Tomoyuki Kanazawa

Non-overt disseminated intravascular coagulation scoring for critically ill patients: The impact of antithrombin levels

Validation of a scoring algorithm for non-overt disseminated intravascular coagulation (DIC) proposed by the International Society on Thrombosis and Haemostasis (ISTH) is still incomplete. It was the objective of this study to assess the impact of including AT to non-overt DIC scoring on the predictability for intensive care unit (ICU) death and the later development of overt-DIC defined by the Japanese Ministry of Health and Welfare (JMHW) or the ISTH. We performed a retrospective observational study conducted in 364 patients in critical care. Coagulation parameters obtained daily for DIC screening were utilised for scoring. There were 194 and 196 patients scored as positive non-overt DIC with and without AT, respectively; diagnostic agreement between the two was 78%. As compared with patients without non-overt DIC, these non-overt DIC patients had significantly higher mortality. In 37 ICU non-survivors, positive non-overt DIC scoring with AT preceded ICU death by a median of 6.8 days, which was significantly earlier as compared with a median of 5.4 days for non-overt DIC without AT (p = 0.022). In patients who developed overt-DIC after admission, the time period from positive non-overt DIC to positive overt-DIC was significantly longer when AT was utilised (overt-DIC ISTH; 1.3 days vs. 0.1 days, p = 0.004, overt-DIC JMHW; 2.5 days vs. 2.0 days, p = 0.04, with AT vs. without AT, respectively). Non-overt DIC scoring predicted a high risk of death in critically ill patients. When information on AT levels was included, non-overt DIC scoring was found to predict development of overt-DIC significantly earlier than non-overt DIC scoring without AT.

Perioperative plasma melatonin concentration in postoperative critically ill patients: Its association with delirium

PURPOSE Delirium is a common complication in postoperative critically ill patients. Although abnormal melatonin metabolism is thought to be one of the mechanisms of delirium, there have been few studies in which the association between alteration of perioperative plasma melatonin concentration and postoperative delirium was assessed. MATERIALS We conducted a prospective observational study to assess the association of perioperative alteration of plasma melatonin concentration with delirium in 40 postoperative patients who required intensive care for more than 48 hours. We diagnosed postoperative delirium using Confusion Assessment Method for the intensive care unit and measured melatonin concentration 4 times (before the operation as the preoperative value, 1 hour after the operation, postoperative day 1, and postoperative day 2). RESULTS Postoperative delirium occurred in 13 (33%) of the patients. Although there was no significant difference in preoperative melatonin concentration, Δ melatonin concentration at 1 hour after the operation was significantly lower in patients with delirium than in those without delirium (-1.1 vs 0 pg/mL, P = .036). After adjustment of relevant confounders, Δ melatonin concentration was independently associated with risk of delirium (odds ratio, 0.50; P = .047). CONCLUSIONS Delta melatonin concentration at 1 hour after the operation has a significant independent association with risk of postoperative delirium.

Urinary Albumin Levels Predict Development of Acute Kidney Injury After Pediatric Cardiac Surgery: A Prospective Observational Study

OBJECTIVE Mortality and morbidity of acute kidney injury (AKI) after cardiac surgery still remain high. The authors undertook the present study to evaluate the utility of early postoperative urinary albumin (uAlb) as a diagnostic marker for predicting occurrence of AKI and its severity in pediatric patients undergoing cardiac surgery. DESIGN A prospective observational study. SETTING A single-institution university hospital. PARTICIPANTS All patients<18 years of age who underwent repair of congenital heart disease with cardiopulmonary bypass between July 2010 and July 2012 were included in the study. Neonates age<1 month were excluded from the study population. INTERVENTIONS The association between uAlb and occurrence of AKI within 3 days after admission to the intensive care unit was investigated. Criteria from pediatric-modified Risk Injury Failure Loss and End-stage kidney disease (pRIFLE) were used to determine the occurrence of AKI. The value of uAlb was measured at intensive care unit admission immediately after cardiac surgery in all participants from whom a 5-mL urine sample was obtained. MEASUREMENTS AND MAIN RESULTS Of 376 patients, AKI assessed by pRIFLE was identified in 243 (64.6%): 172 for risk (R; 45.7%), 44 for injury (I; 11.7%), and 27 for failure (F; 7.2%). One hundred thirty-three patients (35.4%) were classified as being without AKI (normal [N]) by pRIFLE. The concentration of uAlb was significantly higher in AKI patients than in non-AKI patients (median [interquartile range]): uAlb (µg/mL): 13.5 (6.4-39.6) v 6.0 (3.4-16), p<0.001; uAlb/Cr (mg/gCr): 325 (138-760) v 121 (53-269), p< 0.001. CONCLUSIONS The utility of uAlb for prompt diagnosis of AKI was shown. Obtaining uAlb measurements early after pediatric cardiac surgery may be useful for predicting the occurrence and severity of AKI.

Intraoperative change of lactate level is associated with postoperative outcomes in pediatric cardiac surgery patients: retrospective observational study

BackgroundA change of serum lactate concentrations appeared to be useful for predicting outcomes in various acute ill settings. However, there is little information on intraoperative change of lactate level in pediatric cardiac surgery patients.MethodsWe conducted a retrospective observational study of 459 children who received pediatric cardiac surgery to determine the association between change of lactate level after cardiopulmonary bypass (CPB) and patient prognosis (length of ICU stay and incidence of postoperative serious adverse events (SAEs)). We defined change of lactate level after CPB (LAC⊿) as (final lactate level measurement in the operating room) – (lactate level measured at the end of CPB). To study the independent association of LAC⊿ with length of ICU stay, we used linear regression model.ResultsThere were 1145 lactate measurements after CPB in this study cohort. After weaning from CPB, the serum lactate levels significantly increased from 2.1 mmol/L to 2.5 mmol/L (p < 0.001). Patients with higher LAC⊿ had significantly longer stay in ICU (p = 0.017) and higher incidence of SAEs (p = 0.002). In multivariate linear regression analysis, higher LAC⊿ showed a significant independent association with longer length of ICU stay.ConclusionsIncreased lactate level after CPB was associated with the longer duration of ICU stay and increased risk of postoperative SAEs in pediatric cardiac surgery patients. Future studies should be conducted to determine the clinical utility of intraoperative trend of lactate levels.

A Case of Cardiac Arrest Due to Coronary Vasospasm on Extubation Following Thymectomy

大動脈弁閉鎖不全,僧帽弁閉鎖不全,三尖弁閉鎖不 全を認めた.冠動脈造影CTでは有意狭窄や石灰化 を認めなかった. 術式は仰臥位で胸骨正中切開下に拡大胸腺摘出術 が予定された.手術室入室時のバイタルサインは心 拍数(HR)68回/分,血圧(BP)138/84mmHg,SpO2 96%であった.腫瘍の脈管浸潤の可能性が高く遠心 ポンプ使用を念頭に置き,硬膜外麻酔は併用しなか った.全身麻酔はレミフェンタニル,プロポフォー ル,ロクロニウムで導入し,35Fr左気管支用ダブル ルーメンチューブを挿管した.導入後に左橈骨動脈 と右足背動脈に観血的動脈圧ラインを確保し,右大 腿静脈に中心静脈カテーテルを留置した.経食道心 エコー(transesophageal echocardiography:TEE) では,術前所見以外に異常はなかった.麻酔維持は プロポフォールTCI (target controlled infusion)設 定2μg/mLとレミフェンタニル0.1~0.3μg/kg/分 はじめに

242: LOWER SERUM ALBUMIN AT ICU ADMISSION PREDICTS POSTOPERATIVE AKI FOLLOWING PEDIATRIC CARDIAC SURGERY

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Acute kidney injury (AKI) is recognized as a complication after cardiac surgery in adults and children. There has been an effort to identify AKI biomarkers, with the hope of facilitating timely prophylactic and/or early therapeutic interventions. We reported the usefulness of urine albumin as AKI biomarker. However, little is known about relationship between AKI after heart surgery and serum albumin level. Methods: To test the utility of serum albumin at ICU admission as a predictor for AKI in children following cardiac surgery. Prospective observational study. Setting: Singlecenter, university affiliated tertiary teaching hospital. Children younger than 18 years old admitted to intensive care unit (ICU) after cardiac surgery between July 2010 and July 2012. Our institutional review board approved the current study protocol. Children younger than 18 years old admitted to ICU following cardiac surgery from July 2010 to July 2012 were included. Serum albumin and blood samples were measured when the patients admitted to ICU. Age, gender, body weight, RACHS-1 category, vital signs and blood tests for 24 hours from ICU admission were collected. Outcomes such as mortality, cardiovascular events, duration of mechanical ventilation, or duration of ICU stay were also collected. Pediatric RIFLE (pRIFLE) criteria were used to define severity of AKI. Data were analyzed in order to investigate a relationship between serum Albumin and AKI. Results: Our data identified 359 children younger than 18 years of age. Their median age was 18 months [interquartile range (IQR);6–53 months], body weight was 8.8 kg (IQR; 5.4–14.5) and gender male was 201/359(56.1%). On pRIFLE criteria, Normal(N) was 125, Risk(R) was 157, Injury(I) was 39, and Failure(F) was 38. Their median albumin at ICU adimission was 4.6 g/dL (IQR; 4.3– 4.8) and albumin at ICU admission in Failure category by pRIFLE was significantly lower than those in other categories [4.2 (IQR; 3.9–4.8) vs 4.9 (IQR; 4.6–5.3), p < 0.0001]. The AUC of albumin at ICU admission for Failure on pRIFLE was 0.78. There were 15 children (4.2%) who required peritoneal dialysis (PD) as a renal replacement therapy and Alb at ICU admission in PD patients were significantly lower than those in non-PD patients [4.4 (IQR; 4.0–4.8) vs 4.9 (4.8–4.9), p = 0.041]. Conclusions: Serum albumin at ICU admission could be an early marker of AKI in children following cardiac surgery.

High Ionized Calcium Concentration Is Associated With Prolonged Length of Stay in the Intensive Care Unit for Postoperative Pediatric Cardiac Patients

OBJECTIVE There has been controversy regarding the beneficial effects of calcium on myocardial contractility and the harmful effects on myocardial cells, especially in children. The aim of this study was to investigate an association between ionized calcium concentration (iCa) and outcomes for pediatric patients after cardiac surgery. DESIGN A retrospective, single-center study from May 2013 to December 2014. SETTING Referral high-volume pediatric cardiac center in a tertiary teaching hospital. PATIENTS Patients <72 months old with congenital heart disease who underwent palliative or definitive surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The association between pH-corrected iCa within 24 hours after surgery and intensive care unit (ICU) length of stay (ILOS) was defined as the primary outcome. The highest iCa (iCamax), lowest iCa (iCamin), and time-weighted average iCa (iCaave) were stratified and compared with the outcomes. The authors reviewed 5,468 ionized calcium measurements from 357 consecutive pediatric patients during the study period. One patient died at postoperative day 34 in the ICU. Significant differences in ILOS were observed among patients after cardiopulmonary bypass (CPB) according to iCaave, iCamax, and iCamin but not among patients without CPB. Patients with CPB and an iCaave value of 1.31-to-1.40 mmol/L, 1.41-to-1.50 mmol/L, 1.51-to-1.60 mmol/L, and >1.60 mmol/L stayed in the ICU for 7 (interquartile range [IQR] 4-10) days, 8 (IQR 6-16) days, 10 (IQR 8-14) days, and 19 (IQR 12-38) days, respectively, which was significantly longer than the ILOS of 5 (4-8) days for patients with an iCaave of 1.21-to-1.30 mmol/L. Even after adjustment for other predictors of ILOS using multivariable analyses, there were significant relationships of ILOS with iCaave and iCamin values of >1.50 mmol/L among patients with CPB. CONCLUSIONS Higher iCa within 24 hours after congenital cardiac surgery using CPB was independently associated with longer LOS in the ICU.

Storage duration of transfused red blood cells is not significantly associated with postoperative adverse events in pediatric cardiac surgery patients

The aim of this study was to evaluate the association of storage duration of transfused red blood cells with the risk of postoperative serious adverse events in pediatric cardiac surgery patients. We studied 517 patients and found that 22 patients (4.3%) had at least one serious adverse event. The maximum and mean storage duration of transfused red blood cells did not differ significantly between patients with and without serious adverse events (maximum, p = 0.89; mean, p = 0.81). In our study of pediatric cardiac surgery patients, the storage duration of transfused red blood cells was not significantly associated with the risk of serious adverse events.