Optimizing Protein Intake and Nitrogen Balance (OPINiB) in Adult Critically Ill Patients: A Study Protocol for a Randomized Controlled Trial.

BACKGROUND: Adequate nutrition of critically ill patients plays a key role in the modulation of metabolic response to stress. OBJECTIVE: This paper presents the development of a protocol for a randomized controlled trial (RCT) aimed at comparing clinical outcomes of patients in the intensive care unit (ICU) administered with standard and protein-fortified diet. Together with the RCT study protocol, the results of the observational analysis conducted to assess the feasibility of the RCT are presented. METHODS: An RCT on adult patients admitted to ICU and undergoing mechanical ventilation in the absence of renal or hepatic failure will be conducted. Patients enrolled will be randomized with an allocation rate of 1:1 at standard diet versus protein-fortified diet. The estimated sample size is 19 per arm, for a total of 38 patients to be randomized. RESULTS: Enrollment began in January 2017. In the feasibility study, 14 patients were enrolled. Protein administration increased significantly (P<.001) over time but was significantly lower compared to that recommended (P<.001). Blood urea nitrogen significantly increased (P<.03) over the period of observation. Such increased catabolism resulted in negative cumulative nitrogen balance (NB) in all patients, and some patients presented with a more negative NB compared to the others. CONCLUSIONS: Results of the feasibility study clearly confirmed that protein provision in ICU patients is below that recommended and that this results in impaired NB. The emerging of an interindividual variability in NB will be further analyzed in the RCT. TRIAL REGISTRATION: ClinicalTrials.gov NCT02990065; https://clinicaltrials.gov/ct2/show/NCT02990065 (Archived by WebCite at http://www.webcitation.org/6prsqZdRM).

Transcatheter aortic valve implantation for degenerative aortic valve regurgitation long after heart transplantation.

Transcatheter aortic valve implantation (TAVI) has become a feasible therapeutic option for the management of high-risk patients with severe degenerative aortic stenosis. Recently it has been extended to high-risk patients with severe aortic regurgitation. Degenerative aortic valve disease is generally uncommon in heart transplant recipients. We report the case of a 75-year-old man in whom severe degenerative aortic regurgitation developed 14 years after heart transplantation (HTx). Because of multiple comorbidities and high surgical risk, TAVI was preferred. A 29-mm CoreValve prosthesis (Medtronic Inc, Minneapolis, MN) was successfully implanted using a transfemoral approach.

Minimally invasive esophagectomy in a previously pneumonectomized patient.

INTRODUCTION: Surgical resection represents the only therapeutic action having a radical intent for the treatment of resectable esophageal neoplasms. Minimally invasive esophagectomy for esophageal cancer is being more and more frequently performed. Few cases of esophagectomy after pneumonectomy have been described in the literature, and, to our knowledge, none of them was performed by the minimally invasive technique. SUBJECT AND METHODS: A 77-year-old woman, who had undergone left thoracotomic pneumonectomy due to squamous cell lung cancer 2 years before, underwent minimally invasive esophagectomy because of esophageal cancer at the authors' institution. The intervention was performed by right thoracoscopic esophageal mobilization with the patient in the prone position, followed by the laparoscopic and cervicotomic stages, with cervical anastomosis. RESULTS: Total operative time was 230 minutes. Intensive care unit stay was 1 day, followed by a hospital stay of 13 days. We did not observe any major postoperative complication. CONCLUSIONS: Minimally invasive esophagectomy with thoracoscopic esophageal mobilization in the prone position is a valid option in the treatment of esophageal cancer and may be feasible in previously left pneumonectomized patients.

Prognostic power of pre- and postoperative B-type natriuretic peptide levels in patients undergoing abdominal aortic surgery.

OBJECTIVES: The first aim of the present study was to evaluate the pre- and postoperative B-type natriuretic peptide (BNP) levels in patients undergoing surgery for repair of an infrarenal abdominal aortic aneurysm (AAA) and analyze their power as a predictor of in-hospital cardiac events. The second aim was to evaluate the association among pre- and postoperative BNP levels, postoperative patient complications, and length of hospital stay. DESIGN: Prospective observational study. SETTING: A university hospital. PARTICIPANTS: Forty-five patients undergoing elective surgery for an abdominal aortic aneurysm. INTERVENTIONS: The plasma BNP level was assessed just before surgery and then on postoperative day 1. Cardiac troponin I levels were measured postoperatively on arrival to the intensive care unit (time 0) and then 12, 48, and 72 hours later. MEASUREMENTS AND MAIN RESULTS: The preoperative BNP concentration in patients who developed an acute myocardial infarction was 209 (IQR 84-346) pg/mL compared with 74 (IQR 28-142) pg/mL in those who did not. The difference between groups was statistically significant (p = 0.04). The Spearman correlation showed that postoperative BNP levels correlated significantly with preoperative BNP levels (r = 0.73, p = 0.0001), length of hospital stay (r = 0.35, p = 0.04), and troponin I concentration at 0 hour (r = 0.42, p = 0.02), 12 hours (r = 0.51, p = 0.0052), and 48 hours (r = 0.40, p = 0.033). In contrast, preoperative BNP levels correlated with troponin I at only 12 hours (r = 0.34, p = 0.02). Postoperative BNP levels were influenced significantly by transfusions (p = 0.035) and cross-clamping times (p = 0.038). CONCLUSIONS: The present results confirm the high negative predictive value of preoperative BNP levels; and postoperative BNP levels showed a better correlation with postoperative troponin levels, blood transfusion, and postoperative cardiac events.

Mid-term clinical outcomes in cardiac surgery of Jehovah's witnesses.

INTRODUCTION: Surgical treatment of Jehovah's witnesses is a special challenge for cardiac surgery. The purpose of this study was to evaluate perioperative management and mid-term clinical outcome of Jehovah's witnesses who underwent cardiac surgery. METHODS: Between January 1990 and June 2009, 34 Jehovah's witnesses (22 men, mean age 66 +/- 8 years) underwent cardiac surgery. Surgical procedures included 17 coronary artery bypass grafts (CABG): 3 CABG and aortic valve replacements (AVR); 1 CABG and mitral valve plasty (MVP); 6 AVR; 1 subaortic membrane resection; 2 mitral valve replacements (MVR) and 2 MVP; 1 mitro-aortic valve replacement; and 1 cardiac foreign body removal. There were four urgent operations; 14 patients had NYHA class II-III. Sixteen patients received erythropoietin preoperatively. Preoperative haemoglobin (Hb) value was 14.2 +/- 1.4 g/dl. RESULTS: Extracorporeal circulation time was 127 +/- 66 min, aortic cross-clamping 84 +/- 45 min. Haemoglobin value 24 h after surgery was 11.2 +/- 1.7 g/dl, haematocrit 34.1 +/- 5.2%. None required surgical reoperation for bleeding.Intensive care unit stay was 2.3 +/- 4.3 days, hospital stay 12.3 +/- 10.4 days; there was no hospital mortality. Postoperatively, erythropoietin was administered to 19 patients. Follow-up was completed in 100%. Reoperation was necessary 8 years later in one patient for mitral bioprosthesis degeneration; the patient died 8 months later. All other patients are alive 59 +/- 60 months after surgery; actuarial survival is 100% and 80 +/- 2% at 5 and 10 years, respectively. CONCLUSION: In our limited experience, early and late surgical results of Jehovah's witnesses patients are satisfactory. Appropriate preoperative management, optimization of Hb values, intraoperative measures to reduce the risk of bleeding and total blood loss recovery are the goals to achieve these results.