Intensive Care Hospital Research Articles

Endo-Aortic Clamp for Minimally Invasive Redo Mitral Valve Surgery: Early Outcome

Objective: Redo mitral valve surgery still represents a challenging and high-risk procedure in cardiac surgery. The incidence of cardiac structural injuries during re-sternotomy remains consistent and is reported to be an independent risk factor for hospital mortality. Minimally invasive cardiac surgery with retrograde femoral arterial perfusion and endo-aortic clamping avoids re-entry injuries and reduces the requirement for dissection of adhesions and the risk of damage to cardiac structures. The aim of this study is to analyze redo patients undergoing mitral valve surgery with retrograde arterial perfusion and endo-aortic clamping setting. Methods: A retrospective analysis was performed on patients undergoing surgery from 2006 to 2022. Exclusion criteria were more than mild aortic regurgitation, moderate-to-severe peripheral vascular disease, dilated ascending aorta, and a lack of preoperative vascular screening. The primary outcome was perioperative mortality. Results: Two hundred eighty-five patients were analyzed. Mean age was 63.8 ± 13.3 years, mean EuroSCORE was 16.5 ± 14.5%, and one quarter of the patients had undergone two or more previous procedures via sternotomy. Perioperative mortality was 3.9% (11/285). Stroke was reported in six (2.1%) patients. Median intensive care unit and hospital length of stay were 1 and 8 days, respectively. Conclusions: Endo-aortic clamping setting in redo MV surgery avoids re-entry injuries and allows the surgeon to clamp the aorta and deliver the cardioplegia with minimal dissection of adhesions. In high-volume and experienced centers, this approach can be applied safely and effectively and may in the near future become the standard of care for redo mitral valve surgery.

Comparison of the effects of femoral and axillary artery cannulation on ischemic cerebral injury in acute type A aortic dissection surgery: A retrospective study

Background: Acute Type A Aortic Dissection (ATAAD) is a life-threatening condition requiring emergency surgical intervention. This retrospective study evaluates the impact of femoral and axillary arterial cannulation techniques on ischemic neurological damage and mortality.Materials and Method: A total of 60 patients who underwent emergency surgery for ATAAD between 2016 and 2021 were analyzed. Patients were divided into two groups based on the arterial cannulation technique: Group A (axillary cannulation) and Group F (femoral cannulation). Preoperative, intraoperative, and postoperative variables were compared between the groups. The primary outcome was incidence of ischemic cerebral injury and secondary outcomes included 30-day all-cause mortality, intensive care unit and hospital length of stay and postoperative complications.Results: There were no statistically significant differences between the two groups in terms of ischemic cerebral injury (p=0.13). There was no significant difference in 30-day mortality between the groups (p= 0.27). Logistic regression analysis revealed that the cannulation type was a risk factor for ischemic cerebral injury development (OR [95% CI]; 119.034 [1.612–8791.314], p=0.029).Conclusions: Our findings indicate that the type of cannulation may be a risk factor for the development of ischemic cerebral injury. Further studies are needed to determine the optimal arterial cannulation technique for improving outcomes in ATAAD surgery.

Repeat Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Using Open and Closed Abdomen Techniques for Colorectal Peritoneal Metastases and Peritoneal Pseudomyxoma Recurrences: Results from Six French Expert Centers.

Standard treatment for resectable peritoneal metastases (PM) combines cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC); however, the rate of recurrence remains high and repeat CRS/HIPEC may be considered in well-selected patients. We describe our postoperative and oncological outcomes. Between 1994 and 2024, data from 132 repeat CRS/HIPEC procedures were analyzed in this retrospective multicenter study. Morbimortality, overall survival (OS) and recurrence-free survival (RFS) were evaluated for colorectal peritoneal metastases (CRPM) and peritoneal pseudomyxoma (PMP). Overall, 63 patients, including 55 patients with CRPM (87.3%) and 8 patients with PMP (12.7%), underwent CRS/HIPEC. Of these patients, 58 (92%) underwent CRS/HIPEC twice, 4 (6.3%) underwent CRS/HIPEC three times, and 1 (1.6%) underwent CRS/HIPEC four times. Peritoneal Carcinomatosis Index (PCI) score, operating room occupancy, complication and readmission rates at day 90, and length of intensive care unit and hospital stay were similar between the initial and first repeat CRS/HIPEC procedures. No 90-day postoperative mortality occurred. For CRPM, the median OS was 82.3, 53.9, and 74.5 months from the initial, first, and second repeat CRS/HIPEC procedures, respectively, with a median RFS of 22.0, 36.9, and 13.2 months, respectively. For PMP, after a median follow-up of 70.8 and 39.3 months from the initial and first repeat CRS/HIPEC procedures, respectively, all patients were alive, with a median RFS of 22.4 and 39.4 months, respectively. Multivariate analysis shown that no factor was significantly related to severe complications (Dindo-Clavien 3-4) or OS. In selected patients with CRPM and PMP, CRS/HIPEC shows comparable results between the initial and repeat procedures in terms of postoperative outcomes, and appears to improve survival, especially for PMP. Repeat CRS/HIPEC is an option to be considered in patients presenting with CRPM or PMP.

Intraoperative hyperthermia is associated with increased acute kidney injury following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a retrospective cohort study

Background Acute kidney injury (AKI) is common after cytoreduction surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for peritoneal surface malignancies. Herein we analyzed the association between intraoperative hyperthermia and AKI following CRS-HIPEC. Methods In this retrospective cohort study, we collected baseline and perioperative data from patients who underwent CRS-HIPEC mainly for pseudomyxoma peritonei between 2014 and 2020. Nasopharyngeal temperature was recorded at 5-min intervals. The area above the threshold was calculated for intraoperative hyperthermia (>37.0 °C). AKI was diagnosed and classified according to the KDIGO creatinine criteria. A multivariable logistic regression model was established to assess the association between hyperthermia and AKI. Results A total of 480 patients were included in the analysis. Of these, 10.6% (51/480) developed AKI within 7 postoperative days. After correction for confounding factors, a larger area above the threshold of hyperthermia was significantly associated with an increased risk of AKI (odds ratio [OR] 1.36, 95% CI 1.14–1.63, p = 0.001). Among other factors, older age (OR 1.05, 95% CI 1.02–1.09, p = 0.002), postoperative hypotension requiring vasopressors (OR 2.09, 95% CI 1.02–4.27, p = 0.042), and intraperitoneal chemotherapy containing cisplatin (OR 2.75, 95% CI 1.20–6.33, p = 0.017) were also associated with an increased risk of AKI. Patients with AKI required longer mechanical ventilation, stayed longer in the intensive care unit and hospital, developed more complications, and required more intensive care unit readmission. Conclusions Among patients undergoing CRS-HIPEC, intraoperative hyperthermia was independently associated with a higher risk of AKI; this effect was additive to other risk factors including cisplatin-containing chemotherapy.

Choc toxique staphylococcique menstruel en France : ce que vous devez savoir

AbstractAround 30 cases of menstrual staphylococcal toxic shock syndrome are reported each year in France. This is a severe illness that, if not rapidly treated, can result in hospitalization in intensive care and, and, less commonly, death. The initial symptoms include fever, chills, rash and digestive disorders. This syndrome occurs during menstruation, in women who use intravaginal sanitary protection (tampon, menstrual cup, etc.) and who have a vaginal carriage of Staphylococcus aureus producing toxic shock syndrome toxin 1 (TSST-1). This superantigenic toxin, produced in the vagina, non-specifically activates the immune system, leading to the massive release of pro-inflammatory cytokines. Diagnosis of this syndrome is based on a combination of clinical and biological criteria. Biological diagnosis typically involves the isolation of a TSST-1-producing strain of S. aureus, which is usually obtained from a vaginal swab. The removal of intravaginal protection, administration of an anti-staphylococcal beta-lactam antibiotic and an antitoxin such as clindamycin can reduce mortality and sequelae of the disease.

Bibliometric Analysis of Studies on Delirium in Critical Care

Background Delirium leads to prolongation in intensive care unit (ICU) and hospital length of stay and an increase in ICU costs and mortality. As a result of this, the number of studies on delirium in ICUs has recently increased significantly, and many articles have been published. Objectives The aim of this study was to evaluate the articles related to “delirium” in “critical care” field in the Web of Science database and the first hundred most cited articles on this subject. Methods The Web of Science database was searched for articles relevant to “delirium” in the critical care medicine field published between 1980 and 2024. Text analytics and network models used in bibliometric mapping were used for prolific authors, annual trend, citation, and countries. Results In our study, it was determined that a total of 1834 articles in the field of delirium in critical care medicine were included. It was determined that the annual citation average was 42.79 and the H-index value was 134. There is a general upward trend over the years, and it was observed that it has intensified in the last 5 to 6 years. With the Reference Spectroscopy analysis, it was determined that the most intensively cited studies on delirium were the studies of 2013 and 2010. The distribution of keywords in recent years has focused on analgosedation, acute brain injury, older patient, COVID-19, and fragility. When examined for the top 100 cited articles, it was seen that mobilization, guidelines, pain, activities of daily living, anesthesia, sedation, and haloperidol have become prominent in recent years. Conclusion In recent years, there has been a noticeable increase in the volume of research focusing on delirium studies within the field of critical care medicine. Staying current with trends, incorporating findings from frequently cited studies, and customizing interventions to suit modern difficulties can all improve the quality of care offered to critically ill patients and lead to better outcomes.

Acute coronary syndrome and Khat consumption in Yemeni women admitted to Coronary Care and Intensive Care in major hospital in Yemen

Background: There is a significant percent of normal coronaries in patients with a history of documented myocardial infarction among Yemeni patients who have undergone diagnostic coronary angiogram, and they theoretically attributed that to the effect of Khat as a vasoconstrictor to the coronary artery. Also, unadjusted comparisons of mortality and major morbidity after acute myocardial infarction have generally indicated that women have a poorer outcome than men. Methods: Data was collected prospectively from 15 hospitals in 8 governorates with acute coronary syndrome registry in the Gulf countries. All female patients who were admitted in any monitored bed in Coronary Care Units (CCU) or Intensive Care Units (ICU) with a provisional diagnosis of acute coronary syndrome (ACS) were included in the study. The presentations with khat chewing were compared with all other known and documented risk factor outcomes among women using multiple logistic regressions. Results There were 50.5% regular khat chewers of female patients at presentations to the general emergency department with an attack of acute coronary syndrome; 14.4% of all female patients have no other risk factors except khat. These patients were relatively younger and had a lower body mass index (BMI) when compared with the incidence of acute events in other populations. They had no significantly worse outcome during hospitalization in comparison to the males of the same age group. Conclusions It seems likely that there is at most only an intermediate association between Khat and the development of acute coronary syndrome in females, with less mortality and morbidity after suspected acute myocardial infarction. However, a larger study is needed, with more complete adjustment for coexisting risk factors, to determine whether the female has a worse outcome, which increases with khat.

Long-Term Outcomes of Minimally Invasive Endoscopic Versus Sternotomy Surgical Resection of Primary Cardiac Tumors.

Primary cardiac tumors are uncommon, often benign, but can be potentially life threatening. Minimally invasive endoscopic (ENDO) techniques have been shown to be a feasible alternative for tumor resection compared with conventional sternotomy (CS). This study compared the clinical and surgical outcomes of a small series of patients undergoing cardiac tumor resection operations. Between November 2009 and December 2022, 34 consecutive patients underwent cardiac tumor resection using either ENDO (n = 21) or CS (n = 13) techniques. We compared early perioperative outcomes, echocardiographic outcomes, and long-term clinical and tumor recurrence outcomes. Baseline characteristics were similar between groups; however, the ENDO group included younger patients (56 ± 16 vs 62 ± 17 years) and more female patients (83% vs 53%). The tumor was located in the left atrium (n = 19, 56%), right atrium (n = 5, 15%), or either ventricle (n = 4, 12%). In-hospital mortality and stroke frequency were similar for both groups (n = 0). There was no significant difference in cardiopulmonary bypass or cross-clamp times, respiratory or renal failure, or intensive care unit or hospital lengths of stay. At follow-up (ENDO, 42 [2 to 131] months vs CS, 54 [1 to 156] months), there were no deaths in the ENDO group and 2 patients died in the CS group (P = 0.21). No patients in either group experienced tumor recurrence. In selected patients, both ENDO and CS approaches to primary cardiac tumor resection were safe, effective, durable, and associated with similarly good early and late results.

High-flow nasal cannula oxygen therapy versus noninvasive ventilation for elderly chronic obstructive pulmonary disease patients after extubation: a noninferior randomized controlled trial protocol

IntroductionNoninvasive ventilation (NIV) is widely used for sequential extubation in patients with chronic obstructive pulmonary disease (COPD). However, NIV may cause many adverse events such as claustrophobia, facial skin compression, air leakage, bloating, and even reflux aspiration, resulting in poor patient compliance/tolerance and high failure rate, especially for older adults who are at high risk of communication difficulties and consciousness disorder. High-flow nasal cannula (HFNC) oxygen therapy is a new alternative support to NIV, but whether it can effectively reduce the rate of re-intubation after extubation in elderly patients with COPD remains controversial. The purpose of this study is to explore the safety and efficacy of HFNC versus NIV for elderly COPD patients after extubation.Methods and analysisThis study is an investigator-initiated, single-center, prospective, non-inferior, randomized controlled trial. Elderly patients (age > 65 years) who have received invasive ventilation and was diagnosed with COPD will be randomly assigned to HFNC group or NIV group immediately after extubation with a planned enrollment of 168 patients. The primary outcomes will be reintubation rates at 72 h and 7 days after extubation. Secondary outcomes will include treatment failure, post-extubation vital signs and arterial blood gases, the scores of compliance and comfort of patients, duration of respiratory support after extubation, respiratory support related adverse events, sleep quality scores, usage of sedative and analgesic drugs after extubation, and the incidence of delirium. Additionally, clinical outcomes such as ventilator-free days at 28 days post-randomization, tracheotomy rate, duration of intensive care unit (ICU) and hospital stay, ICU and hospital mortality will be evaluated.Ethics and disseminationThis study has been approved by the Ethics Committee of West China Hospital of Sichuan University (2023–2284). Informed consent is required. It is expected that a follow-up randomized controlled trial will be conducted. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registrationThe study was retrospectively registered at ClinicalTrials.gov (ChiCTR2400087312).

Evaluation of the Effect of Vaccination Status on Lung Involvement and Hospitalization in COVID-19 Patients

Background: The spectrum of COVID-19 in adults ranges from asymptomatic infection to mild respiratory tract symptoms to severe pneumonia with acute respiratory distress syndrome (ARDS) and multiorgan dysfunction. In our study, it was aimed to investigate the effects of COVID- 19 vaccine on lung involvement and hospitalization. Materials and Methods: Cases over the age of 18, who had a history of contact with cases infected with COVID-19 or had clinical findings suggestive of COVID-19, who applied to the emergency department and who were diagnosed with COVID-19 by reverse-transcriptase-polymerase chain reaction (RT-PCR) were included in the study. Age, gender, comorbid diseases, hospitalization status, thorax tomography findings, and vaccination status in the last 3 months of the patients included in the study were obtained by examining the hospital information system and patient files. Results: Our study included 496 patients. One hundred eighty-three of the cases were vaccinated and 42.6% (n = 78) of the vaccinated patients were male. Of the 313 unvaccinated patients, 36% (n = 113) were male. Comorbid disease was observed in 55.2% (n = 101) of the vaccinated patients and 38.7% (n = 121) of the unvaccinated patients. Of the 313 unvaccinated patients, 72.2% (n = 226) were discharged from the emergency department, 19.8% (n = 62) were admitted to the service, and 8% (n = 25) were admitted to the intensive care unit. Of the 183 vaccinated patients, 78.1% (n = 143) were discharged from the emergency department, 16.4% (n = 30) were admitted to the service, and 5.5% (n = 10) were admitted to the intensive care unit. In the vaccinated patient group, both the service admission rate and the intensive care hospitalization rate were found to be significantly lower than the non-vaccinated patient group (p < 0.05). Thoracic tomography findings of 32.9% (n = 103) of 313 unvaccinated patients were reported as CORADS 1-2-3, and thoracic tomography of the remaining 210 patients was reported as CORADS 4-5. The number of patients whose thorax tomography report was CORADS 4-5 was found to be significantly higher in the unvaccinated group than in the vaccinated group (p < 0.05). Conclusion: In our study, it was found that vaccination significantly reduced hospitalization in COVID-19 patients. Although the mean age was higher in the vaccinated patient group, both the service admission rate and the intensive care admission rate were found to be lower.

Mechanical ventilation, hospitalization time, deaths and disability according to the variants of Guillain-Barré syndrome: systematic review and meta-analysis.

Motivation for the study. It is unclear which variant of Guillain-Barré syndrome is mostly associated with adverse outcomes. Main findings. Variants had longer time in MV (7.42 days longer), and hospitalization (3.11 days longer). By subgroups, we found that children with the axonal variant had a greater use of MV; whereas, the demyelinating variant was more frequent among adults in MV. Implications. Our results could be used for the implementation of new public health policies, allowing health personnel to have a better knowledge of the prognosis of each variant and the necessary resources to face future outbreaks. To determine the requirement and time to mechanical ventilation and Intensive Care Unit (ICU), hospitalization and hospitalization time, death and disability of the axonal variants of Guillain-Barré Syndrome (GBS) in comparison with the acute demyelinating variant in patients of all the ages. The systematic review that included patients with GBS. The exposure variable was the axonal variants and the comparator was acute inflammatory demyelinating polyneuropathy (AIDP). The outcomes were the requirement and time on mechanical ventilation (MV), requirement and time in the ICU, hospitalization time, disability and death. The NewCasttle-Ottawa Scale (NOS) was used to assess risk of bias. A meta-analysis was conducted to calculate mean differences and relative risks (RR) with their 95% confidence intervals (CI) using inverse variances and random effects models. Of the 3116 articles found, 46 met the selection criteria. The time on MV was 7.42 days (95% CI: 0.36 to 1.48) and the hospitalization time was 3.11 (95% CI: 0.73 to 5.49) days for the axonal variants. The axonal variants had a RR of 0.47 (95% CI: 0.24 to 0.92) for the requirement of MV in adults, but it was 1.68 (95% CI: 1.25 to 2.25) in children. There was a high statistical heterogeneity. Axonal variants showed, on average, longer MV and hospitalization time, overall and by subgroups. A high MV requirement was found for axonal variants in children; it was lower for adults.

Options for optimizing noninvasive respiratory support in the development of hypoxemic acute respiratory failure

Introduction. Acute respiratory failure (ARF) remains one of the most relevant problems of modern medicine and intensive care, and respiratory support (RS) remains the indispensable method of temporary external respiratory function replacement. Despite of widespread use of non-invasive ventilation (NIV) in clinical practice, at present systematic scientific data about possibilities for optimizing the use of these methods of RS in patients with hypoxemic ARF development is absent. It can be assumed that the combination of mask NIV and high-flow oxygen therapy (HFOT) at the stage of ARF development can improve results of treatment in this group of patients.The objective was to improve the results of treatment in patients with hypoxemic ARF through the combined use of mask NIV and HFOT.Materials and methods. The prospective cohort study included 77 patients aged 46.8 ± 11.8 years. Patients were randomized into three groups: in group A, RS was performed by using NIV and traditional low-flow oxygen therapy, in group B – by using HFOT, in group C – by sequential combination of NIV sessions and HFOT. The groups compared gas exchange rates, RS duration, intubation rate and nosocomial pneumonia (NP) incidence, length of treatment in the intensive care unit (ICU) and hospitalizations, overall mortality, and prognostic factors for tracheal intubation were also studied.Results. The combination of mask NIV and HFOT was found to be more clinically effective compared to their separate use. Combination of mask NIV and HFOT had the best effect on gas exchange rates in the long term period, reduced RS duration, intubation rate and pneumonia incidence, ICU treatment duration. Risk factors for tracheal intubation were revealed: RS duration more than 4.5 days, intra-abdominal pressure (IAP) more than 18 cm of water.Conclusions. The combination of mask NIV and HFOT increases the therapeutic potential of each of these RS methods and improves the results of treatment in patients with hypoxemic ARF development.

Early Mortality in Cardiac Surgery - Is Lactate Significant?

Serum lactate is a consequence of tissue hypoperfusion and has been used routinely for patient management following cardiac surgery. This study aims to determine the association of lactate with early mortality and postoperative morbidity. This is a prospective cohort study carried out in the Department of Cardiovascular and Thoracic Surgery, King George's Medical University (India), from January 2020 to December 2022. A total of 270 patients were included in this study. Serum lactate levels were measured preoperatively, intraoperatively on-pump, coming off-pump, and at six, 12, 24, and 48 hours postoperatively. Early mortality was noted in 17 cases (6.3%). While both lactate and lactate clearance correlated with duration of mechanical ventilation, vasopressor duration, and intensive care unit and hospital stay, correlation with early mortality was noted only with lactate at 24 hours. Logistic regression analysis demonstrated that lactate levels at preoperative period (adjusted odds ratio [OR] 4.76 [1.67-13.59], P=0.004) and at 24 hours after bypass (OR 1.21 [1.00-1.47], P=0.046) and vasopressor duration (OR 1.11 [1.04-1.19], P=0.002) are independent predictors of mortality. Receiver operating characteristic curve analysis showed that arterial lactate on-pump, off-pump, and at six, 12, and 24 hours after surgery had significant area under the curve for predicting mortality. Arterial lactate and lactate clearance show good correlation with duration of mechanical ventilation, vasopressor support, and intensive care unit and hospital stay and can serve as a good indicator to guide therapeutic decisions in postoperative period. However, it fails to be a sensitive predictor of mortality.

Effects of Chronic Obstructive Pulmonary Disease on the Outcomes of Fenestrated-Branched Endovascular Aortic Aneurysm Repair.

Chronic obstructive pulmonary disease (COPD) is common in patients with aortic aneurysms. Severe COPD is associated with an increased risk of aneurysm rupture and perioperative complications. This study assesses the outcomes of COPD and non-COPD patients after fenestrated-branched endovascular aortic aneurysm repair (FBEVAR). A single institution, retrospective study of FBEVAR patients between 2011 and 2020 compared outcomes between COPD and non-COPD patients. COPD patients were stratified by Global Initiative for Chronic Obstructive Lung Disease criteria and oxygen dependence. Outcome measures included 30-day mortality, pulmonary complications, major adverse events (MAE), and mid-term survival. 387 patients (71% male, age 72 years, interquartile range [68-79]) underwent FBEVAR. 181 patients (47%) had COPD. Smoking history was more frequent in COPD patients (P = .022). Among COPD patients, 20.4% were oxygen-dependent. Technical success, defined as successful delivery of the main aortic endograft and all intended side branches, was 98.4%. 30-day mortality (P = .83) and MAE rates (P = .87) were similar between groups. While not statistically significant, COPD patients had more frequent pulmonary complications (6.1% vs. 2.4%, P = .13) and were more frequently discharged on oxygen (P = .002). There were no differences in intensive care unit or hospital length of stay between groups (P = .29; P = .85, respectively). 5-year survival was similar between groups (P = .10). Oxygen-dependent COPD and severe-very severe COPD were associated with decreased mid-term survival (Hazard Ratio 2.39, P = .048). FBEVAR is safe and effective for treating complex aortic pathology in COPD patients, including oxygen-dependent patients. Patients with more severe COPD were more frequently discharged on oxygen. Mid-term survival was slightly reduced in patients with oxygen-dependent and severe-very severe COPD. Level 3, non-randomized controlled cohort/follow-up study.

Prehabilitation Interventions for Cardiac Surgery to Prevent Postoperative Pulmonary Complications: Systematic Review and Meta-Analysis

Background: Postoperative pulmonary complications (PPCs) are associated with a higher risk of morbidity and mortality in patients undergoing cardiac surgery. We aimed to investigate the effect of preoperative interventions on PPCs and length of intensive care unit and hospital stay in patients undergoing cardiac surgery. Methods: A systematic review and meta-analysis was conducted on randomized or quasi-randomized trials by searching PubMed, Medline, ISI Web of Science, Science Direct, Physiotherapy Evidence Database (PEDro), and the Cochrane Library for all available years until December 2023. Our primary outcomes were PPCs including atelectasis and Pneumonia and secondary outcomes were length of intensive care unit and hospital stay. Results: Twenty-one included trials provide data on 2895 participants. The preoperative intervention of inspiratory muscle training (IMT) significantly reduced the PPCs including atelectasis (OR: 0.49, 95%CI: 0.28, 0.86) and Pneumonia (OR: 0.41, 95%CI: 0.25, 0.67) in cardiac patients compared with the control group. Preoperative exercise training intervention is significantly associated with a lower risk (OR: 0.15, 95%CI: 0.06, 0.38) of composite PPCs (i.e. atelectasis and Pneumonia) in the intervention group. Preoperative IMT significantly reduced the postoperative hospital stay by -1.57 days (95% CI: -2.33, -0.81) in the intervention group. Preoperative exercise training significantly decreased the postoperative intensive care unit stay by -2.22 hours (95% CI: -3.05, -1.38) and hospital stay by -1.82 days (95% CI: -3.38, -0.27) in the intervention group. Conclusion: Preoperative intervention of IMT and exercise training significantly reduce PPCs and hospital stay in patients undergoing cardiac surgery.

Brain tissue oxygen pressure combined with intracranial pressure monitoring may improve clinical outcomes for patients with severe traumatic brain injury: a systemic review and meta-analysis.

Although the optimization of brain oxygenation is thought to improve the prognosis, the effect of brain tissue oxygen pressure (PbtO2) for patients with severe traumatic brain injury (STBI) remains controversial. Therefore, the present study aimed to determine whether adding PbtO2 to intracranial pressure (ICP) monitoring improves clinical outcomes for patients with STBI. PubMed, Embase, Scopus and Cochrane Library were searched for eligible trials from their respective inception through April 10th, 2024. We included clinical trials contrasting the combined monitoring of PbtO2 and ICP versus isolated ICP monitoring among patients with STBI. The primary outcome was favorable neurological outcome at 6 months, and secondary outcomes including the in-hospital mortality, long-term mortality, length of stay in intensive care unit (ICU) and hospital. A total of 16 studies (four randomized studies and 12 cohort studies) were included in the meta-analysis. Compared with isolated ICP monitoring, the combined monitoring was associated with a higher favorable neurological outcome rate at 6 months (RR 1.33, 95% CI [1.17-1.51], P<0.0001, I2 = 0%), reduced long-term mortality (RR 0.72, 95% CI [0.59-0.87], P=0.0008, I2 = 2%). No significant difference was identified in the in-hospital mortality (RR 0.81, 95% CI 0.66 to 1.01, P=0.06, I2 = 32%), length of stay in ICU (MD 2.10, 95% CI [-0.37-4.56], P=0.10, I2 = 78%) and hospital (MD 1.07, 95% CI [-2.54-4.67], P=0.56, I2 = 49%) between two groups. However, the pooled results of randomized studies did not show beneficial effect of combined monitoring in favorable neurological outcome and long-term mortality. Currently, there is limited evidence to prove that the combined PbtO2 and ICP monitoring may contribute to improved neurological outcome and long-term mortality for patients with STBI. However, the benefit of combined monitoring should be further validated in more randomized studies.

Leveraging Temporal Trends for Training Contextual Word Embeddings to Address Bias in Biomedical Applications: Development Study.

Women have been underrepresented in clinical trials for many years. Machine-learning models trained on clinical trial abstracts may capture and amplify biases in the data. Specifically, word embeddings are models that enable representing words as vectors and are the building block of most natural language processing systems. If word embeddings are trained on clinical trial abstracts, predictive models that use the embeddings will exhibit gender performance gaps. We aim to capture temporal trends in clinical trials through temporal distribution matching on contextual word embeddings (specifically, BERT) and explore its effect on the bias manifested in downstream tasks. We present TeDi-BERT, a method to harness the temporal trend of increasing women's inclusion in clinical trials to train contextual word embeddings. We implement temporal distribution matching through an adversarial classifier, trying to distinguish old from new clinical trial abstracts based on their embeddings. The temporal distribution matching acts as a form of domain adaptation from older to more recent clinical trials. We evaluate our model on 2 clinical tasks: prediction of unplanned readmission to the intensive care unit and hospital length of stay prediction. We also conduct an algorithmic analysis of the proposed method. In readmission prediction, TeDi-BERT achieved area under the receiver operating characteristic curve of 0.64 for female patients versus the baseline of 0.62 (P<.001), and 0.66 for male patients versus the baseline of 0.64 (P<.001). In the length of stay regression, TeDi-BERT achieved a mean absolute error of 4.56 (95% CI 4.44-4.68) for female patients versus 4.62 (95% CI 4.50-4.74, P<.001) and 4.54 (95% CI 4.44-4.65) for male patients versus 4.6 (95% CI 4.50-4.71, P<.001). In both clinical tasks, TeDi-BERT improved performance for female patients, as expected; but it also improved performance for male patients. Our results show that accuracy for one gender does not need to be exchanged for bias reduction, but rather that good science improves clinical results for all. Contextual word embedding models trained to capture temporal trends can help mitigate the effects of bias that changes over time in the training data.

Significant reduction in blood product usage, same early outcomes: blood conservation in infants undergoing open-heart surgery.

ObjectiveTo evaluate the effect of a blood conservation program on trends in use of donor blood products and early clinical outcomes in infants undergoing open-heart surgery. MethodsFour hundred and nine patients under 1 year of age undergoing open-heart surgery between October 1st, 2020 and June 30th, 2023 were reviewed. The study period was divided into 4 eras with the first era as a pre-blood conservation baseline using traditional blood management. The following 3 eras comprised incremental implementation and evolution of blood conservation strategies. The total volume of blood products transfused for each surgical hospitalization was calculated and indexed to body weight at time of surgery. ResultsThere was no significant difference in age at surgery, body weight, distribution of STAT categories and in post-operative length of mechanical ventilation, intensive care unit or hospital length of stay or post-operative mortality (p>0.05 for all) across the 4 eras. Median total volume of blood products administered during hospitalization decreased from 128 (92, 220) mL/kg during the baseline period to 21 (6, 44) mL/kg in the last era (p<0.01). Multivariate analysis demonstrated that later eras were associated with decreased odds of experiencing exposure to blood products during hospitalization. ConclusionsBlood conservation is associated with significant reduction in usage of blood products during open-heart surgery in infants with no significant effect on early outcomes. This trend is observed across all categories of surgical complexity. Additional studies are needed to prove consistency and to determine the longer-term clinical impact of this strategy.

Early deep-to-light sedation versus continuous light sedation for ICU patients with mechanical ventilation: a cohort study

BackgroundSedation strategies have not been well established for patients being treated with invasive mechanical ventilation (MV). This study aimed to compare the potential effects of alternative sedation strategies – including early deep-to-light sedation (DTLS), continuous deep sedation (CDS) and continuous light sedation (CLS, the currently recommended strategy) – on ventilator, intensive care unit (ICU) or hospital mortality. MethodsA cohort study was conducted using two large validated ICU databases, including the Registry of Healthcare-associated Infections in ICUs in China (ICU-HAI) and the Medical Information Mart for Intensive Care (MIMIC). Patients who received MV for more than 3 days with one of three sedation strategies were included. Multivariable survival analyses with inverse probability-weighted competing risk models were conducted separately for ICU-HAI and MIMIC cohorts. Adjusted estimates were pooled using fixed-effects models. ResultsIn total, 6700 patients (2627 ICU-HAI, 4073 MIMIC) were included in the cohort study, of whom 2689 received CLS, 2079 CDS and 1932 DTLS. Compared to CLS, DTLS was associated with lower ICU mortality (9.3% vs. 11.0%; pooled adjusted HR 0.78, 95% CI 0.66-0.94) and hospital mortality (16.0% vs. 14.1%; 0.86, CI 0.74-1.00); and CDS was associated with higher ventilator mortality (32.8% vs. 7.0%; 4.65, 3.91-5.53), ICU mortality (40.6% vs. 11.0%; 3.39, 2.95-3.90) and hospital mortality (46.8% vs. 14.1%; 3.27, 2.89-3.71) than CLS. All HRs were qualitatively consistent in both cohorts. ConclusionsCompared to the continuous light sedation, early deep-to-light sedation strategy was associated with improved patient outcomes, and continuous deep sedation was confirmed with poorer patient outcomes.

Independent Risk Factors and Economic Burden Associated With Delayed Extubation Following Pediatric Liver Transplantation.

Successful early extubation (EE) after liver transplant (LT) has been shown to reduce intensive care unit (ICU) and hospital length of stay and infectious, vascular, and sedation-related complications in adults. EE may not always be feasible in children, and many may require prolonged mechanical ventilation. Limited data exists regarding the candidacy of EE, risk factors, consequences, and hospital costs of delayed extubation (DE) in pediatric LT. We conducted a retrospective review to investigate predictive factors and associated costs of EE and DE in infants and children after orthotopic LT at our institution between 2011 and 2021. Of 338 LT (median age 39 months, 54% females), 246 (73%) had EE (within 24 h of LT), while 27% had DE. Age < 1 year (p = 0.0019), diagnosis of biliary atresia (0.02), abnormal pre-LT echocardiogram (0.02), and patients with ongoing hospital admission before LT (0.0001) were independently associated with DE. Hospital costs were significantly (∼3-fold) higher (p < 0.0001) in the DE group. In addition, factors associated with increased total hospital costs were age < 1 year and hospitalization before LT. EE post-LT is feasible and merits a trial. The prevalence of DE though modest is associated with increased resource utilization and hospital costs. Children who can be extubated early and those at risk for DE can be identified pre-operatively for optimal planning and allocation of resources.