ICU Length Research Articles

Group based trajectory modeling identifies distinct patterns of sympathetic hyperactivity following traumatic brain injury.

Background Paroxysmal Sympathetic Hyperactivity (PSH) occurs with high prevalence among critically ill Traumatic Brain Injury (TBI) patients and is associated with worse outcomes. The PSH-Assessment Measure (PSH-AM) consists of a Clinical Features Scale (CFS) and a Diagnosis Likelihood Tool (DLT), intended to quantify the severity of sympathetically-mediated symptoms and likelihood that they are due to PSH, respectively, on a daily basis. Here, we aim to identify and explore the value of dynamic trends in the evolution of sympathetic hyperactivity following acute TBI using elements of the PSH-AM. Methods We performed an observational cohort study of 221 acute critically ill TBI patients for whom daily PSH-AM scores were calculated over the first 14 days of hospitalization. A principled group-based trajectory modeling approach using unsupervised K-means clustering was used to identify distinct patterns of CFS evolution within the cohort. We also evaluated the relationships between trajectory group membership and PSH diagnosis, as well as PSH DLT score, hospital discharge GCS, ICU and hospital length of stay, duration of mechanical ventilation, and mortality. Baseline clinical and demographic features predictive of trajectory group membership were analyzed using univariate screening and multivariate multinomial logistic regression. Results We identified four distinct trajectory groups. Trajectory group membership was significantly associated with clinical outcomes including PSH diagnosis and DLT score, ICU length of stay, and duration of mechanical ventilation. Baseline features independently predictive of trajectory group membership included age and post-resuscitation motor GCS. Conclusions This study adds to the sparse research characterizing the heterogeneous temporal trends of sympathetic nervous system activation during the acute phase following TBI. This may open avenues for early identification of at-risk patients to receive tailored interventions to limit secondary brain injury associated with autonomic dysfunction and thereby improve TBI patient outcomes.

Perioperative Anesthetic Considerations for Catheter-Based Pulmonary Vein Interventions in Fibrosing Mediastinitis

IntroductionFibrosing mediastinitis is a rare disease characterized by abnormal proliferation of fibrous tissue, causing compression, and narrowing of the airway, blood vessels and other mediastinal structures, including the pulmonary veins. Catheter based interventions are available palliative strategies. Due to the complex nature of the disease and the profound respiratory and hemodynamic sequela that may ensue, anesthetic management requires meticulous interdisciplinary planning. MethodsWe performed a retrospective descriptive study including patients with Fibrosing Mediastinitis undergoing catheter-based interventions for pulmonary vein stenosis from January 2020 to April 2024. A total of fourteen patients underwent chart review and we reported patient sex, preprocedural pulmonary artery pressures, comorbidities, lung isolation strategies, intra-procedural anesthestic complications, post procedural ICU admissions and length of stayResults: All patients underwent pulmonary vasculature angioplasty, with or without stent placement, under general anesthesia with lung isolation capabilities and echocardiogram guidance. 11 of 18 (61%) cases were uncomplicated. 4 of 18 (22%) required unanticipated postoperative ICU care, 2 (11%) in the setting of pulmonary hemorrhage, one due to hypoxic respiratory failure, and one due to difficult airway. One patient developed self-limiting postoperative hemoptysis in two different occasions and one patient developed a vascular access related complication. Mean hospital length of stay (LOS) was 2.6 days (0-13 days) and mean ICU LOS was 1.75 days (1-4 days). One patient presented 6-weeks postoperatively with massive hemoptysis likely secondary to PV rupture and passed away following a protracted ICU course. ConclusionPatients with FM can achieve successful intraprocedural outcomes by ensuring a comprehensive understanding of the disease, addressing significant anesthetic concerns and considerations, and engaging a multi-disciplinary team.

Outcomes of controlled DCDD lung transplantation after thoraco-abdominal vs abdominal normothermic regional perfusion: The Spanish experience

ObjectiveThoraco-abdominal normothermic regional perfusion (TA-NRP) has emerged as a strategy for evaluating and recovering the heart in controlled donation after the circulatory determination of death (cDCDD). However, its impact on lung grafts remains largely unknown. We aimed to assess the impact of TA-NRP on the outcomes of recipients of cDCDD lungs. MethodsThis is a retrospective, multicenter, nationwide study describing the outcomes of cDCDD lung transplants (LTs) performed in Spain from January 2021 to November 2023. Patients were divided in two groups based on the recovery technique: TA-NRP with the simultaneous recovery of the heart versus abdominal NRP (A-NRP) without simultaneous heart recovery. The primary endpoint was the incidence of Primary Graft Dysfunction (PGD) grade 3 at 72 hours. Secondary endpoints included the overall incidence of PGD, days on mechanical ventilation, ICU and hospital length of stay, early survival rates, and mid-term outcomes. Results283 cDCDD LTs were performed during the study period, 28 (10%) using TA-NRP and 255 (90%) using A-NRP. No differences were observed in the incidence of PGD grade 3 at 72 hours between the TA-NRP and the A-NRP group (0% vs. 7.6%; p=0.231), though the overall incidence of PGD was significantly lower with TA-NRP (14.3%% vs. 41.5%; p=0.005). We found no significant differences between the groups regarding other post-transplant outcome variables. ConclusionsTA-NRP allows the simultaneous recovery of both the heart and the lungs in the cDCDD scenario with appropriate LT outcomes comparable to those observed with the A-NRP approach.

Clinical features and surgical strategy of retroperitoneal liposarcoma involving the kidney capsule: a retrospective comparative cohort study.

Valid and generalizable data on the clinical features and surgical strategies for retroperitoneal liposarcoma (LPS) involving the kidney capsule remain scarce. This study aimed to investigate the clinical characteristics, morbidity, mortality, and long-term survival of patients with retroperitoneal LPS involving the kidney capsule. The authors analyzed a prospectively maintained database of patients who underwent surgical resection for retroperitoneal LPS between 2015 and 2020. The patients were categorized into kidney capsule or no kidney capsule groups based on the presence or absence of kidney capsule involvement. A kidney-sparing strategy for retroperitoneal LPS involving the kidney capsule was developed. The primary outcome measure was overall survival (OS). The cumulative event probability curve was estimated using the Kaplan-Meier, and differences between groups using the Log-Rank. The study population consisted of 128 patients-54 with and 74 without kidney capsule involvement. Of these patients, 70 were female (54.7%) and 58 were male (45.3%), with a median age of 55. The median follow-up duration was 35 months. Postoperative morbidity, mortality, length of hospital stay, length of ICU stay, OS, and recurrence-free survival (RFS) did not differ significantly between the groups. Eleven patients developed postoperative acute kidney injury (AKI), and one patient required dialysis during the follow-up period. In multivariable logistic regression analysis, only nephrectomy was independently associated with postoperative AKI. Subgroup analysis of patients with kidney capsule involvement showed that nephrectomy did not improve OS or RFS but significantly decreased postoperative estimated glomerular filtration rate. Nephrectomy was associated with an increased risk of postoperative AKI after retroperitoneal LPS resection. A kidney-sparing strategy for retroperitoneal LPS involving the kidney capsule achieved optimal clinical outcomes.

346. ESOPHAGOGASTRIC JUNCTION SIEWERT II TUMORS, A CHALLENGE FOR THE SURGEON: RESULTS OF TRANSHIATAL EXTENDED GASTRECTOMY VS. IVOR LEWIS ESOPHAGECTOMY

Abstract Background Esophagogastric junction (EGJ) Siewert type II tumors pose unique challenges in terms of adequate surgical treatment due to their anatomical location and potential for abdominal and mediastinal lymph node metastasis. The optimal surgical approach for these tumors remains a topic of debate, with options including transhiatal extended gastrectomy or transthoracic esophagectomy. Understanding the different outcomes associated with these surgical interventions is crucial for informed decision-making and patient-tailored management. The aim of this study was to compare the perioperative and oncological outcomes of these two surgical technique to access which could be the treatment of choice for Siewert II type tumours. Methods This study is a retrospective non-randomized cohort study from a single center. We reviewed the data of all the patients who underwent surgery for EGJ Siewert type II tumors between December 2014 and February 2023. The patients were divided into two groups: those who underwent transthoracic esophagectomy were assigned to “TE group” (72 patients) and those who underwent transhiatal extended gastrectomy were assigned to “TEG group” (21 patients). Results Patients in the TEG group were older (p=0.011) and in worst clinical condition (Charlson Comorbidity Index 4.15±1.78 vs. 4.95±1.46, p=0.064). The tumour stage at the diagnosis was more advanced in the TE group (p=0.004), and upfront surgery was infrequent in this group (p<0.001). The average duration of surgery was higher in the TE group (p<0.001). No difference was seen in the tumour length (p=0.924), implying a statistically significant difference in the proximal margin length (p<0.001), and distal margin length (p<0.001), with a R0 resection rate higher in the TE group (93.1% vs. 66.7%, p=0.002). The higher rate of R1 resection in the TEG group was mainly due to proximal margin infiltration. No difference was seen in the number of harvested lymph nodes (p=0.339). Overall postoperative complications rates were similar (p=0.144). No differences were found in the length of ICU stay (p=0.676) and in hospital stay (p=0.075). At a median follow up of 20 months, there were no statistical differences in Overall Survival and Disease-Free Survival at 5 years. Conclusion Our data suggests that transthoracic esophagectomy for EGJ Siewert type II tumors should be the treatment of choice for patients in good clinical condition, but transhiatal extended gastrectomy could be a good choice for patients presenting in worse clinical condition. A multidisciplinary approach is essential for optimal patient care, and the selection of the surgical technique should be based on a thorough evaluation of the patient's condition and tumor characteristics

Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study.

A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use. To characterize TLT use in patients with acute respiratory failure (ARF). Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours. Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record. Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01). In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.

550. INTRAOPERATIVE VOLUME STATUS DOES NOT AFFECT ERAS OUTCOMES OR COMPLICATION RATES IN HYBRID ROBOTIC ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Intraoperative volume management in patients undergoing esophagectomy is nuanced. Data is conflicting in regards to the benefits of volume restrictive versus liberal approaches. Within a hybrid robotic assisted minimally invasive esophagectomy (hRAMIE) population undergoing oncologic resection there is a paucity of data regarding intraoperative volume status as it affects postoperative outcomes and no data regarding the impact on enhanced recovery after surgery (ERAS) outcomes. Methods Demographics, anthropometrics, cancer characteristics, and perioperative outcome data were gathered between January 2020 and December 2023 at a single, tertiary referral center in patients undergoing oncologic hRAMIE. Intraoperative volume status was defined, as in other reports, by identifying the median operative volume rate per hour and normalizing via the Du Bois body surface area; above or below 225 mL/hour/m2. ERAS outcomes were reported. Complications were stratified in accordance with the Esophagectomy Complications Consensus Group guidelines. Continuous variables were compared via Mann-Whitney U-Test; categorical via Fisher's Exact. Alpha set to 0.05. Results 96 patients (46 volume restrictive, 45 volume liberal) were identified. There were no differences in age, sex, body mass index, ASA class, Charlson Comorbidity Index, cancer histology, location, rate of neoadjuvant chemotherapy, or chemoradiotherapy. ERAS outcomes analysis reveals no statistical difference in ICU length of stay, mobilization times, return of bowel function, or length of stay (Table 1). Complications were reported in 45.8% of patients and did not differ between groups (p=0.8934). Pulmonary complications were most frequent (total 21.9%; restrictive 17.4%, liberal 28.9%, p=0.1422) followed by anastomotic leak (total 12.5%; restrictive 17.4%, liberal 8.9%, p=0.3681). Conclusion The current study demonstrates no impact of volume restriction on perioperative outcomes, ERAS benchmarks, or length of stay in patients undergoing hRAMIE for esophageal cancer. Data suggests that minimally invasive approaches may be associated with less total body and pleural inflammatory mediator generation, perhaps limiting susceptibility to variation in volume status. Highly powered, multicenter retrospective minimally invasive esophagectomy and volume status investigation is warranted prior to proceeding with controlled trial.

Subphenotypes of platelet count trajectories in sepsis from multi-center ICU data

Although thrombocytopenia on admission to the ICU is associated with increased in-hospital mortality in septic patients, the role of longitudinally measured platelet counts, which are dynamically changing, is unclear. We aimed to identify patterns of dynamic platelet count trajectories and evaluate their association with outcomes and thrombocytopenia in septic patients. We tested the longitudinal platelet trajectory patterns of sepsis patients within the first four days of ICU admission in the MIMIC-IV database and their association with 28-day mortality, and independently validated our findings in the eICU-CRD database. Statistical methods used included multivariate regression, propensity score analysis, doubly robust estimation, gradient boosting model, and inverse probability weighting to ensure the robustness of our findings. A total of 22,866 septic patients were included in our study. The trajectory analysis categorizes patients into ascending (AS), stable (ST), or descending (DS) patterns. The risk of 28-day mortality was increased in the DS patients (OR = 2.464, 95%CI 1.895–3.203, p < 0.001) and ST patients (OR = 1.302, 95%CI 1.067–1.589, p = 0.009) compared to AS patients. The AS patients had lower ICU length of stay (2.36 vs. 4.32, p < 0.001) and 28-day maximum SOFA scores (5.00 vs. 6.00, p < 0.001) than the DS patients, but had more ventilator-free days within 28 days than the DS group (26.00 vs. 24.00, p < 0.001). The mediating effect of thrombocytopenia was significant (p < 0.001 for the average causal mediation effect (ACME)). Longitudinal platelet trajectory was associated with risk-adjusted 28-day mortality among patients with sepsis and was proportionally mediated through thrombocytopenia.

Risk Factors Associated With Acute Kidney Injury in Traumatic Brain Injury Patients Treated With Hypertonic Saline: A Retrospective Study.

Background: Hypertonic saline (HTS) is essential pharmacologic treatment for traumatic brain injury (TBI). Previous studies associate HTS with acute kidney injury (AKI), however evidence in TBIs is limited. Objective: This study examines factors associated with AKI in patients requiring HTS for TBI. Methods: This retrospective study was performed at a Level-1 Trauma, Academic Medical Center. Inclusion criteria were TBI, age ≥12years, ICU length of stay ≥72hours, and administration of ≥24hours of continuous HTS or 500mL of HTS boluses. The primary outcome was identifying factors associated with AKI. Secondary outcomes included correlation between chloride load and level with development of AKI. Chloride load was calculated from HTS and non-HTS sources. Results: Of 129 patients included, 18 (14%) developed AKI. Maximum sodium level was higher in the AKI group (P < 0.0001). Hyperchloremia (Cl ≥ 115 mEq/L) was more common in the AKI group (100% vs 81%, P = 0.0428). Maximum and change in serum chloride were higher in the AKI group (median 128 vs 123 mEq/L, P = 0.0026 and +24 mEq/L vs +17 mEq/L, P = 0.0084, respectively). Logistic regression analysis indicated an OR 1.095 times higher [95% CI (1.022, 1.172)] for developing AKI for every one mEq/L increase in maximum chloride level and an OR 1.032 [95% CI (1.006, 1.058)] for developing AKI for every 1-year increase in age. There was no difference in total chloride load between groups (P = 0.2143). Non-HTS sources provided more than 40% of total chloride load in both groups. Conclusion: Chloride level, and age may be associated with AKI in TBI patients treated with HTS.

Associations Between Severe Influenza-Complicated Thromboembolism Events, Intensive Care Unit Stays and Mortality, and Associated Risk Factors: A Retrospective Cohort Study.

A retrospective cohort study was conducted, recruiting consecutive patients with TE events admitted to the ICU between December 2015 through December 2018 at our institution in Taiwan. The study included a group of 108 patients with severe influenza and a control group of 192 patients with severe community-acquired pneumonia. Associations between complicated TE, length of ICU stay, and 90-day mortality were evaluated using logistic regression analysis, and risk factors were identified using univariate and multivariate generalized linear regression analyses. TE event prevalence was significantly higher in ICU patients with severe influenza than in ICU patients with severe CAP (21.3% vs. 5.7%, respectively; p < 0.05). Patients with severe influenza who developed TE experienced a significant increase in the ratio of mechanical ventilation use, length of mechanical ventilation use, ICU stay, and 90-day mortality when compared to patients without TE (all p < 0.05). The comparison of severe CAP patients with and without TE revealed no significant differences (p > 0.05). The development of thromboembolic events in patients with severe influenza or severe noninfluenza CAP is linked to influenza infection and hypertension (p < 0.05). Furthermore, complicated TE and the severity of the APACHE II score are risk factors for 90-day mortality in ICU patients with severe influenza (p < 0.05). Patients with severe influenza and complicated TE are more likely to have an extended ICU stay and 90-day mortality than patients with severe CAP. The risk is significantly higher for patients with a higher APACHE II score. The results of this study may aid in defining better strategies for early recognition and prevention of severe influenza-complicated TE.

Orthopedic pelvic and extremity injuries increase overall hospital length of stay but not in-hospital complications or mortality in trauma ICU patients: Orthopedic Injuries in Trauma ICU Patients

BackgroundThe purpose of this study was to compare the ICU length of stay (LOS), overall hospital LOS, in-hospital complications, and mortality rate between trauma ICU patients with orthopedic injuries versus those without. MethodsThis was a retrospective cohort study in which the trauma registry of a single level 1 trauma center was queried over a 6-year period for patients admitted to the ICU during hospitalization. Patients were stratified based on the presence/absence of an orthopedic fracture. Negative binomial regression was used to evaluate the effect of orthopedic injury on overall hospital and ICU LOS while controlling for confounding factors. Secondary outcomes included group differences with respect to in-hospital complications, mortality, and discharge disposition. ResultsA total of 1,785 trauma patients were admitted to the ICU and included. Among all trauma ICU patients, 61.1 % (n = 1,091) had no associated orthopedic injuries whereas 38.9 % (n = 694) had at least one. Patients with orthopedic injuries had higher odds of being severely injured (ISS ≥ 16: OR [CI] =1.47 [1.2–1.8]; p < 0.001) despite presenting with a higher level of consciousness than those without orthopedic injuries (mean GCS: 13.3 ± 3.5 vs 12.5 ± 4.1, p < 0.001). Multivariable models demonstrated having an orthopedic injury did not moderate ICU LOS (IRR [CI] = 0.93 [0.9–1.0]; p = 0.110) but did contribute significantly to increasing hospital LOS (IRR [CI] = 1.23 [1.1–1.3]; p < 0.001). There was no evidence to suggest that orthopedic injury increases the risk of in-hospital complication or in-hospital mortality. Orthopedically injured trauma ICU patients were less likely to be discharged home than those without orthopedic injuries. ConclusionsTrauma ICU patients with an associated orthopedic injury have significantly longer hospital stays compared to those without an orthopedic injury, despite no evidence to suggest that the orthopedic injury affects the duration of ICU stay or in-hospital complications. Level of evidenceIII, Retrospective cohort study

Factor Eight Inhibitor Bypass Activity use in cardiac surgery: A propensity matched analysis of safety outcomes.

Bleeding during cardiac surgery may be refractory to standard interventions. Off-label use of Factor Eight Inhibitor Bypass Activity (FEIBA) has been described to treat such bleeding. However, reports of safety, particularly thromboembolic outcomes, show mixed results and reported cohorts have been small. Adult patients undergoing cardiac surgery on cardiopulmonary bypass between July 1, 2018 and June 30, 2023 at Stanford Hospital were reviewed (n=3335). Patients who received FEIBA to treat post-cardiopulmonary bypass bleeding were matched with those who did not by propensity scores in a 1:1 ratio using nearest neighbor matching (n= 352 per group). The primary outcome was a composite outcome of thromboembolic complications including any one of deep vein thrombosis (DVT), pulmonary embolism (PE), unplanned coronary artery intervention, ischemic stroke, and acute limb ischemia, in the postoperative period. Secondary outcomes included renal failure, reoperation, postoperative transfusion, ICU length of stay (LOS), and 30-day mortality. 704 encounters were included in our propensity matched analysis. The mean dose of FEIBA administered was 7.3 ±5.5 units/kg. In propensity matched multivariate logistic regression models there was no statistically significant difference in odds ratios for thromboembolic outcomes, ICU LOS, or mortality. Patients who received >750 units of FEIBA had an increased odds ratio for acute renal failure (OR 4.14; 95% CI 1.61 to 10.36, p <0.001). In multivariate linear regression, patients receiving FEIBA were transfused more plasma and cryoprecipitate postoperatively. However, only the dose range of 501-750 units was associated with an increase in transfusion of RBCs (β 2.73; 95% CI 0.68 to 4.78; p=0.009), and platelets (β 1.74; 95% CI 0.85 to 2.63; p <0.001). Low dose FEIBA administration during cardiac surgery does not increase risk of thromboembolic events, ICU LOS, or mortality in a propensity matched cohort. Higher doses were associated with increased acute renal failure and postoperative transfusion. Further studies are required to establish the efficacy of activated factor concentrates to treat refractory bleeding during cardiac surgery.

Contributing factors to hypophosphatemia development in critically Ill ventilated patients: a retrospective cohort study

Hypophosphatemia (serum phosphate < 2.5 mg/dL) is a major concern when initiating nutritional support. We evaluated which factors contribute to hypophosphatemia development in critically ill patients, as well as the association between hypophosphatemia and mortality. A retrospective cohort study of patients who were ventilated for at least 2 days in a 16-bed mixed ICU. Data collected includes demographics, Acute Physiology & Chronic Health Evaluation 2 (APACHE2) admission score, Sequential Organ Failure Assessment score at 24 h (SOFA24), hourly energy delivery, plasma phosphate levels during the first 2 weeks of admission, ICU length of stay (LOS), length of ventilation (LOV), and mortality (ICU and 90 days). For the hypophosphatemia development model, we considered mortality as a competing risk. For mortality analysis, we used the Cox proportional hazards model considering hypophosphatemia development as a time-varying covariate. 462 patients were used in the analysis. 59.52% of the patients developed hypophosphatemia. Several factors were associated with a decreased risk of hypophosphatemia: age, BMI, pre-admission diabetes diagnosis, APACHE2, SOFA24, first kidney SOFA score, hospital admission time before ICU admission, and admission after liver transplantation. Admission due to trauma was associated with an increased risk of hypophosphatemia. Survival analysis with hypophosphatemia as a time-varying covariate showed a protective effect of hypophosphatemia from mortality (HR 0.447, 95% CI 0.281, 0.712). Age, APACHE2, and SOFA24 score were found to be significantly associated with ICU mortality. Fasting duration in the ICU before nutritional support initiation was not found to be significantly associated with hypophosphatemia. We examined several fasting intervals (12 h, 24 h, 36 h, 48 h, 60 h, 72 h). In each fast interval, we compared the prevalence of hypophosphatemia among patients who fasted the specified length of time, with those who did not fast for the same length of time. In each fasting interval, hypophosphatemia prevalence was lower in the fasting group compared to the non-fasting group. However, this difference was insignificant. BMI, APACHE2, and hospital LOS before ICU admission were inversely associated with hypophosphatemia development. Fasting for up to 72 h in the ICU before starting nutritional support did not affect hypophosphatemia occurrence. Hypophosphatemia was associated with lower mortality.

B-type natriuretic peptide informativeness in myocardial revascularization with cardio-pulmonary bypass

The objective was to study the dynamics of B-type natriuretic peptide (BNP) and its relationship with hemodynamic parameters during on-pump coronary artery bypass grafting (CABG), and to evaluate the informativeness of the biomarker as a predictor of myocardial dysfunction.Materials and methods. The study involved 127 patients aged 59 [54–66.75] years with ischemic heart disease who underwent CABG. The BNP blood level was determined in the operating room at stages: I – before surgery (BNP1 ), II – at the end of surgery (BNP2 ). Hemodynamic parameters were analyzed at the same stages. Correlation analysis, logistic regression with the calculation of the odds ratio (OR) and 95% confidence interval (95% CI) and ROC analysis with the calculation of the area under the ROC curve (AUC) were used.Results. BNP1 blood level was 49 [25.6–91.6], BNP2 – 90 [47.8–140.2] pg/ml (p &lt; 0.0001). BNP1 correlated with central venous pressure (CVP) at stage I (rho = 0.212; p = 0.017) and with pulmonary artery wedge pressure (PAWP) at stage II (rho = 0.204; p = 0.045). BNP2 correlated with PAWP at stage II (rho = 0.204; p = 0.045). BNP1 &gt; 52.1 pg/ml was the predictor of ICU length of stay &gt; 24 hours (OR 1.0290, 95% CI 1.0154– 1.0427, p &lt; 0.0001, AUC 0.775), BNP1 &gt; 71 pg/ml was the predictor of inotropic index &gt; 5 c. u. (OR 1.0076, 95% CI 1.0015–1.0138, p = 0.014, AUC 0.705) and BNP1 &gt; 90.8 pg/ml was the predictor of vasoactive inotropic index &gt; 10 c. u. (OR 1.0070, 95% CI 1.0014–1.0126, p = 0.013, AUC 0.727). BNP2 &gt; 67.5 pg/ml was the predictor of ICU length of stay &gt; 24 hours (OR 1.0179, 95% CI 1.0073–1.0287, p &lt; 0.0009, AUC 0.763), BNP2 &gt; 94.3 pg/ml was the predictor of inotropic index &gt; 5 c. u. (OR 1.0063, 95% CI 1.0010–1.0117, p = 0.020, AUC 0.713), BNP2 &gt; 144 pg/ml was the predictor of intra-aortic balloon pumping (OR 1.0037, 95% CI 1 .0000–1.0074, p = 0.048, AUC 0.854), BNP2 &gt; 159 pg/ml was the predictor of vasoactive inotropic index &gt; 10 c. u. (OR 1.0072, 95% CI 1.0006–1.0139, p = 0.033, AUC 0.729) and BNP2 &gt; 161 pg/ml was the predictor of early mortality in the ICU (OR 1.0040, 95% CI 1, 0000-1.0080, p = 0.049, AUC 0.845). Conclusion. In 78.7% of patients undergoing on-pump CABG, BNP blood level does not exceed the upper limit of normal; by the end of surgery, the biomarker level increases by 32.9 [17.7–62.0] pg/ml. Before and at the end of surgery, BNP values are weakly correlated with CVP and PAWP and do not correlate with other hemodynamic parameters. Before surgery, BNP blood level in the range of 52.1–90.8 pg/ml are predictors of ICU stay &gt; 24 hours (AUC 0.775), inotropic scale &gt; 5 (AUC 0.705) and vasoactive-inotropic scale &gt; 10 c. u. (AUC 0.727). At the end of surgery, BNP &gt; 67.5 pg/ml is associated with an ICU stay &gt; 24 hours (AUC 0.763), and BNP &gt; 90.4 pg/ml is associated with inotropic scale &gt; 5 c. u. (AUC 0.713). The BNP, increased to 144.0–161.0 pg/ml, indicates severe myocardial dysfunction, including hemodynamic support with intra-aortic balloon pumping (AUC 0.854), vasoactive-inotropic scale &gt; 10 c. u. (AUC 0.729) and the risk of early mortality in the ICU (AUC 0.845).

Early extubation after elective surgical aortic valve replacement during the COVID-19 pandemic

BackgroundSurgical aortic valve replacement (SAVR) is an established therapy for severe calcific aortic stenosis. Enhanced recovery after cardiac surgery (ERACS) protocols have been shown to improve outcomes for elective cardiac procedures. The COVID-19 pandemic prompted early extubation post-elective surgeries to preserve critical care resources.Aim of this studyTo investigate the effects of extubating patients within 6 h post-elective SAVR on hospital and ICU length of stay, mortality rates, ICU readmissions, and postoperative pneumonia.Study Design and methodsThe retrospective analysis at the University Hospital Aachen, Germany, includes data from 2017 to 2022 and compares a total of 73 elective SAVR patients. Among these, 23 patients were extubated within 6 h (EXT group), while 50 patients remained intubated for over 6 h (INT group).ResultsThe INT group experienced longer postoperative ventilation, needed more vasopressor support, had a higher incidence of postoperative pneumonia, and longer ICU length of stay. No significant differences were noted in overall hospital length of stay, mortality, or ICU readmission rates between the groups.ConclusionThis study demonstrates that early extubation in high-risk, multimorbid surgical aortic valve replacement patients is safe, and is associated with a reduction of pneumonia rates, and with shorter ICU and hospital length of stays, reinforcing the benefits of ERACS protocols, especially critical during the COVID-19 pandemic to optimize intensive care use.

Impact of Sarcopenia on Post-Liver Transplant Hospitalization: Insights From a South Asian Cohort

BackgroundSarcopenia's impact on post-liver transplant outcomes remains a subject of debate, with limited data from South Asia on its association with post-liver transplant hospital stays. This study aims to investigate sarcopenia's influence on post-transplant hospitalization duration in South Asians. MethodsIn this retrospective study, patients with liver cirrhosis who underwent living-donor liver transplantation at Shifa International Hospital in Islamabad, Pakistan, between January 2022 and January 2023 were included. Computed Tomography (CT) images were used to assess the skeletal muscle index (SMI). The areas of the psoas, erector spinae, multifidus, quadratus lumborum, rectus abdominis, transverse abdominis, and internal/external oblique muscles were quantified at the level of L3. The data was analyzed using SPSS v. 29.0 (IBM Chicago, IL). ResultsThere was a total of 84 patients. Mean age was 47.4 ± 12.0 years. There were 62 (73.8%) males and 22 (26.2%) females. Hepatitis C was noted in 36 (42.9%) patients. 22 (26.2%) patients had hepatocellular carcinoma. Sarcopenia was identified in 58 (69.0%) patients. No significant association was observed between sarcopenia and ICU or general floor stays. Regression analysis identified pre-transplant MELD-Na score as the sole significant factor associated with both ICU and total length of stay (p-value 0.002; p-value 0.009). ConclusionIn our population, sarcopenia did not correlate with post-transplant ICU or overall hospital stay. The pre-transplant MELD-Na score emerged as the most influential predictor of length of stay. Therefore, delaying liver transplant procedures based on muscle mass estimations may not be a practical clinical approach for South Asian patients.

Returning to work and health status at 12 months among patients with COVID-19 cared for in intensive care—A prospective, longitudinal study

ObjectiveIntensive care unit (ICU) stay for a serious illness has a long-term impact on patients’ physical and psychological well-being, affecting their ability to return to their everyday life. We aimed to investigate whether there are differences in health status between those who return to work and those who do not, and how demographic characteristics and illness severity impact patients’ ability to return to work 12 months after intensive care for COVID-19. Research methodologyThis was a prospective longitudinal cohort study. The participants were patients who had been in intensive care for COVID-19 and had worked before contracting COVID-19. Data on return to previous occupational status, demographic data, comorbidities, intensive care characteristics, and health status were collected at a 12-month follow-up visit. SettingGeneral ICU at the Uppsala University Hospital in Sweden. ResultsSeventy-three participants were included in the study. Twelve months after discharge from the ICU, 77 % (n = 56) had returned to work. The participants who were unable to return to work reported more severe health symptoms. The (odds ratio [OR] for not returning to work was high for critical illness OR, 12.05; 95 % confidence interval [CI], 2.07–70.29, p = 0.006) and length of ICU stay (OR, 1.06; 95 % CI, 1.01–1.11, p = 0.01) ConclusionTwo-thirds of the participants were able to return to work within 1 year after discharge from the ICU. The primary factors contributing to the failure to work were duration of the acute disease and presence of severe and persistent long-term symptoms. Implications for clinical practicePatients’ health status must be comprehensively assessed and their ability to return to work should be addressed in the rehabilitation process. Therefore, any complications faced by the patients must be identified and treated early to increase the possibility of their successful return to work.

The influence of postoperative morbidity on long-term quality of life outcomes following pelvic exenteration

IntroductionPelvic exenteration provides significant survival benefits for selected patients diagnosed with locally advanced rectal cancer. However, in-hospital postoperative morbidity such as abdominal abscess, sepsis, and anastomotic leak remain highly prevalent, which can have short/long-term impacts on patient quality of life (QoL). The aim of this study was to determine the influence of postoperative morbidity on QoL outcomes in patients following pelvic exenteration. MethodsThis prospective cohort study included patients who underwent pelvic exenteration at a tertiary teaching hospital in Sydney, between 2008 and 2023. QoL measures were collected at baseline, 6, 12, 18, 24, 36, 48, and 60 months using the short-form 36 (SF-36v2) survey. The predictors included variables relating to postoperative morbidity, including hospital and ICU length of stay (LOS), post-discharge mortality and the number of postoperative complications. Mixed-effects analyses were used to determine the influence of these postoperative outcomes on physical and mental QoL trajectories. ResultsThis study included 674 patients, with a median age of 61 years. Shorter hospital and ICU LOS, and fewer or no postoperative complications were associated with higher physical QoL scores across all time points. Conversely, postoperative morbidity did not exhibit a significant impact on mental QoL scores. Furthermore, there was a longitudinal improvement in mental QoL outcomes compared to baseline, independent of postoperative morbidity. ConclusionPostoperative morbidity significantly impacted physical QoL outcomes after pelvic exenteration, whereas mental QoL outcomes were not influenced. Interventions aimed at mitigating postoperative morbidity may hold the potential to enhance long-term QoL outcomes following pelvic exenteration.

Characteristics and Outcomes of Home-Ventilated Children Undergoing Noncardiac Surgery.

To determine the frequency of children with chronic respiratory failure (CRF) and home ventilator dependence undergoing surgery at a tertiary children's hospital, and to describe periprocedural characteristics and outcomes. We conducted a retrospective cohort study of patients with CRF and home ventilator dependence who underwent noncardiac surgery from January 1, 2013, to December 31, 2019. Descriptive statistics were used to report patient and procedural characteristics. Univariable and multivariable analyses were used to assess for factors associated with 30-day readmission. We identified 416 patients who underwent 1623 procedures. Fifty-one percent of patients used transtracheal mechanical ventilation (trach/vent) support at the time of surgery; this cohort was younger (median age 5.5 vs 10.8 years) and more complex according to American Society of Anesthesiologists status compared with bilevel positive airway pressure-dependent patients. Postoperatively, compared with bilevel positive airway pressure-dependent patients, trach/vent patients were more likely to be admitted to the ICU with longer ICU length of stay (median 5 vs 2 days). Overall 30-day readmission rate was 12% (n = 193). Presence of chronic lung disease (adjusted odds ratio 1.65, 95% confidence interval 1.01-1.69) and trach/vent dependence (adjusted odds ratio 1.65, 95% confidence interval 1.02-2.67) were independently associated with increased odds for readmission. Children with CRF use anesthetic and surgical services frequently and repeatedly. Those with trach/vent dependence have higher hospital and ICU resource utilization. Although overall mortality for these patients is quite low, underlying diagnoses, nuances of technology dependence, and other factors for frequent readmission require further study to optimize resource utilization and outcomes.

Survival analysis of COVID-19 versus non-COVID-19 patients requiring intensive care for acute respiratory distress syndrome: An observational retrospective study.

This study analyzed clinical factors impacting the survival of COVID-19 patients with acute respiratory distress síndrome, or ARDS (CARDS) to ICU compared to non-COVID-19 ARDS patients. Clinical variables from 1,008 CARDS cases and 332 ARDS cases were computed using learning algorithms. The multivariable Cox proportional hazards regression models with the enter method evaluated risk factors and ICU mortality relationships. The survival analysis was completed with Kaplan-Meier and the log-rank tests. A Random Forest model revealed that mechanical ventilation-related factors, oxygenation, blood pH, superinfection, shock, and ICU length of stay have the greatest effects on ICU survival. According to a multivariate Cox model, reintubation and a high-flow nasal cannula were essential for survival in CARDS patients during the ICU stay. The length of stay in the ICU diminishes in patients older than 45 years, regardless of the source of ARDS. This study gives recommendations for the respiratory care of ARDS in COVID-19 patients.