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Deng J, Li L, Feng Y, Yang J. Comprehensive Management of Blood Pressure in Patients with Septic AKI. J Clin Med 2023; 12:jcm12031018. [PMID: 36769666 PMCID: PMC9917880 DOI: 10.3390/jcm12031018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
Acute kidney injury (AKI) is one of the serious complications of sepsis in clinical practice, and is an important cause of prolonged hospitalization, death, increased medical costs, and a huge medical burden to society. The pathogenesis of AKI associated with sepsis is relatively complex and includes hemodynamic abnormalities due to inflammatory response, oxidative stress, and shock, which subsequently cause a decrease in renal perfusion pressure and eventually lead to ischemia and hypoxia in renal tissue. Active clinical correction of hypotension can effectively improve renal microcirculatory disorders and promote the recovery of renal function. Furthermore, it has been found that in patients with a previous history of hypertension, small changes in blood pressure may be even more deleterious for kidney function. Therefore, the management of blood pressure in patients with sepsis-related AKI will directly affect the short-term and long-term renal function prognosis. This review summarizes the pathophysiological mechanisms of microcirculatory disorders affecting renal function, fluid management, vasopressor, the clinical blood pressure target, and kidney replacement therapy to provide a reference for the clinical management of sepsis-related AKI, thereby promoting the recovery of renal function for the purpose of improving patient prognosis.
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Affiliation(s)
- Junhui Deng
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Lina Li
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Yuanjun Feng
- Department of Renal Rheumatology, Space Hospital Affiliated to Zunyi Medical University, Zunyi 563002, China
| | - Jurong Yang
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
- Correspondence: or
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Liu C, Zhang HT, Yue LJ, Li ZS, Pan K, Chen Z, Gu SP, Pan T, Pan J, Wang DJ. Risk factors for mortality in patients undergoing continuous renal replacement therapy after cardiac surgery. BMC Cardiovasc Disord 2021; 21:509. [PMID: 34674651 PMCID: PMC8529736 DOI: 10.1186/s12872-021-02324-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the risk factors for mortality in patients with acute kidney injury requiring continuous renal replacement therapy (AKI-CRRT) after cardiac surgery. METHODS In this retrospective study, patients who underwent AKI-CRRT after cardiac surgery in our centre from January 2015 to January 2020 were included. Univariable and multivariable analyses were performed to identify the risk factors for in-hospital mortality. RESULTS A total of 412 patients were included in our study. Of these, 174 died after AKI-CRRT, and the remaining 238 were included in the survival control group. Multivariable logistic regression analysis revealed that EuroSCORE > 7 (odds ratio [OR], 3.72; 95% confidence interval [CI], 1.92-7.24; p < 0.01), intraoperative bleeding > 1 L (OR, 2.14; 95% CI, 1.19-3.86; p = 0.01) and mechanical ventilation time > 70 h (OR, 5.03; 95% CI, 2.40-10.54; p < 0.01) were independent risk factors for in-hospital mortality in patients who had undergone AKI-CRRT. Our study also found that the use of furosemide after surgery was a protective factor for such patients (odds ratio, 0.48; 95% confidence interval, 0.25-0.92; p = 0.03). CONCLUSIONS In summary, the mortality of patients with AKI-CRRT after cardiac surgery remains high. The EuroSCORE, intraoperative bleeding and mechanical ventilation time were independent risk factors for in-hospital mortality. Continuous application of furosemide may be associated with a better outcome.
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Affiliation(s)
- Chang Liu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China
| | - Li-Jun Yue
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Ze-Shi Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China
| | - Ke Pan
- Nanjing Drum Tower Hospital, The Affiliated Clinical College of Xuzhou Medical University, Nanjing, 210008, Jiangsu, China
| | - Zhong Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, Jiangsu, China
| | - Su-Ping Gu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Jun Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China. .,Nanjing Drum Tower Hospital, The Affiliated Clinical College of Xuzhou Medical University, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
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Hemodynamic disturbances and oliguria during continuous kidney replacement therapy in critically ill children. Pediatr Nephrol 2021; 36:1889-1899. [PMID: 33433709 DOI: 10.1007/s00467-020-04804-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/15/2020] [Accepted: 09/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND About 1.5% of patients admitted to the Pediatric Intensive Care Unit (PICU) will require continuous kidney replacement therapy (CKRT)/renal replacement therapy (CRRT). Mortality of these patients ranges from 30 to 60%. CKRT-related hypotension (CKRT-RHI) can occur in 19-45% of patients. Oliguria after onset of CKRT is also common, but to date has not been addressed directly in the scientific literature. METHODS A prospective observational study was conducted to define factors involved in the hemodynamic changes that take place during the first hours of CKRT, and their relationship with urinary output. RESULTS Twenty-five patients who were admitted to a single-center PICU requiring CKRT between January 1, 2014, and December 31, 2018, were included, of whom 56.3% developed CKRT-RHI. This drop in blood pressure was transient and rapidly restored to baseline, and significantly improved after the third hour of CKRT, as core temperature and heart rate decreased. Urine output significantly decreased after starting CKRT, and 72% of patients were oliguric after 6 h of therapy. Duration of CKRT was significantly longer in patients presenting with oliguria than in non-oliguric patients (28.7 vs. 7.9 days, p = 0.013). CONCLUSIONS The initiation of CKRT caused hemodynamic instability immediately after initial connection in most patients, but had a beneficial effect on the patient's hemodynamic status after 3 h of therapy, presumably owing to decreases in body temperature and heart rate. Urine output significantly decreased in all patients and was not related to negative fluid balance, patient's hemodynamic status, CKRT settings, or kidney function parameters.
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Prendin A, Marinelli E, Marinetto A, Daicampi C, Trevisan N, Strini V, de Barbieri I. Paediatric nursing management of renal replacement therapy: Intensive care nursing or dialysis nursing? Nurs Crit Care 2020; 26:510-516. [PMID: 33283418 DOI: 10.1111/nicc.12576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Children who develop Acute Kidney Injury may start renal replacement therapy (RRT) in Paediatric or Neonatal Intensive Care Units (hereafter PICU or NICU); RRT can be delivered either by paediatric dialysis nurses or by critical care nurses. In both case, nurses devoted to this task must have a high level of competence in providing care to children receiving haemodialytic treatment in a specific technological environment. AIM The objective of this research was to investigate which models have been adopted to organize nursing care in RRT management in different Italian PICU and NICU, and to explore the training of ICU nurses on the management of RRT. METHODS A multi-centre survey was conducted through an online questionnaire directed to the Italian PICU and NICU nurse coordinators. RESULTS A total of 15 Intensive Care Units (12 PICU and 3 NICU) in 12 hospitals were involved. The mean nurse/patient ratio in these units is 1:3. In 72.7% of critical care units, dialysis treatment is delivered by critical care nurses belonging to the unit itself, while in 27.3% of units paediatric dialysis nurses are in charge of dialysis treatment in collaboration with critical care nurses. In 25% of surveyed units there is some structured form of collaboration between Paediatric Dialysis nurses and critical care nurses. However, 75% of units did not respond to this specific question. The different units adopt various forms of RRT training for nursing staff. CONCLUSION The scenario resulting from this analysis showed how in our sample of Italian hospitals there is no standard practice for RRT nursing management. In addition, although various forms of training for nursing staff exist, a proper educational programme and/or a standardized specific training about RRT management for nursing staff is not in place in the surveyed hospitals. RELEVANCE TO CLINICAL PRACTICE The lack of standardized protocols or guidelines for RRT delivery to critically ill children can compromise their safety. The structuring of these protocols and the production of best clinical practice guidelines would allow standardization of the nursing management of the RRT and of the corresponding training. This may help to provide the proper care and to guarantee the patients' safety.
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Affiliation(s)
- Angela Prendin
- Palliative Care and Antalgic Therapy/ Pediatric Hospice, University-Hospital of Padua, Padua, Italy
| | - Elena Marinelli
- Pediatric Intensive Care Unit, University-Hospital of Padua, Padua, Italy
| | - Anna Marinetto
- Palliative Care and Antalgic Therapy/ Pediatric Hospice, University-Hospital of Padua, Padua, Italy
| | - Chiara Daicampi
- Pediatric Clinic, University-Hospital of Padua, Padua, Italy
| | - Nicola Trevisan
- Head Nurse Pediatric Emergency Unit, University-Hospital of Padua, Padua, Italy
| | - Veronica Strini
- Clinical Research Unit, University-Hospital of Padua, Padua, Italy
| | - Ilaria de Barbieri
- Nurse Coordinator of Woman's & Child's Health Department, University-Hospital of Padua, Padua, Italy
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Renal replacement therapy in the pediatric cardiac intensive care unit. J Thorac Cardiovasc Surg 2019; 158:1446-1455. [PMID: 31395365 DOI: 10.1016/j.jtcvs.2019.06.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 05/31/2019] [Accepted: 06/09/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE There is an increased risk of mortality in patients in whom acute kidney injury and fluid accumulation develop after cardiothoracic surgery, and the risk is especially high when renal replacement therapy is needed. However, renal replacement therapy remains an essential intervention in managing these patients. The objective of this study was to identify risk factors for mortality in surgical patients requiring renal replacement therapy in a pediatric cardiac intensive care unit. METHODS We performed a retrospective review of patients requiring renal replacement therapy for acute kidney injury or fluid accumulation after cardiothoracic surgery between January 2009 and December 2017. Survivors and nonsurvivors were compared with respect to multiple variables, and a multivariable logistic regression analysis was performed to identify independent risk factors associated with mortality. RESULTS The mortality rate for the cohort was 75%. Nonsurvivors were younger (nonsurvivors: 0.8 years; interquartile range, 0.1-8.2; survivors: 14.6 years; interquartile range, 4.2-19.7; P = .002) and had a lower weight-for-age z-score (nonsurvivors: -1.5; interquartile range, -3.1 to -0.4; survivors: -0.5; interquartile range, -0.9 to 0.3; P = .02) compared with survivors. There was no difference with respect to fluid accumulation. In multivariable analysis, a longer duration of stage 3 acute kidney injury before initiation of renal replacement therapy was independently associated with mortality (adjusted odds ratio, 1.39; 95% confidence interval, 1.05-1.83; P = .021). CONCLUSIONS Mortality in patients requiring renal replacement therapy after congenital heart disease surgery is high. A longer duration of acute kidney injury before renal replacement therapy initiation is associated with increased mortality.
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Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nat Rev Nephrol 2017; 13:697-711. [DOI: 10.1038/nrneph.2017.119] [Citation(s) in RCA: 367] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Seghaye MC. Management of children with congenital heart defect: state of the art and future prospects. Future Cardiol 2016; 13:65-79. [PMID: 27936920 DOI: 10.2217/fca-2016-0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The treatment of children with congenital heart defects has evolved in the last 60 years from conservative care to a highly specialized management where advances in imaging, surgical, interventional and support techniques meet together to ensure satisfactory development and good quality of life to the child and to the upcoming grown up. Management of congenital heart defects best begins before birth with the aim, whenever possible, to maintain or establish biventricular physiology or, if this is excluded, to optimize the conditions for univentricular physiology. Current research in the field of genetics, device bioengineering and miniaturization, stem cell therapy, and fusion imaging technology is expected to help to improve further patient outcome. In this review, current management strategies and future prospects are discussed.
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Affiliation(s)
- Marie-Christine Seghaye
- Department of Pediatrics-Pediatric Cardiology, University Hospital Liège, Rue de Gaillarmont 600, B. 4032 Liège, Belgium
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Abstract
OBJECTIVES Focusing on critically ill children with cardiac disease, we will review common causes of fluid perturbations, clinical recognition, and strategies to minimize and treat fluid-related complications. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS Meticulous fluid management is vital in critically ill children with cardiac disease. Fluid therapy is important to maintain adequate blood volume and perfusion pressure in order to support cardiac output, tissue perfusion, and oxygen delivery. However, fluid overload and acute kidney injury are common and are associated with increased morbidity and mortality. Understanding the etiologies for disturbances in volume status and the pathophysiology surrounding those conditions is crucial for providing optimal care.
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de Galasso L, Emma F, Picca S, Di Nardo M, Rossetti E, Guzzo I. Continuous renal replacement therapy in children: fluid overload does not always predict mortality. Pediatr Nephrol 2016; 31:651-9. [PMID: 26563114 DOI: 10.1007/s00467-015-3248-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 10/07/2015] [Accepted: 10/15/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mortality among critically ill children requiring continuous renal replacement therapy (CRRT) is high. Several factors have been identified as outcome predictors. Many studies have specifically reported a positive association between the fluid overload at CRRT initiation and the mortality of critically ill pediatric patients. METHODS This study is a retrospective single-center analysis including all patients admitted to the pediatric intensive care unit (PICU) of our hospital who received CRRT between 2000 and 2012. One hundred thirty-one patients were identified and subsequently classified according to primary disease. Survival rates, severity of illness and fluid balance differed among subgroups. The primary outcome was patient survival to PICU discharge. RESULTS Overall survival to PICU discharge was 45.8 %. Based on multiple regression analysis, mortality was independently associated with onco-hematological disease [odds ratio (OR) 11.7, 95 % confidence interval (CI) 1.3-104.7; p = 0.028], severe multiple organ dysfunction syndrome (MODS) (OR 5.1, 95 % CI 1.7-15; p = 0.003) and hypotension (OR 11.6, 95 % CI 1.4-93.2; p = 0.021). In the subgroup analysis, a fluid overload (FO) of more than 10 % (FO>10 %) at the beginning of CRRT seems to be a negative predictor of mortality (OR 10.9, 95 % CI 0.78-152.62; p = 0.07) only in children with milder disease (renal patients). Due to lack of statistical power, the independent effect of fluid overload on mortality could not be analyzed in all subgroups of patients. CONCLUSIONS In children treated with CRRT the underlying diagnosis and severity of illness are independent risk factors for mortality. The degree of FO is a negative predictor only in patients with milder disease.
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Affiliation(s)
- Lara de Galasso
- Nephrology and Dialysis A Unit, "Sapienza" University of Rome, Viale dell'Università, 33, 00185, Rome, Italy.
| | - Francesco Emma
- Department of Nephrology and Urology, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Stefano Picca
- Department of Nephrology and Urology, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Emanuele Rossetti
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Isabella Guzzo
- Department of Nephrology and Urology, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
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Sanchez-de-Toledo J, Perez-Ortiz A, Gil L, Baust T, Linés-Palazón M, Perez-Hoyos S, Gran F, Abella RF. Early Initiation of Renal Replacement Therapy in Pediatric Heart Surgery Is Associated with Lower Mortality. Pediatr Cardiol 2016; 37:623-8. [PMID: 26687178 DOI: 10.1007/s00246-015-1323-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/07/2015] [Indexed: 11/26/2022]
Abstract
Acute kidney injury (AKI) is frequent in the postoperative period of pediatric heart surgery and leads to significant morbidity and mortality. Renal replacement therapies (RRTs) are often used to treat AKI; however, these therapies have also been associated with higher mortality rates. Earlier initiation of RRT might improve outcomes. This study aims to investigate the relationship between the RRT and morbidity and mortality after pediatric heart surgery. We performed a single-center retrospective study of all children undergoing pediatric heart surgery between April 2010 and December 2012 at a tertiary children's hospital. A total of 480 patients were included. Of those, 109 (23 %) were neonates and 126 patients (26 %) developed AKI within the first 72 postoperative hours. Patients who developed AKI had longer PICU admissions [12 days (4-37.75) vs. 4 (2-11); p < 0.001] and hospital length of stay [27 (11-53) vs. 14 (8-24) p < 0.001] and higher mortality [22/126 (17.5 %) vs. 13/354 (3.7 %); p < 0.001]. RRT techniques were used in 32 (6.6 %) patients [18/109 (16 %) neonates and 14/371 (3.8 %) infants and children; p < 0.01], with 25 (78 %) receiving peritoneal dialysis (PD) and 7 (22 %) continuous RRT (CRRT). Patients who received PD within the first 24 postoperative hours had lower mortality compared with those in whom PD was initiated later [4/16 (25 %) vs. 4/9 (44.4 %)]. Mortality among patients who received CRRT was 28.6 % (2/7). No deaths were reported in patients treated with CRRT within the first 24 postoperative hours. Postoperative AKI is associated with higher mortality in children undergoing cardiac surgery. Early initiation of RRT, both PD in neonates and CRRT in pediatric patients, might improve morbidity and mortality associated with AKI.
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Affiliation(s)
- Joan Sanchez-de-Toledo
- Cardiac Intensive Care Division, Department of Critical Care Medicine, Children Hospital of Pittsburgh, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, USA.
- Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Alba Perez-Ortiz
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Gil
- Department of Neonatology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tracy Baust
- Cardiac Intensive Care Division, Department of Critical Care Medicine, Children Hospital of Pittsburgh, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Marcos Linés-Palazón
- Department of Neonatology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Perez-Hoyos
- Unit of Clinical Research Support, Vall d'Hebron Research Institut, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferran Gran
- Department of Pediatric Cardiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Raul F Abella
- Department of Pediatric Cardiothoracic Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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