hemorrhagic shock and cardiopulmonary failure due to amniotic fluid embolism. The patient was ultimately discharged home 19 days after presentation free from neurologic or other significant disability.
Main Results and Conclusion:
Through this case, we describe a tailored approach to extracorporeal life support initiation and advanced extracorporeal membrane oxygenation management as a bridge to recovery in patients with mixed shock. Additionally, we discuss how the culmination of prehospital, outpatient and inpatient provider teamwork, easily portable extracorporeal membrane oxygenation equipment, and multispecialty collaboration can afford promising therapeutic options for patients who were previously deemed ineligible for extracorporeal life support.
Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.
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Barrier Techniques to Reduce Aerosolization During Cardiopulmonary Resuscitation.
Crit Care Explor2020 Jul;2(7):e0161. doi: 10.1097/CCE.0000000000000161.
Paroya Azzam A, Patel Kinner M, Ahmad Sahar,
Abstract
Preventing the dispersion of virulent particles during aerosol generating procedures has never been more relevant than during the current coronavirus pandemic. The American Heart Association released interim guidelines to assist in limiting exposure during advanced cardiovascular life support. These include maintaining a closed circuit on the ventilator for intubated patients and to use a high-efficiency particulate air filter during airway management of nonintubated patients. We developed additional modifications to the suggested guidelines such that providers are even further protected from unnecessary aerosolization, and illustrate a sample protocol for provider safety during advanced cardiovascular life support in the coronavirus pandemic. For the intubated patient, our protocol maintains the patient to the ventilator in addition to being draped with a plastic barrier over the mouth and nares. In the nonintubated patient, a plastic drape or a non-rebreather mask is used to help reduce aerosolization during manual chest compressions. Our modified protocol allows providers to perform advanced cardiac life support by further minimizing exposure risk.
Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.
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Perceptions of ICU Care Following Do-Not-Resuscitate Orders: A Military Perspective.
Crit Care Explor2020 Jul;2(7):e0153. doi: 10.1097/CCE.0000000000000153.
Dishman Sydney E, Driggers Kathryn E, Johnson Laura S, Olsen Cara H, Ryan Andrea B, McLawhorn Melissa M, Chung Kevin K,
Abstract
Although do-not-resuscitate orders only prohibit cardiopulmonary resuscitation in the case of cardiac arrest, the common initiation of this code status in the context of end-of-life care may lead providers to draw premature conclusions about other goals of care. The aim of this study is to identify concerns regarding care quality in the setting of do-not-resuscitate orders within the Department of Defense and compare differences in perceptions between members of the critical care team.
Design:
A cross sectional observational study was conducted.
Setting:
This study took place in the setting of critical care within the Department of Defense.
Subjects:
All members of the Uniformed Services Section of the Society of Critical Care Medicine were invited to participate.
Interventions:
A validated 31-question survey exploring the perceptions of care quality in the setting of do-not-resuscitate status was distributed.
Measurements and Main Results:
Exploratory factor analysis was used to categorically group survey questions, and average factor scores were compared between respondent groups using t tests. Responses to individual questions were also analyzed between comparison groups using Fisher exact tests. Factor analysis revealed no significant differences between respondents of different training backgrounds; however, those with do-not-resuscitate training were more likely to agree that active treatment would be pursued ( = 0.024) and that trust and communication would be maintained ( = 0.005). Although 38% of all respondents worry that quality of care will decrease, 93% agree that life-prolonging treatments should be offered. About a third of providers wrongly believed that a do-not-resuscitate order must be reversed prior to an operation.
Conclusions:
Although providers across training backgrounds held similar concerns about decreased care quality in the ICU, there is wide belief that the routine and noninvasive interventions are offered as indicated. Those with do-not-resuscitate training were more likely to believe that standards of care continued to be met after code status change.
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Derangement of Arginine and Related Amino Acids in Children Undergoing Surgery for Congenital Heart Disease With Cardiopulmonary Bypass.
Crit Care Explor2020 Jul;2(7):e0150. doi: 10.1097/CCE.0000000000000150.
Navaei Amir H, Shekerdemian Lara S, Mohammad Mahmoud A, Coss-Bu Jorge A, Bastero Patricia, Ettinger Nicholas A, Orellana Renan, Fernandes Caraciolo J, Marini Juan C,
Abstract
Arginine is a conditionally essential amino acid, the precursor for nitric oxide and a key factor in cell proliferation, protein synthesis, and energy metabolism. When there is increased demand in the setting of inflammation, ischemia-reperfusion injury, and organ dysfunction, endogenous arginine production falls short, and external supplementation may be necessary. The goal of this study was to assess changes in concentrations of plasma arginine, citrulline, ornithine, glutamine, and plasma arginase in infants and children undergoing surgery for congenital heart disease with cardiopulmonary bypass.
Design:
Prospective observational study.
Setting:
The study was conducted in the Heart Center at Texas Children's Hospital.
Subjects:
Children undergoing surgery for congenital heart disease with cardiopulmonary bypass.
Interventions:
None.
Measurements and Main Results:
Serial perioperative blood samples were collected for quantification of amino acids, arginase, nitric oxide metabolites, and markers of organ function (lactate, Pao/Fio ratio, and creatinine clearance). Thirty children (18 males) were included in the study; median (interquartile range) age 0.5 years (0.3-0.9 yr). The mean ± sd for plasma amino acid concentrations before cardiopulmonary bypass: arginine 62 ± 20 µmol/L, citrulline 24 ± 6 µmol/L, ornithine 53 ± 32 µmol/L, and glutamine 591 ± 126 µmol/L. Arginine concentration was decreased within the first 24 hours (43 ± 15 µmol/L; = 0.004), citrulline and glutamine concentrations decreased over the first 48 hours (11 ± 4 µmol/L; < 0.001 and 493 ± 131 µmol/L; = 0.019, respectively) and were associated with an increase in arginase (3.8 ± 3 µg/mL; < 0.05). There was an increase in Vasoactive-Inotropic Score (5.9 ± 19 vs 0.5 ± 2; < 0.001), decrease in creatinine clearance (76 ± 24 vs 93 ± 31; = 0.002), and Pao/Fio ratio (243 ± 138 vs 374 ± 200; = 0.007) comparing to baseline.
Conclusions:
A widely variable degree of arginine, citrulline, and glutamine depletion occurs in children after surgery for congenital heart disease. These findings were associated with increased arginase and coincide with some of the markers of organ perfusion.
Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.
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Risk Factors for Candidemia After Open Heart Surgery: Results From a Multicenter Case-Control Study.
Open Forum Infect Dis2020 Aug;7(8):ofaa233. doi: 10.1093/ofid/ofaa233.
Giacobbe Daniele Roberto, Salsano Antonio, Del Puente Filippo, Miette Ambra, Vena Antonio, Corcione Silvia, Bartoletti Michele, Mularoni Alessandra, Maraolo Alberto Enrico, Peghin Maddalena, Carnelutti Alessia, Losito Angela Raffaella, Raffaelli Francesca, Gentile Ivan, Maccari Beatrice, Frisone Stefano, Pascale Renato, Mikus Elisa, Medaglia Alice Annalisa, Conoscenti Elena, Ricci Davide, Lupia Tommaso, Comaschi Marco, Giannella Maddalena, Tumbarello Mario, De Rosa Francesco Giuseppe, Del Bono Valerio, Mikulska Malgorzata, Santini Francesco, Bassetti Matteo,
Abstract
Background:
species are among the most frequent causative agents of health care-associated bloodstream infections, with mortality >40% in critically ill patients. Specific populations of critically ill patients may present peculiar risk factors related to their reason for intensive care unit admission. The primary objective of the present study was to assess the predictors of candidemia after open heart surgery.
Methods:
This retrospective, matched case-control study was conducted in 8 Italian hospitals from 2009 to 2016. The primary study objective was to assess factors associated with the development of candidemia after open heart surgery.
Results:
Overall, 222 patients (74 cases and 148 controls) were included in the study. Candidemia developed at a median time (interquartile range) of 23 (14-36) days after surgery. In multivariable analysis, independent predictors of candidemia were New York Heart Association class III or IV (odds ratio [OR], 23.81; 95% CI, 5.73-98.95; ?
Conclusions:
Previous broad-spectrum antibiotic therapy and high NYHA class were independent predictors of candidemia in cardiac surgery patients with prolonged postoperative intensive care unit stay.
© The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases Society of America.
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Pulmonary Recruitment Maneuver for Reducing Shoulder Pain after Laparoscopic Gynecologic Surgery: A Network Meta-Analysis of Randomized Controlled Trials.
Minim Invasive Surg2020 ;2020():7154612. doi: 10.1155/2020/7154612.
Kietpeerakool Chumnan, Rattanakanokchai Siwanon, Yantapant Aranya, Roekyindee Ratchadaporn, Puttasiri Songphol, Yanaranop Marut, Srisomboon Jatupol,
Abstract
Background:
Shoulder pain is a common symptom following laparoscopic surgery. This systematic review was undertaken to assess updated evidence regarding the effectiveness and complications of the pulmonary recruitment maneuver (PRM) for reducing shoulder pain after laparoscopic gynecologic surgery.
Methods:
A number of databases for randomized controlled trials (RCTs) investigating PRM for reducing shoulder pain were searched up to June 2019. Two authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, and compared results. Network meta-analyses were employed to simultaneously compare multiple interventions. Effect measures were presented as pooled mean difference (MD) or risk ratio (RR) with corresponding 95% confidence intervals (CI).
Results:
Of the 44 records that we identified as a result of the search (excluding duplicates), eleven RCTs involving 1111 participants were included. Three studies had an unclear risk of selection bias. PRM with a maximum pressure of 40?cm HO was most likely to result in the lowest shoulder pain intensity at 24 hours (MD -1.91; 95% CI -2.06 to -1.76) while PRM with a maximum pressure of 40?cm?HO plus intraperitoneal saline (IPS) appeared to be the most efficient at 48 hours (MD -2.09; 95% CI -2.97 to -1.21). The estimated RRs for analgesia requirement, nausea/vomiting, and cardiopulmonary events were similar across the competing interventions.
Conclusion:
PRM with 40?cm HO performed either alone or accompanied by IPS is a promising intervention for alleviating shoulder pain within 48 hours following gynecologic laparoscopy.
Copyright © 2020 Chumnan Kietpeerakool et al.
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Efficient detection of differentially methylated regions in the genome of patients with thoracic aortic dissection and association with MMP2 hypermethylation.
Exp Ther Med2020 Aug;20(2):1073-1081. doi: 10.3892/etm.2020.8753.
Li Ni, Lin Hangjuan, Zhou Hua, Zheng Dawei, Xu Guodong, Shi Huoshun, Zhu Xiuying, Gao Jianqing, Shao Guofeng, Sun Lebo,
Abstract
DNA methylation is known to regulate the expression of numerous genes but its role in the pathogenesis of thoracic aortic dissection (TAD) has remained largely elusive. In the present study, the DNA methylome of patients with TAD was analyzed using a methylation microarray and bisulfite pyrosequencing was used to determine whether the hypermethylation of matrix metalloproteinase 2 (MMP2) specifically is associated with TAD. Chip-based whole-DNA methylome analysis was performed on 4 male patients with TAD and 4 male healthy controls using an Illumina HumanMethylation EPIC 850K BeadChip. The resulting data were analyzed by clustering and principal component analysis, and Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were performed on the differentially methylated genes to interrogate their biological functions. Compared to the healthy controls, 3,362 loci were differentially methylated in the patients with TAD with a statistical significance of P<0.05, while 1,223 loci had a significance of P<0.01. Among these loci, 2,019 were hypermethylated and 1,343 were hypomethylated. From GO analysis within the biological process category, the MMP2, MMP14 and WNT2B genes were identified. enrichment was observed for loci involved in cellular component organization, enzyme-linked receptor protein signaling pathways (potentially having a key role in the development of cardiopulmonary function disorders) and vascular reconstruction. Bisulfite pyrosequencing of plasma samples indicated significantly increased methylation (P<0.01) of the CpG site at position 2 in the promoter of MMP2 in the TAD group relative to the healthy controls, and the mean methylation level of four CpG sites on the MMP2 gene in the TAD group was slightly higher than that in the control group, but not significantly. Hypermethylation of the MMP2 promoter may be a promising novel diagnostic and prognostic biomarker for TAD. Future studies on the epigenetics of biomarkers linked to vascular reconstruction and immune function may provide further insight into the pathogenesis and progression of TAD.
Copyright: © Li et al.
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Evaluation of Exertional Ventilatory Parameters Using Oscillometry in COPD.
Int J Chron Obstruct Pulmon Dis2020 ;15():1697-1711. doi: 10.2147/COPD.S260735.
Yamamoto Yuji, Miki Keisuke, Matsuki Takanori, Fukushima Kiyoharu, Oshitani Yohei, Kagawa Hiroyuki, Tsujino Kazuyuki, Yoshimura Kenji, Miki Mari, Kida Hiroshi,
Abstract
Background:
Oscillometry is a tool to measure respiratory impedance that requires minimal patients' effort. In patients with chronic obstructive pulmonary disease (COPD), the correlation of respiratory impedance at rest with exertional ventilatory parameters, including exercise tolerance, has scarcely been reported. In addition, the utility of oscillometric parameters might differ between the inspiratory and expiratory phases due to airflow obstruction during expiration, but the hypothesis had not been validated. The aim of the present study was to investigate whether oscillometric parameters are associated with exertional ventilatory parameters in patients with COPD.
Methods:
Fifty-five subjects with COPD who attended clinics at the National Hospital Organization Osaka Toneyama Medical Center performed spirometry, oscillometry, and cardiopulmonary exercise testing (CPET) within 2 weeks. The correlations between parameters of spirometry, oscillometry, and CPET were analyzed using Spearman's rank correlation coefficient, univariate, and multivariate analyses.
Results:
Respiratory reactance had better correlations with the CPET parameters than respiratory resistance. Moreover, inspiratory reactance at rest correlated with the CPET parameters stronger than expiratory reactance. In particular, inspiratory resonant frequency (Fres-ins) correlated with peak oxygen uptake (r=-0.549, p<0.01) and dead space to tidal volume ratio at peak exercise (r=0.677, p<0.01) and the best predicted expiratory tidal volume (V ex) at peak exercise of all the oscillometric parameters (r=-0.679, p<0.01). However, the correlation between Fres-ins and ex at peak exercise became weak in subjects with severe and very severe COPD during exercise.
Conclusion:
Measurement of respiratory reactance is useful for the effortless evaluation of not only exertional ventilatory parameters but exercise tolerance in patients with COPD. The correlation of respiratory impedance with exertional ventilatory parameters can become weak in patients with advanced COPD; thus, the measurement of oscillometry might not be appropriate for evaluating exertional ventilatory parameters of patients with advanced COPD.
© 2020 Yamamoto et al.
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Commentary: Is perfusate arterial oxygen tension the best barometer of inflammation following cardiopulmonary bypass for congenital heart surgery?
J Thorac Cardiovasc Surg -
Mimicking Real-Life Decision Making in Health: Allowing Respondents Time to Think in a Discrete Choice Experiment.
Value Health2020 Jul;23(7):945-952. doi: S1098-3015(20)32058-1.
Veldwijk Jorien, Johansson Jennifer Viberg, Donkers Bas, de Bekker-Grob Esther W,
Abstract
OBJECTIVE:
To empirically test the impact of allowing respondents time to think (TTT) about their choice options on the outcomes of a discrete choice experiments (DCE).
METHODS:
In total, 613 participants of the Swedish CArdioPulmonary bioImage Study (SCAPIS) completed a DCE questionnaire that measured their preferences for receiving secondary findings of a genetic test. A Bayesian D-efficient design with 60 choice tasks divided over 4 questionnaires was used. Each choice task contained 2 scenarios with 4 attributes: type of disease, disease penetrance probability, preventive opportunities, and effectiveness of prevention. Respondents were randomly allocated to the TTT or no TTT (NTTT) sample. Latent class models (LCMs) were estimated to determine attribute-level values and their relative importance. In addition, choice certainty, attribute-level interpretation, choice consistency, and potential uptake rates were compared between samples.
RESULTS:
In the TTT sample, 92% of the respondents (245 of 267) indicated they used the TTT period to (1) read the information they received (72%) and (2) discuss with their family (24%). In both samples, respondents were very certain about their choices. A 3-class LCM was fitted for both samples. Preference reversals were found for 3 of the 4 attributes in one class in the NTTT sample (34% class-membership probability). Relative importance scores of the attributes differed between the 2 samples, and significant scale effects indicating higher choice consistency in TTT sample were found.
CONCLUSIONS:
Offering respondents TTT influences decision making and preferences. Developers of future DCEs regarding complex health-related decisions are advised to consider this approach to enhance the validity of the elicited preferences.
Copyright © 2020 ISPOR?The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.
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Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week.
J Am Coll Cardiol2020 Aug;76(6):745-754. doi: S0735-1097(20)35641-2.
Teran Felipe, Prats Michael I, Nelson Bret P, Kessler Ross, Blaivas Michael, Peberdy Mary Ann, Shillcutt Sasha K, Arntfield Robert T, Bahner David,
Abstract
Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes.
Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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