Background:The COVID-19 pandemic and subsequent social distancing measures have disrupted various aspects of child development, with particular concern for infants in neonatal intensive care units (NICUs), where heightened vulnerabilities and limited external stimuli may exacerbate neurodevelopmental risks.Objective:The objective of this study was to examine the impact of the COVID-19 pandemic on neurodevelopmental outcomes in infants admitted to NICUs at birth, comparing neurodevelopmental indicators from before and during the pandemic period.Materials and Methods:A retrospected matched cohort study was conducted on infants admitted to NICUs at birth during the COVID-19 pandemic, with neurodevelopmental evaluations carried out at 6 and 12 months of age. Neurodevelopmental outcomes were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III, 2006).Results:From September 2020 to December 2021, a total of 114 infants were consecutively enrolled in the study, with a matched control group selected. Analyses revealed no significant differences in Bayley-III scores between infants in the pandemic group and those in the control group.Conclusion:Short-term neurodevelopmental outcomes for NICU infants were unexpectedly unaffected by the additional stress of pandemic-related restrictions.

BACKGROUND:Admission to the neonatal intensive care unit (NICU) is a challenging experience for parents. The use of narrative diaries could be a helpful support strategy to reduce psychological complications. AIM:To describe feasibility in terms of acceptability, demand and implementation of a narrative diary in the NICU and explore parents' and healthcare providers' (HCPs) perceptions and attitudes on its use. STUDY DESIGN:Prospective feasibility study using quantitative and qualitative approaches was conducted in a NICU at a tertiary care children's hospital in Italy. Participants are newborns admitted to the NICU, their families and HCPs. The narrative NICU diary intervention was assessed in terms of adherence, type of entries and perceptions on satisfaction, usability and usefulness. RESULTS:Twenty-three parents of critically ill newborns participated in this study between January 2024 and July 2025. The median length of NICU stay was 38 days (IQR: 27-48). Sixteen caregivers were mothers (84%). A total of 581, entries were collected in 21 diaries, with a median of 22 (IQR: 12-38) entries per diary and a median NICU diary duration of 30 (IQR: 20-51) days per family. Parents contributed at least once a day in 350/951 diary-days (37%), while HCPs contributed in 49/951 diary-days (5%). At 1-month follow-up after NICU discharge, 19 (83%) parents reported high levels of satisfaction and usefulness on a 1-10 Likert Scale (LS) with the diary for themselves and their newborn (LS = 9; IQR: 8-10). At the end of the study, 17 (24%) NICU HCPs reported greater usefulness of the diary for parents (LS = 9; IQR: 7-10) than for themselves (LS = 7; IQR: 5-9). CONCLUSIONS:The implementation of a narrative NICU diary was feasible and perceived as beneficial by both parents and HCPs. RELEVANCE TO CLINICAL PRACTICE:The use of a narrative NICU diary may support parents and prevent the family post-intensive care syndrome (PICS-f). Strategies are needed to promote diary writing by HCPs.

BACKGROUND:An infant's admission into the Neonatal Intensive Care Unit (NICU) disrupts the normal transition to parenthood due to the separation. Non-narrative diaries are structured tools that record predefined information and activities. Their use could facilitate parent-infant closeness, while also serving as a data collection tool for clinical research. AIM:To explore the use of non-narrative diaries in NICU in terms of definitions, formats, recorded variables and the identity of the diarist. STUDY DESIGN:A scoping review was conducted following the Joanna Briggs Institute (JBI) methodology. The search strategy was conducted consulting PubMed, Embase, Scopus, PsycInfo, CINAHL and Grey Literature up to March 2025. Studies reporting on the use of non-narrative diaries in the NICU were included. Descriptive and thematic analyses were performed. RESULTS:Of the initial 538 initial records, 18 were included. Most studies had an observational design (88%); one included a validation process of a diary. Parents (50%) were the most common diarists, in particular mothers (33%). Parental presence (72.2%) was the most documented variable in the diary, followed by skin-to-skin contact (66.6%) and holding (33.3%). Only seven studies used a validated tool called 'the parent-infant closeness diary'. Non-narrative diaries were adaptable for collecting diverse quantitative and semi-structured data, including behavioural, emotional, organisational, well-being and breastfeeding outcomes. CONCLUSIONS:Non-narrative diaries show promise as versatile, user-friendly tools both for research and family-centred care in NICU settings. Future studies should aim for greater methodological rigor and broader stakeholder involvement. RELEVANCE TO CLINICAL PRACTICE:Non-narrative diaries offer a practical and low-cost method for documenting parent-infant interactions in the NICU.

AIM:To describe and categorize the thematic content emerging from narrative diaries in Neonatal Intensive Care Unit (NICU) written by parents and healthcare providers. METHODS:A qualitative study of NICU diary writings, provided for a feasibility study, was conducted at a tertiary-care hospital in Central Italy. Parents of neonates admitted to a 22-bed NICU, who underwent intubation and sedation for at least 48 h, were enrolled. Parents, relatives, visitors, and healthcare professionals were invited to write about their experiences, emotions, reflections, along with drawings, or photographs in the NICU narrative diary during the hospitalization. Narrative data were analyzed using thematic analysis following Braun and Clarke's approach. FINDINGS:Twenty-one NICU narrative diaries were collected between January 2024 and January 2025. Each diary contained a median of 22 entries (IQR = 12-28), and the majority of which were written by mothers (91%). Thematic analysis of diaries revealed 15 subthemes, which were then categorized into three overarching themes: 1) the NICU journey, reporting the newborn's clinical course and development, the first-time experience, the NICU environment, and parents' involvement in care; 2) parenthood, encompassing emotions, parental identity, bonding and separation, partner mutual support, and relationships with siblings; and 3) resilience and coping, highlighting narratives of communicating with the newborn, gratitude, support from relatives and peers, spirituality and the role of the narrative diary. CONCLUSIONS:NICU narrative diaries provide valuable insight into the clinical, emotional, and relational dimensions of the NICU experience. Clear communication, recognition of meaningful moments, and structured opportunities for parental participation and narrative expression may foster bonding, resilience, and overall quality of care. IMPLICATIONS FOR CLINICAL PRACTICE:NICU narrative diaries promote a more humane and participatory care environment by supporting parental involvement, caregiver emotional well-being, and a relationship-oriented care culture.

Anorectal malformations (ARM) and Hirschsprung disease (HD) pose challenges not only in diagnosis and treatment but also in the psychological well-being of patients and their families. This study aims to report our single-center experience with psychological follow-up in these populations. We conducted an observational, retrospective study by reviewing the clinical records of patients enrolled in our dedicated follow-up program who were born between 2009 and 2018. Neurodevelopmental assessments were performed during the first year of life, and psychological evaluations were conducted during childhood (ages 6–10) and adolescence (ages 13–18). The study included 167 patients (101 with ARM, 66 with HD). A total of 120 patients underwent neurodevelopmental assessment at a median age of 11 months, yielding the following results (mean ± SD): cognitive: 105.4 ± 10.8; motor: 96.3 ± 9.5; language: 97.3 ± 9.2. Psychological follow-up was conducted in 139 children and 26 adolescents, with 35.3

BACKGROUND:Premature birth and the Neonatal Intensive Care Unit (NICU) experience can be challenging for parents, affecting their psychological and emotional well-being. NICU diaries could help to reduce the separation gap and strengthen the bonding process with their infant. AIM:To review the literature on narrative diaries, definitions and use in the NICU. STUDY DESIGN:We conducted a scoping review following the Joanna Briggs Institute (JBI) methodology. We searched PubMed, Embase, Scopus, PsycINFO, Cinahl, and Grey Literature up to September 2024. Studies reporting on the use or effect of narrative diaries in the NICU were included. A descriptive and thematic analysis was conducted. RESULTS:Of a total of 526 records, 21 were included. Most studies had a quasi-experimental or qualitative design, including a framework conceptualization. Editorials were common. Mothers (33%), nurses (9%) and fathers (5%) were the most common diarists. Seven studies evaluated the effect of NICU diaries on family post-intensive care syndrome (PICS-F), satisfaction, and family separation. The benefits of NICU diaries for parents included improved communication, empowerment, personal emotional awareness and parental closeness with their newborn, while for staff, they reduced burnout and fostered the humanization of care. Acceptability was high. CONCLUSIONS:Acceptability and perceived benefits of NICU diaries were widely reported. Heterogeneity in aims, use, and follow-up was high. Well-designed effective multicentre studies providing evidence of impact on PICS-F and a position statement framing the intervention in NICU are recommended. RELEVANCE TO CLINICAL PRACTICE:This study has shown that NICU diaries have the potential to improve humanization, communication between NICU staff and parents, parents' coping, and closeness to their newborn.

STUDY OBJECTIVE:Postoperative sore throat (POST) and hoarseness are common complications of tracheal intubation. This study aims to evaluate the efficacy of flurbiprofen administered through the subglottic port of tracheal tubes to prevent POST after cardiac surgery. DESIGN:Single-center, prospective, randomized, double-blind, placebo-controlled trial. SETTING:Tertiary Care Referral University Hospital (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome). PATIENTS:Included 71 patients undergoing for elective cardiac surgery. Inclusion criteria were (a) age between 50 and 75 years, (b) NYHA class I or II, (c) surgery for myocardial revascularization or valve repair or replacement under cardiopulmonary bypass. INTERVENTION:Patients were double blind randomized to receive flurbiprofen or saline in the subglottic port of the endotracheal tube (groups F and P). The solution was injected ten minutes after tracheal tube placement, ten minutes after ICU admission and ten minutes before tracheal tube removal. MEASUREMENTS:The primary outcome was to assess the effect of topical flurbiprofen administered through the subglottic port of the tracheal tube to prevent post-operative sore throat (POST). The secondary outcomes were the presence of hoarseness safety and patient's subjective satisfaction with their recovery. We did not report any exploratory outcomes. MAIN RESULTS:We analyzed 68 patients, 34 patients in each group. In group F, two patients complained of POST and hoarseness (5.9%), while all controls did. The two groups significantly differed in the severity scores (VAS and TPS for sore throat and HOAR for hoarseness) at all time points. In group P, patients reported mild to moderate symptoms that significantly improved or disappeared 36 h after tracheal tube removal. According to the multivariable model, hoarseness affected women less than men, in the control group (p = 0.002). None of the patients in either group reported any adverse effects. CONCLUSIONS:Repeated administration of flurbiprofen through the subglottic port of tracheal tubes reduced the incidence of sore throat and hoarseness after cardiac surgery without evidence of complications.

Parents are the main contributor to the development of children's sleep patterns. Familial disorders and parental difficulties could represent a risk factor for children's sleep onset and maintenance, interfering with their emotional self-regulation strategies. This study investigated whether aspects of parental post-partum depression, agreement between parental perceptions of co-parenting quality, and infants' at-risk health conditions, explain infants' longest continuous sleep bouts reported by parents. We enrolled 95 Italian families (33 had children with congenital anomalies) with children aged 8-12 months. A significant effect of post-partum depressive dimensions emerged. Moreover, parental similarities in co-parenting quality moderated the relationship between post-partum depressive dimensions and infants' sleep in both families with healthy and at-risk children. Our results will deepen our understanding of the risks and protective factors related to children's sleep for families, healthcare providers, and the general public.

PURPOSE:Caudal regression syndrome (CRS) is a rare congenital abnormality including orthopedic deformities, urological, anorectal, and cardiac malformations. The clinical spectrum of CRS varies in severity, therefore multiple surgeries and complex medical care may be required with the efforts and support of a multidisciplinary team to ensure the most accurate treatment and the best outcome. The aim of our retrospective study was to evaluate the role of a multidisciplinary treatment and the long-term outcome in patients with severe CRS.METHODS:Clinical, surgical and psychological data were collected for all patients with diagnosis of CRS, treated at our Pediatric Hospital from January 1995 to December 2020. Patients with a severe form of CRS according to Pang's classification were included in the study. All patients have been followed by a multidisciplinary team composed by urologists, neurosurgeons, neonatal and digestive surgeons, orthopedic surgeon, physiatrists and psychologists. On admission, patients were screened for CRS with sacrum, spine and legs X-ray, spine MRI, renal ultrasound, voiding cystography and urodynamic, and renography. Clinical data about bowel function were evaluated.RESULTS:During the study period, 55 patients with CRS were treated at our Institution. Six out of 55 (10.9%), presented with severe form of CRS (5 pts with type 1; 1 pt, with type 2) and represent our study group. Diagnosis of severe CRS was made at birth because of the typical deformities of the pelvis (fusion of the iliac wings), and of the lower extremities (undeveloped legs with flexion of the knees, clubfoot). All patients presented with neurogenic bladder, 4/6 (66.6%) with vesicoureteral reflux (VUR) and 2/6 (33.3%) with renal agenesia and contralateral ectopic hypoplastic kidney. Bowel symptoms occurred in 5/6 pts (83.3%). All patients were started with an earlier clean intermittent catheterization (CIC) regimen. In 3 patients oxybutynin has been effective or well tolerated, while in other 3 onabotulinumtoxin A has been used. Vesicoureteral reimplantation has been performed in 1 patient, 2 required endoscopic treatment of VUR. On long-term, 2 patients required bladder augmentation with ileum and appendicostomy (Mitrofanoff). Low adherences in CIC have been observed in three patients, mainly at puberty. Two patients presented with chronic renal failure. One patient reported suicide proposal. Regarding social life, only one is regularly performing sport activity.CONCLUSION:CRS is characterized by maldevelopment of the caudal half of the body with variable involvement of the gastrointestinal, genitourinary, skeletal, and nervous systems. Management of CRS includes a wide variety of interventions to address the full spectrum of possible anatomical abnormalities. Hence, a multidisciplinary team is also mandatory for a correct bladder and bowel management, in order to maintain continence and preserve renal function, improve quality of life and increase self-esteem.

Purpose Urethral duplication (UD) is a rare malformation, which can be associated with other anomalies, like anorectal malformations (ARM). ARM has been described with occult spinal dysraphism (OSD). No ARM-UD-OSD combination has been reported. Aim To share our experience and to discuss the management of ARM-UD-OSD association. Methods We retrospectively reviewed records of five boys with UD. Four of these had ARM-UD-OSD association. ARM was the first diagnosis in all; OSD and UD was detected during screening for associated malformation. Results All patients underwent ARM correction, 3 after colostomy. All reached fecal continence, 3 are performing bowel management. Three patients underwent UD surgical correction. Because of symptoms' worsening, 2 children had detethering surgery. At a mean follow-up of 9.5 years, all patients have normal renal function, 3 are on clean intermittent catheterization (CIC) for neurogenic bladder (1 has a cystostomy, another one an appendicostomy). Conclusions UD and OSD should be considered in patients with ARM. Children with these conditions associated must be centralized in a third-level Center and management carefully planned; in particular, urethral reconstruction should be weighed, considering CIC could be required. Suspicion of neurogenic bladder must be present in OSD patient.

Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.

Background: Iron deficiency (ID), with or without anemia, is commonly observed among patients scheduled for cardiac surgery. We investigated if screening ID in the immediate preoperative period and treating ID patients regardless of anemia could reduce perioperative transfusion requirements.Methods: This is an observational single-center propensity score-matched study including candidates to elective cardiac surgery prospectively and retrospectively enrolled. Prospectively enrolled patients were screened for ID at hospital admission: if ferritin was < 100 mu g/L or < 300 mu g/L with transferrin saturation index & LE;20% they received intravenous ferric carboxymaltose, B12-vitamin, and folic acid. A retrospective series of patients not screened for ID and matched for gender, type of surgery, BMI, Goudie transfusion risk score, hemoglobin level, and red blood cell (RBC) indices, served as controls. The primary outcome was the proportion of patients requiring < 1 packed RBC (pRBC) unit within day 7 or discharge The main secondary outcomes were intra-operative and postoperative pRBC transfusions, duration of hospitalization, and cost-effectiveness of ID screening and treatment.Results: We included 479 prospective and 833 retrospective cases: 442 patients screened for ID and 442 matched controls with unknown iron status were analyzed. ID was observed in 196 patients (44.3%) and iron was administered 1 day (IQR 1-2) before surgery. Overall, 76.9% of patients in the prospective group and 69.7% of controls received < 1 pRBC transfusion (p = 0.014). The risk for multiple transfusions was lower in patients screened for ID (OR 0.689, 95% CI 0.510-0.930). Despite similar Hb levels at day 7, patients in the prospective group received fewer postoperative pRBC transfusions (p < 0.001) and had a shorter hospital length of stay (p < 0.001). Globally, hospitalization costs were lower in patients screened and treated for ID.Conclusions: Short-term pre-operative iron therapy is associated with a reduction in postoperative transfusions in anemic and non-anemic ID cardiac surgery patients and has a favorable impact on hospitalization costs. Clinical trial registration: NCT04744181

In patients affected by CDH, survival beyond the neonatal period continues to increase thanks to technological and pharmacological improvements. Conversely, patients, families and caregivers are more and more frequently facing "new" complex late comorbidities, including chronic pulmonary and cardiac dysfunctions, neurodevelopmental challenges, and specific nutritional requirements, that often require ongoing long-term medical or surgical care. Therefore, late morbidity is now a key focus in clinical care of CDH. The aims of this paper are to stress some of the most important "unsolved problems" for CDH patients at long-term follow-up.

The dopaminergic control of respiration in conscious and urethane-anaesthetized rabbits, was studied by comparing the respiratory effects of 4-aminopyridine alone (4-AP; 1 mg/kg i.v.) and those after the administration of dopamine antagonists (domperidone and haloperidol; 1 mg/kg each). The respiratory rate in conscious rabbits was increased by 4-AP. After domperidone this increase was reduced and preceded by a transient decrease. In spontaneously breathing, anesthetized rabbits there was a transient reduction after which the respiratory rate was increased by 4-AP; tidal volume was affected in an inverse manner. After domperidone, the excitatory effect of 4-AP on respiratory rate and the inhibitory effect on tidal volume were blocked. The effects of 4-AP on respiratory rate were prevented by vagotomy. In anesthetized, vagotomized, paralyzed and artificially ventilated rabbits (VPV animals) the peak amplitude of the integrated phrenic nerve activity ("phrenic activity') was increased by 4-AP. After pretreatment with haloperidol this effect of 4-AP on phrenic activity was reduced while the respiratory rate was now increased. In VPV animals with denervated carotid bodies the excitatory effect of 4-AP on phrenic activity was strongly enhanced and respiratory rate was increased. These effects were slightly reduced but not blocked by haloperidol. It is concluded that endogenous dopamine is involved in the control of respiration through effects on peripheral mechanisms (inhibition of inspiratory activity and enhancement of respiratory rate) as well as on central mechanisms (stimulation of inspiratory activity and reduction of respiratory rate).

Background: Pediatric medical traumatic stress (PMTS) is a psychological and physiological response of children and their families to pain, serious illness, and invasive medical procedures. We aimed to apply the PMTS model to parents of newborns operated at birth for a congenital malformation and to identify clinical and sociodemographic risk factors associated with PMTS symptoms at 6 months. Methods: We designed a cross-sectional study to assess PMTS symptoms (avoidance, arousal, reexperiencing) in parents of six months children operated on for a congenital anomaly, with the Italian version of the Impact of Event Scale - Revised (IES-R). Results: One-hundred-seventy parents form the object of the study. Eighty-two parents (48.2%) fell over the clinical cut-off. Ventilatory time (p = 0.0001), length of hospital stay (p = 0.0001). associated anomalies (p = 0.0002 ), medical devices at discharge (p = 0.0001) and Bayley motor scale (p = 0.0002) were significantly correlated with IES-R Total and Subscale Scores. Multivariate linear regression showed length of hospital stay and number of associated anomalies as significant predictors of IES-R Scores. Conclusions: Regardless the type of anomaly and sociodemographic factors, it is the clinical history of the child which seems to predict the severity of PMTS symptoms in this population of parents. PMTS represents a useful model to describe the psychological reactions of parents of newborns operated at birth for a congenital malformation. NICU and outpatient pediatric staff should be aware of risk factors to identify families who may request early multidisciplinary interventions since the first admission. (C) 2020 Elsevier Inc. All rights reserved.

Abstract Background Congenital heart disease (CHD) accounts for nearly a third of all major congenital anomalies. Advances in pediatric cardiology shifted attention from mortality to morbidity and health-related quality of life (HRQOL) of patients with CHD and impact on their families. The purposes of this study were to assess the validity and reliability of the Italian version of the Pediatric Quality of Life (PedsQL) Cardiac Module and to create normative data for the Italian population. Methods This was an observational cross-sectional study of pediatric patients (aged 2–18 years) with congenital or acquired Heart Disease (HD) and their parents. Families were asked to complete the cardiac pediatric health-related quality of life questionnaire (the Italian PedsQL™ 3.0 Cardiac Module) and the generic pediatric health-related quality of life questionnaire (PedsQL™ 4.0 Generic Core Scales). The sequential validation procedure of the original United States version of the PedsQL™ 3.0 Cardiac Module was carried out under the instruction of the MAPI Research Institute. To assess construct validity, Pearson’s correlation coefficients were assessed between scores on the Cardiac Module scales and scores on the scales of the General Module. To determine agreement between patient self-report and parent proxy-report, we used intraclass correlation coefficients (ICCs). To evaluate Internal consistency of items, we used Cronbach’s alpha Coefficient. Results The study enrolled 400 patients. Construct validity is good between PedsQL Cardiac Module total scores and PedsQL total scores (p < 0.001). The recommended standard value of 0.7 was reached on the Cardiac and General Module core scales. Intercorrelations between PedsQL Cardiac module and PedsQL scores revealed medium to large correlations. In general, correlations between Patient self-reports are poorer than Parent-proxy ones. Conclusions Cardiac PedsQL scores are valid and reliable for pediatric patients with congenital and acquired HD and may be useful for future research and clinical management.

Editor—Carbon dioxide partial pressure (Pco2) and oxygen saturation (So2) in venous blood are informative measures of tissue perfusion and oxygenation.1Gutierrez G. Central and mixed venous O2 saturation.Turk J Anaesthesiol Reanim. 2020; 48: 2-10Crossref PubMed Scopus (2) Google Scholar,2van Beest P.A. Lont M.C. Holman N.D. Loef B. Kuiper M.A. Boerma E.C. Central venous-arterial pCO2 difference as a tool in resuscitation of septic patients.Intensive Care Med. 2013; 39: 1034-1039Crossref PubMed Scopus (64) Google Scholar Mixed venous blood collected from the pulmonary artery (PA) is representative of whole-body perfusion, but is usually unavailable. Blood samples from central venous catheters (CVCs) are often used as a surrogate, but may differ from PA-derived values significantly in Pco2 and So2.3Dubin A. Pozo M.O. Kanoore Edul V.S. Vazquez A.R. Enrico C. Poor agreement in the calculation of venoarterial PCO2 to arteriovenous O2 content difference ratio using central and mixed venous blood samples in septic patients.J Crit Care. 2018; 48: 445-450Crossref PubMed Scopus (11) Google Scholar Differences likely reflect the composition of CVC blood, which may derive disproportionately from the two venae cavae, coronary sinus, and azygos vein.4Cavaliere F. Zamparelli R. Martinelli L. et al.Blood from the right atrium may provide closer estimates of mixed venous saturation than blood from the superior vena cava. A pilot study.Minerva Anestesiol. 2014; 80: 11-18PubMed Google Scholar,5Cavaliere F. Antoniucci M.E. Arlotta G. et al.Is the pCO2 gap obtained from the superior vena cava in agreement with that from the pulmonary artery?.Minerva Anestesiol. 2019; 85: 1308-1314Crossref PubMed Scopus (3) Google Scholar This suggests that the superior and inferior venae cavae, which provide most PA blood, may differ substantially in Pco2 and So2 values. We hypothesised that differences between blood from the superior vena cava (SVC) and the PA are not random, but reflect the values in the SVC territory (i.e. the portion of venous flow from above the diaphragm except for the heart). If this hypothesis were correct, Pco2 and So2 should be assessed in blood drawn from the right atrium and not from the SVC. This study (ClinicalTrials.gov identifier: NCT03591029) compared Pco2 and So2 values in the left brachiocephalic vein (LBV) and the PA. After approval by the local ethics committee, we enrolled and obtained written informed consent from 50 adult patients scheduled for either myocardial revascularisation or valve replacement/repair with cardiopulmonary bypass. All patients had arterial, central venous, and PA catheters, the last two into the left internal jugular vein. Central venous catheters were advanced until proximal ports were about 3 cm below the origin of the LBV (usually 6 cm long); the position was verified with ultrasound by visualising agitated saline microbubbles. We collected blood samples from the radial artery, PA, and proximal CVC port (LBV): (i) after positioning the catheters, (ii) 10 min after sternotomy, (iii) 10 min after weaning from cardiopulmonary bypass, (iv) 30 min after arrival in the ICU, (v) postoperative Day 1 (POD 1), and (vi) POD 2. We measured Pco2 and So2 values with a Stat Profile® pHOx® Ultra Analyzer (Nova Biomedical, city, USA). Sequential Organ Failure Assessment difference (ΔSOFA) between POD 2 and baseline was considered high if it is ≥2. We reported values as mean (standard deviation [sd]), and analysed Pco2 and So2 values with two-way analysis of variance (anova) and arterial–venous differences with mixed factorial anova. Sampling site and blood collection time were within-subjects variables, and high or low ΔSOFA was a between-subjects variable. Based on a previous study, 44 patients were needed to measure a Pco2 difference >0.35 kPa (effect size: 0.50; α=0.05; β=0.10) using a paired Student's t-test, as a conservative estimate, given the uncertainty of the variance–covariance matrix structure. We enrolled 50 patients, mean 65.7 (40–81) yr old, 64% male; 24 underwent myocardial revascularisation and 26 underwent valve replacement/repair. The SOFA score was 1(0, 1) before surgery and 2(2, 4) on POD 2, with 22 patients presenting with a high ΔSOFA. The Pco2(LBV) was significantly higher than Pco2(PA) at all times of the study (anova: P<0.0001; Student–Newman–Keuls test: P<0.0001); the mean difference was 0.36 (0.35) kPa (95% limits of agreement: –1.10 and 1.15 kPa). Arterial–venous difference analysis included ΔSOFA, which was significant (interaction ΔSOFA-SITE: P=0.039) (Fig. 1a and b). Indeed, Pco2(LBV-ART) did not differ between patients with low or high ΔSOFA, whilst Pco2(PA-ART) was higher in patients with high ΔSOFA. The So2(LBV) did not differ from So2(PA), P=0.31, but was poorly informative of it (mean difference: 0.5%; 95% limits of agreement: –11.8% and 12.8%). Arterial–venous differences were affected by ΔSOFA (interaction ΔSOFA-SITE: P<0.0001 (Fig. 1c and d). As for Pco2, So2(ART-LBV) did not differ between patients with low or high ΔSOFA, whilst So2(ART-PA) was larger in patients with high ΔSOFA. Our results confirmed that Pco2 and So2 differences between LBV and PA blood were not random but systematic. Other authors have stated that CVC blood was not an acceptable substitute for PA blood1Gutierrez G. Central and mixed venous O2 saturation.Turk J Anaesthesiol Reanim. 2020; 48: 2-10Crossref PubMed Scopus (2) Google Scholar,3Dubin A. Pozo M.O. Kanoore Edul V.S. Vazquez A.R. Enrico C. Poor agreement in the calculation of venoarterial PCO2 to arteriovenous O2 content difference ratio using central and mixed venous blood samples in septic patients.J Crit Care. 2018; 48: 445-450Crossref PubMed Scopus (11) Google Scholar; our study adds that differences might reflect dissimilarities in tissue perfusion when CVC blood derives exclusively from the SVC. From a clinical perspective, an average Pco2 gradient of >0.36 kPa between LBV and PA blood is significant, as venous-arterial differences >0.8 kPa have been associated with tissue hypoperfusion and increased mortality. High Pco2 levels in LBV blood probably mirror those in the cerebral vasculature. In a study of healthy subjects, the Pco2 value in blood from the jugular venous sinus was ∼6.7 kPa, and the venous-arterial difference is ∼1.3 kPa.6Peebles K. Celi L. McGrattan K. Thomas K. Ainslieet P.N. Human cerebrovascular and ventilatory CO2 reactivity to end-tidal, arterial and internal jugular vein PCO2.J Physiol. 2007; 584: 347-357Crossref PubMed Scopus (113) Google Scholar We also found that Pco2 and So2 arterial–venous differences increased in high ΔSOFA patients, but only in PA blood and not in LBV blood. These patients likely experienced tissue hypoperfusion because ΔSOFA effectively reflects the degree of organ dysfunction over time.7Lambden S. Laterre P.F. Levy M.M. Francois B. The SOFA score—development, utility and challenges of accurate assessment in clinical trials.Crit Care. 2019; 23: 374Crossref PubMed Scopus (138) Google Scholar Hypothetically, differences between PA and LBV blood might reveal renal and splanchnic hypoperfusion. Ho and colleagues8Ho K.M. Harding R. Chamberlain J. A comparison of central venous-arterial and mixed venous-arterial carbon dioxide tension gradient in circulatory failure.Anaesth Intensive Care. 2007; 35: 695-701Crossref PubMed Google Scholar reported a negative correlation between the cardiac output and So2 difference between central and mixed venous blood in patients affected by circulatory failure. However, Pco2 and So2 of the LBV mainly reflect cerebral blood flow, with the brain receiving 20% of the cardiac output while the entire compartment drained by the SVC receives 35%. Pco2 and So2 values of LBV blood were less affected by moderate low cardiac output states, which do not seriously impair cerebral perfusion.9Mohiaddin R.H. Wann S.L. Underwood R. Duranteau J. Vena caval flow: assessment with cine MR velocity mapping.Radiology. 1990; 177: 537-541Crossref PubMed Scopus (98) Google Scholar,10Torbey M.T. Bhardwaj A. Cerebral blood flow physiology and monitoring.in: Suarez J.I. Critical care Neurology and neurosurgery. Current clinical neurology. Humana Press, Totowa, NJ2004: 23-35Crossref Google Scholar The main limitations of this study were the inability to measure Pco2 and So2 in the inferior vena cava and coronary sinus, and the assumption that Pco2 and So2 values were equal in left and right brachiocephalic veins. In conclusion, CVC blood should be collected from the right atrium to provide information on the whole-body perfusion, including renal and splanchnic areas. Further studies are needed to investigate whether any useful information can be obtained by analysing LBV blood and, in general, SVC blood, which may be mainly representative of cerebral perfusion. The authors declare that they have no conflicts of interest.

Data on neurodevelopmental outcomes of infants born with esophageal atresia (EA) are still scarce and controversial. The aims of our study were to evaluate motor and cognitive development during the first year of life, in patients operated on of EA and to investigate potential risk factors for motor and cognitive development both at 6 and 12 months. This is an observational prospective longitudinal study in a selected cohort of type C and D EA infants enrolled in our follow-up program from 2009 to 2017. In order to exclude possible confounding factors, the following exclusion criteria were applied: (i) gestational age <= 32 weeks and/or birth weight <= 1500 g; (ii) genetic syndrome or chromosomal anomaly known to be associated with neurodevelopmental delay; (iii) neurologic disease; (iv) esophageal gap >= three vertebral bodies. Patients were evaluated at 6 and 12 months of life (corrected age for infants with a gestational age of 32-37 weeks) with the Bayley Scales of Infant and Toddler Development-3rd Edition. In our selected cohort of EA infants, 82 were evaluated at 6 months and 59 were reevaluated at 12 months. Both Motor and Cognitive average scores were within the norm at both time points. However, we report increased number of infants with motor delay with time: 14% at 6 months and 24% at 12 months. Multiple regression analysis for Motor scores at 6 [F(4,74)= 4.363, P= 0.003] and 12 months [F(6,50)= 2.634, P= 0.027] identified (i) low birth weight, (ii) longer hospital stay and (iii) weight < fifth percentile at 1 year as risk factors. Interestingly, average Cognitive scores also increased with time from 85.2% at 6 months and 96.6% at 12 months. Multiple regression models explaining variance of Cognitive scores at 6 [F(4, 73)= 2.458, P= 0.053] and 12 months [F(6, 49)= 1.232, P= 0.306] were nonsignificant. Our selected cohort of EA patients shows, on the average, Motor and Cognitive scores within the norm both at 6 and 12 months. Nevertheless, the percentage of infants with Motor scores below the average increases regardless gestational age. None of clinical and sociodemographic variables taken into consideration was able to predict cognitive development both at 6 and 12 months whereas risk factors for Motor development change during the first year of life. Healthcare providers should pay particular attention to patients with low birth weight, longer hospital stays and weight under fifth percentile at 1 year. Future studies should include long-term outcomes to reveal possible catch up in motor development and/or possible findings in Cognitive scores.

Recently, there has been a growing attention to patients defined by the acronym AYA (adolescents and young adults). Therapeutic strategies and management protocols were developed to recognize the specific psychosocial needs of this age group (1, 2). A cancer diagnosis places the patients at risk of adaptation disorders and anxiety-depressive syndromes due to emotionally and psychologically impacting effects (3). The effects can be more severe in adolescents (4). The disease and its treatment could compromise adolescent developmental paths: the construction and affirmation of the identity, the autonomy development, and the independence from the family unit (5, 6). Currently, the patients who need to be treated go beyond the oncological cure, utilizing a biopsychosocial approach involving the patients’ personal and social norms. One of the strategies for a specific professional care in the multidisciplinary team is to ensure an adequate quality of life during hospitalization (6). From this point of view, it is essential to support discussion and aggregation with other adolescents in the hospital setting, reduce isolation, and encourage emotional sharing and expression. By organizing moments for aggregation, sharing is encouraged between patients, which is helpful to the patients’ well-being and quality of life during treatment. The AYA cancer team utilizes a multidisciplinary care model focused on providing each patient with a holistic and tailored approach including social support together with the best cancer treatments. This approach is more attentive to quality of life and encourages the peer support group to “engage in conversation about having cancer with each other (7, 8). It is necessary to have an approach that includes both patient and caregiver needs in order to support AYA patients (9). Since there is no reproducible AYA program, each pediatric or adult center should create and adapt a dedicated program according to structural and economic resources (5, 10).

How to ventilate during CPR in time of Covid-19?To the Editor, Since Covid-19 outbreak in March 2020, concerns have risen about how to perform ventilation during cardiopulmonary resuscitation (CPR), balancing the need for victim to be resuscitated according to the best evidence with rescuers safety.Indeed, SARS-Cov-2 virus has shown to be highly transmissible via aerosol droplets generated from the airways of an infected person, both symptomatic and not. 1 While for occasional rescuers (i.e.laypeople), chest compression-only (CCO) CPR can be recommended as an alternative to compressionsventilations technique, 2 reasonable suggestions for healthcare professionals are lacking.So far, safety focus for personnel with a duty to respond has been placed on high-level personal protection equipment (PPE) rather than on a method to minimize dispersion of exhaled gases from the patient.Endotracheal intubation (ETI) is still considered the best way to isolate airways provided that it is performed by a high-skilled operator, possibly with a video laryngoscope aid. 3 Recently, an American interim guidance for basic and advanced life support has been published suggesting questionable approaches to obtain oxygenation of the patient in cardiac arrest prior ETI. 4 It is unlikely that both ventilation with a tight seal bag-mask device or passive oxygenation with an oxygen high flow facial mask can effectively constrain exhalation and limit rescuers exposition to patient-generated droplets during CPR.