Exploring the impacts of social media and crowdsourcing on disaster resilience.

Social media and crowdsourcing (SMCS) are increasingly proving useful for addressing the effects of natural and human-made hazards. SMCS allow different stakeholders to share crucial information during disaster management processes and to strengthen community resilience through engagement and collaboration. To harvest these opportunities there is a need for better knowledge on SMCS for diverse disaster scenarios. These challenges are being addressed within the LINKS Horizon 2020 project. The project aims at strengthening societal resilience by producing advanced learning on the use of SMCS in disasters. This is done through an in-depth study across three knowledge domains (disaster risk perception and vulnerability, disaster management processes, SMCS technologies), the establishment of an interactive framework, and an online platform in which a community of relevant stakeholders can learn and share knowledge and experiences. This paper provides an overview of the project objectives and approaches and a summary of the initial results.

Acute and Long-Term Effects of LVAD Support on Right Ventricular Function in Children with Pediatric Pulsatile Ventricular Assist Devices.

Right ventricular failure (RVF) is a significant issue when considering left ventricular assist device (LVAD) implantation in pediatrics. The aim of this study was to evaluate the effects of LVAD on right ventricular (RV) function in children. We retrospectively reviewed clinical and echocardiographic data of children who underwent Berlin Heart EXCOR LVAD focusing on RV function before and after implantation (1, 3, and 6 month follow-up). An isolated LVAD was used in 27 patients. Median age was 11 months (interquartile range [IQR]: 5-24 months), with a median weight of 6.3 kg (IQR: 5-9 kg). Median time on ventricular assist device (VAD) support was 147 days (IQR: 86-210 days). Twenty patients were successfully bridged to orthotopic heart transplantation (OHT) (74%), six patients died (22%), and also heart function recovered in one patient (4%). Before LVAD implantation, nine patients (33%) showed a RV fractional area change (RVFAC) less than or equal to 30%. After implantation, mean RVFAC increased up until the 3 month follow-up (43.13%; p = 0.033) and then slightly decreased. In a subgroup of 18 patients, the average strain value increased after the 1 month follow-up (p = 0.022). Right ventricular failure developed in 33% of patients before the 1 month follow-up, and 7.4% experienced RVF at the 6 month follow-up. No patient required biventricular assist device (BiVAD). In our population, pulsatile-flow LVAD in children allows optimal RV decompression and function post-LVAD as measured by improvement in RV function at echo particularly at 1 and 3 month follow-up. At long-term follow-up, the beneficial effects of LVAD on RV function seem to be reduced as signs and symptoms of late RVF may develop in some patients despite LVAD support.

Early hybrid approach and enteral feeding algorithm could reduce the incidence of necrotising enterocolitis in neonates with ductus-dependent systemic circulation.

BACKGROUND: The reported incidence of necrotising enterocolitis in neonates with complex CHD with ductus-dependent systemic circulation ranges from 6.8 to 13% despite surgical treatment; the overall mortality is between 25 and 97%. The incidence of gastrointestinal complications after hybrid palliation for neonates with ductus-dependent systemic circulation still has to be defined, but seems comparable with that following the Norwood procedure. METHODS: We reviewed the incidence of gastrointestinal complications in a series of 42 consecutive neonates with ductus-dependent systemic circulation, who received early hybrid palliation associated with a standardised feeding protocol. RESULTS: The median age and birth weight at the time of surgery were 3 days (with a range from 1 to 10 days) and 3.07 kg (with a range from 1.5 to 4.5 kg), respectively. The median ICU length of stay was 7 days (1-70 days), and the median hospital length of stay was 16 days (6-70 days). The median duration of mechanical ventilation was 3 days. Hospital mortality was 16% (7/42). In the postoperative period, 26% of patients were subjected to early extubation, and all of them received treatment with systemic vasodilatory agents. Feeding was started 6 hours after extubation according to a dedicated feeding protocol. After treatment, none of our patients experienced any grade of necrotising enterocolitis or major gastrointestinal adverse events. CONCLUSIONS: Our experience indicates that the combination of an "early hybrid approach", systemic vasodilator therapy, and dedicated feeding protocol adherence could reduce the incidence of gastrointestinal complications in this group of neonates. Fast weaning from ventilatory support, which represents a part of our treatment strategy, could be associated with low incidence of necrotising enterocolitis.

Acute Biventricular Interaction in Pediatric Patients Implanted with Continuous Flow and Pulsatile Flow LVAD: A Simulation Study.

Left ventricular assist devices (LVADs) are used to bridge pediatric patients till transplantation. However, the LVADs effects on right ventricular (RV) function are controversial. This work aims at studying the ventricular interdependency in the presence of continuous (c-) and pulsatile (p-) flow LVAD in pediatric patients using a lumped parameter model including the representation of the septum. Five pediatric patients' data were used to simulate patients' baseline. The effects on LV and RV functions, energetics, preloads and afterloads of different c-LVAD speeds, p-LVAD rate, p-LVAD systole duration, p-LVAD filling and ejection pressures were simulated. c-LVAD and p-LVAD unload the LV decreasing the LV external work and improving the LV ventriculo-arterial coupling and these effects are more evident increasing the c-LVAD speed and the p-LVAD rate. Continuous-LVAD and p-LVAD decrease the RV afterload, increase the RV ejection fraction and improve the RV ventriculo-arterial coupling. The changes in RV function are inversely proportional to the degree of the interventricular septum leftward shift that increased by increasing the LVAD contribution. The study of the interventricular interaction could lead to the development of a dedicated algorithm to optimize LVAD setting in pediatric population.

Neurological complications during pulsatile ventricular assistance with the Berlin Heart EXCOR in children: incidence and risk factors.

The aim of this study is to describe the incidence of brain injury (BI) in children with end-stage cardiac failure who were supported with the Berlin Heart EXCOR ventricular assist device (VAD) as a bridge to heart transplantation. Between January 2002 and January 2012, all patients <18 years of age who underwent the implantation of the Berlin Heart EXCOR at Bambino Gesú Children's Hospital were included. A total of 25 patients were included in this study. Median age and weight at implantation were 22.4 months (range 3.6-154.2) and 10 kg (range 4.5-36), respectively. Diagnosis included cardiomyopathy (n = 20) and congenital heart disease (n = 5). Eleven patients received atrial cannulation. Nine patients underwent biventricular assist device support. Seven patients underwent extracorporeal membrane oxygenation before the implantation of the EXCOR VAD. Median duration of VAD support was 51 days (range 2-167). Nine patients had evidence of acute BI including intracranial hemorrhage (n = 5) and cerebral ischemia (n = 4). Freedom from BI at 30, 60, and 90 days from VAD implantation was 80.7, 69.9, and 43.3%, respectively. Weight <10 kg at implantation was significantly associated with BI. BI is a frequent complication among children supported with EXCOR VAD and is associated with lower weight at implantation. However, our data do not support the association between size and BI. Future prospective multicenter studies are warranted to further help understand the etiology and the impact of BI and to improve functional outcomes for children undergoing EXCOR VAD mechanical support.

Neutrophil gelatinase-associated lipocalin levels during extracorporeal membrane oxygenation in critically ill children with congenital heart disease: preliminary experience.

OBJECTIVE: To evaluate diagnostic and prognostic significance of neutrophil gelatinase-associated lipocalin during extracorporeal membrane oxygenation in children with congenital heart disease. DESIGN: Prospective observational study. SETTING: Pediatric cardiac intensive care unit. PATIENTS: Ten pediatric patients with congenital heart disease requiring venoarterial extracorporeal membrane oxygenation for postoperative cardiorespiratory support were prospectively enrolled. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five patients were successfully weaned from extracorporeal membrane oxygenation and survived to intensive care unit discharge; five children died during extracorporeal therapy or within 12 hrs from extracorporeal membrane oxygenation stop. Continuous renal replacement therapy after extracorporeal membrane oxygenation start was indicated for three patients. When patients on continuous venovenous hemofiltration were compared with patients not on continuous venovenous hemofiltration, diuretic administration was lower (1.5 vs. 10 mg/kg/day), extracorporeal membrane oxygenation duration was longer (7 [range, 6-14]) vs. 4 [range, 3-8] days), and survival decreased from 60% (four of seven) to 33% (one of three). Neutrophil gelatinase-associated lipocalin levels were higher at the first extracorporeal membrane oxygenation day in patients who underwent continuous venovenous hemofiltration, 285 (range, 181-513) vs. 130 (range, 81-277) ng/mL, in patients who did not undergo continuous venovenous hemofiltration (p = .045). Neutrophil gelatinase-associated lipocalin levels remained higher among patients on continuous venovenous hemofiltration than others throughout the examined extracorporeal membrane oxygenation period (p = .0007), whereas creatinine levels tended to be equivalent between the two groups (p = .38). However, a trend toward increasing neutrophil gelatinase-associated lipocalin levels was noticed also in patients not on continuous venovenous hemofiltration. CONCLUSIONS: Neutrophil gelatinase-associated lipocalin levels at the first extracorporeal membrane oxygenation day may have predictive value for continuous venovenous hemofiltration. During the course of extracorporeal membrane oxygenation support, creatinine levels were normalized in patients with acute kidney injury undergoing continuous venovenous hemofiltration; in these patients, neutrophil gelatinase-associated lipocalin levels may provide further information on kidney injury.

High-dose fenoldopam reduces postoperative neutrophil gelatinase-associated lipocaline and cystatin C levels in pediatric cardiac surgery.

INTRODUCTION: The aim of the study was to evaluate the effects of high-dose fenoldopam, a selective dopamine-1 receptor, on renal function and organ perfusion during cardiopulmonary bypass (CPB) in infants with congenital heart disease (CHD). METHODS: A prospective single-center randomized double-blind controlled trial was conducted in a pediatric cardiac surgery department. We randomized infants younger than 1 year with CHD and biventricular anatomy (with exclusion of isolated ventricular and atrial septal defect) to receive blindly a continuous infusion of fenoldopam at 1 µg/kg/min or placebo during CPB. Perioperative urinary and plasma levels of neutrophil gelatinase-associated lipocaline (NGAL), cystatin C (CysC), and creatinine were measured to assess renal injury after CPB. RESULTS: We enrolled 80 patients: 40 received fenoldopam (group F) during CPB, and 40 received placebo (group P). A significant increase of urinary NGAL and CysC levels from baseline to intensive care unit (ICU) admission followed by restoration of normal values after 12 hours was observed in both groups. However, urinary NGAL and CysC values were significantly reduced at the end of surgery and 12 hours after ICU admission (uNGAL only) in group F compared with group P (P = 0.025 and 0.039, respectively). Plasma NGAL and CysC tended to increase from baseline to ICU admission in both groups, but they were not significantly different between the two groups. No differences were observed on urinary and plasma creatinine levels and on urine output between the two groups. Acute kidney injury (AKI) incidence in the postoperative period, as indicated by pRIFLE classification (pediatric score indicating Risk, Injury, Failure, Loss of function, and End-stage kidney disease level of renal damage) was 50% in group F and 72% in group P (P = 0.08; odds ratio (OR), 0.38; 95% confidence interval (CI), 0.14 to 1.02). A significant reduction in diuretics (furosemide) and vasodilators (phentolamine) administration was observed in group F (P = 0.0085; OR, 0.22; 95% CI, 0.07 to 0.7). CONCLUSIONS: The treatment with high-dose fenoldopam during CPB in pediatric patients undergoing cardiac surgery for CHD with biventricular anatomy significantly decreased urinary levels of NGAL and CysC and reduced the use of diuretics and vasodilators during CPB. TRIAL REGISTRATION: Clinical Trial.Gov NCT00982527.

Pneumatic pulsatile ventricular assist device as a bridge to heart transplantation in pediatric patients.

Despite the remarkable advances with the use of ventricular assist devices (VAD) in adults, pneumatic pulsatile support in children is still limited. We report on our experience in the pediatric population. A retrospective review of 17 consecutive children offered mechanical support with Berlin Heart as a bridge to heart transplant from February 2002 to April 2010 was conducted. The median patient age was 3.9 years (75 days to 13.3 years). The median patient weight was 14.1 kg (2.9-43kg). Before VAD implantation, all children were managed by multiple intravenous inotropes and mechanical ventilation (14) or extracorporeal membrane oxygenation (3). All patients had right ventricular dysfunction. Nine patients required biventricular mechanical support (BVAD), but in all other cases a single left ventricular assist device proved sufficient (47%). The median duration of VAD support was 47 days (1-168 days). The median pre-VAD pulmonary vascular resistance index (Rpi) was 5.7 WU/m(2) (3.5 to 14.4WU/m(2) ). Eleven patients (65%) were successfully bridged to heart transplantation after a median duration of mechanical support of 68 days (6-168 days). Six deaths occurred (35%), three for neurological complications, one for sepsis, and two others for device malfunctioning. Since 2007, the survival rate of our patients has increased from 43% to 80%, and the need for BVAD has decreased from 86% to 30%. In two patients with Rpi >10WU/m(2) , unresponsive to pulmonary vasodilatator therapy, Rpi dropped to 2.2 and 2WU/m(2) after 40 and 23 days of BVAD support, respectively. Seven patients (41%) required at least one pump change. Of 11 patients undergoing heart transplant, four developed an extremely elevated (>60%) panel reactive antibody by enzyme-linked immunosorbent assay, confirmed by Luminex. All of them experienced at least one acute episode of rejection in the first month after heart transplant, needing plasmapheresis. The survival rate after heart transplantation was 100% with a median follow-up of 25.4 months (6 days to 7.7 years). Mechanical support in children with end-stage heart failure is an effective strategy as a bridge to heart transplantation with a reasonable morbidity and mortality. BVAD support may offer an additional means to reverse extremely elevated pulmonary vascular resistance.

Mechanical assist device as a bridge to heart transplantation in children less than 10 kilograms.

BACKGROUND: Despite the remarkable advances with the use of ventricular assist devices (VAD) in adults, pneumatic pulsatile support in children is still limited. We report a retrospective review of our experience in very small children (<10 kg of body weight). METHODS: Ten consecutive children weighing less than 10 kg were offered mechanical support with Berlin Heart (Berlin Heart AG, Berlin, Germany) as a bridge to heart transplant from March 2002 to March 2010. RESULTS: The median patient age was 10.4 months (38 days to 2.2 years). The median patient weight was 6.4 kg (2.9 to 10 kg). Prior to VAD implantation, all children were managed by multiple intravenous inotropes and mechanical ventilation (8) or extracorporeal membrane oxygenation (2). The median pre-VAD pulmonary vascular resistance index was 5.7 Woods units/m(2). Three patients required biventricular mechanical support, but in all other cases a single left VAD proved sufficient. The median duration of VAD support was 61 days (2 to 168 days). Four deaths occurred; from stroke in three and sepsis in one. Five patients were successfully bridged to heart transplantation after a median duration of mechanical support of 89 days (37 to 168 days) and another is still waiting a suitable organ after 77 days of VAD support. There were no complications related to postoperative bleeding. Five patients required at least one pump change. Of 5 patients undergoing heart transplant, 3 developed an extremely elevated (>60%) panel reactive antibody by enzyme-linked immunosorbent assay, confirmed by Luminex (Luminex Corp, Austin, TX). All 3 experienced at least one acute episode of rejection in the first month after heart transplant, needing plasmapheresis. The survival rate after heart transplantation was 100% with a median follow-up of 7.5 months. CONCLUSIONS: Mechanical support in very small children with end-stage heart failure is an effective strategy of bridge to heart transplantation with a reasonable mortality rate. The high rate of complications suggests to optimize indications and timing of VAD implantation.

Neurally adjusted ventilatory assist and lung transplant in a child: A case report.

OBJECTIVE: To report the successful application of neurally adjusted ventilatory assist to a child with cystic fibrosis who underwent single-lung transplantation. DESIGN: Case report. SETTING: Pediatric cardiac intensive care unit. PATIENT: A 15-yr-old male with cystic fibrosis was admitted to our pediatric cardiac intensive care unit after single-lung transplantation. The child had previously received two bowel resections at the age of 1 yr, right pneumonectomy at the age of 3 yrs, and endoscopic percutaneus gastrostomy at the age of 10 yrs. After transplant, the child failed several attempts of weaning off mechanical ventilation with pressure-support ventilation, due to infection, pneumothorax, and ventilator asynchrony that caused gastric distension and numerous episodes of nausea and vomiting. INTERVENTION: Use of neurally adjusted ventilatory assist to avoid patient-ventilator dyssynchrony and consequent gastric distension. CONCLUSIONS: The utilization of neurally adjusted ventilatory assist allowed to limit the risk of overassistance and prevent patient-ventilator asynchrony and to successfully wean the child off mechanical ventilation after single-lung transplant.

Initial single-center experience with levosimendan infusion for perioperative management of univentricular heart with ductal-dependent systemic circulation.

The aim of this study was to evaluate the safety and the efficacy of levosimendan, a novel calcium sensitizer agent, on postoperative hemodynamic and metabolic parameters of neonates affected by single ventricle anatomy. Twenty consecutive neonates scheduled for the Norwood procedure with Blalock Taussig shunt were prospectively enrolled. All patients received an infusion of levosimendan at 0.1 µg/kg/min commencing 24 hours before surgery, and the infusion was continued for 48 hours after surgery. No side effects (intolerance to the drug, hypotension, arrhythmias) were shown. A median inotropic score (IS) of 37 was necessary to maintain a mean arterial pressure between 45 and 50 mm Hg at intensive care unit (ICU) admission: IS was significantly reduced after 72 hours (P < .05). Brain natriuretic peptide values decreased significantly from 1210 to 459 pg/mL in 72 hours (P < .05). Median SvO2 increased significantly from 38% to 59% during the evaluated period (P < .05). Cerebral near-infrared spectroscopy values were close to 40% at ICU admission with a significant stable increase to 50% after 12 hours (P < .05). Median lactate level was 13 mmol/L at ICU admission but showed a trend to a rapid and significant decrease after 12 hours (P < .05). Median urine output was surprisingly elevated, always remaining between 5.2 and 6.2 mL/kg/h throughout the postoperative period. Survival rate was 85% at 30 days (17/20 patients) and 75% (15/20) at hospital discharge. Levosimendan infusion in a cohort of neonates with univentricular anatomy was safe and potentially beneficial on postoperative hemodynamic and metabolic parameters.

Brain natriuretic peptide is removed by continuous veno-venous hemofiltration in pediatric patients.

We wanted to evaluate if brain natriuretic peptide (BNP) is cleared during continuous veno-venous hemofiltration (CVVH) sessions in children with congenital heart disease. A prospective observational single-center study was conducted in a post-cardiac surgery intensive care unit of the city children's hospital. Ten children requiring CVVH for acute kidney injury following cardiac surgery were enrolled. Seven of them were undergoing postoperative extracorporeal membrane oxygenation. BNP clearance was evaluated by the difference between pre-filter and post-filter BNP blood amount indexed to pre-filter BNP concentration. All CVVH treatments were performed with 0.6 m2 polyacrylonitrile filter, in predilution setting, at a dose of 80 ml/kg/h. Troponin I and myoglobin levels were also measured and CVVH clearances of these markers calculated for comparison with BNP. A significant decrease in post-filter compared with pre-filter levels of BNP was shown in all 10 cases (P<0.01). Median BNP clearance was 35.6 (29-39.3) ml/min. Troponin I and myoglobin levels did not show any significant drop between pre- and post-filter values (P>0.05) and their clearance was significantly lower than BNP (P: 0.0004). A daily analysis of BNP levels showed a significant decrease of its blood concentration. BNP levels were significantly reduced after three and four days from CVVH start (P<0.05). During 80 ml/kg/h CVVH, utilizing polyacrylonitrile membranes, BNP is efficiently cleared from blood in a small cohort of pediatric post-cardiosurgical patients. In this situation, BNP absolute blood levels may be unpredictable.

Fenoldopam in newborn patients undergoing cardiopulmonary bypass: controlled clinical trial.

We determined if low dose fenoldopam in neonates already receiving conventional diuretics improves urine output, fluid balance, acute kidney injury incidence (AKI) and time to extubation. A prospective controlled clinical trial in a pediatric cardiac intensive care unit on 40 neonates undergoing cardiac surgery with cardiopulmonary bypass, excluding simple ventricular septal defect and atrial septal defect. Fenoldopam was infused at a low dose of 0.1 microg/kg/min soon after anesthesia induction and infusion prolonged for 72 h in 20 patients. Twenty neonates with standardized perioperative therapy except fenoldopam administration served as controls. Demographic, hemodynamic, daily urine output, creatinine, creatinine clearance, serum and urinary sodium and potassium were recorded. Inotropic score (IS) was calculated as a surrogate for the degree of hemodynamic impairment. Low dose fenoldopam infusion did not show beneficial effects in renal function. The treatment did not significantly affect IS value, AKI incidence, fluid balance control, time to sternal closure, time to extubation and time to intensive care unit discharge. Low dose fenoldopam in neonates undergoing cardiac surgery with CPB did not produce effects on urine output, fluid balance and AKI incidence. Fenoldopam was well tolerated and did not negatively affect hemodynamics and vasopressor support.

Role of vasopressin in the treatment of anaphylactic shock in a child undergoing surgery for congenital heart disease: a case report.

INTRODUCTION: The incidence of anaphylactic reactions during anesthesia is between 1:5000 and 1:25000 and it is one of the few causes of mortality directly related to general anesthesia. The most important requirements in the treatment of this clinical condition are early diagnosis and maintenance of vital organ perfusion. Epinephrine administration is generally considered as the first line treatment of anaphylactic reactions. However, recently, new pharmacological approaches have been described in the treatment of different forms of vasoplegic shock. CASE PRESENTATION: We describe the case of a child who was undergoing surgery for ventricular septal defect, with an anaphylactic reaction to heparin that was refractory to epinephrine infusion and was effectively treated by low dose vasopressin infusion. CONCLUSION: In case of anaphylactic shock, continuous infusion of low-dose vasopressin might be considered after inadequate response to epinephrine, fluid resuscitation and corticosteroid administration.

Inotropic support and peritoneal dialysis adequacy in neonates after cardiac surgery.

We describe the impact of cardiovascular pharmacologic support on peritoneal dialysis adequacy in 20 neonates who required postoperative renal replacement therapy following cardiopulmonary bypass exposure. Peritoneal dialysis was administered for 2.5 (2) days. Peritoneal dialysis creatinine clearance was 3.4 (2.1) ml/min/1.73 m(2) and ultrafiltration rate was 9.75 (10) ml/h. Residual creatinine clearance was 31 (26) ml/min/1.73 m(2). Peritoneal dialysis creatinine clearance appeared to be a function of dialysate flow up to 100 ml/h. No correlation was present between inotropes and vasopressors infusion and peritoneal dialysis creatinine clearance/ultrafiltration rate. LDH clearance was 0.59 (0.85) ml/min/1.73 m(2) and it did not appear to have a correlation with dialysate flow. Patients in-hospital mortality was 20%, significantly higher than overall neonatal population admitted to our ICU (4.8%, P=0.02). Peritoneal dialysis in neonates allows optimal ultrafiltration rate and adequate small solute clearance, irrespective of hemodynamic status or vasopressor support.

Renal replacement therapy in neonates with congenital heart disease.

BACKGROUND: The acute renal failure (ARF) incidence in pediatric cardiac surgery intensive care unit (ICU) ranges from 5 to 20% of patients. In particular, clinical features of neonatal ARF are mostly represented by fluid retention, anasarca and only slight creatinine increase; this is the reason why medical strategies to prevent and manage ARF have limited efficacy and early optimization of renal replacement therapy (RRT) plays a key role in the outcome of cardiopathic patients. METHODS: Data on neonates admitted to our ICU were prospectively collected over a 6-month period and analysis of patients with ARF analyzed. Indications for RRT were oligoanuria (urine output less than 0.5 ml/kg/h for more than 4 h) and/or a need for additional ultrafiltration in edematous patients despite aggressive diuretic therapy. RESULTS: Incidence of ARF and need for RRT were equivalent and occurred in 10% of admitted neonates. Eleven patients of 12 were treated by peritoneal dialysis (PD) as only RRT strategy. PD allowed ultrafiltration to range between 5 and 20 ml/h with a negative balance of up to 200 ml over 24 h. Creatinine clearance achieved by PD ranged from 2 to 10 ml/min/1.73 m2. We reported a 16% mortality in RRT patients. CONCLUSION: PD is a safe and adequate strategy to support ARF in neonates with congenital heart disease. Fluid balance control is easily optimized by this therapy whereas solute control reaches acceptable levels.