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

Hemodynamic changes during beating heart coronary artery bypass surgery

Background and objective: The use of cardiopulmonary bypass during coronary artery by-pass grafting (CABG) represents a modality with multilevel invasiveness followed by im-mediate and long-term complications. Avoidance of CPB in “off-pump” coronary revascu-larization (OPCAB) is considered advantageous as neurophysiologic disorders, stroke, renal and respiratory failure, nerve injury, whole-body inflammatory response and coagu-lation disorders are likely to be prevented. Optimal exposure and stabilization of the target coronary vessel is essential to allow the construction of a precise coronary anastomosis, during OPCAB procedure. However, this might be achieved at the expense of significant hemodynamic deterioration. The present study was designed to determine the impact of heart’s mobilization and stabilization, during off-pump coronary surgery, on patient’s he-modynamics, acid-base balance, blood gas status and also on metabolic and functional pa-rameters of the lungs. Methods: Fifty seven patients (n=57) undergoing OPCAB surgery, under propofol-remi-fentanil anesthetic technique, were included in this study. LIMA was anastomosed to LAD in all patients. Anastomosis of a second or third vessel was followed in twenty of the pa-tients (n1=20). Compression fork-type stabilizer was used. Full hemodynamic profile, mixed venous oxygen saturation, acid base status, end-tidal partial pressure of carbon dio-xide, BIS values and ST-segment changes were monitored before heart’s stabilization (T1 values-baseline), 5 minutes after stabilization (T2 values), before stabilizer’s removal (T3 values) and 10 minutes after stabilizer’s removal (T4 values). Oxygen delivery and con-sumption, physiologic dead space (VD/VT) and shunt fraction (Qs/Qt) were also calculated. Data were collected under unchanged ventilation with FiO2 equaling 1. Statistical analysis was performed with paired sample t-test. Significance was set at p <0,05.· Απ’τα ευρήματα της παρούσας μελέτης προκύπτει ότι η τοποθέτηση και παραμονή του επικαρδιακού σταθεροποιητή, κατά τη διάρκεια των αναστομώσεων στις OPCAB επεμβά-σεις, συνοδεύεται από σημαντικές αιμοδυναμικές μεταβολές, που αφορούν κυρίως τη μεί-ωση του όγκου παλμού και επιγενώς της καρδιακής παροχής. Ο κύριος μηχανισμός που ε-νοχοποιείται για την εμφάνιση της προσωρινής αιμοδυναμικής αστάθειας είναι η διαταρα-χή της διαστολικής πλήρωσης και η μείωση της κοιλιακής ευενδοτότητας. · Οι μεταβολές είναι εντονότερες σε θέσεις καρδιάς-σταθεροποιητή που αφορούν αγγεία -στόχους του οπισθίου ή πλαγίου καρδιακού τοιχώματος. · Η περίοδος ιστικής υποάρδευσης που ακολουθεί την τοποθέτηση και παραμονή του ε-πικαρδιακού σταθεροποιητή συνδυάζεται με ανάλογες οξεοβασικές και μεταβολικές δια-ταραχές. Τάση προς μεταβολική οξέωση συνοδεύει την ελάττωση της ιστικής άρδευσης, ε-νώ η αποκατάσταση της ροής συνοδεύεται από έκλυση πρωτονίων και ρύθμισή τους (buf-fering) από τα διττανθρακικά. · Η ελάττωση της καρδιακής παροχής οδηγεί στην ελάττωση του φορτίου του CO2 στον πνεύμονα, σχετική υποκαπνία και εικόνα αύξησης αερισμού νεκρού χώρου. · Η τοποθέτηση του σταθεροποιητή, σε συνδυασμό με την αύξηση των διαστολικών εν-δοκοιλοτικών πιέσεων της καρδιάς, ενδέχεται να διαφοροποιήσει τη φλεβική απορροή της στεφανιαίας κυκλοφορίας. Η παρατήρηση αυτή συνάγεται εμμέσως, από την διαφοροποί-ηση (ελάττωση) του εξωπνευμονικού shunt κατά την τοποθέτηση του σταθεροποιητή και οδηγεί σε προβληματισμούς που χρειάζονται περαιτέρω έρευνα. · Η τιτλοποίηση του αερισμού και η αποφυγή της υποκαπνίας στη φάση της κατασκευ-ής της αναστόμωσης είναι απαραίτητη για δύο λόγους. Πρώτον,η περίοδος ελάττωσης της καρδιακής παροχής συνδυάζεται με ελάττωση της PaCO2, που, με τη σειρά της, αποτελεί επιπλέον παράγοντα ελάττωσης στην «εκφόρτωση» οξυγόνου σε ευπαθή όργανα (πχ: εγ-κέφαλος). Δεύτερον, η υποκαπνία καταναλώνει διττανθρακικά που όμως είναι εξαιρετικά χρήσιμα στην αντιμετώπιση-ρύθμιση της έκπλυσης πρωτονίων που ακολουθεί την ελευθέ-ρωση της κυκλοφορίας. · Όλες οι παραπάνω διαταραχές έχουν παροδικό κι αντιστρεπτό χαρακτήρα. Η μη ενδε-δειγμένη όμως διαχείρησή τους σε οριακούς ασθενείς ενδέχεται να επιτείνει ή να οδηγήσει σε προβληματική περιεγχειρητική έκβαση

Nocebo-Prone Behavior Associated with SARS-CoV-2 Vaccine Hesitancy in Healthcare Workers

Among healthcare workers (HCWs), SARS-CoV-2 vaccine hesitancy may be linked to a higher susceptibility to nocebo effects, i.e., adverse events (AEs) experienced after medical treatments due to negative expectations. To investigate this hypothesis a cross-sectional survey was performed with a self-completed questionnaire that included a tool (Q-No) for the identification of nocebo-prone individuals. A total of 1309 HCWs (67.2% women; 43.4% physicians; 28.4% nurses; 11.5% administrative staff; 16.6% other personnel) completed the questionnaires, among whom 237 (18.1%) had declined vaccination. Q-No scores were ≥15 in 325 participants (24.8%) suggesting nocebo-prone behavior. In a multivariate logistic regression model with Q-No score, age, gender, and occupation as independent variables, estimated odds ratios (ORs) of vaccination were 0.43 (i.e., less likely, p &lt; 0.001) in participants with Q-No score ≥ 15 vs. Q-No score &lt; 15, 0.58 in females vs. males (p = 0.013), and 4.7 (i.e., more likely) in physicians vs. other HCWs (p &lt; 0.001), independent of age, which was not significantly associated with OR of vaccination. At least one adverse effect (AE) was reported by 67.5% of vaccinees, mostly local pain and flu-like symptoms. In a multivariate logistic regression model, with Q-No score, age, gender, and occupation as independent variables, estimated ORs of AE reporting were 2.0 in females vs. males (p &lt; 0.001) and 1.47 in physicians vs. other HCWs (p = 0.017) independently of age and Q-No score, which were not significantly associated with OR of AE. These findings suggest that nocebo-prone behavior in HCWs is associated with SARS-CoV-2 vaccination hesitancy indicating a potential benefit of a campaign focused on nocebo-prone people

Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE)

Background: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. Methods: This prospective, observational study 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. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. Results: Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (&gt;30% decrease in blood pressure) or reduced oxygenation (SpO2 &lt;85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7). Conclusions: Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants

Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

International audienceBackground: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences.Methods: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes.Results: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1-6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality.Conclusions: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event