Minerva anestesiologica
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In patients undergoing cardiac surgery, postoperative brain injury significantly contributes to increase morbidity and mortality and has negative consequences on quality of life and costs. Moreover, over the past years, compelling medical and technological improvements have allowed an even older patients' population, with several comorbidities, to be treated with cardiac surgery; however, the risk of brain injury after such interventions is also increased in these patients. With the aim of improving post-operative neurological outcome, a variety of neuromonitoring methods and devices have been introduced in clinical practice. ⋯ Some of them have been used to optimize the hemodynamic management of such patients and to select specific therapeutic interventions. Also, various pharmacological and non-pharmacological approaches have been proposed to minimize the incidence of brain injury in this setting. In this review we describe the risk factors and mechanisms of cerebral injury after cardiac surgery and focus on monitoring techniques and clinical strategies that could help clinicians to minimize the incidence of brain injury.
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Acute kidney injury (AKI) represents 18-47% of all causes of hospital-acquired AKI and it is associated with a high incidence of morbidity and mortality especially in patients requiring dialysis. Only recently, with the application of new AKI classifications and guidelines (RIFLE, AKIN and KDIGO), a more accurate evaluation of the real incidence of kidney dysfunction in patients undergoing surgery has been detailed. In patients undergoing non-cardiac, non-vascular and non-thoracic surgery several independent preoperative and intraoperative predictors of AKI have been identified. ⋯ Multi-hit mechanisms (ischemia, inflammation, toxins) co-act on patients' predisposition (susceptibility). A multi-step approach is probably necessary to limit the incidence and the severity of postsurgery AKI patients, such as careful risk stratification, adoption of preventive measures and goal directed intraoperative algorithms. The present review will summarize the current literature about the epidemiology of postoperative AKI focusing on patient-related and technical-related risk factors, outcome and prevention strategies in different groups of surgeries.
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Minerva anestesiologica · Jun 2015
Multicenter StudyRelationship of ECMO duration with outcomes after pediatric cardiac surgery: a multi-institutional analysis.
There are very sparse data on the outcomes of children receiving prolonged extracorporeal membrane oxygenation (ECMO) after cardiac surgery. This study was aimed to evaluate the association of ECMO duration with outcomes in children undergoing surgery for congenital heart disease using the Pediatric Health Information System (PHIS) database. ⋯ Data from this large multicenter database suggest that longer duration of ECMO support after pediatric cardiac surgery is associated with worsening outcomes.
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Minerva anestesiologica · Jun 2015
ReviewMeasuring and predicting long-term outcomes in older survivors of critical illness.
Older adults (age ≥65 years) now initially survive what were previously fatal critical illnesses, but long-term mortality and disability after critical illness remain high. Most studies show that the majority of deaths among older ICU survivors occur during the first 6 to 12 months after hospital discharge. Less is known about the relationship between critical illness and subsequent cause of death, but longitudinal studies of ICU survivors of pneumonia, stroke, and those who require prolonged mechanical ventilation suggest that many debilitated older ICU survivors die from recurrent infections and sepsis. ⋯ Long-term health-related quality-of-life studies suggest that some older ICU survivors may accommodate to a degree of physical disability and still report good emotional and social well-being, but these studies are subject to survivorship and proxy-response bias. In order to risk-stratify older ICU survivors for long-term (6-12 months) outcomes, we will need a paradigm shift in the timing and type of predictors measured. Emerging literature suggests that the initial acuity of critical illness will be less important, whereas prehospitalization estimates of disability and frailty, and, in particular, measures of comorbidity, frailty, and disability near the time of hospital discharge will be essential in creating reliable long-term risk-prediction models.