Levosimendan versus Milrinone for Inotropic Support in Pediatric Cardiac Surgery: Results from a Randomized Trial

Objective : We aimed to determine the differential effects of intra-operative administration of milrinone versus levosimendan on myocardial function after pediatric cardiac surgery. Transthoracic echocardiography was employed for myocardial function evaluation, utilizing biventricular longitudinal strain with two-dimensional speckle tracking echocardiography in addition to conventional echocardiographic variables. Design : A secondary analysis of a randomized, prospective, double-blinded clinical drug trial Setting : Two pediatric tertiary university hospitals Participants : Infants between 1-12 months of age diagnosed with ventricular septal defect, complete atrioventricular septal defect, or tetralogy of Fallot who were scheduled for corrective surgery with cardiopulmonary bypass. Interventions : The patients were randomized to receive an infusion of milrinone or levosimendan at the start of cardiopulmonary bypass and for 26 consecutive hours. Measurements and main results : Biventricular longitudinal strain and conventional echocardiographic variables were measured preoperatively, on the first postoperative morning and prior to hospital discharge. The association between perioperative parameters and postoperative myocardial function was also investigated. Images were analyzed for left ventricular (n=67) and right ventricular (n=44) function. The day after surgery, left ventricular longitudinal strain was deteriorated in both the milrinone and levosimendan groups; 33% and 39%, respectively. The difference was not significant. The corresponding deterioration in right ventricular longitudinal strain was 42% and 50% (non-significant difference). For both groups, biventricular longitudinal strain approached their preoperative values at hospital discharge. Preoperative N-terminal pro-brain natriuretic peptide could predict the left ventricular strain on postoperative day one (p=0.014). Conclusions : Levosimendan was comparable to milrinone for left and right ventricular inotropic support in pediatric cardiac surgery.Peer reviewe

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

How to improve patient safety in intensive care units

There is a need for us, Norwegian physicians, to develop our patient safety knowledge, attitude, and practice. The components of this should include the notions that errors are common and many of them are preventable. Moreover, simple techniques can imply substantial impact on preventing errors or reducing their effects. We need a strong leadership directed towards patient safety, and we need to be convinced that our leaders and employers support us in our efforts to improve patient safety. Norwegian Medical Association stated in December 2006 that the work of patient safety is still in its starting phase in Norwegian healthcare system and included five suggestions for promoting patient safety. These suggestions are in accordance with the results of the extensive literature survey performed in this thesis. The suggestions were constructed by "cooperation, culture, professionalism, regulations, and technology". Co-operation between the medical profession, governmental authorities, and the public is of vital importance to achieve a high quality patient safety policy and practice. Without cooperation it is impossible to promote the culture of patient safety and professionalism. Continuous medical education and continuous professional development are cornerstones of professionalism that should be improved along with a well-defined adherent financing system. Regarding regulations we should take into consideration the experiences from other comparable countries and be open-minded to them. These experiences may include the Danish hospital accreditation program and the program of individual practitioner revalidation in the United Kingdom, both aiming for system changes for promoting patient safety. In connection with this thesis, we performed a limited survey of perceived concepts of patient safety among the physician-leaders of ICUs in the Norwegian university hospitals as well as those Norwegian physicians who are the members of European Society of Intensive Care Medicine. This survey illustrated that the great majority of physicians believe that it is necessary to improve patient safety in the ICUs. This is also in accordance with the statement from Norwegian Medical Association in 2006: "there is a lack of systems for nationwide dissemination and implementation of the achieved experiences and knowledge". It seems that promoting patient safety is primarily a question of culture and attitudes. It remains to see whether a change of attitudes and culture can be achieved without going through regulations

Exploration of 27 plasma immune markers: A cross-sectional comparison of 64 old psychiatric inpatients having unipolar major depression and 18 non-depressed old persons

Background: The prevalence of major depression (MD) according to population studies is the same for old (65 years and older) and younger adults. In contrast, an elevated proportion of old MD patients are hospitalized compared to younger adults with MD, indicating a need to expand the characteristics of old inpatients with MD. To illustrate this point, the association between inflammation and MD in old psychiatric inpatients is sparsely investigated even though an association between inflammation and treatment resistance among younger adults with MD has been reported. In this study, we aimed to explore the plasma concentrations of 27 immune markers in old inpatients with MD, and our purpose was to expand the understanding of inflammatory mechanisms in these patients. Methods: Prior to electroconvulsive treatment of MD, we compared 64 inpatients with unipolar MD (mean age 75.2 years) and 18 non-depressed controls (mean age 78.0 years). Symptoms characterizing MD were assessed by the Hamilton Rating Scale of Depression (HRSD)-17, and the immune markers from peripheral blood plasma were analysed using multiplex assay technology. For statistical analysis of data, we used the independent samples median test, independent samples t-test, χ2-test, receiver operating characteristic curve analyses, stepwise discriminant analysis, and multivariate linear regression. Results: Twenty-two immune markers representing pro- and anti-inflammatory, adaptive and trophic signalling had higher concentrations in the inpatients compared to the controls. Only the four immune markers IL-1β, IL-5, IL-10 and IL-15 had concentrations below the lower detection limit in a considerable portion (above 20%) of the patient cases. A combination of the concentration in plasma of TNF, vascular endothelial growth factor (VEGF), IL-1β, IL-7 and monocyte chemotactic protein (MCP)-1, correctly classified 98.4% of the depressed patients and 83.3% of the non-depressed controls. Plasma concentration of TNF and VEGF were associated with the HRSD-17 scores (p = 0.017 and 0.005, respectively). Conclusions: Our results indicate that several inflammatory mechanisms may be highly activated in old psychiatric inpatients with MD, and indicate that immune markers may contribute to a more comprehensive understanding of MD in old persons.</p

Outcome following anaesthesia in infancy in the Nordic countries : Subgroup analysis of the NECTARINE study

Introduction: The neonate and children audit of anaesthesia practice in Europe (NECTARINE) prospective observational study reported an incidence of 35.2% of critical events requiring intervention during 6542 anaesthetics in 5609 infants up to 60 weeks postmenstrual age (PMA) from 165 centres in 31 European countries. Methods: Sub-analysis of the cohort from the Nordic countries (8% of the entire cohort) was conducted. Secondary aims were to describe the Nordic countries' anaesthetic practices and compare morbidity and mortality with the overall European cohort. Results: Eleven Nordic centres recruited 447 infants (66% males, 37.3% born preterm and 45% had congenital anomalies) undergoing anaesthesia for 530 surgical or non-surgical procedures at 25–60 weeks PMA. Perioperative critical events triggered interventions in 228/530 (43%) cases. Hypotension (12.6%) or hypoxaemia (11.7%) were more common in younger patients and those with co-morbidities. Hypo/hypercapnia occurred in 1.5%/4.7% of cases. More than two attempts for intubation were required in 13 (2.9%) infants (max three attempts). Distribution of ASA-Physical Status Scores was similar to the total European cohort (40% was ASA > 2). A total of 236/530 (44.5%) patients were admitted to the postoperative intensive care unit. Thirty-day morbidity (complications in 87/447 = 19.5%) and mortality (8/447, 1.8%) did not differ from the overall European cohort. Hospital re-admissions were significant up to 90 days (98/447 = 21.9%). Conclusions: In Nordic countries, anaesthesia in young infant children is resource-demanding, and perioperative critical events and co-morbidities are common. Thirty-day morbidity and mortality data in the Nordic countries did not differ from the overall European cohort.publishedVersionPeer reviewe

Additional file 3: of Exploration of 27 plasma immune markers: a cross-sectional comparison of 64 old psychiatric inpatients having unipolar major depression and 18 non-depressed old persons

Table S3. Dataset supporting. Data on all characteristics and the concentrations of all 27 immune markers of 64 patients and 18 controls. (XLSX 25 kb

Additional file 2: of Exploration of 27 plasma immune markers: a cross-sectional comparison of 64 old psychiatric inpatients having unipolar major depression and 18 non-depressed old persons

Table S2. Correlation among the immune markers and the HRSD-17. Correlation among IL-1β, IL-7, MCP-1, TNF, VEGF and the HRSD-17. (DOCX 17 kb

Additional file 1: of Exploration of 27 plasma immune markers: a cross-sectional comparison of 64 old psychiatric inpatients having unipolar major depression and 18 non-depressed old persons

Table S1. Characteristics of the patients. The variables; HRSD-17, age, BMI, CIRS-G, gender, number of drugs and current depression in weeks are compared between patients with and without physical diseases affecting the immune system activity. (DOCX 15 kb