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IntroductionRetroperitoneal soft tissue sarcomas (RPSs) are mesenchymal neoplasms. The prevalence of protein energetic malnutrition (PEM) and its impact in RPS patients who were candidates for surgery is unknown.Materials and MethodsA prospective feasibility study enrolled 35 patients with primary RPS who were candidates for extended multivisceral resection. PEM was screened at enrollment. Preoperative high protein β-hydroxy-β-methyl butyrate oral nutritional support (ONS) was provided according to the degree of PEM. After surgery, nutritional support followed standard practice, targeting at least 1 g/kg/day protein and 20 kcal/kg/day caloric intake within the third postoperative day (POD). PEM was re-evaluated before surgery on POD 10, and at 4 and 12 months after surgery. Primary outcomes were the patient’s compliance to preoperative ONS and the physician’s compliance to postoperative nutritional targets.ResultsPEM was documented in 46% of patients at baseline; ONS met a 91% adherence (overall well tolerated). After ONS, PEM reduced to 38% (p = 0.45). The postoperative caloric target was reached on day 4.1 (standard error ± 2.7), with a protocol adherence rate of 52%. On POD 10, 91% of patients experienced PEM, the worsening of which was greater after resection of four or more organs (p = 0.06). At 4 and 12 months after surgery, almost all patients had fully recovered. A significant correlation between PEM at surgery and postoperative complications was found (p = 0.04).ConclusionsRelevant PEM prevalence in RPS is documented for the first time. PEM correlates with greater morbidity. In this setting, preoperative ONS was feasible and well-tolerated. Disease-related factors for PEM and the ideal perioperative caloric target in the context of extended multivisceral resection need to be further investigated. Nutritional support should be included in enhanced recovery after surgery programs for RPS.Trial RegistryClinicalTrials.gov identifier: NCT03877588.

PurposeTo document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU.MethodsThis prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up.ResultsLST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32–7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78–2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12–1.34) and SOFA score [OR of 1.07 (95% CI 1.05–1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries.ConclusionsThe most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country.Trial registrationClinicalTrials.gov (ID: NTC03134807).

We aimed to evaluate differences in outcome between patients admitted to intensive care unit (ICU) after elective versus acute surgery in a multinational cohort of very old patients (≥80 years; VIP). Predictors of mortality, with special emphasis on frailty, were assessed. In total, 5063 VIPs were included in this analysis, 922 were admitted after elective surgery or intervention, 4141 acutely, with 402 after acute surgery. Differences were calculated using Mann-Whitney-U test and Wilcoxon test. Univariate and multivariable logistic regression were used to assess associations with mortality. Compared patients admitted after acute surgery, patients admitted after elective surgery suffered less often from frailty as defined as CFS (28% vs 46%; p < 0.001), evidenced lower SOFA scores (4 ± 5 vs 7 ± 7; p < 0.001). Presence of frailty (CFS >4) was associated with significantly increased mortality both in elective surgery patients (7% vs 12%; p = 0.01), in acute surgery (7% vs 12%; p = 0.02). VIPs admitted to ICU after elective surgery evidenced favorable outcome over patients after acute surgery even after correction for relevant confounders. Frailty might be used to guide clinicians in risk stratification in both patients admitted after elective and acute surgery. Trial registration: NCT03134807. Registered 1st May 2017. •We evaluated differences in outcome between VIPs admitted to ICU after elective versus acute intervention•VIPs after elective intervention evidenced favorable outcome after correction for relevant confounders•Frailty might be used to guide clinicians in risk stratification in both patients admitted after elective and acute surgery.

Recurrent haemolytic uraemic syndrome (HUS) is a genetic form of thrombotic microangiopathy that is mostly associated with low activity of complement factor H. The disorder usually develops in families, leads to end stage renal disease, and invariably recurs after kidney transplantation. We did a simultaneous kidney and liver transplantation in a 2-year-old child with HUS and a mutation in complement factor H to restore the defective factor H, with no recurrence of the disease. The operation was successful, and at discharge, the child had healthy kidney and liver function, with no sign of haemolysis.

Background Centralisation of critically ill children to paediatric intensive care units is supported by a strong rationale, but evidence is not overwhelming. Objective To compare the outcome of children admitted to adult intensive care units (ICUs) in Italy between 2003 and 2007 with that of children admitted to paediatric intensive care units (PICUs) in Italy between 1994 and 1995. Methods Prospective, multicenter cohort study and historical controls. Risk of ICU mortality was assessed with the PRISM score in both study and historical control groups. Descriptive statistics, standardized mortality ratios (SMRs) with their 95% confidence intervals, and the calibration plots were reported. Results A total of 1,265 children admitted to 124 adult ICUs between 2003 and 2007 were compared with an historical control group formed by 1,533 children admitted to 26 PICUs between 1994 and 1995. The PRISM score slightly underestimated hospital deaths for low-risk patients in both groups. The overall SMR was 1.11 (95% CI 0.91–1.31) for adult ICUs and 1.04 (95% CI: 0.88–1.19) for PICUs. Conclusions The level of care provided nowadays to children admitted to adult ICUs in Italy is similar to that provided by Italian PICUs 10 years earlier. On the other hand, there is evidence that Italian PICUs have improved the level of care in the same period. These findings, if confirmed, suggest a better quality of care for children admitted to PICUs as compared to adult ICUs and support the indication, when possible, of early referral to more specialized units in countries where paediatric intensive care is not centralised.

In the original publication Dr Patrick Meybohm of the Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt University Hospital, Frankfurt, Germany was inadvertently omitted from the list of investigators.

Mechanical circulatory support after congenital heart surgery is uncommon, but not unusual. Stunning of ischemic myocardium after cardiopulmonary bypass could occur due to many reasons. According to the literature, this complication is rare in our center, but some options about implantation of a postcardiotomy left ventricular assistance device (LVAD) in toddlers deserve attention. Furthermore, although the VAD has been a well-established therapy for larger adolescents and adult patients with advanced heart failure, current experience with the use of VAD for mechanical circulatory support in infants and young children with small body surface area is still limited.