Effect of Levosimendan Treatment in Pediatric Patients With Cardiac Dysfunction: An Update of a Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Levosimendan increasingly has been used to treat heart failure and cardiac dysfunction in pediatric patients. Currently, there is only limited evidence that this drug positively affects outcomes. The authors' aim was to investigate the effects of levosimendan on hemodynamic parameters and outcomes in pediatric patients in all clinical settings. The study design was a systematic review of randomized and nonrandomized studies. Randomized clinical trials (RCTs) were included in a meta-analysis. The primary outcome of the meta-analysis was the effect of levosimendan on central venous oxygen saturation (ScvO) and lactate values as surrogate markers of low-cardiac-output syndrome. The study setting was any acute care setting. Study participants were pediatric patients (age <18 years) receiving levosimendan, and the intervention was levosimendan versus any control treatment. The authors identified 44 studies published from 2004 to 2020, including a total of 1,131 pediatric patients. Nine studies (enrolling 547 patients) were RCTs, all performed in a pediatric cardiac surgery setting. Three RCTs were judged to carry a low risk of bias. In the RCTs, levosimendan administration was associated with a significant improvement of ScvO (p = 0.03) and a trend toward lower postoperative lactate levels (p = 0.08). No differences could be found for secondary outcomes. Levosimendan use in pediatric patients is not associated with major side effects and may lead to hemodynamic improvement after cardiac surgery. However, its impact on major clinical outcomes remains to be determined. Overall, the quality of evidence for levosimendan use in pediatric patients is low, and further high-quality RCTs are needed

Successful Extracorporeal Blood Purification Therapy using Double Haemoadsorption Device in Severe Endotoxin Septic Shock: A Case Report

Introduction:In patients admitted to the Intensive Care Unit (ICU), sepsis can lead to acute kidney injury (AKI), which may require the initiation of continuous renal replacement therapy (CRRT) in 15-20% of cases. There is no consensus about the best extracorporeal treatment to choose in septic patients with AKI. Case presentation We describe the case of a 70-year-old woman admitted to the ICU with a severe endotoxin septic shock due to Neisseria meningitidis serogroup C. Despite prompt medical intervention, including fluid resuscitation, high dose vasopressor, inotrope support, and broad-spectrum antimicrobial treatment, in a few hours patient's haemodynamic worsened and she developed multi-organ failure, including severe AKI, requiring CRRT. So, continuous veno-venous haemodiafiltration was started, using an oXiris (R) haemodiafilter set, in series with an adsorber device (CytoSorb (R)). After 48 hours of this combined extracorporeal treatment, haemodynamic parameters improved, allowing a significant reduction of the vasoactive therapy, with a concomitant decrease in endotoxin and inflammatory markers serum levels. In the following days patient's conditions still improved and renal function recovered. Conclusions Timely extracorporeal blood purification therapy, using a double haemoadsorption device, may be effective in the management of severe septic shock

Extracorporeal Carbon Dioxide Removal: From Pathophysiology to Clinical Applications; Focus on Combined Continuous Renal Replacement Therapy

Lung-protective ventilation (LPV) with low tidal volumes can significantly increase the survival of patients with acute respiratory distress syndrome (ARDS) by limiting ventilator-induced lung injuries. However, one of the main concerns regarding the use of LPV is the risk of developing hypercapnia and respiratory acidosis, which may limit the clinical application of this strategy. This is the reason why different extracorporeal CO2 removal (ECCO2R) techniques and devices have been developed. They include low-flow or high-flow systems that may be performed with dedicated platforms or, alternatively, combined with continuous renal replacement therapy (CRRT). ECCO2R has demonstrated effectiveness in controlling PaCO2 levels, thus allowing LPV in patients with ARDS from different causes, including those affected by Coronavirus disease 2019 (COVID-19). Similarly, the suitability and safety of combined ECCO2R and CRRT (ECCO2R–CRRT), which provides CO2 removal and kidney support simultaneously, have been reported in both retrospective and prospective studies. However, due to the complexity of ARDS patients and the limitations of current evidence, the actual impact of ECCO2R on patient outcome still remains to be defined. In this review, we discuss the main principles of ECCO2R and its clinical application in ARDS patients, in particular looking at clinical experiences of combined ECCO2R–CRRT treatments

In vivo calibration of esophageal pressure in the mechanically ventilated patient makes measurements reliable

Abstract Background Esophageal pressure (Pes) can provide information to guide mechanical ventilation in acute respiratory failure. However, both relative changes and absolute values of Pes can be affected by inappropriate filling of the esophageal balloon and by the elastance of the esophagus wall. We evaluated the feasibility and effectiveness of a calibration procedure consisting in optimization of balloon filling and subtraction of the pressure generated by the esophagus wall (Pew). Methods An esophageal balloon was progressively filled in 36 patients under controlled mechanical ventilation. VBEST was the filling volume associated with the largest tidal increase of Pes. Esophageal wall elastance was quantified and Pew was computed at each filling volume. Different filling strategies were compared by performing a validation occlusion test. Results Fifty series of measurements were performed. VBEST was 3.5 ± 1.9 ml (range 0.5–6.0). Esophagus elastance was 1.1 ± 0.5 cmH2O/ml (0.3–3.1). Both Pew and the result of the occlusion test differed among filling strategies. At filling volumes of 0.5, VBEST and 4.0 ml respectively, Pew was 0.0 ± 0.1, 2.0 ± 1.9, and 3.0 ± 1.7 cmH2O (p < 0.0001), whereas the occlusion test was satisfactory in 22 %, 98 %, and 88 % of cases (p < 0.0001). Conclusions Under mechanical ventilation, an increase of balloon filling above the conventionally recommended low volumes warrants complete transmission of Pes swings, but is associated with significant elevation of baseline. A simple calibration procedure allows finding the filling volume associated with the best transmission of tidal Pes change and subtracting the associated baseline artifact, thus making measurement of absolute values of Pes reliable

Renal Outcomes of Dialysis-Dependent Acute Kidney Injury in Noncritically Ill Patients: A Retrospective Study

Introduction: Acute kidney injury (AKI) is a common complication among hospitalized patients, potentially affecting short- and long-term clinical outcomes. In this retrospective study, we evaluated renal outcomes in noncritically ill patients who required acute hemodialysis (HD) because of an AKI episode occurring during hospitalization. Methods: Sixty-three hemodynamically stable patients with AKI undergoing acute intermittent HD were included. Kidney function was evaluated at baseline control (pre-AKI), at AKI diagnosis and during the follow-up. According to serum creatinine and the estimated glomerular filtration rate (eGFR), we defined three clinical conditions: renal recovery, different stages of acute kidney disease (AKD), and chronic kidney disease (CKD). Results: Among the 63 patients evaluated, 34 patients (54%) had a history of CKD. Six patients (10%) presented early full renal recovery. HD treatment was stopped in 38 patients (60%), while 25 patients (40%) required maintenance HD. Dialysis-independent patients presented lower comorbidity and higher baseline eGFR and delta creatinine, compared to dialysis-dependent patients. Baseline CKD, previous AKI episodes, and parenchymal causes of AKI were associated with a significant risk of dialysis dependence. At 1-month control, 15 patients (39%) presented AKD stage 0, 6 patients (16%) AKD stage 1, and 17 patients (44%) AKD stage 2-3. At 3-month control, 29 out of 38 patients recovering from AKI (76%) presented CKD. AKD stage was significantly correlated with the risk of CKD development, which, resulted higher in patients with lower baseline eGFR. Conclusions: AKI might represent a risk factor for the development of chronic kidney damage, even in noncritically ill patients

Renal Outcomes of Dialysis-Dependent Acute Kidney Injury in Noncritically Ill Patients: A Retrospective Study

Introduction: Acute kidney injury (AKI) is a common complication among hospitalized patients, potentially affecting short- and long-term clinical outcomes. In this retrospective study, we evaluated renal outcomes in noncritically ill patients who required acute hemodialysis (HD) because of an AKI episode occurring during hospitalization. Methods: Sixty-three hemodynamically stable patients with AKI undergoing acute intermittent HD were included. Kidney function was evaluated at baseline control (pre-AKI), at AKI diagnosis and during the follow-up. According to serum creatinine and the estimated glomerular filtration rate (eGFR), we defined three clinical conditions: renal recovery, different stages of acute kidney disease (AKD), and chronic kidney disease (CKD). Results: Among the 63 patients evaluated, 34 patients (54%) had a history of CKD. Six patients (10%) presented early full renal recovery. HD treatment was stopped in 38 patients (60%), while 25 patients (40%) required maintenance HD. Dialysis-independent patients presented lower comorbidity and higher baseline eGFR and delta creatinine, compared to dialysis-dependent patients. Baseline CKD, previous AKI episodes, and parenchymal causes of AKI were associated with a significant risk of dialysis dependence. At 1-month control, 15 patients (39%) presented AKD stage 0, 6 patients (16%) AKD stage 1, and 17 patients (44%) AKD stage 2-3. At 3-month control, 29 out of 38 patients recovering from AKI (76%) presented CKD. AKD stage was significantly correlated with the risk of CKD development, which, resulted higher in patients with lower baseline eGFR. Conclusions: AKI might represent a risk factor for the development of chronic kidney damage, even in noncritically ill patients

Spontaneous rupture of a simple renal cyst: clinical management

Spontaneous rupture of a simple renal cyst: clinical management Spontaneous renal bleeding mainly occurs in patients with polycystic kidney diseases or cancer. Indeed, despite the high prevalence of simple cysts, their spontaneous atraumatic rupture is a rare event. Underlying mechanisms may involve the increase of intracystic pressure and/or the development of a haemorrhage into the cyst. Management of this condition includes surgery, interventional radiology or conservative strategies. Here, we report a case of spontaneous rupture of a simple renal cyst, successfully managed with conservative treatment

Additional file 1 of In vivo calibration of esophageal pressure in the mechanically ventilated patient makes measurements reliable

Figure S1. In vitro and in vivo Pressure-Volume curves of the esophageal balloon. Within the intermediate linear section of the esophageal balloon PV curve, Pes is stable when the balloon is inflated in vitro (dotted line), whereas Pes linearly increases with the increase of the filling volume in vivo (open circles) due to esophageal elastance (Ees). When pressure generated by the esophageal wall is subtracted from Pes (Pes-Pew; closed circles), in vitro and in vivo curves closely parallel each other. Dotted line: in vitro PV curve obtained by progressive inflation of the balloon while the surrounding pressure was maintained at 10 cmH2O. Open circles: end-expiratory PV curve obtained in a patient under controlled mechanical ventilation with high positive end-expiratory pressure (15 cmH2O). Closed circles: end-expiratory PV curve obtained by subtraction of Pew from raw Pes values in the same patient. Figure S2. Average end-expiratory and end-inspiratory esophageal balloon pressure-volume curves in acute respiratory failure patients. Open circles: end-expiratory static Pes values (PesEE); open squares: end-inspiratory static Pes values (PesEI). Vertical lines refer to standard deviation of Pes. Horizontal lines refer to standard deviation of specific filling volumes detected on the esophageal balloon pressure-volume curves (VMIN, VBEST and VMAX). V0.5 was lower than VMIN, i.e. it was associated to balloon underfilling at end-expiration, in 42 cases (84 %); V0.5 was lower than VBEST, i.e. it was associated to suboptimal ΔPes in 47 cases (94 %). VMIN was lower than VBEST in 37 cases (74 %), being the VBEST - VMIN difference 2.0 ± 1.7 ml. Figure S3. End-expiratory static esophageal balloon pressure-volume curves at different PEEP levels. In panel A, raw Pes values are presented; in panel B, the pressure generated by the esophageal wall (Pew) is subtracted from Pes value. Circles: ZEEP; squares: PEEP 5 cmH2O; triangles: PEEP 15 cmH2O. Closed symbols refer to VBEST, i.e. the balloon filling volume corresponding to the largest respiratory ΔPes (not displayed in figure). In the same patient, at increasing level of PEEP, a progressively larger balloon filling volume is needed to optimize respiratory ΔPes. Optimal filling volume (VBEST) stimulates a variable esophageal pressure reaction, confounding Pes measurement. For example, by filling the esophageal balloon with 5 ml, corresponding to VBEST at PEEP 15 cmH2O, raw Pes values at the three PEEP levels are very similar (panel A). Once the pressure generated by the esophageal wall is subtracted from Pes values, the PEEP-induced increase of the pressure surrounding the esophagus becomes clearly detectable (Panel B). Figure S4. Pes measured with traditional low filling volume (V0.5) or with manufacturer’s recommended filling volume (V4.0) compared to calibrated Pes. Panel A. Compared to calibrated Pes, bias and precision (± 1.96 SD) of PesV0.5 were -4.1 ± 5.5 cmH2O. The Pes0.5 - PesCAL difference inversely correlated with the Pes0.5 - PesCAL mean value (R= -0.694, p<0.0001): the higher the Pes value, the higher the Pes underestimation due to balloon underfilling. Panel B. Compared to calibrated Pes, bias and precision (± 1.96 SD) of PesV4.0 were -2.9 ± 3.3 cmH2O. The Pes4.0 - PesCAL difference inversely correlated with the Pes4.0 - PesCAL mean value (R= -0.470, p<0.0001): the lower the Pes value, the higher the Pes overestimation due to the esophageal reaction to balloon inflation at 4 ml. (PDF 424 kb

In vivo calibration of esophageal pressure in the mechanically ventilated patient makes measurements reliable

open8siBackground: Esophageal pressure (Pes) can provide information to guide mechanical ventilation in acute respiratory failure. However, both relative changes and absolute values of Pes can be affected by inappropriate filling of the esophageal balloon and by the elastance of the esophagus wall. We evaluated the feasibility and effectiveness of a calibration procedure consisting in optimization of balloon filling and subtraction of the pressure generated by the esophagus wall (Pew). Methods: An esophageal balloon was progressively filled in 36 patients under controlled mechanical ventilation. VBEST was the filling volume associated with the largest tidal increase of Pes. Esophageal wall elastance was quantified and Pew was computed at each filling volume. Different filling strategies were compared by performing a validation occlusion test. Results: Fifty series of measurements were performed. VBEST was 3.5 ± 1.9 ml (range 0.5-6.0). Esophagus elastance was 1.1 ± 0.5 cmH2O/ml (0.3-3.1). Both Pew and the result of the occlusion test differed among filling strategies. At filling volumes of 0.5, VBEST and 4.0 ml respectively, Pew was 0.0 ± 0.1, 2.0 ± 1.9, and 3.0 ± 1.7 cmH2O (p &lt; 0.0001), whereas the occlusion test was satisfactory in 22 %, 98 %, and 88 % of cases (p &lt; 0.0001). Conclusions: Under mechanical ventilation, an increase of balloon filling above the conventionally recommended low volumes warrants complete transmission of Pes swings, but is associated with significant elevation of baseline. A simple calibration procedure allows finding the filling volume associated with the best transmission of tidal Pes change and subtracting the associated baseline artifact, thus making measurement of absolute values of Pes reliable.openMojoli, Francesco; Iotti, Giorgio Antonio; Torriglia, Francesca; Pozzi, Marco; Volta, Carlo Alberto; Bianzina, Stefania; Braschi, Antonio; Brochard, LaurentMojoli, Francesco; Iotti, Giorgio Antonio; Torriglia, Francesca; Pozzi, Marco; Volta, Carlo Alberto; Bianzina, Stefania; Braschi, Antonio; Brochard, Lauren

Morbidity and mortality after anesthesia in early life in Italy. A subgroup analysis of the NECTARINE Trial

Background: Recent literature on neonatal anesthesia focuses on the importance of keeping physiology within the ranges of normality to improve the long-term neurological outcome. The Neonate and Children audit of Anesthesia pRactice IN Europe (NECTARINE) showed a derangement of one or more than one physiological parameters during anesthesia needing a medical intervention in 35.2% of 6592 anesthesia procedure performed in infants up to 60 weeks postmenstrual age. Methods: Subanalysis of the Italian NECTARINE cohort providing a snapshot of anesthesia management, incidence of clinical events requiring intervention during anesthesia, and morbidity and mortality at 30 and 90 days. Secondary aim was to compare outcomes between Italy and Europe. Results: Twenty-three Italian centers recruited 501 patients (63% male, 37% female) undergoing 611 procedures (441 surgical and 170 non-surgical) with a mean gestational age at birth of 38 weeks. Events requiring a medical intervention during anesthesia occurred in 177 cases (28.9%), lower than those reported in Europe (35.3%). The majority of events concerned episodes of cardiovascular instability, most commonly due to hypotension. The incidence of mortality at 30 days was 2.7%, consistent with the European incidence. Conclusions: Anesthetizing neonates is challenging. It is crucial that neonatal anesthesia practice is performed in specialized centers to maximize the potential positive outcome. We recommend a certification of quality for Institutions providing care for very young patients