J. Neidecker

Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study.

Objective:Matching healthcare staff resources to patient needs in the ICU is a key factor for quality of care. We aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. Design:We performed a multicenter longitudinal study using routinely collected hospital data. Setting:Information pertaining to every patient in eight ICUs from four university hospitals from January to December 2013 was analyzed. Patients:A total of 5,718 inpatient stays were included. Interventions:None. Measurements and Main Results:We used a shift-by-shift varying measure of the patient-to-caregiver ratio in combination with workload to establish their relationships with ICU mortality over time, excluding patients with decision to forego life-sustaining therapy. Using a multilevel Poisson regression, we quantified ICU mortality-relative risk, adjusted for patient turnover, severity, and staffing levels. The risk of death was increased by 3.5 (95% CI, 1.3–9.1) when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 (95% CI, 1.3–3.2) when the patient-to-physician ratio exceeded 14. The highest ratios occurred more frequently during the weekend for nurse staffing and during the night for physicians (p < 0.001). High patient turnover (adjusted relative risk, 5.6 [2.0–15.0]) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9 [4.3–7.9]) were also associated with increased mortality. Conclusions:This study proposes evidence-based thresholds for patient-to-caregiver ratios, above which patient safety may be endangered in the ICU. Real-time monitoring of staffing levels and workload is feasible for adjusting caregivers’ resources to patients’ needs.

Glucose versus lactated ringer's solution during pediatric cardiac surgery

OBJECTIVE Whether intraoperative fluid infusion should contain glucose during pediatric cardiac surgery remains controversial. This study was performed to compare the effects of glucose and glucose-free solutions on blood glucose and blood insulin levels during total repair of congenital heart diseases. DESIGN Prospective randomized and blinded study. SETTING Cardiovascular university center. PARTICIPANTS Forty nondiabetic children, weight ranging from 4 to 10 kg, scheduled for cardiac surgical procedures requiring cardiopulmonary bypass (CPB) without total circulatory arrest. INTERVENTIONS Group R (n = 20) was administered lactated Ringers solution intraoperatively, and group G (n = 20) received 5% glucose. Fluids were infused at a rate of 3 mL/kg/h in the two groups from the induction of anesthesia to the end of the surgical procedure. Blood glucose and insulin were sampled before infusion (Tzero), before CPB (T1), 10 minutes after initiation of CPB (T2), 10 minutes after initiation of rewarming (T2), and at the end of the procedures (T4). Postoperatively, blood glucose was measured at the first, 12th, and 24th hours. MEASUREMENTS AND RESULTS During the prabypass period, three children in group R had severe hypoglycemia (blood glucose < 40 mg/dL). After initiation of CPB, blood glucose increased in both groups, with a small difference at the end of the procedure. No infants in the two groups had blood glucose higher than 239 mg/dL. CONCLUSIONS Glucose withdrawal during pediatric cardiac surgery induces threatening hypoglycemia during the prabypass period, and moderate intraoperative glucose administration (2.5 mg/kg/min) is not responsible for major hyperglycemia.

Comprendre la variabilité de la pression artérielle et de la fréquence cardiaque

Resume Objectif. – Faire une revue de l’etat actuel des connaissances sur la variabilite de la frequence cardiaque et de la pression arterielle. Sources des donnees. – Recherche des donnees dans la banque de donnees Medline® des articles de langue francaise ou anglaise. Les articles originaux et les observations cliniques ont ete retenus. Extraction des donnees. – Les articles ont ete analyses de facon a extraire toutes les informations disponibles sur la variabilite de la pression arterielle et de la frequence cardiaque (ou de l’intervalle RR), en mettant l’accent sur l’analyse spectrale. La non stationnarite est abordee, cas ou les analyses temps–frequence et temps–echelle sont d’un interet particulier. Synthese des donnees. – En raison de sa capacite a moduler rapidement les niveaux de pression et la frequence cardiaque, l’activite du systeme nerveux autonome peut etre evaluee par la mesure de la variabilite de la pression arterielle et de la frequence cardiaque. Le baroreflexe appartient au systeme nerveux autonome, et est l’un des principaux mecanismes de controle a court terme de la pression arterielle. En faisant varier la frequence cardiaque et les resistances systemiques, le baroreflexe tend a maintenir le niveau de la pression arterielle. La variabilite de la pression arterielle et de la frequence cardiaque a aide a la comprehension des mecanismes physiopathologiques de certaines affections. Un nombre croissant de travaux suggere que les composantes spectrales de ces signaux, notamment la balance sympathovagale, peuvent avoir une valeur pronostique. Les differents types d’analyse spectrale des signaux biologiques, en particulier la transformee de Fourier rapide, peuvent etre utilises d’une facon facilement lisible et interpretable, en particulier en clinique. L’analyse spectrale des signaux non stationnaires a conduit a developper des outils specifiques adaptes a ces signaux, parmi lesquels emergent les methodes temps–frequence et temps–echelle qui prennent explicitement en compte une possible evolution temporelle du contenu frequentiel d’un signal.

Intraoperative Transesophageal Echocardiography Using a Miniaturized Transducer in a Neonate Undergoing Norwood Procedure for Hypoplastic Left Heart Syndrome

A 7-day–old neonate (weight, 2.7 kg; height, 48 cm) with hypoplastic left heart syndrome was referred to our institution for a Norwood stage I palliation procedure. In the small neonate, conventional transesophageal echocardiographic probe insertion and manipulation can induce hemodynamic instability or respiratory compromise. Therefore, the usual weight range for neonates and infants who can be safely imaged in the operating department with the use of currently available echocardiographic probes is >3 kg. Recently, a …

Utilisation clinique d’un oxymètre de pouls de nouvelle génération dans le cadre de la chirurgie cardiaque pédiatrique ☆

OBJECTIVES Arterial oxygen saturation (SaO(2)) monitoring using pulse oximeter (SpO(2)) is mandatory in the intensive care unit. The aim was to assess bias and precision of new (SpO(2)ng) and old (SpO(2)og) pulse oximeter technologies in the postoperative period following pediatric cardiac surgery in cyanotic children. STUDY DESIGN Prospective, monocentric. PATIENTS AND METHODS Ten patients (7 days to 53 months old) were studied in the postoperative period following palliative cardiac surgery. SaO(2), SpO(2)og, and SpO(2)ng were obtained every 4 hours. SaO(2) of arterial blood sample was obtained from an intra-arterial catheter located in the radial artery, on the same side as the oximeters. Bias and precision were assessed using Bland-Altman analysis. RESULTS We obtained 136 SaO(2) determinations. Mean SaO(2) was 76+/-15%. SpO(2)og was significantly different from SaO(2), while SpO(2)ng was not different from SaO(2). In 21 (15%) cases, SpO(2)og was not available whereas SpO(2)ng was available in 136 (100%) cases. In the remaining 115 cases, SpO(2)ngs precision was significantly better than SpO(2)ogs precision. DISCUSSION SpO(2)ng is more accurate and more reliable than SpO(2)og for SaO(2) monitoring in the postoperative period following pediatric cardiac surgery in cyanotic children.

Anesthesia management in a child with PHACE syndrome and agenesis of bilateral internal carotid arteries

This is the first case report of successful anesthesia management in a high‐risk neurological procedure in a patient with PHACE syndrome. PHACE syndrome is rare but an important clinical entity. Anesthesiologists should be aware of the neurological, otolaryngogical, and vascular risk associated with this syndrome.

Cardioplégie au sang, cardioplégie cristalloïde en pédiatrie

Resume La majorite des operations en chirurgie cardiaque du nouveau-ne et de l’enfant necessite une periode d’arret cardiaque afin de realiser le geste operatoire dans de bonnes conditions. Beaucoup d’efforts ont ete faits, afin de preserver au mieux le myocarde durant cette periode d’ischemie. Cependant, la plupart des etudes porte sur le cœur adulte et s’interesse peu a l’enfant et au nouveau-ne. Or, la reponse myocardique a l’ischemie semble differente entre le cœur « immature » en pediatrie et le cœur adulte. De plus, la frontiere entre ces deux etats physiologiques est loin d’etre precise. Par ailleurs, chez l’enfant, la physiologie myocardique des cardiopathies cyanogenes differe de celle des cardiopathies non cyanogenes. Le but de notre etude est d’abord de decrire cette specificite pediatrique et congenitale puis d’effectuer une synthese de la litterature sur les differents types de protection myocardique en chirurgie cardiaque pediatrique.

Anestesia y reanimación en la cirugía cardíaca del recién nacido y del lactante

Resumen Las cardiopatias congenitas se caracterizan por una gran variedad de lesiones anatomicas que precisan una cirugia correctora que se realiza en ninos cada vez mas pequenos. La utilizacion de anestesicos de forma segura en los recien nacidos y lactantes se basa en el dominio de la farmacocinetica en funcion de la edad y en el conocimiento de la fisiopatologia de la cardiopatia. En los cortocircuitos izquierda-derecha, la anestesia debe ser profunda y se debe evitar que la hipoxia y la hipercapnia agraven la hipertension arterial pulmonar. La oxigenacion excesiva puede ser inoportuna si reduce demasiado las resistencias pulmonares y aumenta el cortocircuito izquierda-derecha. Por otra parte, se debe evitar un llenado vascular demasiado importante. En los cortocircuitos derecha-izquierda, un descenso marcado de la resistencia sistemica producido por la anestesia general puede agravar el cortocircuito y la cianosis. Habitualmente, hay poco riesgo con el llenado vascular. La existencia de un cortocircuito derecha-izquierda intracardiaco expone al riesgo de embolia gaseosa, y el riesgo de endocarditis infecciosa es especialmente elevado. Ninguno de los farmacos utilizados en anestesia carece por completo de efectos perjudiciales. No hay indicaciones ni contraindicaciones absolutas para emplear algunos de los anestesicos que se utilizan normalmente en la anestesia pediatrica, pero para que se desarrolle bien la intervencion es necesaria la administracion controlada de anestesicos, basada en el buen conocimiento de sus efectos, el control peroperatorio apropiado y el conocimiento de los diferentes tiempos quirurgicos.