Gianluca Paternoster - Academia.edu (original) (raw)

Papers by Gianluca Paternoster

Journal of anesthesia, analgesia and critical care, Jan 25, 2024

Cardiac surgery with cardiopulmonary bypass (CBP) is essential for different cardiac procedures i... more Cardiac surgery with cardiopulmonary bypass (CBP) is essential for different cardiac procedures in order to perform surgery with a clear sight field. To safely perform surgery with CPB and preserve brain, kidney, and patient tissue from ischemic damage, cold cardioplegia, and mild to deep hypothermia are induced during the operation. Cryoglobulinemia is a hematological/infective-related disease (in certain cases idiopathic) in which temperaturedependent antibodies tend to aggregate and form emboli in the vascular system causing tissue damage if exposed to low temperature. The patient with cryoglobulinemia (known and unknown) can be at risk of a major ischemic event during CPB and induced hypothermia. This article's aim is to evaluate the present scientific literature in order to understand how, in years, the therapeutic or preventive approach, is evolving, and to analyze and make improvements to the management of a cryoglobulinemic patient who must undergo elective or emergency cardiac surgery. In the last part of our article, we expose our single-center experience during a 32-month-long period of survey. In all cases, our medical team (anesthesiologists, perfusionists, and cardiac surgeons) opted for a normothermic cardiopulmonary bypass to lower the risk of cryoglobulin-associated complications. In our experience, along with therapeutic intervention to lower the cryoglobulin titer, normothermic management of cardiopulmonary bypass is as safe as hypothermic management. Notwithstanding our results, further studies with a larger population are needed to confirm this perioperative management in a cardiac surgery setting.

Journal of cardiothoracic and vascular anesthesia, Apr 1, 2024

Springer eBooks, Nov 23, 2013

Levosimendan is a calcium sensitizer, a class of relatively new drugs including among others pimo... more Levosimendan is a calcium sensitizer, a class of relatively new drugs including among others pimobendan and senazodan, and it is the only one approved for administration in clinical practice. Levosimendan is used in acute or chronic heart failure, in cardiac surgery, and in critically ill patients, with evidence of beneficial effects in each of these settings. It also has a fundamental role in pediatric and neonatal cardiac surgery and intensive care. In a recent International Consensus Conference, focusing on drugs and techniques affecting survival in the perioperative period, levosimendan was identified to have a positive effect on survival, with randomized evidence supporting its action.

Journal of Cardiothoracic and Vascular Anesthesia, Jul 1, 2023

Journal of Cardiothoracic and Vascular Anesthesia, Sep 1, 2019

Results: Of the 823 patients (40.3 % women; median age, 64 years), 30 patients (3.6 %) died withi... more Results: Of the 823 patients (40.3 % women; median age, 64 years), 30 patients (3.6 %) died within one year. Cumulative 1year mortality rate was 3.4% (95% confidence interval; 1.5À5.2%) in the normal strain group and 3.9% (95% confidence interval; 2.1À5.6%) in the abnormal strain group. After propensity score matching (a total of 606 patients in matched cohort), there was no statistically significant difference in 1-year mortality between strain groups; 3.3% (95% confidence interval; 1.3À5.3%) in the normal strain group, 3.6% (95% confidence interval; 1.5À5.7%) in the abnormal group, hazard ratio of 1.11 (95% confidence interval; 0.47À2.61, P-value = 0.81).

Oxford University Press eBooks, Mar 1, 2022

Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention option for critically il... more Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention option for critically ill patients with cardiac and/or respiratory failure. Worldwide many medical centers started to use ECMO as a rescue treatment option when conventional therapies failed. This chapter describes conventional strategies of anticoagulation for ECMO. Indeed, during ECMO support the continuous flow and the contact between the patient’s blood and nonbiological surfaces such as cannulae or the oxygenator triggers the activation of the coagulation cascade, with formation of clots and consumption of coagulation factors and platelets, leading to peculiar alteration in the hemostasis. Therefore, the activation of coagulation pathways increases the risk of both thrombosis and hemorrhage. Unfractionated heparin remains the anticoagulant of choice for several reasons in patients supported by ECMO, among them the consolidated experience in its use, its low cost, and the presence of protamine, which can be used as an antagonist, even though its use is very rare in ECMO patients. There are different methods of monitoring the anticoagulation level while on heparin infusion for patients supported by ECMO, and among them the two most common are the activated coagulation time (ACT) and the activated partial thromboplastin time (aPTT), while the routine uses of viscoelastic tests and levels of anti-Xa activity are less common.

Springer eBooks, Dec 27, 2016

Journal of Cardiothoracic and Vascular Anesthesia, Aug 1, 2022

Objective To analyze the survival rates of patients with COVID-19 supported with ECMO and compare... more Objective To analyze the survival rates of patients with COVID-19 supported with ECMO and compare survival rates of COVID-19 patients supported with ECMO to Influenza patients supported with ECMO. Design We carried out a systematic review and meta-analysis to assess the impact of ECMO as supportive therapy of COVID-19. Setting We performed a search through Cochrane, EMBASE and MEDLINE/PubMed from inception to February 19, 2021 for studies reporting hospitalized COVID-19 patients managed with ECMO. Participants A total of 134 studies was selected, including 6 eligible for the comparative meta-analysis of COVID-19 vs influenza. Interventions We pooled risk ratio and random effects model. Measurements and Main Results The primary endpoint was the overall mortality of patients with COVID-19 receiving ECMO. Of the total number of 58,472 patients with COVID-19 reported, ECMO was used in 4,044 patients. The analysis suggested an overall in-hospital mortality of 39% (95% confidence interval [0.34 to 0.43]). In the comparative analysis, COVID-19 patients on ECMO had an higher risk ratio (RR) for mortality when compared to influenza patients on ECMO: 72/164 (44%) vs 71/186 (38%) RR 1.34; 95% CI [1.05 – 1.71]; p = 0.03. Conclusions ECMO could be beneficial in COVID-19 patients according to our meta-analysis. Reported mortality rate was 39%. This systematic analysis can provide clinical advice in the current era and ongoing pandemic.

JAMA

ImportanceMeropenem is a widely prescribed β-lactam antibiotic. Meropenem exhibits maximum pharma... more ImportanceMeropenem is a widely prescribed β-lactam antibiotic. Meropenem exhibits maximum pharmacodynamic efficacy when given by continuous infusion to deliver constant drug levels above the minimal inhibitory concentration. Compared with intermittent administration, continuous administration of meropenem may improve clinical outcomes.ObjectiveTo determine whether continuous administration of meropenem reduces a composite of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria compared with intermittent administration in critically ill patients with sepsis.Design, Setting, and ParticipantsA double-blind, randomized clinical trial enrolling critically ill patients with sepsis or septic shock who had been prescribed meropenem by their treating clinicians at 31 intensive care units of 26 hospitals in 4 countries (Croatia, Italy, Kazakhstan, and Russia). Patients were enrolled between June 5, 2018, and August 9, 2022, and the final 90-day follow-up was co...

Blood Purification, 2014

Background/Aims: Cardiopulmonary bypass (CPB) has been thought to promote endotoxin translocation... more Background/Aims: Cardiopulmonary bypass (CPB) has been thought to promote endotoxin translocation from the gut. Increased endotoxin activity (EA) has been related to a worsening of organ dysfunction, particularly acute kidney injury (AKI). This study aims to determine if CPB could influence EA after cardiac surgery, and if EA variations are associated with renal dysfunction following CPB. Methods: This was an observational study of patients subjected to complex cardiac surgery, likely to last for >120 min. Blood samples were obtained before, during and after CPB for EA analysis. AKI occurrence defined by the Acute Kidney Injury Network criteria was evaluated. Results: Eighteen patients were enrolled. EA significantly increased after 12 h following CPB. Variations of EA from baseline were significantly associated with variations of creatinine, i.e. AKI. Conclusion: Complex cardiac surgery requiring long CPB promotes EA increases that could be associated with variations of serum creatinine and AKI occurrence.

Journal of Anesthesia, Analgesia and Critical Care

Background The role of β-blockers in the critically ill has been studied, and data on the protect... more Background The role of β-blockers in the critically ill has been studied, and data on the protective effects of these drugs on critically ill patients have been repeatedly reported in the literature over the last two decades. However, consensus and guidelines by scientific societies on the use of β-blockers in critically ill patients are still lacking. The purpose of this document is to support the clinical decision-making process regarding the use of β-blockers in critically ill patients. The recipients of this document are physicians, nurses, healthcare personnel, and other professionals involved in the patient’s care process. Methods The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects underlying the use of β-blockers in critically ill adult patients. The methodology followed by the experts during this process was in line with principles of modified Delphi and RAND-UCLA methods. T...

Journal of Cardiothoracic and Vascular Anesthesia, Apr 1, 2017

Objective: Of the 230 million patients undergoing major surgical procedures every year, more than... more Objective: Of the 230 million patients undergoing major surgical procedures every year, more than 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. The authors have updated a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality. Design and Setting: A web-based international consensus conference. Participants: The study comprised 500 clinicians from 61 countries. Interventions: A systematic literature search was performed to identify published literature about nonsurgical interventions, supported by randomized evidence, showing a statistically significant impact on mortality. A consensus conference of experts discussed eligible papers. The interventions identified by the conference then were submitted to colleagues worldwide through a web-based survey. Measurements and Main Results: The authors identified 11 interventions contributing to increased survival (perioperative hemodynamic optimization, neuraxial anesthesia, noninvasive ventilation, tranexamic acid, selective

Journal of Cardiothoracic and Vascular Anesthesia, Oct 1, 2021

Introduction Infective endocarditis is a serious disease condition. Depending on the causative mi... more Introduction Infective endocarditis is a serious disease condition. Depending on the causative microorganism and clinical symptoms, cardiac surgery and valve replacement may be needed, posing additional risks to patients who may simultaneously suffer from septic shock. The combination of surgery bacterial spreadout and artificial cardiopulmonary bypass (CPB) surfaces results in a release of key inflammatory mediators leading to an overshooting systemic hyperinflammatory state frequently associated with compromised hemodynamic and organ function.(1) Combined use of hemoadsorption (2)and IgM enriched Immunoglobulin (3) might represent a potential approach to control the hyperinflammatory systemic reaction associated with the procedure itself and subsequent clinical conditions by reducing a broad range of immuno-regulatory mediators and endotoxemia. Methods We describe retrospectively 8 cardiac surgery patients with proven acute infective endocarditis obtaining valve replacement with CPB surgery in combination with intra e postoperative CytoSorb hemoadsorption and intravenous administration of IgM enriched Immunoglobulin (Pentaglobin®) 250 mg/kg die. for three consecutive days Results Combined treatment of hemoadsorption and IgM enriched Immunoglobulin was associated with a mitigated postoperative response of key cytokines (4) with a significative reduction of IL-6 and Endotoxemia (5) an increase of IL10 (6); an improvement of clinical metabolic parameters (WBC and SOFA score). Moreover, patients showed hemodynamic stability which possibly could be attributed to the additional combined treatment. Intraoperative hemoperfusion and Pentaglobin administration were well tolerated and safe without the occurrence of any related adverse event. Discussion Conclusion: This approach may open up potentially promising therapeutic options for infective endocarditis, with pro and antiflammatory modulation, improved hemodynamic stability and organ function as seen in our experience.

Journal of Cardiothoracic and Vascular Anesthesia, Jun 1, 2015

No RBC transfusion RBC transfusion Cell saver Control p Cell saver Control p n 191 143 173 207 In... more No RBC transfusion RBC transfusion Cell saver Control p Cell saver Control p n 191 143 173 207 Infection n (%) 16 (8,4) 12 (8,4) 1.00 42 (24,2) 34 (16,4) 0,05 Interleukin-6 ϮSD (pg.ml-1

Trials, Jun 7, 2017

Background: There is no consensus on which lung-protective strategies should be used in cardiac s... more Background: There is no consensus on which lung-protective strategies should be used in cardiac surgery patients. Sparse and small randomized clinical and animal trials suggest that maintaining mechanical ventilation during cardiopulmonary bypass is protective on the lungs. Unfortunately, such evidence is weak as it comes from surrogate and minor clinical endpoints mainly limited to elective coronary surgery. According to the available data in the academic literature, an unquestionable standardized strategy of lung protection during cardiopulmonary bypass cannot be recommended. The purpose of the CPBVENT study is to investigate the effectiveness of different strategies of mechanical ventilation during cardiopulmonary bypass on postoperative pulmonary function and complications. Methods/design: The CPBVENT study is a single-blind, multicenter, randomized controlled trial. We are going to enroll 870 patients undergoing elective cardiac surgery with planned use of cardiopulmonary bypass. Patients will be randomized into three groups: (1) no mechanical ventilation during cardiopulmonary bypass, (2) continuous positive airway pressure of 5 cmH 2 O during cardiopulmonary bypass, (3) respiratory rate of 5 acts/min with a tidal volume of 2-3 ml/Kg of ideal body weight and positive end-expiratory pressure of 3-5 cmH 2 O during cardiopulmonary bypass. The primary endpoint will be the incidence of a PaO 2 /FiO 2 ratio <200 until the time of discharge from the intensive care unit. The secondary endpoints will be the incidence of postoperative pulmonary complications and 30-day mortality. Patients will be followed-up for 12 months after the date of randomization. Discussion: The CPBVENT trial will establish whether, and how, different ventilator strategies during cardiopulmonary bypass will have an impact on postoperative pulmonary complications and outcomes of patients undergoing cardiac surgery. Trial registration: ClinicalTrials.gov, ID: NCT02090205. Registered on 8 March 2014.

Springer eBooks, 2016

Acute kidney injury (AKI) is most commonly caused by sepsis and septic shock and it is associated... more Acute kidney injury (AKI) is most commonly caused by sepsis and septic shock and it is associated with high mortality. Intravenous immunoglobulin (IVIG) therapy has been used for many years as replacement therapy in primary immunodeficiency disorders and has more recently been proposed to be beneficial in sepsis and septic shock. Many studies have been conducted in order to test this hypothesis. However, the results of clinical trials are conflicting and there is a high degree of heterogeneity among studies. We have reviewed the available literature, and we conclude that the current evidence to recommend IVIG therapy to reduce mortality in septic patients with AKI is limited.

Minerva Anestesiologica, Mar 1, 2023

Journal of Cardiothoracic and Vascular Anesthesia, Jul 1, 2021