Clinical Evaluation of the Eurosets Trilly Oxygenator During Cardiopulmonary Bypass in a Pediatric Population.

The equipment selected for cardiopulmonary bypass (CPB) in pediatric cardiac surgery critically influences the safety, efficiency, efficacy and pathophysiological impact in perioperative use and the post-operative outcome. In this report, we present a single-center retrospective analysis of the clinical efficacy, efficiency and safety of the Trilly oxygenator (Eurosets Srl, Medolla, MO, Italy), which has an integrated arterial filter. It has a blood flow capacity of 500 to 3500ml/min, an AAMI index of 4.000ml / min, and a static fill prime (oxygenating module + heat exchanger) of 130 ml. We used this device on 42 pediatric patients who underwent repair of various congenital heart defects with cardiopulmonary bypass. Pre- and intraoperative patient data were collected for the evaluation of gas transfer and metabolic parameters in relation to blood flow, temperature and hematologic profiles. The mean age of the patients was 8.07 ± 2.9 years. Eight patients had cyanotic heart disease, 7 had chromosomal abnormalities and 9 had previously undergone cardiac surgery. The STAT Mortality Category Score was distributed as follows: Cat. 1 (37.5%), Cat. 2 (35%), Cat. 3 (5%), Cat. 4 (22.5%), Cat. 5 (0%). The mean bodyweight was 29.03 ± 8.25 kg and the blood flow rate was 2664.88 ± 508.43 ml / min. The mean cardiopulmonary bypass time was 95±51.4 min and the cross-clamp time was 37±34.6 min. The mean gas transfer values were as follows: partial pressure of oxygen, post oxygenator, 224.7±28 mmHg; partial pressure of carbon dioxide, post oxygenator, 42±4 mmHg; oxygen delivery 356.9± 88.8 ml/min/m2; carbon dioxide transfer, 52.81± 1.98 mmHg, mixed venous saturation 77.78 %; and mean hematocrit value 29.0±4 %. The Trilly oxygenator was effective in terms of oxygen uptake, carbon dioxide removal, and heat exchange in a pediatric population undergoing cardiopulmonary bypass. This retrospective analysis showed that the Trilly is both safe and effective in clinical practice without iatrogenic problems.

Potential role of a subcutaneously anchored securement device in preventing dislodgment of tunneled-cuffed central venous devices in pediatric patients.

INTRODUCTION: The potential drawbacks of tunneled-cuffed catheters are complications such as local or systemic infection, dislodgment, rupture, malfunction, and deep venous thrombosis. Aim of this study is to describe the incidence of complications, focusing on dislodgment and on the role of new securement devices in reducing this annoying issue. METHODS: We enrolled all pediatric patients with tunneled-cuffed central venous catheters (CVCs) inserted at the Giannina Gaslini Institute during a 16-month period. Demographic data, technical details, intraoperative and postoperative complications were recorded and stored in a digital database according to Data Protection Act. RESULTS: During the study period, we collected 173 tunneled-cuffed CVCs. All but three insertions were successful. There were 50 complications involving 47 CVCs. Complications included 13 infections, 27 dislodgments, 4 thromboses, 3 obstructions, and 3 malfunctions/breaking. In 51 of 173 CVCs, we used subcutaneously anchored securement device (SAS). CONCLUSIONS: The use of SAS proved to significantly reduce the incidence of complications in pediatric patients, particularly during the first 30 postoperative days. Basing on our results we suggest to routinely adopt this new securement device for high-risk CVC.

Atypical use of PICC in infants and small children: a unicentric experience.

INTRODUCTION: The peripherally inserted central catheters (PICCs) are vascular access devices (VAD) that are increasingly being used in the pediatric population. If a small vein caliber prevents positioning the catheter in the arm, the following step is to position the same catheter in the supraclavicular area, which can be defined as an off-label use or "atypical" approach, first described by Pittiruti. MATERIALS AND METHODS: We retrospectively reviewed PICC positioning with puncture-site in the supra-clavicular area ("atypical" PICC insertion) and then tunneled on the chest. RESULTS: Nineteen atypical PICCs were positioned in 18 patients. The median age of patients at the day of implant was 14 months (IQR 3-27 months), and weight 7.5 kg (IQR 4-12 kg). Within this population, 74% of cases scheduled for a typical PICC insertion presented vein caliber too small for this procedure. For this reason, the typical PICC insertion was changed in favor of an atypical PICC procedure. Atypical PICCs were successfully used in 100% of cases without immediate complications. CONCLUSIONS: Atypical PICC positioning is a safe and useful alternative to the conventional technique when there is need for a central vascular access device (CVAD) for mid- or long-term therapy.

Adaptation of non-technical skills behavioural markers for delivery room simulation.

BACKGROUND: Simulation in healthcare has proved to be a useful method in improving skills and increasing the safety of clinical operations. The debriefing session, after the simulated scenario, is the core of the simulation, since it allows participants to integrate the experience with the theoretical frameworks and the procedural guidelines. There is consistent evidence for the relevance of non-technical skills (NTS) for the safe and efficient accomplishment of operations. However, the observation, assessment and feedback on these skills is particularly complex, because the process needs expert observers and the feedback is often provided in judgmental and ineffective ways. The aim of this study was therefore to develop and test a set of observation and rating forms for the NTS behavioural markers of multi-professional teams involved in delivery room emergency simulations (MINTS-DR, Multi-professional Inventory for Non-Technical Skills in the Delivery Room). METHODS: The MINTS-DR was developed by adapting the existing tools and, when needed, by designing new tools according to the literature. We followed a bottom-up process accompanied by interviews and co-design between practitioners and psychology experts. The forms were specific for anaesthetists, gynaecologists, nurses/midwives, assistants, plus a global team assessment tool. We administered the tools in five editions of a simulation training course that involved 48 practitioners. Ratings on usability and usefulness were collected. RESULTS: The mean ratings of the usability and usefulness of the tools were not statistically different to or higher than 4 on a 5-point rating scale. In either case no significant differences were found across professional categories. CONCLUSION: The MINTS-DR is quick and easy to administer. It is judged to be a useful asset in maximising the learning experience that is provided by the simulation.

Brachiocephalic vein for percutaneous ultrasound-guided central line positioning in children: A 20-month preliminary experience with 109 procedures.

BACKGROUND: Ultrasound-guided (USG) cannulation of the brachiocephalic vein (BCV) is gaining worldwide consensus for central venous access in children. This study reports a 20-month experience with this approach in children. METHODS: All patients who underwent percutaneous USG central venous catheter (CVC) positioning in the BCV between August 2013 and March 2015 have been included. Devices inserted during this period were open-ended, either single or double-lumen tunneled CVC. Our series was divided into three consecutive study periods in order to determine the relative incidence of repositioning and complications. RESULTS: During the study period, a total of 95 patients underwent 109 CVC insertions in the BCV. The median length of CVC duration was 230 days for a total of 23,212 catheter days. No major intraoperative complications occurred. Overall rate of CVC-related postoperative complications requiring repositioning or precocious removal was 0.90 per 1,000 catheter days and involved 21 CVC (19%, 95% confidence interval 13-28). These included 18 dislodgments, two infections, and one malfunction. Double-lumen CVCs represented the only significant risk factor for complications (52% complications-three per 1,000 catheter days). CONCLUSION: USG supraclavicular cannulation of the BCV represents a safe approach for central line placement in children. It proved to be versatile, as it can be used in premature infants as well as in adolescents. Provided it is adopted by operators experienced in USG cannulation, we strongly suggest to resort to this approach as a first-line choice in children undergoing tunnelled central line placement for long-lasting therapy.