Duration Of Intensive Care Research Articles

Clinical study of ventilator associated pneumonia in a tertiary care centre

Background: Ventilator associated pneumonia (VAP) remains to be the commonest cause of hospital morbidity and mortality in spite of advances in diagnostic techniques and management. VAP refers to bacterial pneumonia developing in patients who have been receiving mechanical ventilation for at least 48 hours. It is the commonest complication associated with mechanical ventilation. The objectives were to know the incidence and outcome of VAP in a tertiary care centre at Indira Gandhi Institute of child health (IGICH) and to identify the probable risk factors for ventilator associated pneumonia (VAP) and to identify the most common pathogenic bacteria causing VAP. Methods: This is a prospective study of children mechanically ventilated in the pediatric intensive care unit of Indira Gandhi Institute of Child Health. Children between the age group of >1month to <18 years were included in the study. Ventilator associated pneumonia is defined as per the clinical pulmonary infection score given by Pugin et al, patients were monitored with various clinical and laboratory parameters like fever, purulent endotracheal aspirates, pulmonary radiological changes, leukocytosis, arterial blood gas analysis, blood culture and endotracheal tube aspirate grams stain and culture and sensitivity pattern and other relevant investigations. Results: Out of the seventy five children requiring mechanical ventilation 17 developed VAP giving the incidence of 22.66%. Early onset VAP constituted 41.1% of the cases and the rest is late onset VAP (58.9%). Reintubation of more than 2 times, central venous lines, tracheostomy and prolonged ventilation are the risk factors for VAP. Pseudomonas (6), Klebsiella (8) were the most frequent and significant etiological agents causing VAP. Pseudomonas and Klebsiella are the common organisms in late onset VAP and Staphylococcus aureus (MRSA) (2) and E coli (1) are isolated in early onset VAP. There is no statistically significant difference in mortality between the VAP and Non-VAP cases. VAP prolongs the duration of mechanical ventilation, length of intensive care and the duration of hospital stay compared to the Non VAP cases. The average duration of ventilation in VAP cases is 6.68±4.12 days. The mean duration of PICU care (16.65days) and hospital stay in VAP children is also prolonged (20.53 days) and it is statistically significant. Conclusions: VAP is an important nosocomial infection in PICU with the incidence of 22.66%. Prolonged ventilation and repeated intubations are the major risk factors. Central venous lines and tracheostomy are the added risk factors for VAP. Judicious use of ventilator support and early weaning will reduce the incidence of VAP. Gram negative organisms are the most common organisms causing VAP. VAP did not influence the mortality but it did prolong the duration of ventilation, intensive care and hospital stay in turn increasing the morbidity.

Intoxication Cases in an Intensive Care Unit

Aim: Intoxication is the development of unwanted effects due to exposure to an agent. We retrospectively investigated intoxication cases requiring intensive care treatment, and aim to present demographics, etiologies and prognoses. Material and Methods: We retrospectively investigated records of 23 patients, who were diagnosed with acute drug intoxication and treated in surgical intensive care unit during January 2013 and January 2014. Results: Data from a total of 23 patients (12 female, 52,5%) were analysed. The mean age of the patients was 26±10 years in women and 37±19 years in men. The reason of acute intoxication was suicide attempt with drugs in twenty patients (87%), bee bites in 2 patients (9%), and alcohol intoxication in one patient (3%). Five patients required mechanical ventilation secondary to respiratory insufficiency for an average of 9.6 days. The overall average duration of intensive care stay was 4.6 days. Conclusion: We conclude that majority of patients requiring intensive care treatment due to acute intoxication were female patients who attempted suicide and these patients required a very short duration of follow-up. We are in the opinion that follow-up quality of these patients and clinical management of intensive care units may benefit from periodical retrospective analysis of acute intoxication cases. Keywords: Intensive Care; Intoxication; Suicide.

Effect of Early Tracheostomy on Resource Utilization and Clinical Outcomes in Critically Ill Patients

Background Early tracheostomy may decrease the duration of mechanical ventilation, sedation exposure, and intensive care stay, possibly resulting in improved clinical outcomes, but the evidence is conflicting. Methods Systematic review and meta-analysis of randomized trials in patients allocated to tracheostomy within 10 days of start of mechanical ventilation was compared with placement of tracheostomy after 10 days if still required. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register, and Google Scholar were searched for eligible trials. The co-primary outcomes were mortality within 60 days, and duration of mechanical ventilation, sedation, and intensive care unit stay. Secondary outcomes were the number of tracheostomy procedures performed, and incidence of ventilator-associated pneumonia (VAP). Outcomes are described as relative risk or weighted mean difference with 95% confidence intervals. Results Of note, 4482 publications were identified and 14 trials enrolling 2406 patients were included. Tracheostomy within 10 days was not associated with any difference in mortality [risk ratio (RR): 0.93 (0.83–1.05)]. There were no differences in duration of mechanical ventilation [−0.19 days (−1.13–0.75)], intensive care stay [−0.83 days (−2.05–0.40)], or incidence of VAP. However, duration of sedation was reduced in the early tracheostomy groups [−2.78 days (−3.68 to −1.88)]. More tracheostomies were performed in patients randomly assigned to receive early tracheostomy [RR: 2.53 (1.18–5.40)]. Conclusion We found no evidence that early (within 10 days) tracheostomy reduced mortality, duration of mechanical ventilation, intensive care stay, or VAP. Early tracheostomy leads to more procedures and a shorter duration of sedation.

Influence of biomarkers level during follow-up when operating under cardiopulmonary bypass

Systemic inflammatory response was first determined in 1980 and cardiac surgeons turned to it in 1996. At present, there are a lot of publications on this issue, however, the extent of operation and duration of CPB are considered in clinical practice as crucial indicators of severity of patient's condition following cardiac surgery. In our study we tried to look at this problem from a different perspective and draw a parallel between the severity of patient's condition resulting from operational trauma and CPB. We included 48 patients who under-went cardiac surgery under CPB. Plasma levels of procalcitonin (PCT), lactate and interleukin-6 were investigated before the operation, after CPB and at 24 hours. Also revealed was the relationship between the plasma levels of IL-6, lactate and PCT (r = 0.53; p = 0.000 in both cases). The level of PCT at the 3rd stage was found to relate to the duration of CPB (r = 0.4; p = 0.005), ALV (r = 0.44; p = 0.001) and length of stay at ICU (r = 0.53; p = 0.000). We didn't manage to find any relationship between the length of stay at ICU and the duration of CPB. Correlation between the PCT plasma level and the duration of intensive care indicates the importance of dynamics of the given biomarker for early prediction of follow-up course after open-heart surgery.

Postoperative Hyperglycemia and 4-Year Neurodevelopmental Outcome in Children Operated for Congenital Heart Disease

To study the long-term neurodevelopmental effects of hyperglycemia in infant bypass surgery for congenital heart disease (CHD). Prospective cohort study on neurodevelopmental outcome after infant cardiac bypass surgery. age older than 1 year at first surgery, genetic comorbidity, and birth weight <2000 g. Of 167 eligible infants, follow-up examination at 4 years was completed in 150 children (90%). Intraoperative and postoperative highest and lowest glucose levels within 24 hours after bypass surgery were prospectively collected. Neurodevelopmental outcome at 4 years of age was assessed using standardized IQ tests and the Movement Assessment Battery for Children-second version for motor outcome assessment. Mean age at surgery was 2.8 months (0.1-10.7 months), 33% of children had an acyanotic CHD and 67% a cyanotic CHD. Glucose levels were elevated (>8 mmol/L) in 21 (14%) children in the first 24 postoperative hours. Glucose levels normalized in all children within 48 hours, 7 children (4%) received insulin infusions. Mean total IQ was within the normal range, but significantly lower than the normal population (92.5 [SD 15.0], P < .001). Higher postoperative glucose levels were related to better cognitive performance in the univariate analysis (P < .03), but not when other risk factors were taken into account. Independent risk factors for adverse outcome were lower socioeconomic status, higher risk adjustment for congenital heart surgery score, and longer duration of intensive care stay. Hyperglycemia is common in the early postoperative course after infant bypass surgery for CHD and normalizes within 48 hours. Hyperglycemia has no adverse effect on long-term neurodevelopmental outcome.

Intravenous Artesunate Reduces Parasite Clearance Time, Duration of Intensive Care, and Hospital Treatment in Patients With Severe Malaria in Europe: The TropNet Severe Malaria Study.

Intravenous artesunate improves survival in severe malaria, but clinical trial data from nonendemic countries are scarce. The TropNet severe malaria database was analyzed to compare outcomes of artesunate vs quinine treatment. Artesunate reduced parasite clearance time and duration of intensive care unit and hospital treatment in European patients with imported severe malaria.

Oxygen balance and systemic inflammation after cardio-pulmonary bypass in elderly patients with different intensive care duration

Background & Aim. The aim was to investigate the prognostic significance of oxygen balance and systemic inflammation after cardio-pulmonary bypass (CPB) in elderly patients (pts). Methods. We evaluated 78 pts aged more than 74 years old undergoing cardiac surgery. Mixed venous saturation (SvO2), oxygen delivery (DO2), oxygen consuption (VO2), O2 extraction rate (ERO2), arterio-venous O2 difference (A-V O2), lactate level after CPB, postoperative leukocytosis, intensive care unit (ICU) stay were registered. Data are given as mean SD. Student’s t-test was used with Po0.05 as significant. Results. Fifty two pts were discharged from ICU within one day after surgery (group 1). The rest 26 pts (group 2) had ICU staing 5 2 days, characterized by lover post-CPB DO2, VO2, ERO2, AV O2, higher SvO2, lactate (table). Leucocytes number had the significant (po0,05) dirrect correlation (r1⁄40.58) with SvO2, and inverse (r 0.64) – with A-V O2.

Anesthetic Management for Left Ventricular Assist Device Implantation Without Using Cardiopulmonary Bypass: Case Series

PurposeVentricular assist devices are an alternative to medical treatment in patients with hemodynamic disturbances related to acute or chronic congestive heart failure. In this case series, we present our anesthesia management for implantation of left ventricular assist device (LVAD) with thoracotomy. MethodSixteen patients with end-stage heart failure undergoing LVAD implantation via thoracotomy between November 2012 and August 2014 were analyzed prospectively. Preoperative characteristics, intraoperative hemodynamic and respiratory parameters, use of anesthetic and blood products, and durations of mechanical ventilation, hospital, and intensive care stays were recorded. ResultsSixteen patients (mean age, 54.6 ± 13 years) were investigated. Single-lung ventilation was applied to 2 patients. Cardiopulmonary bypass (CPB) was required in 5 patients. Intraoperative ketamine, midazolam, fentanyl, and rocuronium requirements were 112 ± 63 mg, 5.5 ± 3.5 mg, 438 ± 187 μg, and 179 ± 49 mg, respectively. Requirements of fresh donor blood, fresh frozen plasma, and thrombocyte and erythrocyte suspension were 1.19 ± 1, 1 ± 0.8, 0.44 ± 0.5, and 0.25 ± 0.7 U, respectively. Durations of mechanical ventilation, intensive care unit, and hospital stay were 46 ± 53 hours, 8.2 ± 6.6 days, and 20.5 ± 11.6 days, respectively. Twelve patients were discharged from hospital with full recovery and 2 patients died; 2 patients are still receiving treatment in the hospital. ConclusionA left thoracotomy approach can be used without CPB, because it reduces the incidences of pump complications and blood transfusion. In addition, this case series showed that the implantation of LVAD by thoracotomy can be implemented securely with single-lumen endotracheal tube without single-lung ventilation.

Factors affecting perioperative mortality in tetralogy of Fallot.

We evaluated the preoperative, operative and postoperative risk factors affecting early mortality in patients who underwent total correction of tetralogy of Fallot (TOF). One hundred and twenty-two TOF patients who underwent reparative surgery between January 2010 and November 2013 were enrolled in the study. Mean patient age and weight was 2.3 ± 2.5 years and 11.3 ± 6.4 kg, respectively. Cardiac catheterization was performed in 101 patients (83%),and coronary anomalies were found in 11 patients. Mean McGoon index, pulmonary annulus z-score, main pulmonary artery z-score, left pulmonary artery z-score and right pulmonary artery z-score were 2.0 ± 0.4, -1.85 ± 1.54, -2.84 ± 2.06, 1.17 ± 1.73, and 0.74 ± 1.57, respectively. Total reparative surgery with a transannular patch was performed in 97 patients (79.6%); the rest underwent valve-sparing surgery. Median duration of postoperative mechanical ventilation, intensive care and hospital stay were 19 h, 3 days and 9 days, respectively. Extracorporeal membrane oxygenation (ECMO) was required in 10 patients in the postoperative early period. Arrhythmias occurring in the early postoperative period were junctional ectopic tachycardia (n = 13), complete atrioventricular block(n = 10; permanent epicardial pacemaker implanted in four) and ventricular tachycardia (n = 4). Nine patients died in the early postoperative period (7.3%). Parameters found to be associated with increased mortality were low preoperative oxygen saturation; high right ventricular/aortic pressure ratio immediately after surgery; presence of coronary anomaly; requirement of postoperative ECMO; and pacemaker (P = 0.02, P = 0.04, P = 0.01, P = 0.0001, P = 0.03, respectively). Poor preoperative oxygenation, presence of coronary anomaly, complete AV block in the early postoperative period, high RV pressure and requirement of ECMO appear to be the most significant factors that affect early mortality in the surgical treatment of TOF. Appropriate preoperative assessment, correct surgical strategies and attentive intensive care monitoring are required in order to reduce mortality.

Extracorporeal Life Support Bridge to Ventricular Assist Device: The Double Bridge Strategy.

In patients requiring left ventricular assist device (LVAD) support, it can be difficult to ascertain suitability for long-term mechanical support with LVAD and eventual transplantation. LVAD implantation in a shocked patient is associated with increased morbidity and mortality. Interest is growing in the utilization of extracorporeal life support (ECLS) as a bridge-to-bridge support for these critically unwell patients. Here, we reviewed our experience with ECLS double bridging. We hypothesized that ECLS double bridging would stabilize end-organ dysfunction and reduce ventricular assist device (VAD) implant perioperative mortality. We conducted a retrospective review of prospectively collected data for 58 consecutive patients implanted with a continuous-flow LVAD between January 2010 and December 2013 at The Alfred Hospital, Melbourne, Victoria, Australia. Twenty-three patients required ECLS support pre-LVAD while 35 patients underwent LVAD implantation without an ECLS bridge. Preoperative morbidity in the ECLS bridge group was reflected by increased postoperative intensive care duration, blood loss, blood product use, and postoperative renal failure, but without negative impact upon survival when compared with the no ECLS group. ECLS stabilization improved end-organ function pre-VAD implant with significant improvements in hepatic and renal dysfunction. This series demonstrates that the use of ECLS bridge to VAD stabilizes end-organ dysfunction and reduces VAD implant perioperative mortality from that traditionally reported in these "crash and burn" patients.

Influence of Parkinson's Disease on the Perioperative Course of Patients after Lumbar Fusion Surgery

The incidence of Morbus Parkinson (MP) increases with age. An increasing number of patients with MP in the orthopaedic patient population is expected. In the case of general surgery and trauma surgery MP in patients was identified as an important factor for perioperative morbidity. This study investigates the influence of MP on the perioperative course of patients after elective lumbar fusion. A retrospective matched-pairs analysis with 17 patients in each group was conducted with patients treated in the department of spinal surgery in an orthopaedic university hospital for symptomatic degenerative lumbar spine disease without improvement after conservative therapy. The analysis compared the perioperative courses of patients with MP (MP) and patients without MP (no MP) concerning duration of hospital and intensive care treatment, duration for mobilisation, rehabilitation and occurrence of complications. The mean duration of inpatient treatment (MP 18.4 ± 11.6 d; no MP 14.7 ± 5.4 d), duration of intensive care (MP 1.7 ± 4.2 d; no MP 1,0 ± 1,9 d) and duration for mobilisation (MP 8.8 ± 12.46 d; no MP 5.0 ± 4.2 d) tend to be longer for MP patients. There was no statistically significant difference between both patient groups. A rehabilitative inpatient follow-up treatment was more frequent in patients with MP (MP n = 4; no MP n = 2). None of the two groups showed an increased occurrence of complications. While general surgery and trauma surgery patients show significant differences regarding duration of inpatient treatment, more frequent falls and more frequent rehabilitative inpatient follow-up treatments, patients after elective lumbar fusion show only a trend. Possibly the result is due to the underlying degenerative disease of the lumbar spine with spinal stenosis and gait disturbance in the MP group and as well in the control group. Therefore both groups suffered from impaired mobility. Additionally there was a high incidence of other comorbidities in the control group, which could have affected the results of this study. Another limitation is the number of the included patients. Although, this study showed no increased occurrence of complications, typical risk factors, like increased risk for airway complications, urinary tract infection and falls, should be considered for the treatment of MP patients.

Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries.

This single-centre study evaluated the efficacy of damage control surgery and delayed pancreatoduodenectomy and reconstruction in patients who had combined severe pancreatic head and visceral venous injuries. Prospectively recorded data of patients who underwent an initial damage control laparotomy and a subsequent pancreatoduodenectomy for severe pancreatic injuries were evaluated to assess optimal operative sequencing. During the 20-year study period, 312 patients were treated for pancreatic injuries of whom 14 underwent a pancreatoduodenectomy. Six (five men, one woman, median age 20, range 16-39years) of the 14 patients were in extremis with exsanguinating venous bleeding and non-reconstructable AAST grade 5 pancreatoduodenal injuries and underwent a damage control laparotomy followed by delayed pancreatoduodenectomy and reconstruction when stable. During the initial DCS, the blood loss compared to the subsequent laparotomy and definitive procedure was 5456ml, range 2318-7665 vs 1250ml, range 850-3600ml (p<0.01). The mean total fluid administered in the operating room was 11,150ml, range 8450-13,320 vs 6850ml, range 3350-9020ml (p<0.01). The mean operating room time was 113min, range 90-140 vs 335min, range 260-395min (p<0.01). During the second laparotomy five patients had a pylorus-preserving pancreatoduodenectomy and one a standard Whipple resection. Four of the six patients survived. Two patients died in hospital, one of MOF and coagulopathy and the other of intra-abdominal sepsis and multi-organ failure. Median duration of intensive care was 6days, (range 1-20days) and median duration of hospital stay was 29days, (range 1-94days). Damage control laparotomy and delayed secondary pancreatoduodenectomy is a live-saving procedure in the small cohort of patients who have dire pancreatic and vascular injuries. When used appropriately, the staged resection and reconstruction allows survival in a previously unsalvageable group of patients who have severe physiological derangement.

Prophylactic milrinone for the prevention of low cardiac output syndrome and mortality in children undergoing surgery for congenital heart disease.

Children with congenital heart disease often undergo heart surgery at a young age. They are at risk for postoperative low cardiac output syndrome (LCOS) or death. Milrinone may be used to provide inotropic and vasodilatory support during the immediate postoperative period. This review examines the effectiveness of prophylactic postoperative use of milrinone to prevent LCOS or death in children having undergone surgery for congenital heart disease. Electronic and manual literature searches were performed to identify randomised controlled trials. We searched CENTRAL, MEDLINE, EMBASE and Web of Science in February 2014 and conducted a top-up search in September 2014 as well as clinical trial registries and reference lists of published studies. We did not apply any language restrictions. Only randomised controlled trials were selected for analysis. We considered studies with newborn infants, infants, toddlers, and children up to 12 years of age. Two review authors independently extracted data according to a pre-defined protocol. We obtained additional information from all study authors. Three of the five included studies compared milrinone versus levosimendan, one study compared milrinone with placebo, and one compared milrinone verus dobutamine, with 101, 242, and 50 participants, respectively. Three trials were at low risk of bias while two were at higher risk of bias. The number and definitions of outcomes were non-uniform as well. In one study comparing two doses of milrinone and placebo, there was some evidence in an overall comparison of milrinone versus placebo that milrinone lowered risk for LCOS (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.28 to 0.96; 227 participants). The results from two small studies do not provide enough information to determine whether milrinone increases the risk of LCOS when compared to levosimendan (RR 1.22, 95% CI 0.32 to 4.65; 59 participants). Mortality rates in the studies were low, and there was insufficient evidence to draw conclusions on the effect of milrinone compared to placebo or levosimendan or dobutamine regarding mortality, the duration of intensive care stay, hospital stay, mechanical ventilation, or maximum inotrope score (where available). Numbers of patients requiring mechanical cardiac support were also low and did not allow a comparison between studies, and none of the participants of any study received a heart transplantation up to the end of the respective follow-up period. Time to death within three months was not reported in any of the included studies. A number of adverse events was examined, but differences between the treatment groups could not be proven for hypotension, intraventricular haemorrhage, hypokalaemia, bronchospasm, elevated serum levels of liver enzymes, or a reduced left ventricular ejection fraction < 50% or reduced left ventricular fraction of shortening < 28%. Our analysis did not prove an increased risk of arrhythmias in patients treated prophylactically with milrinone compared with placebo (RR 3.59, 95% CI 0.83 to 15.42; 238 participants), a decreased risk of pleural effusions (RR 1.78, 95% CI 0.92 to 3.42; 231 participants), or a difference in risk of thrombocytopenia on milrinone compared with placebo (RR 0.86, 95% CI 0.39 to 1.88; 238 participants). Comparisons of milrinone with levosimendan or with dobutamine, respectively, did not clarify the risk of arrhythmia and were not possible for pleural effusions or thrombocytopenia. There is insufficient evidence of the effectiveness of prophylactic milrinone in preventing death or low cardiac output syndrome in children undergoing surgery for congenital heart disease, compared to placebo. So far, no differences have been shown between milrinone and other inodilators, such as levosimendan or dobutamine, in the immediate postoperative period, in reducing the risk of LCOS or death. The existing data on the prophylactic use of milrinone has to be viewed cautiously due to the small number of small trials and their risk of bias.

Palifermin for prevention of oral mucositis in allogeneic hematopoietic stem cell transplantation: a single-institution retrospective evaluation.

The purpose of this study is to assess the impact of palifermin on oral mucositis (OM) and its sequelae in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) who were conditioned with fractionated total body irradiation (FTBI) and etoposide. This retrospective chart review study compared the effect of palifermin on the development of OM in patients who received this agent during an allo-HSCT (n = 99) to those who did not (n = 30). The primary end points were severity and duration of OM. Secondary end points included requirements for opioids, total parenteral nutrition (TPN), and intensive oral care; incidence of infection; length of hospital stay; and overall survival. There was no significant difference in the incidence of all grades of OM, but incidence of severe OM was decreased in palifermin-exposed patients (34 vs 80 %, p < 0.0001). In patients who developed OM (all grades), the median duration of OM was shorter in palifermin-exposed patients (13 vs 18 days, p = 0.0001); there was no difference in the median duration of severe OM. Patients who received palifermin used less opioids and required a shorter duration of intensive oral care. There was no difference in duration of TPN, incidence of infection, length of hospital stay, and overall survival. Our findings demonstrated a significant benefit with the use of palifermin for allo-HSCT recipients who were conditioned with FTBI and etoposide. Palifermin can potentially improve quality of life for this patient population and reduce complications and resources used during the transplant process. A randomized clinical trial is required to confirm these results.

Haemoglobin level at birth is associated with short term outcomes and mortality in preterm infants.

BackgroundBlood volume and haemoglobin (Hb) levels are increased by delayed umbilical cord clamping, which has been reported to improve clinical outcomes of preterm infants. The objective was to determine whether Hb level at birth was associated with short term outcomes in preterm infants born at ≤32 weeks gestation.MethodsData were collected retrospectively from electronic records: Standardised Electronic Neonatal Database, Electronic Patient Record, Pathology (WinPath), and Blood Bank Electronic Database. The study was conducted in a tertiary perinatal centre with around 5,500 deliveries and a neonatal unit admission of 750 infants per year. All inborn preterm infants of 23 to 32 weeks gestational age (GA) admitted to the neonatal unit from January 2006 to September 2012 were included.The primary outcomes were intra-ventricular haemorrhage, necrotising entero-colitis, broncho-pulmonary dysplasia, retinopathy of prematurity, and death before discharge. The secondary outcomes were receiving blood transfusion and length of intensive care and neonatal unit days. The association between Hb level (g/dL) at birth and outcomes was analysed by multiple logistic regression adjusting for GA and birth weight (BWt).ResultsOverall, 920 infants were eligible; 28 were excluded because of missing data and 2 for lethal congenital malformation. The mean (SD) GA was 28.3 (2.7) weeks, BWt was 1,140 (414) g, and Hb level at birth was 15.8 (2.6) g/dL.Hb level at birth was significantly associated with all primary outcomes studied (P <0.001) in univariate analyses. Once GA and BWt were adjusted for, only death before discharge remained statistically significant; the OR of death for infants with Hb level at birth <12 g/dL compared with those with Hb level at birth of ≥18 g/dL was 4.1 (95% CI, 1.4–11.6). Hb level at birth was also significantly associated with blood transfusion received (P <0.01) but not with duration of intensive care or neonatal unit days.ConclusionsLow Hb level at birth was significantly associated with mortality and receiving blood transfusion in preterm infants born at ≤32 weeks gestation. Further studies are needed to determine the association between Hb level at birth and long-term neurodevelopmental outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0247-6) contains supplementary material, which is available to authorized users.

TRACHEOSTOMY PRACTICE IN A UK DGH: ARE WE MOVING WITH THE TIMES?

Tracheostomy is commonly performed in critically ill patients with the objective of increasing comfort and shortening the duration of sedation, mechanical ventilation, and intensive care stay [1]. As the percutaneous technique has become widely available, the earlier use of tracheostomy has become commonplace [2, 3]. Consequently, there is ongoing debate about the benefits of early tracheostomy [4].

291-POS

Objectives In addition to blood pressure control, postpartum control of urine output is a major issue in hypertensive pregnancy, HELLP syndrome or placental abruption. Delayed diuresis after delivery may easily cause abdominal dropsy, pulmonary edema, or late-onset renal failure. We recently added a new medicine, carperitide (atrial natriuretic peptide, hANP®), in addition to standard diuretic, like furosemide, for diuresis in such severe postpartum conditions. The objective of this study was to reveal the clinical and cost effectiveness of use carperitide in postpartum intensive care after preeclampsia. Methods Medical records of the patients who were administered carperitide in Nara Medical University Hospital after delivery or cesarean section for severe preeclampsia, HELLP syndrome and placental abruption were reviewed. Six patients who used carperitide were compared with ten patients who did not. Duration between delivery or administration of carperitide and maternal massive diuresis were retrieved as well as background, maternal outcome, duration of stay in hospital and blood pressure. Results There have been no maternal deaths or the need for artificial dialysis after these diseases for recent five years. Use of carperitide significantly decreased maternal mean blood pressure after 48 h of operation and shortened the duration between delivery or cesarean section and massive diuresis. No adverse effect was defined. Conclusions Though it was not a randomized, controlled study, in the intensive care setting, use of carperitide in infusion-and-output control after preeclampsia and related severe diseases was associated with improved kidney protection, shortened duration of intensive care and hospitalization with fewer side effects. In difficulty of hydration control after preeclampsia, carperitide may be a useful medicine for intensive maternal care. Disclosures A. Shigemitsu: None. J. Akasaka: None. H. Shigetomi: None. T. Tsunemi: None. N. Koike: None. K. Iwai: None. K. Naruse: None. H. Kobayashi: None.

Results of surgical treatment for pulmonary aspergilloma

Aspergilloma results from the development, inside preexisting pulmonary cavities, of aspergillus spores. It is most commonly manifested by hemoptysis. The goal of this retrospective study is to report our surgical experience of this disease. From January 2004 to December 2008, 35 patients underwent surgery at the same center for pulmonary aspergilloma. We examined the epidemiological, clinical, paraclinical, therapeutic, and outcome data. The patients' median age was 43.37 years (range: 20-70 years), 28 were male. The average time to consultation was 19.35 months (1-120 months), and all patients had a history of pulmonary tuberculosis. Hemoptysis was the symptom observed most often, in 54.3% of patients, followed by bronchorrhea. Aspergillus serology was positive for 22 patients. The standard radiological image was found in 20 patients. We performed 14 lobectomies, 1 bilobectomy, 1 segmentectomy, 1 bisegmentectomy, 3 lobectomies with segmentectomies, 1 bilobectomy with segmentectomy, and 14 pleuropneumonectomies. In one case, the pulmonary artery was damaged and repaired. The average duration of intensive care was 3.54 days (2-7 days) and of total hospitalization, 17.33 days (7-48). Complications were: empyema (3 cases), a large air leak (1 case), parietal suppuration (5 cases), and pleural effusion, which was drained (3 cases). There was no postoperative mortality. After 35 months (1-72), one case of recurrent hemoptysis by reinfestation was observed. Three patients died of respiratory failure, one at 6 months and the other two at 1 year after the surgery. Despite the associated morbidity, surgical treatment of pulmonary aspergilloma must be proposed systematically to these subjects presenting hemoptysis.

Physician's preference-based instrumental variable analysis: is it valid and useful in a moderate-sized study?

Instrumental variable methods can potentially circumvent the unmeasured confounding inherent in observational data analyses. We investigated the validity and usefulness of physician's preference instrumental variable analysis in the setting of a moderate-sized clinical study. Using routine care data from 476 elective cardiac surgery patients, we assessed the effect of preoperative corticosteroids on mechanical ventilation time and duration of intensive care and hospital stay, occurrence of infections, atrial fibrillation, heart failure, and delirium. Although results of the physician's preference-based instrumental variable analysis corresponded in direction to results of a recent large randomized trial of the same therapy, the instrumental variable estimates showed much larger effects with very wide confidence intervals. The lesser statistical precision limits the usefulness of instrumental variable analysis in a study that might be of sufficient size for conventional analyses, even if a strong and plausible instrument is available.

Feasibility and safety of transoral robotic surgery (TORS) for early hypopharyngeal cancer: a subset analysis of the Hamburg University TORS-trial.

Over the past 5 years, transoral robotic surgery (TORS) has become well established as one of the standard treatment options for T1 and T2 oropharyngeal squamous cell carcinoma. Besides this main indication, TORS can provide with improved access to other subsites of the upper aerodigestive tract as well, such as the supraglottic larynx and the hypopharynx, with superior visibility and maneuverability to that of transoral laser microsurgery (TOLM). Since September 2011, over one hundred TORS procedures have been performed at our institution, predominantly for oropharyngeal cancer. As part of our first 50 transoral robotic cases making up our initial TORS-trial, five patients underwent TORS for early hypopharyngeal carcinoma. The present case series evaluates its feasibility, safety and the completeness of resection in this well-defined subgroup of patients. Main outcome measures were completeness of resection, the presence or lack of postoperative bleeding, number of days intubated, rate of elective tracheotomy, duration of intensive care and/or intermediate care, speech and swallowing function, and duration of nasogastric and/or gastrostomy tube dependency. All patients have been free of recurrence to date. One patient died of other disease. Four patients are alive and free of tumour, three of them did not need adjuvant therapy. Transoral robotic surgery with appropriate neck dissection is a valid primary treatment option for select early hypopharyngeal carcinoma, especially in cases that did not require adjuvant treatment. In contrast to TOLM, TORS allows a multi-planar en bloc resection in the hypopharynx which makes histopathological evaluation more reliable. In addition to this, its faster learning curve makes the results less dependent on the individual surgeons' capabilities.