Right Ventricular Dysfunction Patterns among Patients with COVID-19 in the Intensive Care Unit: A Retrospective Cohort Analysis

Rationale: Right ventricular (RV) dysfunction is common among patients hospitalized with coronavirus disease (COVID-19); however, its epidemiology may depend on the echocardiographic parameters used to define it. Objectives: To evaluate the prevalence of abnormalities in three common echocardiographic parameters of RV function among patients with COVID-19 admitted to the intensive care unit (ICU), as well as the effect of RV dilatation on differential parameter abnormality and the association of RV dysfunction with 60-day mortality. Methods: We conducted a retrospective cohort study of ICU patients with COVID-19 between March 4, 2020, and March 4, 2021, who received a transthoracic echocardiogram within 48 hours before to at most 7 days after ICU admission. RV dysfunction and dilatation, respectively, were defined by guideline thresholds for tricuspid annular plane systolic excursion (TAPSE), RV fractional area change, RV free wall longitudinal strain (RVFWS), and RV basal dimension or RV end-diastolic area. Association of RV dysfunction with 60-day mortality was assessed through logistic regression adjusting for age, prior history of congestive heart failure, invasive ventilation at the time of transthoracic echocardiogram, and Acute Physiology and Chronic Health Evaluation II score. Results: A total of 116 patients were included, of whom 69% had RV dysfunction by one or more parameters, and 36.3% of these had RV dilatation. The three most common patterns of RV dysfunction were the presence of three abnormalities, the combination of abnormal RVFWS and TAPSE, and isolated TAPSE abnormality. Patients with RV dilatation had worse RV fractional area change (24% vs. 36%; P = 0.001), worse RVFWS (16.3% vs. 19.1%; P = 0.005), higher RV systolic pressure (45 mm Hg vs. 31 mm Hg; P = 0.001) but similar TAPSE (13 mm vs. 13 mm; P = 0.30) compared with those with normal RV size. After multivariable adjustment, 60-day mortality was significantly associated with RV dysfunction (odds ratio, 2.91; 95% confidence interval, 1.01-9.44), as was the presence of at least two parameter abnormalities. Conclusions: ICU patients with COVID-19 had significant heterogeneity in RV function abnormalities present with different patterns associated with RV dilatation. RV dysfunction by any parameter was associated with increased mortality. Therefore, a multiparameter evaluation may be critical in recognizing RV dysfunction in COVID-19.

Autoantibodies are highly prevalent in non-SARS-CoV-2 respiratory infections and critical illness

The widespread presence of autoantibodies in acute infection with SARS-CoV-2 is increasingly recognized, but the prevalence of autoantibodies in non-SARS-CoV-2 infections and critical illness has not yet been reported. We profiled IgG autoantibodies in 267 patients from 5 independent cohorts with non-SARS-CoV-2 viral, bacterial, and noninfectious critical illness. Serum samples were screened using Luminex arrays that included 58 cytokines and 55 autoantigens, many of which are associated with connective tissue diseases (CTDs). Samples positive for anti-cytokine antibodies were tested for receptor blocking activity using cell-based functional assays. Anti-cytokine antibodies were identified in > 50% of patients across all 5 acutely ill cohorts. In critically ill patients, anti-cytokine antibodies were far more common in infected versus uninfected patients. In cell-based functional assays, 11 of 39 samples positive for select anti-cytokine antibodies displayed receptor blocking activity against surface receptors for Type I IFN, GM-CSF, and IL-6. Autoantibodies against CTD-associated autoantigens were also commonly observed, including newly detected antibodies that emerged in longitudinal samples. These findings demonstrate that anti-cytokine and autoantibodies are common across different viral and nonviral infections and range in severity of illness.

Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

Deconvoluting complex correlates of COVID-19 severity with a multi-omic pandemic tracking strategy

The SARS-CoV-2 pandemic has differentially impacted populations across race and ethnicity. A multi-omic approach represents a powerful tool to examine risk across multi-ancestry genomes. We leverage a pandemic tracking strategy in which we sequence viral and host genomes and transcriptomes from nasopharyngeal swabs of 1049 individuals (736 SARS-CoV-2 positive and 313 SARS-CoV-2 negative) and integrate them with digital phenotypes from electronic health records from a diverse catchment area in Northern California. Genome-wide association disaggregated by admixture mapping reveals novel COVID-19-severity-associated regions containing previously reported markers of neurologic, pulmonary and viral disease susceptibility. Phylodynamic tracking of consensus viral genomes reveals no association with disease severity or inferred ancestry. Summary data from multiomic investigation reveals metagenomic and HLA associations with severe COVID-19. The wealth of data available from residual nasopharyngeal swabs in combination with clinical data abstracted automatically at scale highlights a powerful strategy for pandemic tracking, and reveals distinct epidemiologic, genetic, and biological associations for those at the highest risk.

Autoantibodies targeting cytokines and connective tissue disease autoantigens are common in acute non-SARS-CoV-2 infections

The widespread presence of autoantibodies in acute infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is increasingly recognized, but the prevalence of autoantibodies in infections with organisms other than SARS-CoV-2 has not yet been reported. We used protein arrays to profile IgG autoantibodies from 317 samples from 268 patients across a spectrum of non-SARS-CoV-2 infections, many of whom were critically ill with pneumonia. Anti-cytokine antibodies (ACA) were identified in > 50% of patients infected with non-SARS-CoV-2 viruses and other pathogens, including patients with pneumonia attributed to bacterial causes. In cell-based functional assays, some ACA blocked binding to surface receptors for type I interferons (Type I IFN), granulocyte-macrophage colony-stimulating factor (GM-CSF), and interleukin-6 (IL-6). Autoantibodies against traditional autoantigens associated with connective tissue diseases (CTDs) were also commonly observed in these cohorts, including newly-detected antibodies that emerged in longitudinal samples from patients infected with influenza. We conclude that autoantibodies, some of which are functionally active, may be much more prevalent than previously appreciated in patients who are symptomatically infected with diverse pathogens.

Prospective validation of an 11-gene mRNA host response score for mortality risk stratification in the intensive care unit

Several clinical calculators predict intensive care unit (ICU) mortality, however these are cumbersome and often require 24 h of data to calculate. Retrospective studies have demonstrated the utility of whole blood transcriptomic analysis in predicting mortality. In this study, we tested prospective validation of an 11-gene messenger RNA (mRNA) score in an ICU population. Whole blood mRNA from 70 subjects in the Stanford ICU Biobank with samples collected within 24 h of Emergency Department presentation were used to calculate an 11-gene mRNA score. We found that the 11-gene score was highly associated with 60-day mortality, with an area under the receiver operating characteristic curve of 0.68 in all patients, 0.77 in shock patients, and 0.98 in patients whose primary determinant of prognosis was acute illness. Subjects with the highest quartile of mRNA scores were more likely to die in hospital (40% vs 7%, p < 0.01) and within 60 days (40% vs 15%, p = 0.06). The 11-gene score improved prognostication with a categorical Net Reclassification Improvement index of 0.37 (p = 0.03) and an Integrated Discrimination Improvement index of 0.07 (p = 0.02) when combined with Simplified Acute Physiology Score 3 or Acute Physiology and Chronic Health Evaluation II score. The test performed poorly in the 95 independent samples collected > 24 h after emergency department presentation. Tests will target a 30-min turnaround time, allowing for rapid results early in admission. Moving forward, this test may provide valuable real-time prognostic information to improve triage decisions and allow for enrichment of clinical trials.

Cytokine profile in plasma of severe COVID-19 does not differ from ARDS and sepsis

BACKGROUND

Elevated levels of inflammatory cytokines have been associated with poor outcomes among COVID-19 patients. It is unknown, however, how these levels compare with those observed in critically ill patients with acute respiratory distress syndrome (ARDS) or sepsis due to other causes.

METHODS

We used a Luminex assay to determine expression of 76 cytokines from plasma of hospitalized COVID-19 patients and banked plasma samples from ARDS and sepsis patients. Our analysis focused on detecting statistical differences in levels of 6 cytokines associated with cytokine storm (IL-1β, IL-1RA, IL-6, IL-8, IL-18, and TNF-α) between patients with moderate COVID-19, severe COVID-19, and ARDS or sepsis.

RESULTS

Fifteen hospitalized COVID-19 patients, 9 of whom were critically ill, were compared with critically ill patients with ARDS (n = 12) or sepsis (n = 16). There were no statistically significant differences in baseline levels of IL-1β, IL-1RA, IL-6, IL-8, IL-18, and TNF-α between patients with COVID-19 and critically ill controls with ARDS or sepsis.

CONCLUSION

Levels of inflammatory cytokines were not higher in severe COVID-19 patients than in moderate COVID-19 or critically ill patients with ARDS or sepsis in this small cohort. Broad use of immunosuppressive therapies in ARDS has failed in numerous Phase 3 studies; use of these therapies in unselected patients with COVID-19 may be unwarranted.

FUNDING

Funding was received from NHLBI K23 HL125663 (AJR); The Bill and Melinda Gates Foundation OPP1113682 (AJR and CAB); Burroughs Wellcome Fund Investigators in the Pathogenesis of Infectious Diseases #1016687 NIH/NIAID U19AI057229-16; Stanford Maternal Child Health Research Institute; and Chan Zuckerberg Biohub (CAB).

The levels of inflammatory cytokines in COVID-19 patients are compared to patients with other critical illness, such as sepsis or acute respiratory distress syndrome.

A single-cell atlas of the peripheral immune response in patients with severe COVID-19

There is an urgent need to better understand the pathophysiology of Coronavirus disease 2019 (COVID-19), the global pandemic caused by SARS-CoV-2, which has infected more than three million people worldwide1. Approximately 20% of patients with COVID-19 develop severe disease and 5% of patients require intensive care2. Severe disease has been associated with changes in peripheral immune activity, including increased levels of pro-inflammatory cytokines3,4 that may be produced by a subset of inflammatory monocytes5,6, lymphopenia7,8 and T cell exhaustion9,10. To elucidate pathways in peripheral immune cells that might lead to immunopathology or protective immunity in severe COVID-19, we applied single-cell RNA sequencing (scRNA-seq) to profile peripheral blood mononuclear cells (PBMCs) from seven patients hospitalized for COVID-19, four of whom had acute respiratory distress syndrome, and six healthy controls. We identify reconfiguration of peripheral immune cell phenotype in COVID-19, including a heterogeneous interferon-stimulated gene signature, HLA class II downregulation and a developing neutrophil population that appears closely related to plasmablasts appearing in patients with acute respiratory failure requiring mechanical ventilation. Importantly, we found that peripheral monocytes and lymphocytes do not express substantial amounts of pro-inflammatory cytokines. Collectively, we provide a cell atlas of the peripheral immune response to severe COVID-19.

A single-cell atlas of the peripheral immune response to severe COVID-19

There is an urgent need to better understand the pathophysiology of Coronavirus disease 2019 (COVID-19), the global pandemic caused by SARS-CoV-2. Here, we apply single-cell RNA sequencing (scRNA-seq) to peripheral blood mononuclear cells (PBMCs) of 7 patients hospitalized with confirmed COVID-19 and 6 healthy controls. We identify substantial reconfiguration of peripheral immune cell phenotype in COVID-19, including a heterogeneous interferon-stimulated gene (ISG) signature, HLA class II downregulation, and a novel B cell-derived granulocyte population appearing in patients with acute respiratory failure requiring mechanical ventilation. Importantly, peripheral monocytes and lymphocytes do not express substantial amounts of pro-inflammatory cytokines, suggesting that circulating leukocytes do not significantly contribute to the potential COVID-19 cytokine storm. Collectively, we provide the most thorough cell atlas to date of the peripheral immune response to severe COVID-19.

[Characteristics of drug interactions in a pediatric intensive care unit]

INTRODUCTION

The aim of this study is to calculate the theoretical frequency of potential drug interactions (PDI) and their characteristics in the therapeutic plan of hospitalized patients in a Pediatric Intensive Care Unit (PICU).

PATIENTS AND METHODS

An observational study was conducted which analyzed PICU prescriptions between September and November 2011. The inclusion criteria included to be hospitalized in a PICU, requirements of at least 3 drugs, except those topically applied, either gender, no age limit, no hospital stay required. The Micromedex® 2.0 program was used to detect and classify PDI.

RESULTS

Of 223 patients, 100 met inclusion criteria, 610 prescriptions were analyzed and 815 drugs were prescribed. 1,240 PDI were detected in 44 patients; 12 patients received more than 10 drugs each, presenting 1,162 PDI (93.7% of total PDI). 8 patients were hospitalized for more than 10 days, presenting 1,035 PDI (83.5% of total PDI). According to PDI theoretical severity, 37.5% were high, 51.7% moderate, 6.7% low and 4.1% contraindicated. The therapeutic group most involved was antimicrobials (17.6%) and the most frequently involved individual drugs were chloral hydrate (15.9%), midazolam (14.1%) and vecuronium (13.4%).

CONCLUSION

PDI were more frequent in patients associated with major polypharmacy and longer hospital stay.

Multiple causes for an ischemic stroke: myxoma, papillary fibroelastomas and patent foramen ovale

We report a case in which multiple uncommon causes of an ischemic vascular accident coexisted in the same patient. The patient was admitted with signs of acute stroke. Investigation workup revealed a left atrial tumor (myxoma) and a patent foramen ovale. Intraoperatively, transesophageal echocardiography added new information: papillary fibroelastomas were found in the aortic valve. This finding dictated a change in the surgical plan, adding resection of aortic valve masses to the planned excision of the left atrial tumor and patent foramen ovale closure. The uniqueness of this case derives from the coexistence of rare primary cardiac tumors. There are only five cases in literature of myxoma concomitant with fibroelastoma and the occurrence of multiple fibroelastoma is also extremely rare. Moreover this case emphasizes the benefit of the intraoperative use of transesophageal echocardiography to improve the diagnosis and management of cardiac surgical patients.

[Left ventricle free wall rupture - a 10-year experience]

The left ventricle free wall rupture is one of the most serious and lethal complications associated to myocardial infarction.The most common treatment in our days consists in direct closure of the rupture with pericardium or synthetic material, applied with the help of histoacryl glue, without extracorporeal circulation.Between January 2000 and September 2010, 35 consecutive patients underwent operation for left ventricle free wall rupture at our hospital.The mean age was 69,5 years and most of the patients were male ( 65,7 % ). 2,9 days was the mean time for rupture after infarction and the anterior and lateral wall were most frequently involved. 94,7 % of the patients were in shock. Surgery was performed without extracorporeal circulation using a patch of pericardium and/or Dacron Sauvage, with histoacryl glue in 85,7 % of cases.Mean time of ICU stay was 7,9 days, in-hospital global mortality 28,6 %. At 2,5 years follow-up, 86 % of the patients were alive.Despite the high morbidity and mortality associated to surgery, the procedure is now safer, simpler and quick allowing the treatment of a situation that conducted to a most certain death without management.

[Pulmonary arteriovenous malformations in Rendu-Osler-Weber disease. Case report]

The authors report the clinical case of a 59 year-old woman who was incidentally diagnosed as having arteriovenous pulmonary malformation (AVPM). Through clinical history a diagnosis of Rendu-Osler-Weber disease (ROWD) was made, a disease manifesting itself through the existence of vascular malformations in the skin, mucosae and viscera (like the lungs, liver and brain). The surgical therapy offered to the patient had no complications. The essential aspects of pathofisiology, clinical manifestations and treatment of AVPM and ROWD are discussed.

[Minimally invasive thoracic surgery: a fifteen-years experience]

The evolution of surgical techniques has rendering possible for thoracic surgery to be performed efficiently and safely, with less aggressive approaches. Being less traumatic, minimally invasive surgery allows a faster post-operative recovery, less complications and reduces in patient days and morbidity. The authors consider as minimally invasive approaches the video-assisted thoracic surgery, as well as the minithoractomy and the ministernotomy. The present paper reviews thoracic surgeries performed for the last 15 years in a cardiothoracic surgical unit using a minimally invasive surgical approach.

[Intra-thoracic goiter: analysis of the Department's experience]

A review of all clinical files with pre-operative diagnosis of intra-thoracic goiter operated in our Department from 2001-2009 was made. We identified 30 patients, of which 66% were females. 63% of the patients were asymptomatic, 46% had clinical or radiological findings of mediastinal structures compression and 2 patients were ventilated prior to surgery. 50% of the patients were operated on through an inferior transverse cervicotomy, the remaining were operated on through partial or complete sternotomy, with cervical approach. 6,6% of patients (n=2) had an intra-operative diagnosis of invasive thymoma, 3,3% (n=1) had a very invasive mediastinal tumor and 3,3% (n=1) had an ectopic thyroid. Average surgical length of time was of 83 minutes. In 10% of patients (n=3) post-operative invasive ventilation was required, one of which for unilateral permanent lesion of the recurrent laryngeal nerve. In the long term follow-up we assessed 18 patients. The median follow up was 53 months. One patient died at the 15th post-operatory day of pneumonia, one expired at the 30th day for anaplasic thyroid carcinoma progression and one died at the 18 month from invasive thymoma progression. One patient currently reveals evidence of local recurrence 3 patients are currently taking levothyroxine and one is taking propiltiouracil. Pathological studies revealed that 66% of cases were multinodular goiter and neoplasia was present in 13% of the patients. Other results were thymic pathology in 13% of cases (n=4), parathyroid cyst in 3,3% (n=1), and ectopic thyroid in 3,3% (n=1(.

[Kommerell diverticula associated with dysphagia: a clinical case and review of the literature]

We report the case of a young female with disphagia and weigth loss caused by a vascular ring associated with right aortic arch, Kommerell diverticula, and left retroesophageal ligamentum arteriosum (ductus arteriosus). The patient underwent surgical treatment. A left thoracotomy was performed. Surgical technique included diverticulum ressection and an aortopexia. There were no major complications. We also discuss the incidence, pathology, diagnosis, clinical features and treatment of this rare disease.

Early Posttransplant Lymphoproliferative Disease in Pediatric Liver Transplant Recipients

Among 23 pediatric patients who underwent orthotopic liver transplant (OLT), we report two (11 and 26 months old) with posttransplant lymphoproliferative disease (PTLD) that occurred in the early posttransplantation period. They were Epstein-Barr Virus (EBV)-negative and received graft from EBV-positive donors. The surveillance for EBV viremia using serial EBV polymerase chain reaction determinations in the peripheral blood was positive at 10 and 90 days after OLT concomitant with symptoms of primary infection, both patients were treated with gancyclovir. The patients should progression to a Burkitt's and a non-Hodgkin's lymphoma that appeared 3 months posttransplantation. They were treated by withdrawal of immunosuppression and six courses of cyclophosphamide as well as anti-CD20 monoclonal antibody (Rituximab) every 21 days. One patient experienced acute graft rejection, which resolved with steroids and low doses of tacrolimus, she is free of disease at 24 months after the end of treatment. The other patient relapsed with a cerebral lymphoma, receiving aggressive chemotherapy, but died due to sepsis. In conclusion, PTLD occurred among in 2/23 patients who underwent OLT and appeared in the first quarter post OLT. The risk factors associated with early PTLD were primary EBV infection after OLT, young age, and EBV-negative recipient receiving a transplant from an EBV-positive donor. Antiviral treatment alone was inefficient; withdrawal of immunosuppression and courses of Rituximab and cyclophosphamide were well tolerated and controlled PTLD. The risk of graft rejection was increased by withdrawal of immunosuppression. One patient died.

Oxygen consumption, lactate metabolism, and gastric intramucosal pH in an experimental liver transplantation model

OBJECTIVE

To assess the usefulness of measuring whole-body oxygen consumption (VO2), arterial lactate concentration, and gastric intramucosal pH (pHi) as parameters for evaluating hepatic graft viability in a model of experimental liver transplantation.

DESIGN

Experimental, prospective study.

SETTING

Hospital laboratory for experimental surgery.

SUBJECTS

Twenty-eight Landrace-Largewhite pigs: 14 donors and 14 recipients.

INTERVENTIONS

Orthotopic liver transplantation. Two groups were differentiated by graft preservation status: an optimal-graft group (group 1), which received donor livers that had been preserved in Collins solution at 4 degrees C for <4 hrs (n = 7), and an injured-graft group (group 2), which received donor livers that had been preserved in Collins solution at 4 degrees C for >24 hrs (n = 7).

MEASUREMENTS AND MAIN RESULTS

Hemodynamic parameters, variables related with systemic and hepatic oxygen and lactate metabolism, gastric pHi, and arterial pH were measured at two stages: a) preanhepatic stage; and b) neohepatic stage (60 mins after reperfusion). There were no differences in VO2 between graft groups or stages. In the neohepatic stage, hepatic oxygen extraction and lactate turnover were significantly higher in the optimal-graft group than in the injured-graft group. In the neohepatic stage, gastric pHi decreased significantly and arterial lactate concentrations increased significantly in both groups.

CONCLUSIONS

Changes in hepatic VO2 cannot be detected by VO2 measurements. Optimal-state grafts increased their lactate turnover as a result of substrate overload, but injured grafts did not. Therefore, the evolution of arterial lactate concentrations in the immediate postoperative period may be useful for the early evaluation of transplanted livers. Gastric pHi can be a useful measurement in the immediate posttransplantation period for differentiating between hyperlactacidemia produced by liver dysfunction (normal pHi) and hyperlactacidemia produced by lactate generation as a consequence of inadequate tissue oxygenation or of a mixed origin (abnormal pHi).

Infection and associated risk factors in the immediate postoperative period of pediatric liver transplantation: a study of 176 transplants

OBJECTIVE

To describe the characteristics of infections occurring in the immediate postoperative period of orthotopic liver transplantation (OLT) in children in a pediatric intensive care unit (PICU) and the associated risk factors.

DESIGN

Retrospective cohort study.

SETTING

Multidisciplinary 16-bed pediatric intensive care unit in a tertiary university hospital.

PATIENTS

One hundred and thirty-three pediatric patients (range 6M to 22 yr) who underwent 176 liver transplantations and were admitted to the pediatric intensive care unit for at least 48 h.

RESULTS

A total of 180 infectious episodes (IE) occurred in 78 (59%) patients who underwent 96 (54.5%) liver transplantations (1.35 IE/patient; 1.02 IE/transplantation). The mean stay was 15.4 +/- 1.1 d (mean +/- SD) and 22 patients died in the pediatric intensive care unit. One hundred and thirty-one IE (72.8%) were bacterial, 31 (17.2%) fungal, and 14 (7.8%) mixed bacterial and fungal. 39% of the IE appeared in the first postoperative week and 27% in the second postoperative week. The most common sites of infection were abdomen (48.3%) and blood stream (26.1%). Bacteria, alone or with fungi, were present in 145 IE (1.1 IE/patient). Gram-positive aerobic bacteria (63%) predominated over gram-negative bacteria (54%) and fungi. Fungi were present in 45 IE; 53.4% of the infections occurred in lung (73% yeasts). The risk factors for infection that were identified were related with younger age, lower body weight, longer cold ischemia time, partial graft, and the volume of packed red blood cell transfusions. Infected patients had more postoperative complications and longer stay in the PICU (21 +/- 16 vs. 8 +/- 6 d), but no increase in mortality. The risk of infection increased 2.38 times with partial grafts and 1.1 times with each intraoperative transfusion of 20 ml/kg of packed red blood cells (RBC).

CONCLUSIONS

Infection in the immediate postoperative period of pediatric OLT was related with a high morbidity but was not related significantly with increased mortality. The main risk factors for infection in the postoperative period of OLT were related essentially with small recipient size and the inherent complexity of the operation. Routine oropharyngeal decontamination is recommended, as well as early administration of oral nystatin in preoperative intestinal decontamination. The risk of infection increased 2.38 times with partial grafts and 1.1 times with the transfusion of every 20 ml of packed RBC.