Use Of Inotropes Research Articles

The CSP (Cardiogenic Shock Prognosis) Score: A Tool for Risk Stratification of Cardiogenic Shock.

BackgroundCardiogenic shock (CS) is a critical condition and the leading cause of mortality after acute myocardial infarction (AMI). Scores that predict mortality have been established, but a patient's clinical course is often nonlinear. Thus, factors present during acute care management may be explored. This study intended to develop a risk-predictive model for patients with CS.MethodsIn this observational study, adult patients who received inotropic support at the Emergency Room (ER) from January 2017 to August 2020 and were admitted to the cardiac care unit (CCU) with a diagnosis of CS were enrolled in this study. Patients with out-of-hospital cardiac arrest, inotropic support for bradycardia, and survival <24 h after ER arrival were excluded. A total of 311 patients were enrolled and categorized into derivation (n = 243) and validation (n = 68) cohorts.ResultsA history of coronary artery disease, multiple inotrope use, ejection fraction <40%, lower hemoglobin concentration, longer cardiopulmonary resuscitation duration, albumin infusion, and renal replacement therapy were identified as independent prognostic factors for in-hospital mortality. The cardiogenic shock prognosis (CSP) score was established as a nomogram and three risk groups were identified: low-risk (score 115, 0% of mortality), medium-risk (score 116–209, 8.75% of mortality), and high-risk (score 210, 66.67% of mortality). The area-under-the-curve (AUC) of the CSP score was 0.941, and the discrimination value in the validation cohort was consistent (AUC = 0.813).ConclusionsThe CSP score represents a risk-predictive model for in-hospital mortality in patients with CS in acute care settings. Patients identified as the high-risk category may have a poor prognosis.

Repetitive milrinone therapy in ambulatory advanced heart failure patients.

BackgroundAdvanced heart failure (HF) patients usually poorly tolerate guideline‐directed HF medical therapy (GDMT) and suffer high rates of morbidity and mortality. The use of continuous inotropes in the outpatient settings is hampered by previous data showing excess morbidity. We aimed to assess the safety and efficacy of repetitive, intermittent, short‐term intravenous milrinone therapy in advanced HF patients with an intention to introduce and up‐titrate GDMT and improve functional class.HypothesisRepetitive, intermittent milrinone therapy may assist with the stabilization of advanced HF patients.MethodsAdvanced HF patients treated with beta‐blockers and implanted with defibrillators were initiated with repetitive, intermittent short‐term intravenous milrinone therapy at our HF outpatient unit. Patients were prospectively followed with defibrillator interrogation, functional class assessment, B‐natriuretic peptide (BNP) levels, and echocardiography parameters.ResultsThe cohort included 24 patients with a mean 330 ± 240 days of milrinone therapy exposure. Mean age was 73 ± 6 years with male predominance (96%). Following milrinone therapy, median BNP levels decreased significantly (882 [286−3768] to 631 [278−1378] pg/ml, p = .017) with a significant reduction in the number of patients with New York Heart Association (NYHA) Class III and IV (p = .012, 0.013) and an increase in number of patients on GDMT. Importantly, the number of total sustained ventricular tachycardia events and HF hospitalizations did not change.ConclusionsIn this small cohort of advanced HF, repetitive, intermittent, short‐term milrinone therapy was found to be safe and potentially efficacious.

The Association Between Alveolar Dead Space Fraction and Mortality in Pediatric Acute Respiratory Distress Syndrome: A Prospective Cohort Study.

BackgroundAlveolar dead-space fraction (AVDSF), the volume of alveolar gas that does not participate in gas exchange, has been reported to predict mortality and morbidity in adults with acute respiratory distress syndrome (ARDS). This study aims to characterize AVDSF in patients with pediatric ARDS (PARDS), to determine its association with clinical outcomes and examine the validity of a previously studied cutoff (AVDSF > 0.25).MethodsThis was a prospective cohort study performed in the setting of a lung protective mechanical ventilation protocol. AVDSF was calculated by the equation: AVDSF = [partial pressure of arterial carbon dioxide (PaCO2) – end tidal carbon dioxide (etCO2)]/PaCO2. Receiver operating curve and Youden index were used to identify an AVDSF cutoff associated with mortality, which characterized “high or low AVDSF” groups. Correlation between AVDSF and clinical indices of severity were determined [including daily oxygenation index (OI), admission Pediatric Index of Mortality 2 (PIM 2) and Pediatric Logistic Organ Dysfunction (PELOD) scores]. The primary outcome, mortality in PARDS patients, was compared between the high and low AVDSF groups and analyzed in a multivariable logistic regression adjusting for inotrope use and PIM 2 score. Secondary outcomes included 28-day ventilator-free (VFD) and intensive care unit-free (IFD) days.ResultsSixty-nine PARDS patients with a median (interquartile range) age of 4.5 (0.8, 10.6) years were included in this analysis. Daily AVDSF correlated with daily OI (R2 = 0.10; p < 0.001). Mean AVDSF over the first 7 days of PARDS correlated with PIM 2 (R2 = 0.10; p = 0.010) and PELOD (R2 = 0.12; p = 0.004) scores. The greatest area under the curve identified an AVDSF cutoff of 0.22, which was close to the previously suggested 0.25. The high AVDSF group had higher mortality [7/19 (36.8%) vs. 5/50 (10.0%); p = 0.009] and lower VFD [2 (0, 18) vs. 21 (15, 24); p = 0.007] and IFD [0 (0, 16) vs. 16 (5, 21); p = 0.013]. In the multivariable model, being in the high AVDSF group [adjusted odds ratio 4.67 (95% CI: 1.12, 19.39)] was significantly associated with mortality.ConclusionsHigh AVDSF was independently associated with increased mortality and decreased VFD and IFD. AVDSF may be complementary to oxygenation indices in risk stratifying PARDS and warrant further study.

Characteristics and Risk Factors of Children Requiring Prolonged Mechanical Ventilation vs. Non-prolonged Mechanical Ventilation in the PICU: A Prospective Single-Center Study.

BackgroundProlonged mechanical ventilation (PMV) has become an enormous challenge in intensive care units (ICUs) around the world. Patients treated with PMV are generally in poor health. These patients represent a select cohort with significant morbidity, mortality, and resource utilization. The status of children who have undergone PMV in China is unknown. Our goal is to investigate the prevalence and characteristics of pediatric patients with PMV, as well as the risk factors of PMV in the pediatric intensive care unit (PICU).MethodsThe subjects were divided into two groups. The PMV group(MV ≥ 14 days) and the non-PMV group(2 days < MV <14 days). The baseline characteristics, treatments, mortality and other results between the two groups were compared. The risk factors associated with PMV were evaluated using univariate and multivariable analyses.ResultsOf the 382 children enrolled, 127 (33.2%) received prolonged mechanical ventilation. The most common cause of MV in the PMV group was acute lung disease (48.0%), followed by acute circulatory system disease (26.0%), acute neurological disease (15.0%), postoperative monitoring (10.2%), and others (0.8%). Comorbidities were more prevalent among the PMV group (P = 0.004). The patients with PMV had a higher rate of premature birth (24.4 vs. 14.1%, P = 0.013) and higher PIM3 score at admission [5.6(3.0–9.9) vs. 4.1(1.7–5.5), P < 0.001]. The use of inotropes/vasopressors (63.8 vs. 43.1%, P < 0.001) was more common in patients with PMV compared with those in the non-PMV group. In the PMV group, the rate of extubation failure (39.4 vs. 6.7%, P < 0.001) was higher than the non-PMV group. The median hospital stay [35(23.0–50.0)d vs. 20(14.0–31.0)d, P < 0.001], PICU stay [22(15.0–33.0)d vs. 9(6.0–12.0)d, P < 0.001], hospitalization costs [¥391,925(263,259–614,471) vs. ¥239,497(158,723–350,620), P < 0.001], and mortality after 1-month discharge (22.0 vs. 1.6%, P < 0.001) were higher in the PMV group. Multivariate analysis revealed that age <1 year old, a higher PIM3 score at admission, prematurity, the use of inotropes or vasopressors, extubation failure, and ventilator mode on the first day of MV were associated with PMV.ConclusionsThe incidence and mortality of PMV in pediatric patients is surprisingly high. Premature infants or patients with severe disease or extubation failure are at higher risk of PMV. Patients with PMV exhibit a greater burden with regard to medical costs than those on non-PMV. It is important to establish specialized weaning units for mechanically ventilated patients with stable conditions.

Spectrum and Outcome of Intra-abdominal Tumors in children Under-five in a Pediatric Critical Care Unit of a Tertiary Care Center of Pakistan

Objective: To determine the spectrum and outcome of intra-abdominal tumors in children less than five years admitted in the critical care unit of a tertiary care center of Pakistan. Methodology: This retrospective study included children less than five years with malignant abdominal mass admitted in the pediatric critical care unit of the tertiary care center of Pakistan from July 2015 to June 2019.&#x0D; Undiagnosed patients or with relapsed or benign abdominal tumors managed in an outpatient or admitted in the critical care for post-operative care only were excluded from the study. Data was entered and analyzed by using SPSS version 21.0. Result: Total 55 patients were included with 69% boys and median age three years (IQR – 2 years). Abdominal distention was the commonest complain (100%). Only 42% children survived (n=23/55). High grade mature Bcell Non Hodgkin Lymphoma was the most common (45%) diagnosis. Advance Stage III/IV was seen in 94%. Combined multiple site metastasis was most common (45.4%). Sepsis (OR-5.30, 95% CI-1.24-22.65, p-0.024), inotropic use (OR-9.00, 95% CI-1.33-60.92, p-0.024) and malnutrition (OR-4.85, 95% CI-1.08-21.63, p-0.039) were identified as the most significant prognostic factors related to high mortality. Conclusion: B-cell Non-Hodgkin Lymphoma was the most common histopathological diagnosis, while sepsis was the commonest reason for admission in critical care unit. Majority presented with advanced stages (stage III/IV) with poor outcome(58% mortality). Sepsis, malnutrition and need of inotropes were found to be the independent risk factors contributing to this high mortality. We recommend for early recognition of abdominal distention as an important sign of cancer with prompt referral to pediatric oncology unit which would definitely decrease the upfront critical care requirement and improve survival.

EuroSCORE II as Predictor of Mortality and Morbidity in Post-CABG Patient in Dr. Soetomo General Academic Hospital

Introduction: European System for Cardiac Operative Risk Evaluation (EuroSCORE) is a scoring system to predict mortality risk after cardiac surgery. EuroSCORE II was introduced to replace and show superiority over EuroSCORE I which tends to overestimate the risk of heart surgery procedures and have a low discrimination ability. Meanwhile, this is the first study to analyze EuroSCORE II as a predictor of mortality and morbidity in Indonesians. Objective: This study aims to analyze EuroSCORE II as a predictor of mortality and morbidity in Indonesians. Materials and Methods: This is a retrospective study using medical records of CABG patients in Dr. Soetomo General Academic Hospital from January 2016 to December 2017. Results and Discussion: Out of 39 Patients who have performed CABG surgery, most were male (89.7%) with the highest age range of 46-65 years (59%). Deceased patients had an average EuroSCORE II of 22.36% and SD±26.97%7%, while 27 patients who survived had an average EuroSCORE II of 6.78% and SD±6.4%. Based on morbidity assessment, EuroSCORE II only accurately predicted the risk of kidney failure and did not properly assess the length of inotropic use, vasopressors, hospitalization time, the risk of arrhythmias, low cardiac output syndrome, Durante-operative bleeding, and the need for blood transfusion. These inaccuracies occurred because the samples that were included varied based on their standard deviation and pattern-less graph. Conclusion: EuroSCORE II is inadequate to predict morbidity and mortality in postoperative patients, therefore, it is considered less effective.

The impact of pulmonary function tests on early postoperative complications in open lung resection surgery: an observational cohort study

We investigated whether pulmonary function tests (PFTs) can predict pulmonary complications and if they are, to find new cutoff values in current open lung resection surgery. In this observational study, patients underwent open lung resection surgery at a tertiary hospital were analyzed (n = 1544). Various PFTs were tested by area under the receiver-operating characteristic curve (AUCROC) to predict pulmonary complications until 30 days postoperatively. In results, PFTs were generally not effective to predict pulmonary complications (AUCROC: 0.58–0.66). Therefore, we could not determine new cutoff values, and used previously reported cutoffs for post-hoc analysis [predicted postoperative forced expiratory volume in one second (ppoFEV1) < 40%, predicted postoperative diffusing capacity for carbon monoxide (ppoDLCO) < 40%]. In multivariable analysis, old age, male sex, current smoker, intraoperative transfusion and use of inotropes were independent risk factors for pulmonary complications (model 1: AUCROC 0.737). Addition of ppoFEV1 or ppoDLCO < 40% to model 1 did not significantly increase predictive capability (model 2: AUCROC 0.751, P = 0.065). In propensity score-matched subgroups, patients with ppoFEV1 or ppoDLCO < 40% showed higher rates of pulmonary complications [13% (21/160) vs. 24% (38/160), P = 0.014], but no difference in in-hospital mortality [3% (8/241) vs. 6% (14/241), P = 0.210] or mean survival duration [61 (95% CI 57–66) vs. 65 (95% CI 60–70) months, P = 0.830] compared to patients with both > 40%. In conclusion, PFTs themselves were not effective predictors of pulmonary complications. Decision to proceed with surgical resection of lung cancer should be made on an individual basis considering other risk factors and the patient's goals.

Early High-Dose Methylprednisolone Therapy Is Associated with Better Outcomes in Children with Acute Necrotizing Encephalopathy.

Background: The neurologic outcomes of acute necrotizing encephalopathy (ANE) are very poor, with a mortality rate of up to 40% and fewer than 10% of patients surviving without neurologic deficits. Steroid and immunoglobulin treatments have been the most commonly used options for ANE, but their therapeutic efficacy is still controversial. Method: We retrospectively reviewed the medical records of 26 children diagnosed with ANE. We also divided these patients into two groups: 21 patients with brainstem involvement and 8 patients without brainstem involvement. Pulse steroid therapy (methylprednisolone at 30 mg/kg/day for 3 days) and intravenous immunoglobulin (2 g/kg for 2–5 days) were administered to treat ANE. Results: The overall mortality rate was 42.3%, and patients who did not survive had significantly higher initial lactate and serum ferritin levels, as well as higher rates of inotropic agent use with brainstem involvement. There were no significant differences in the outcomes of pulse steroid therapy or pulse steroid plus immunoglobulin between survivors and non-survivors. When analyzing the time between symptom onset and usage of pulse steroid therapy, pulse steroid therapy used within 24 h after the onset of ANE resulted in significantly better outcomes (p = 0.039). In patients with brainstem involvement, the outcome was not correlated with pulse steroid therapy, early pulse steroid therapy, or pulse steroid therapy combined with immunoglobulin. All patients without brainstem involvement received “early pulse methylprednisolone” therapy, and 87.5% (7/8) of these patients had a good neurologic outcome. Conclusion: Pulse steroid therapy (methylprednisolone at 30 mg/kg/day for 3 days) administered within 24 h after the onset of ANE may be correlated with a good prognosis. Further studies are needed to establish a consensus guideline for this fulminant disease.

Artificial Intelligence for Risk Prediction of Rehospitalization with Acute Kidney Injury in Sepsis Survivors.

Sepsis survivors have a higher risk of long-term complications. Acute kidney injury (AKI) may still be common among sepsis survivors after discharge from sepsis. Therefore, our study utilized an artificial-intelligence-based machine learning approach to predict future risks of rehospitalization with AKI between 1 January 2008 and 31 December 2018. We included a total of 23,761 patients aged ≥ 20 years who were admitted due to sepsis and survived to discharge. We adopted a machine learning method by using models based on logistic regression, random forest, extra tree classifier, gradient boosting decision tree (GBDT), extreme gradient boosting, and light gradient boosting machine (LGBM). The LGBM model exhibited the highest area under the receiver operating characteristic curves (AUCs) of 0.816 to predict rehospitalization with AKI in sepsis survivors and followed by the GBDT model with AUCs of 0.813. The top five most important features in the LGBM model were C-reactive protein, white blood cell counts, use of inotropes, blood urea nitrogen and use of diuretics. We established machine learning models for the prediction of the risk of rehospitalization with AKI in sepsis survivors, and the machine learning model may set the stage for the broader use of clinical features in healthcare.

Current use of inotropes according to initial blood pressure and peripheral perfusion in the treatment of congestive heart failure: findings from a multicentre observational study

ObjectivesCurrent guidelines restrict the use of inotropes for the treatment for heart failure (HF) unless the patients are hypotensive or hypoperfused because of safety concerns. This study sought to characterise...

Outcome Analyses of the Admitted Patients in a Paediatric Intensive Care Unit in a Resource Poor Setting: A Prospective Observational Study

Introduction: Paediatric intensive care is an indispensible part in the management of critically ill children. Facilities for intensive care are sparse in low income countries requiring strict admission criteria. Adequate data generation regarding the profile of patients, outcomes and identification of the risk factor for poor prognosis can help in appropriate utilisation of this specialised care. Aim: To analyse the outcome of admissions in the Paediatric Intensive Care Unit (PICU) of a tertiary care centre in upper Assam and identification of risk factors for poor prognosis. Materials and Methods: A prospective observational study was carried out at the PICU of Assam Medical College Hospital, Dibrugarh, Assam, India, from March 2019 to April 2020. Data collected were -demographic details of the admitted children, the outcome and the risk factors affecting the mortality. Statistical methods used were Odds Ratio (OR), simple proportion test, Chi-square test and Relative Risk (RR) estimation with 95% confidence intervals, backward and forward logistic regression. Results: Total 495 children were enrolled in the study. The three most common disease categories were neurological disease (33.3%), respiratory disease (31.1%), and sepsis (10.7%). The overall mortality was 17.8%. Diseases related to the nervous system were the leading cause of death (38.6%). Highest mortality (43.2%) was in the age group of 1 month to 1 year. Highest disease specific mortality was due to Acute Encephalitis Syndrome (28.4%). Presence of circulatory shock, Poor Glasgow Coma Scale (GCS) (GCS&lt;8), hypoxia, dyselectrolytemia, malnutrition, renal failure, and requirement of ionotropic support, mechanical ventilation were significantly associated with mortality with p value&lt;0.05. Conclusion: Mortality rate (17.7%) was relatively high. Requirement of mechanical ventilation and Cardiopulmonary Resuscitation (CPR), use of inotropes, GCS ≤8, malnutrition, renal failure, dyselectrolytemia, hypoxia and sepsis were associated with increased mortality. Circulatory shock, requirement of CPR and mechanical ventilation were the independent predictors of mortality.

Burden of cardiovascular dysfunction and outcome among term newborns having birth asphyxia.

Objectives:To find out the burden of cardiovascular dysfunction and outcome among term newborns having birth asphyxia.Methods:This prospective observational study was conducted at The Department of Neonatology, Children’s Hospital and The Institute of Child Health, Multan from August 2020 to March 2021.A total of 171 term newborns having asphyxia were enrolled. Detailed history along with clinical and physical examination were done at the time of admission at Neonatal Intensive Care Unit (NICU). All neonates were followed up for duration of 14 days following birth. Echocardiographic patterns as well as electrocardiography grading were described among neonates with cardiovascular abnormalities.Results:Out of a total of 171 neonates, there were 94 (55.0%) male and 77 (45.0%) female. Lowe segment cesarean section was the mode of delivery in 72 (42.1%) while normal vaginal delivery was noted in 99 (57.9%). Mean gestational age was noted to be 38.3±1.8 weeks. Mean birth weight was calculated to be 2574.10±122.30 grams. Cardiovascular dysfunction was noted among 60 (35.1%) neonates as exhibited by the use of inotropes while abnormal ECHO was observed in 52 (30.4%), abnormal ECG in 27 (15.8%) and elevated CK-MB in 31 (18.1%). A total of 29 (17.0%) asphyxiated neonates died while among 60 asphyxiated neonates with cardiovascular dysfunction, 23 (38.3%) died and all remaining survived and discharged (p<0.0001).Conclusion:Cardiovascular dysfunction among asphyxiated neonates was found to be in high proportion of cases. Cardiovascular dysfunction was noted to have significant association with poor outcome.

Can surfactants affect mortality and morbidity in term infants with respiratory failure?

We aimed to discuss term infants who are given surfactant due to respiratory disorder according to the underlying etiology, the dose of surfactant administration, and the need for repeated surfactant administration. In this retrospective study infants hospitalized in the 4th level neonatal intensive care unit during January 2019 and December 2021 and administered surfactant due to respiratory distress were included. Term infants given surfactant due to respiratory failure were included in the study through the data recording system. The number of surfactant doses, indications for administration, mortality, duration of hospitalization, intubation time, and inotrope use were recorded in the infants included in the study. : During the two-year period, 1250 infants were hospitalized in our neonatal intensive care unit. Of those, 56 infants received surfactant replacement therapy for severe respiratory failure. There were 30 infants with pneumonia, 4 infants with meconium aspiration syndrome (MAS), and 22 infants with transient tachypnea of the newborn (TTN). It was seen that single-dose administration was higher in patients with TTN (p = 0.01), while multiple-dose surfactant administration was more common in patients with MAS, resulting in a statistical difference (p = 0.02). Mortality was lower, especially in cases given early surfactant administration and this situation was statistically significant (p < 0.001). Duration of intubation was 5.05 ± 4.7 days in early surfactant administration group and 8.0 ± 6.1 days in late surfactant administration group. This difference was statistically significant (p = 0.04). While early surfactant application was statistically higher in the TTN group (p = 0.007), late surfactant application was statistically higher in the pneumonia group (p = 0.001). Despite the difference on administration time and repeat dose interval due to etiology, surfactant treatment is improving the respiratory distress of term infants.

A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock.

This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.

MILESTONE: More Than 1,200 Children Bridged to Heart Transplantation with Mechanical Circulatory Support.

Pediatric mechanical circulatory support (MCS) has been successfully used to bridge numerous children to transplantation who otherwise would have been unlikely to survive on the waitlist and, in many cases, make them better transplant candidates. The purpose of this study was to analyze what the pediatric heart failure community has achieved over the last 15 years in reaching 1,200 cases of bridging children to heart transplantation. The United Network for Organ Sharing database was used to identify MCS patients ages 0-18 at the time of listing for heart transplantation between 2005 and 2019, divided into three eras: first (2005-2009), second (2010-2014), and third (2015-2019). From 2005 to 2019, 1,289 pediatric cases were identified. More patients were successfully bridged to transplantation with MCS in the third-era (28%) [vs. first-era (16%), second-era (24%), p ≤ 0.004]. The proportion of discharges on ventricular assist device has increased as well from 3% to 22% (p < 0.001). Post-transplant survival was significantly better in the third era (1-year survival: 96%; 3-year survival: 89%) compared to the two previous eras (p = 0.006). On MCS, renal dysfunction, ventilator dependence, inotrope use, and functional status improved from the time of listing to transplantation (p < 0.01). Hepatic dysfunction (p < 0.001), renal dysfunction (p = 0.004), congenital heart disease (p = 0.023), and infant age (p = 0.002) were risk factors for post-transplant mortality. Over the last 15 years, pediatric MCS has become an accepted and increasingly used strategy for bridging children to transplantation. MCS therapy is associated with improved end-organ function at the time of transplantation, perhaps contributing to the increasing post-transplantation survival of patients bridged with MCS.

Inotropes and vasopressors are associated with increased short-term mortality but not long-term survival in critically ill patients

ObjectiveLimited information is currently available on the impact of vasoactive medications in intensive care (ICU) and long-term outcomes. The main objective of our study was to describe the association between the use of inotropes and/or vasopressors and ICU mortality. Secondary objectives were to evaluate the association between the use of vasoactive drugs and in-hospital as well as 1-year all-cause mortality in ICU survivors. MethodsFROG-ICU was a prospective, observational, multi-centre cohort designed to investigate long-term mortality of critically ill adult patients. Cox proportional hazards models were used to evaluate the association between the use of inotropes and/or vasopressors and ICU mortality, as well as in-hospital and 1-year all-cause mortality in a propensity-score matched cohort. ResultsThe study included 2087 patients, 939 of whom received inotropes and/or vasopressors during the initial ICU stay. Patients treated with vasoactive medications were older and had a more severe clinical presentation. In a propensity score-matched cohort of 1201 patients, ICU mortality was higher in patients who received vasoactive medications (HR of 1.40 [1.10–1.78], p = 0.007). One thousand six hundred thirty-five patients survived the index ICU hospitalisation. There was no significant difference according to the use of inotropes and/or vasopressors in the propensity-score matched cohort on in-hospital mortality (HR of 0.94 [0.60–1.49], p = 0.808) as well as one-year all-cause mortality (HR 0.94 [0.71–1.24], p = 0.643). ConclusionInotropic and/or vasopressor therapy is a strong predictor of in-ICU death. However, the use of inotropes and/or vasopressors during ICU admission was not associated with a worse prognosis after ICU discharge.

Clinical characteristics, predictors and pregnancy outcomes in Indian women with peripartum cardiomyopathy.

Predictors, pregnancy and subsequent pregnancy outcomes in women with peripartum cardiomyopathy (PPCM) are poorly understood in our geographical region. We retrospectively analysed 58 women with PPCM diagnosed using criteria by the European Society of Cardiology during 2015 to 2019. The main outcome measures were predictors of left ventricular (LV) recovery. LV recovery was defined as return of LV ejection fraction to over 50%. Nearly 80% of women had LV recovery during 6 months follow up. Univariate logistic regression revealed LV end diastolic diameter (adjusted odds ratio (OR); 0.87; 95% CI, 0.78-0.98; p = 0.02), LV end systolic diameter (OR; 0.89; 95% CI, 0.8-0.98; p = 0.02) and inotrope use (OR; 0.2, 95% CI, 0.05-0.7; p = 0.01) as predictors of LV recovery. Relapse was not seen in any of the nine women who had a subsequent pregnancy. LV recovery was higher than those reported in contemporary PPCM cohorts from other parts of the world.

P-P18 Thoracic epidural VS intrapleural analgesia for pancreaticoduodenectomy – a study on analgesic and non-analgesic outcomes

Abstract Background Thoracic epidural analgesia (TEA) has been the traditional option for post-operative pain management for Kausch-Whipple pancreaticoduodenectomy (KWPD) via a ‘reverse L’ incision. An alternative option with inter-pleural analgesia (IPA) has become popular. However, the superior form of analgesia for KWPD regarding analgesic and non-analgesic outcomes is unclear. This study aims to establish if IPA is equivalent to TEA. Methods Retrospective study of all patients who underwent KWPD with ‘reverse L’ incision by a single surgeon between February 2014 to June 2016. All received either IPA or TEA post-operatively; patients who had rectus sheath catheter and spinal anaesthesia were excluded. To reduce bias, the Anaesthetist, rather than Surgeon, decided the choice of analgesia based on personal skill. Efficacy regarding analgesia were collected by nursing staff as patient-reported pain severity (mild, moderate or severe). Data were collected from patient case notes and electronic records. This study analysed analgesia efficacy, complications, inotrope use, and intensive treatment unit (ITU) stay. Results A total of 40 included in the study. Twenty-two patients had TEA (45% female, median age 68 years) and 18 had IPA (44% female, median age 67 years). Median Charleson Comorbidity Index (CCI) was 5 for both. Patient-reported pain was not statistically different (p = 0.15). We noted more analgesia complications with TEA (not working=4, leakage=2, haemodynamic instability=1, lower limb anaesthesia=1) than IPA (leakage=1; p = 0.027). Eleven (50%) TEA and eight (44%) IPA patients required inotropes. TEA patients required significantly longer duration (median duration 35 VS 18 hours, p = 0.047). Median ITU stay was 3 and 2 days for TEA and IPA patients, respectively. Conclusions Both TEA and IPA provide adequate pain relief for KWPD performed via a ‘reversed L’ incision. However, evidence suggests TEA was associated with significantly more analgesia-related complications and longer inotropic requirements. Furthermore, there was also a trend towards ITU stays with TEA. Therefore, we would recommend the use of inter-pleural analgesia over thoracic epidural.

Comparison between Bilateral Internal Mammary Artery Graft and LIMAG in Patients Undergoing CA Bypass Grafting

Background: Increasing evidence continues to demonstrate a survival advantage for bilateral internal mammary artery (BIMA) over Left internal mammary artery for coronary artery bypass grafting (CABG). However, there are still uncertainties about which surgical approach is the best one to use with BIMA grafting. Objective: To compare Bilateral Internal Mammary Artery (BIMA) Grafting with Left Internal Mammary Artery (LIMA) Grafting during Coronary Artery Bypass Grafting (CABG) in terms of early mortality and sternal wound infections. Materials &amp; Methods Randomized: control trialtechnique enrolled. The study was conducted at the Cardiac Surgery Department, King Edward Medical University (KEMU), Mayo Hospital Lahore Results: Total 96patients undergoing CABG were included in this study. Patients were randomly divided into 2 groups; each group contains 48 patients. Group A included patients having Left IMA to LAD; second and third graft by Great Saphenous Vein and Group B included patients having Bilateral Internal Mammary Arteries with Left IMA to LAD or OM and Right IMA to RCA, LAD or Ramus Intermedius. The superficial and deep sternal wound infections was recorded along with the different risk factors including diabetes, obesity, hypertension, smoking and use of inotropes intra-operatively and post operatively. The incision site over the sternum was being evaluated on daily basis throughout the stay of the patients (from 5–8 days). Diagnosis of Sternal infections was based on the presence of positive cultures, dehiscence of the sternum incision, fever, redness pain, and infected (purulent) secretions. Sternal instability and discharge, ventilation time, length of ICU stay, chest drainage, re-exploration and length of hospital stay was also recorded. Results:Not any of the patients included in these two treatment groups suffered from mortality (LIMA: 0%, BIMA: 0%). Deep sternal wound infection [LIMA: 4.17% &amp; BIMA: 6.25%, p-value=0.646] and superficial wound infection [LIMA: 4.17% &amp; BIMA: 6.25%, p-value=0.646] did not show any statistically significant association towards both grafts type. Patients who underwent BIMA grafting suffered from higher in hospital stay as compared to patients who underwent LIMAgrafting. i.e. [LIMA: 7.02 &amp; BIMA: 8.02, P value = 0.000] Conclusion: Results of the study showed no significant difference for deep sternal wound infection and superficial wound infection between the two grafts BIMA and LIMA. However, patients who underwent BIMA grafting had significantly higher hospital stay as compared to patients who underwent LIMA grafting. Keywords: Bilateral, Internal, Mammary Artery, Grafting, Left, Internal Mammary Artery, Coronary Artery, Bypass, Grafting, Mortality, Sternal wound infections.

Outcome and Risk Factors of Febrile Episodes Treated with Broad Spectrum Antibiotics and Polyclonal IgM–Enriched Immunoglobulin in Pediatric Oncology Hematology Patients: A Retrospective Study

Abstract Objective Preparations with high-titer immunoglobulin-M (HT-IgM) have been used to treat neonatal and adult sepsis as adjuvant to antibiotics. Limited data are available of this use in pediatric oncohematological patients. We retrospectively assessed the characteristics and outcome of febrile episodes treated with broad-spectrum antibiotics and HT-IgM. Methods This study included febrile episodes diagnosed after chemotherapy or hematopoietic stem cell transplantation (HSCT) treated with antibiotics and HT-IgM. Study period was from January 2011 to March 2019. Results Seventy febrile episodes in 63 patients were eligible. In 40% of episodes (n = 28), blood cultures identified a causative organism: Gram-negative (n = 15), Gram-positive (n = 8), polybacterial (n = 4), fungi (n = 1). Twenty-six percent of Gram-negatives were extend spectrum β-lactamase (ESBL)-producers. In 44% of episodes, a deep-organ localization was present, mostly pulmonary. Severe or profound neutropenia, hypotension, and hypoxemia were present in 89, 26, and 21% of episodes, respectively; 20% of episodes required intensive care and 20% of episodes required the use of inotropes. Overall, 90-day mortality was 13% and infection-attributable mortality resulted 8.6%. More than half of the patients received HT-IgM within 24 hours from fever onset. HT-IgM-related allergic reactions occurred in three episodes. Risk factors for 90-day mortality were as follows: hypotension and hypoxemia at fever presentation, admission to intensive care unit (ICU), use of inotropes, presence of deep-organ infection, and escalation of antibiotic therapy within 5 days. Conclusion The combination of broad-spectrum antibiotics and HT-IgM was feasible, tolerated, and promising, being associated with a limited infectious mortality. Further prospective controlled studies are needed to assess the efficacy of this combination over a standard antibiotic approach.