Procalcitonin for the diagnosis of postoperative bacterial infection after adult cardiac surgery: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Patients undergoing cardiac surgery are subject to infectious complications that adversely affect outcomes. Rapid identification is essential for adequate treatment. Procalcitonin (PCT) is a noninvasive blood test that could serve this purpose, however its validity in the cardiac surgery population is still debated. We therefore performed a systematic review and meta-analysis to estimate the accuracy of PCT for the diagnosis of postoperative bacterial infection after cardiac surgery. METHODS: We included studies on adult cardiac surgery patients, providing estimates of test accuracy. Search was performed on PubMed, EmBase and WebOfScience on April 12th, 2023 and rerun on September 15th, 2023, limited to the last 10 years. Study quality was assessed with the QUADAS-2 tool. The pooled measures of performance and diagnostic accuracy, and corresponding 95% Confidence Intervals (CI), were calculated using a bivariate regression model. Due to the variation in reported thresholds, we used a multiple-thresholds within a study random effects model for meta-analysis (diagmeta R-package). RESULTS: Eleven studies were included in the systematic review, and 10 (2984 patients) in the meta-analysis. All studies were single-center with observational design, five of which with retrospective data collection. Quality assessment highlighted various issues, mainly concerning lack of prespecified thresholds for the index test in all studies. Results of bivariate model analysis using multiple thresholds within a study identified the optimal threshold at 3 ng/mL, with a mean sensitivity of 0.67 (0.47-0.82), mean specificity of 0.73 (95% CI 0.65-0.79), and AUC of 0.75 (IC95% 0.29-0.95). Given its importance for practice, we also evaluated PCT's predictive capability. We found that positive predictive value is at most close to 50%, also with a high prevalence (30%), and the negative predictive value was always > 90% when prevalence was < 20%. CONCLUSIONS: These results suggest that PCT may be used to help rule out infection after cardiac surgery. The optimal threshold of 3 ng/mL identified in this work should be confirmed with large, well-designed randomized trials that evaluate the test's impact on health outcomes and on the use of antibiotic therapy. PROSPERO Registration number CRD42023415773. Registered 22 April 2023.

Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review.

Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.

A case of thrombotic thrombocytopenic purpura associated with COVID-19.

Acquired thrombotic thrombocytopenic purpura (TTP) is an autoimmune disease that can be triggered by different events, including viral infections. It presents as thrombotic microangiopathy and can lead to severe complications that often require management in the intensive care unit (ICU). We report a patient who presented with acquired TTP following COVID-19 infection. A 44-year-old woman presented to the emergency department with severe anemia, acute kidney injury and respiratory failure due to COVID-19. Clinical and laboratory findings were suggestive for thrombotic microangiopathy. On day 8 laboratory tests confirmed the diagnosis of acquired TTP. The patient needed 14 plasma exchanges, treatment with steroids, rituximab and caplacizumab and 18 days of mechanical ventilation. She completely recovered and was discharged home on day 51. Acquired TTP can be triggered by different events leading to immune stimulation. COVID-19 has been associated with different inflammatory and auto-immune diseases. Considering the temporal sequence and the lack of other possible causes, we suggest that COVID-19 infection could have been the triggering factor in the development of TTP. Since other similar cases have already been described, possible association between COVID and TTP deserves further investigation.

Perineural catheter infection: a systematic review of the literature.

Perineural catheter infection is a rare but potentially dramatic complication of continuous peripheral nerve block. Different risk factors have been identified and the incidence of infection is increased in trauma victims, intensive care unit patients, immunodeficient individuals, and diabetic patients. Also, postoperative hyperglycemia, the absence of antibiotic prophylaxis, and catheter lasting more than 48 hours seem to be associated with a greater risk of infection. Skin disinfection and a strict aseptic technique during catheter placement are fundamental. The use of micropore filters, antiseptic dressings, catheter tunneling, and aseptic preparation of the infused drug has all been hypothesized to reduce infection rate, but the existing evidence is conflicting. Infection is a rare complication of continuous peripheral nerve blocks. Severe and even fatal cases have been reported, even if morbidity is generally very low. The identification of high risk patients and adoption of preventive measures might reduce the incidence of this complication.

The effect of isoflurane on survival and myocardial infarction: a meta-analysis of randomized controlled studies.

OBJECTIVE: The aim of this meta-analysis was to investigate the cardioprotective properties of isoflurane versus any comparator in terms of the rate of myocardial infarction and all-cause mortality. DESIGN: Pertinent studies were searched independently in Biomed, Central, PubMed, Embase, and the Cochrane Central Register of clinical trials. The primary endpoint was mortality at the longest follow-up available. SETTING: A hospital. PARTICIPANTS: Randomized controlled trials. INTERVENTION: A meta-analysis of 37 trials. MEASUREMENTS AND MAIN RESULTS: The 37 included trials randomized 3,539 patients in cardiac (16 studies) and in noncardiac surgery (21 studies) with noninhalation comparators in 55% of trials. The overall analysis showed no difference in mortality between the isoflurane and control groups (16/1,602 [1.0%] v 23/1,937 [1.2%], odds ratios (OR) = 0.76 [0.39-1.47], p = 0.4 with 37 studies included) and no difference in the rate of myocardial infarction (3/1,312 [0.2%] v 1/1,532 [0.07%], OR = 2.03 [0.27-15.49], p = 0.5 with 30 studies included). Mortality was reduced in the isoflurane group when only studies with a low risk of bias were included in the analyses (0/540 [0%] v 5/703 [0.7%] in the control arm, OR = 0.13 [0.02-0.76], p = 0.02) with 4 cardiac and 6 noncardiac trials included and 5 noninhalation and 5 inhalation agents as the comparator. A trend was noted when a subanalysis was performed with propofol as a comparator (1/544 [0.2%] v 6/546 [1.1%], p = 0.05, with 16 studies included). CONCLUSIONS: Isoflurane reduced mortality in high-quality studies and showed a trend toward a reduction in mortality when it was compared with propofol. No differences in the rates of overall mortality and myocardial infarction were noted.

Validation of a decision-making strategy for systolic anterior motion following mitral valve repair.

Low cardiac output syndrome and hypotension are dreadful consequences of systolic anterior motion (SAM) after a mitral valve (MV) repair. The management of SAM in the operating room remains controversial. We validate a recently suggested two-step management method and classification of this complication. This was a teaching hospital-based observational study. We validated a novel two-step conservative management method, consisting in intravascular volume expansion and discontinuation of inotropic drugs (step 1), and increasing the afterload by ascending aorta manual compression while administering esmolol e.v. (step 2). We also validate a novel classification of SAM: easy-to-revert (responding to step 1), difficult-to-revert (responding to step 2), or persistent. Fifty patients had an easy-to-revert while 26 had a difficult-to-revert SAM; 4 patients had a persistent condition (promptly diagnosed through our decisional algorithm) and underwent an immediate second pump run to repeat the mitral repair surgery. We confirmed that SAM after a repair of a degenerative MV is common and validated a simple two-step conservative management method that allows to clearly identify those few patients who require immediate surgical revision.

Recombinant activated factor VII increases stroke in cardiac surgery: a meta-analysis.

OBJECTIVES: Recombinant activated factor VII (rFVIIa) is used in various surgical procedures to reduce the incidence of major blood loss and the need for re-exploration. Few clinical trials have investigated rFVIIa in cardiac surgery. The authors performed a meta-analysis focusing on the rate of stroke and surgical re-exploration. DESIGN: Meta-analysis. SETTING: Hospitals. PARTICIPANTS: A total of 470 patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four investigators independently searched PubMed and conference proceedings including backward snowballing (ie, scanning of reference of retrieved articles and pertinent reviews) and contacted international experts. A total of 470 patients (254 receiving rFVIIa and 216 controls) from 6 clinical trials (2 randomized, 3 propensity matched, and 1 case matched) were included in the analysis. The use of rFVIIa was associated with an increased rate of stroke (12/254 [4.7%] in the rFVIIa group v 2/216 [0.9%] in the control arm, odds ratio [OR] = 3.69 [1.1-12.38], p = 0.03) with a nonsignificant reduction in rate of surgical re-exploration (13% v 42% [OR = 0.27 (0.04-1.9), p = 0.19]). The authors observed a trend toward an increase of overall perioperative thromboembolic events (19/254 [7.5%] in the rFVIIa group v 10/216 [5.6%] in the control arm [OR = 1.84 (0.82-4.09), p = 0.14]). No difference in the rate of death was observed. CONCLUSIONS: The administration of rFVIIa in cardiac surgery patients could result in a significant increase of stroke with a trend toward a reduction of the need for surgical re-exploration. The authors do not recommend routine use in cardiac surgery patients. rFVIIa may be considered with caution in patients with refractory life-threatening bleeding.

Cardiac index assessment by the pressure recording analytic method in unstable patients with atrial fibrillation.

OBJECTIVE: Most-Care (powered by the pressure-recording analytic method [PRAM]; Vytech HealthTM, Padova, Italy) is a minimally invasive cardiac output monitoring. This system already has been studied and validated in cardiac surgery and in children. It already showed a correlation with thermodilution methods in hemodynamically unstable patients. The purpose of this study was to confirm the reliability of cardiac index determinations by Most-Care in unstable patients with atrial fibrillation. DESIGN: A prospective study. SETTING: A teaching hospital. PARTICIPANTS: Forty-nine patients. INTERVENTIONS: Simultaneous cardiac index measurements by bolus thermodilution and by PRAM from a standard arterial access (radial and femoral) were obtained. The thermodilution cardiac index was calculated as the mean of 3 separate measurements. Because PRAM is a beat-to-beat monitoring system, the mean cardiac index of 12 consecutive beats was considered for the analysis. Correlations were calculated and differences compared by Bland-Altman analysis. MEASUREMENTS: Eight patients were excluded because the signal was altered by the arterial catheter resonance so that the study described the remaining 41 patients. The overall estimates of cardiac index measured by PRAM did not show agreement with the reference cardiac index by thermodilution (mean difference = 0.136 L/min/m(2) [0,43 L/min/m(2)-0.15 L/min/m(2)], with an upper limit of agreement of 1.94 L/min/m(2) and a lower limit of agreement of -1.665 L/min/m(2), respectively). The median (interquartile) value of cardiac index assessed by thermodilution was 2.42 L/min/m(2) (2.21-2.98 L/min/m(2)), and by PRAM it was 2.48 L/min/m(2) (1.80-3.00 L/min/m(2), p = 0.6). CONCLUSIONS: The authors concluded that PRAM did not compare well with thermodilution in unstable patients with atrial fibrillation.

Publication trends in the journal of cardiothoracic and vascular anesthesia: a 10-year analysis.

OBJECTIVE: Good quality clinical research in anesthesiology is now performed all over the world. The aim of this article was to present and analyze the scientific contributions published in the Journal of Cardiothoracic and Vascular Anesthesia and to give a structured view focused on the countries where these studies were performed. DESIGN: Bibliometric analysis. SETTING: Teaching hospital. PARTICIPANTS: None. INTERVENTIONS: The authors analyzed the geographic distribution of the authors publishing in cardiac anesthesia. MEASUREMENTS AND MAIN RESULTS: Data were obtained from the Scopus database. All works belonging to document-type articles, reviews, letters, and editorials published over a 10-year period (2000-2009) in the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) were tracked. For each article, the country of origin of the corresponding author was retrieved. JCVA published 1,816 articles from 45 different countries. The United States accounted for 43.8% of the total, followed by India (8.3%), Germany (5.5%), United Kingdom (4.7%), and Italy (4.4%). CONCLUSIONS: JCVA has a widespread influence and receives contributions from all over the world. More and more biomedical research is conducted outside North America and Europe, with India leading the group of "rest of the world" countries. The recent development of Asian countries clearly challenges North America and European countries that can no longer ignore the scientific contribution from these parts of the world. With this in mind, some journals such as JCVA are giving voice to these prolific countries, which represents a fundamental forum for these newcomers to the field of cardiac anesthesia.