Inotropic Requirement Research Articles

Association of obesity and mortality in patients with COVID-19 acute respiratory distress syndrome: A retrospective cohort study.

Chronic conditions such as obesity are associated with adverse outcomes in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) patients. The aim of our study was to evaluate the relationship between BMI and outcomes in critically ill patients with COVID-19 ARDS. A retrospective study including all patients with COVID-19 and ARDS on mechanical ventilation admitted to the intensive care unit (ICU) over 2 years. Patients with obesity (BMI ≥30 kg/m2) were compared with those without obesity (BMI >18.5 up to 29.9 kg/m2). Outcomes compared were primary (mortality, duration of mechanical ventilation, and length of ICU stay) and secondary complications during the ICU course (inotrope requirement, acute kidney injury [AKI] requiring renal replacement therapy [RRT], and bloodstream and urinary tract infections). One hundred and eight patients were included in the study. The mean age of patients was 52 years, and 94 (87%) patients were males. As compared to COVID-19 ARDS patients without obesity, COVID-19 patients with obesity were more prone to develop complications like AKI, necessitating continuous RRT (P = 0.005). There was no significant difference in other complications between the two groups (all P > 0.05). There was no increased mortality in these obese patients (P = 0.056). In these patients with obesity, those who also had ischemic heart disease had an increased likelihood of mortality (P = 0.036). Our study concludes that patients with COVID-19 ARDS who are obese are not at higher risk of mortality and more likely to develop renal complications. When these patients develop cardiac complications or bloodstream infections, they have a significantly higher risk of mortality.

Comparison Of Antegrade And Antegrade/Retrograde Blood Cardioplegia Applications In Cardiopulmonary Bypass Accompanıed Cardiac Surgery

Introduction: Ischemic heart disease (IHD) is among the leading causes of death worldwide. Sometimes, cardiopulmonary bypass (CPB) is inevitable in the treatment of heart diseases by open heart surgery procedures. Myocardium protection is of great importance in CPB cases. Various techniques and applications exist for the protection of the myocardium.
 Objective: In this study, it was aimed to determine the perioperative and postoperative early outcomes of coronary artery bypass grafting (CABG) operations with CPB by comparing intermittent antegrade and intermittent antegrade (Initial) combined with retrograde (Maintenance) blood cardioplegia applications.
 Materials and Methods: 240 patients with similar characteristics who underwent CPB-guided CABG operation were included. Two groups were formed as Antegrade (Group 1) and Antegrade/retrograde (Group 2). The preoperative, intraoperative, and early postoperative results of the groups were compared.
 Results: Gender, age, body surface area, flow, ejection fraction percentages, EuroSCORE and LMCA lesion presence values were similar in both groups (p>0.05). Cross-clamp time, total perfusion time, mean activated clotting time during CPB and perioperative drainage were similar in both groups (p>0.05). There was no statistically significant difference between the sodium, potassium, calcium, glucose, and lactate levels evaluated after CPB of the two groups (p>0.05). In addition, there was no statistically significant difference between the two groups in terms of defibrillation requirement, inotropic requirement, and IABP requirement after CPB. (p>0.05).
 Conclusion: Similar results were observed between antegrade cardioplegia alone and antegrade combined with retrograde cardioplegia in CPB-guided CABG operations. For this reason, we think that the antegrade cardioplegia technique alone will be more advantageous in terms of ease of application, not requiring additional invasive intervention, and eliminating the risks of the necessity of additional intervention. Furthermore, we think that the importance of case-based evaluation in cardioplegia techniques should not be ignored.

Obesity and Outcomes of Kawasaki Disease and COVID-19–Related Multisystem Inflammatory Syndrome in Children

Obesity may affect the clinical course of Kawasaki disease (KD) in children and multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. To compare the prevalence of obesity and associations with clinical outcomes in patients with KD or MIS-C. In this cohort study, analysis of International Kawasaki Disease Registry (IKDR) data on contemporaneous patients was conducted between January 1, 2020, and July 31, 2022 (42 sites, 8 countries). Patients with MIS-C (defined by Centers for Disease Control and Prevention criteria) and patients with KD (defined by American Heart Association criteria) were included. Patients with KD who had evidence of a recent COVID-19 infection or missing or unknown COVID-19 status were excluded. Patient demographic characteristics, clinical features, disease course, and outcome variables were collected from the IKDR data set. Using body mass index (BMI)/weight z score percentile equivalents, patient weight was categorized as normal weight (BMI <85th percentile), overweight (BMI ≥85th to <95th percentile), and obese (BMI ≥95th percentile). The association between adiposity category and clinical features and outcomes was determined separately for KD and MIS-C patient groups. Of 1767 children, 338 with KD (median age, 2.5 [IQR, 1.2-5.0] years; 60.4% male) and 1429 with MIS-C (median age, 8.7 [IQR, 5.3-12.4] years; 61.4% male) were contemporaneously included in the study. For patients with MIS-C vs KD, the prevalence of overweight (17.1% vs 11.5%) and obesity (23.7% vs 11.5%) was significantly higher (P < .001), with significantly higher adiposity z scores, even after adjustment for age, sex, and race and ethnicity. For patients with KD, apart from intensive care unit admission rate, adiposity category was not associated with laboratory test features or outcomes. For patients with MIS-C, higher adiposity category was associated with worse laboratory test values and outcomes, including a greater likelihood of shock, intensive care unit admission and inotrope requirement, and increased inflammatory markers, creatinine levels, and alanine aminotransferase levels. Adiposity category was not associated with coronary artery abnormalities for either MIS-C or KD. In this international cohort study, obesity was more prevalent for patients with MIS-C vs KD, and associated with more severe presentation, laboratory test features, and outcomes. These findings suggest that obesity as a comorbid factor should be considered at the clinical presentation in children with MIS-C.

Later Brain Death Declaration Correlates to Favorable Donor Characteristics but Decreased Heart Acceptance.

With rates of potential donor heart discard as high as 66% nationally, quality improvement efforts must seek to optimize donor utilization. Whether the timing of donor brain death declaration (BDD) influences organ acceptance is understudied. The authors sought to characterize the impacts of time between donor hospital admission and BDD on heart utilization and posttransplant outcomes. All potential heart donors and recipients in the United Network for Organ Sharing database were identified (2006-2021). Admission-to-BDD cohorts were: 1 to 2 d (n = 52 469), 3 to 4 d (n = 44 033), 5 to 7 d (n = 24 509), and 8 to 10 d (n = 8576). Donor clinical characteristics were compared between cohorts, and donor acceptance was assessed using multivariable binary logistic regression. Recipient posttransplant survival was assessed with the Kaplan-Meier method. Donor demographics and comorbidity profiles (diabetes and hypertension) were comparable across cohorts. Anoxia/overdose deaths were more common (10% > 21% > 24% > 18%, respectively) and cardiopulmonary resuscitation requirements were higher (37% > 52% > 58% > 47%) when BDD occurred longer after admission. Renal dysfunction (44% > 44% > 35% > 29%) and inotrope requirements (52% > 25% > 36% > 29%) were lower in the later BDD cohorts. Proportions of hepatic dysfunction (18%-21%) and left ventricular ejection fraction <50% (13%-16%) were clinically equivalent. Donor acceptance differed by admission-to-BDD cohort (36% [1-2 d], 34% [3-4 d], 30% [5-7 d], and 28% [8-10 d]). Admission-to-BDD >4 d was independently associated with lower odds of acceptance on multivariable analysis (odds ratio 0.79, P < 0.001). Recipients experienced equivalent posttransplant survival for all donor admission-to-BDD cohorts ( P = 0.999 adults and P = 0.260 pediatrics). Heart donors with later BDD were disproportionately discarded despite similar-to-favorable overall clinical profiles, resulting in nearly 3000 fewer transplants during the study. Increased utilization of donors with later BDD and "high-risk" characteristics (eg, anoxia/overdose, cardiopulmonary resuscitation requirement) can improve rates of transplantation without compromising outcomes.

Myocardial infarction with non obstructive coronary arteries (MINOCA): clinical profile and prognosis

Abstract Background MINOCA is a clinical condition that has grown interest in the last few years. The aim of this study is to compare the clinical profile, treatment and prognosis of MINOCA patients and those with myocardial infarction (MI) with obstructive coronary artery disease (MICAD). Methods We analyzed all consecutive patients with MI who underwent coronary angiography admitted in our Hospital. The database and all the patient's angiographies were revised by a group of experts in order to adequate MINOCA definition to 2020 ESC Guidelines definition and American Heart Association consensus statement. Results We included 915 patients, of whom 108 (12%) were MINOCA, with a median follow-up of 45 [21-65] months (see table 1). The underlying mechanism in MINOCA was coronary spasm (15%), plaque rupture (9.3%), coronary embolism (4.7%), coronary dissection (5.6%), type II infarction (17.8%) or unknown (43.8%). A total of 58.3% had angiographically smooth coronary arteries and 38.9% had plaques &amp;lt;50%. MINOCA patients in our study were younger and mostly female, with higher prevalence of connective tissue diseases, migraine or patient-reported stress and less smoking, diabetes and chronic kidney disease compared to patients with obstructive coronary artery disease. Symptoms at admission did not differ between both groups, although MINOCA had EKG with fewer alterations, most had a diagnosis of non-ST-elevation MI (NSTEMI) and significantly lower myocardial injury biomarkers’ levels (Troponine T hs peak 176 [37.25-430] vs 860 [187.50- 2640.50] ng/L, p&amp;lt;0.001 and CK 179 [86.75-342.75] vs 435 [159.50-1090] U/L, p&amp;lt;0.001). They had fewer cardiovascular complications during hospitalization such as inotropic requirements (0% vs 8%, P=0.003), cardiogenic shock (0% vs 6.4%, P=0.007) or left ventricular dysfunction (11.1% vs 29.6%, P&amp;lt;0.001). There were no significant differences in MACE (25.3% vs 34.7%, p=0,086): death (10.7% vs 15.5%, p=0.25), readmission (19% vs 28.7%, p=0.06), AMI (8.3 % vs 7.3%, p=0.74) and stroke (2.4% vs 3.4%, p=0.61) in both groups at follow-up. Conclusions 1) MINOCA is frequent (12% of MI), 2) the clinical profile of MINOCA patients is different than MICAD (lower cardiovascular risk factors burden, younger and more females), 3) the severity of myocardial infarction is lower (more diagnosis of NSTEMI, lower myocardial injury biomarkers’ levels, fewer complications during hospitalization and less left ventricular dysfunction), 4) we found no differences in prognosis in both groups.Table 1

Is the combination of conventional ultrafiltration and modified ultrafiltration superior to modified ultrafiltration in pediatric open-heart surgery?

ABSTRACT Background: Cardiopulmonary bypass (CPB) during open-heart surgery is associated with increased body fluids as a consequence of hemodilution due to the use of CPB. Ultrafiltration (UF) is a method used to decrease the body fluid volume on CPB. Aims and Objectives: This study aimed to compare the effects of combined conventional UF (CUF) and modified UF (MUF) versus MUF on the clinical outcomes of pediatric patients undergoing open-heart surgery for congenital heart disease. Materials and Methods: This was a prospective, single-center, randomized, and double-blinded clinical study that involved 74 pediatric patients undergoing open-heart surgery on CPB. Patient management was standardized. Preoperative Aristotle comprehensive complexity level, ultrafiltrate volumes, hematocrit, hemodynamic data, transesophageal echocardiographically (TEE) determined ejection fraction (EF), fractional area change (FAC), temperature drift, arterial oxygenation, time of extubation, ventilation, comparison of inotropic drugs, postoperative chest tube drainage, cardiac care unit (CCU), and hospital length of stay (LOS) were recorded in both groups. The analysis was conducted using SPSS-23.0, IBM, Armonk, NY, USA. Results: There was no mortality in both groups. Technical difficulties prevented the completion of MUF in two patients out of 37 in the CUF + MUF group. In this study, there were 43.26% of females and 56.75% of males, with a median age of 439 days, a mean weight of 9.98 kg, and an Aristotle Comprehensive Complexity score of level 2. Group CUF + MUF had a greater ultrafiltrate volume of 122 ± 39.7 ml (P = 0.036). The duration of ventilatory support was 11.2 ± 6.4 h versus 34.4 ± 5.7 h (P = 0.013), average CCU LOS was 4.3 ± 3.5 days versus 7.2 ± 3.6 days (P = 0.008), and chest tube drain in the first 48 h was 89.76 ± 34.82 ml versus 106.65 ± 47.29 ml (P = 0.029) in groups CUF + MUF and MUF, respectively. Inotropic infusion requirements were significantly lower in the CUF + MUF group compared to the MUF group. EF and FAC were 14% and 5% higher at 45 min in group CUF + MUF, respectively. Conclusions: The advantage of combining CUF and MUF over MUF is the significant improvement in the hemodynamic status of patients, which significantly decreases the duration of mechanical ventilation, average CCU LOS, inotrope requirements after surgery, and chest tube drain in the first 48 h.

PASS: A scoring system to evaluate persistent kidney injury in critically ill ICU adult patients

Background: We evaluated if the course of recovery from sepsis-induced acute kidney injury (AKI) can be predicted using variables collected at admission. Methods: A total of 63 patients admitted for sepsis-induced AKI in our Mangalore ICU were evaluated and baseline demographic and clinical/laboratory parameters, including serum creatinine (SCr), base excess (BE), Plethysmographic Variability Index (PVI), Caval Index, R wave variability index (RVI), mean arterial pressure (MAP) and renal resistivity index (RI) using renal doppler and need for inotropes were assessed on admission. Patients were managed as per standard protocol. After six hours of fluid resuscitation, patients were classified as volume responders or non-responders. Re-assessment was done at 24 hours and 72 hours after admission. Primary outcome was persistent AKI after 72 hours. Secondary outcome was initiation of dialysis or death within 15 days of admission. Results: A total of 34 subjects recovered from AKI, of whom 32 patients were volume responders and 31 were non-responders. Response to fluid, MAP at admission and six hours, BE at admission, inotrope requirement, and PVI at admission did not correlate with recovery. Multiple logistic regression showed that SCr &lt; 2.36 mg%, RVI &gt; 14.45 and RI &lt; 0.8 on admission correlated with recovery and they were evaluated further to model AKI recovery and develop PASS. PASS score = (SCr points × 5.4) + (RVI points × 4.0) + (RI points × 6.2). One point each was allotted if SCr was &lt; 2.36, RVI was &gt; 14.45 and RI was &lt;0.8, and 0 otherwise. A score &gt; 7.8 predicted recovery with a sensitivity of 79.4%, specificity of 72.4%, PPV 81.8%, NPV 76.7% and AuROC of 0.85. Conclusions: The PASS score can be used to identify salvageable cases of sepsis-AKI, guiding fluid resuscitation and aiding early referral from rural to tertiary care centers for better management.

Postoperative outcome of neonatal emergency surgeries in a tertiary care institute-A prospective observational study.

Neonatal surgical mortality continues to be high in developing countries. A better understanding of perioperative events and optimization of causative factors can help in achieving a favorable outcome. The present study was designed to evaluate the perioperative course of surgical neonates and find out potential factors contributing to postoperative mortality. This prospective observational study enrolled neonates, undergoing emergency surgical procedures in a tertiary care institute. Primary outcome was 6 weeks postsurgical mortality. The babies were observed till discharge and subsequently followed up telephonically for 6 weeks after surgery. Multivariable logistic regression analysis of various parameters was performed. Out of the 324 neonates who met inclusion criteria, 278 could be enrolled. The median age was 4 days. Sixty-two (27.7%) neonates were born before 37 weeks period of gestation (POG), and 94 (41.8%) neonates weighed below 2.5 kg. The most common diagnoses was trachea-esophageal fistula (29.9%) and anorectal malformation (14.3%). The median duration of hospital stay for survivors was 14 days. The in-hospital mortality was 34.8%. Mortality at 6 weeks following surgery was 36.2%. Five independent risk factors identified were POG < 34 weeks, preoperative oxygen therapy, postoperative inotropic support postoperative mechanical ventilation, and postoperative leukopenia. In neonates where invasive ventilation was followed by non-invasive positive pressure ventilation in the postoperative period, risk of postoperative surgical mortality was significantly reduced. Present study identified preterm birth, preoperative oxygen therapy, postoperative positive pressure ventilation, requirement of inotropes, and postoperative leukopenia as independent predictors of 6-week mortality. The possibility of early switch to noninvasive positive pressure ventilation was associated with a reduction in neonatal mortality.

Effect of preoperative ivabradine on hemodynamics during elective off-pump CABG.

Ivabradine is a specific heart rate (HR)-lowering agent which blocks the cardiac pacemaker If channels. It reduces the HR without causing a negative inotropic or lusitropic effect, thus preserving ventricular contractility. The authors hypothesized that its usefulness in lowering HR can be utilized in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. To study the effects of preoperative ivabradine on hemodynamics (during surgery) in patients undergoing elective OPCAB surgery. Fifty patients, New York Heart Association (NYHA) class I and II, were randomized into group I (control, n = 25) and group II (ivabradine group, n = 25). In group I, patients received the usual anti-anginal medications in the preoperative period, as per the institutional protocol. In group II, patients received ivabradine 5 mg twice daily for 3 days before surgery, in addition to the usual anti-anginal medications. Anesthesia was induced with fentanyl, thiopentone sodium, and pancuronium bromide as a muscle relaxant and maintained with fentanyl, midazolam, pancuronium bromide, and isoflurane. The hemodynamic parameters [HR and mean arterial pressure (MAP)] and pulmonary artery (PA) catheter-derived data were recorded at the baseline (before induction), 3 min after the induction of anesthesia at 1 min and 3 min after intubation and at 5 min and 30 min after protamine administration. Intraoperatively, hemodynamic data (HR and MAP) were recorded every 10 min, except during distal anastomosis of the coronary arteries when it was recorded every 5 min. Post-operatively, at 24 hours, the levels of troponin T and brain natriuretic peptide (BNP) were measured. This trial's CTRI registration number is CTRI/005858. The HR in group II was lower when compared to group I (range 59.6-72.4 beats/min and 65.8-80.2 beats/min, respectively) throughout the study period. MAP was comparable [range (78.5-87.8 mm Hg) vs. (78.9-88.5 mm Hg) in group II vs. group I, respectively] throughout the study period. Intraoperatively, 5 patients received metoprolol in group I to control the HR, whereas none of the patients in group II required metoprolol. The incidence of preoperative bradycardia (HR <60 beats/min) was higher in group II (20%) vs. group I (8%). There was no difference in both the groups in terms of troponin T and BNP level after 24 hours, time to extubation, requirement of inotropes, incidence of arrhythmias, in-hospital morbidity, and 30-day mortality. Ivabradine can be safely used along with other anti-anginal agents during the preoperative period in patients undergoing OPCAB surgery. It helps to maintain a lower HR during surgery and reduces the need for beta-blockers in the intraoperative period, a desirable and beneficial effect in situations where the use of beta-blockers may be potentially harmful. Further studies are needed to evaluate the beneficial effects of perioperative Ivabradine in patients with moderate-to-severe left ventricular dysfunction.

Differentiation of Multi-system Inflammatory Syndrome Associated with COVID-19 Versus Kawasaki Disease Using Cardiac Biomarkers.

Multisystem inflammatory syndrome in children (MIS-C) after COVID-19 shares clinical similarities to Kawasaki disease (KD). We sought to determine whether cardiac biomarker levels differentiate MIS-C from KD and their association with cardiac involvement. Subjects included 38 MIS-C patients with confirmed prior CoVID-19 and 32 pre-pandemic and 38 contemporaneous KD patients with no evidence of COVID-19. Patient, clinical, echocardiographic, electrocardiographic and laboratory data timed within 72 hours of cardiac biomarker assessment were abstracted. Groups were compared, and regression analyses were used to determine associations between biomarker levels, diagnosis and cardiac involvement, adjusting for clinical factors. MIS-C patients had fewer KD clinical features, with more frequent shock, ICU admission, inotrope requirement, and ventricular dysfunction, with no difference regarding coronary artery involvement. Multivariable regression analysis showed that both higher N-terminal pro-B-type natriuretic peptide (NTproBNP) and cardiac troponin I (TnI) were associated with MIS-C versus KD, after adjusting for significant covariates. Receiver operating characteristic curves for diagnosis showed that any detectable TnI greater than 10 ng/L was predictive of MIS-C versus KD with 91% sensitivity and 76% specificity. NTproBNP >2000 ng/L predicted MIS-C versus KD with 82% sensitivity and 82% specificity. Higher TnI but not NTproBNP was associated with lower LV ejection fraction; neither biomarker was associated with coronary artery involvement. Positive TnI and higher NTproBNP may differentiate MIS-C from KD, which may become more relevant as evidence of prior COVID-19 becomes more challenging to determine. Cardiac biomarkers may have limited associations with cardiac involvement in this setting.

Risk factors for development of acute kidney injury and acute kidney disease in critically ill children.

Acute kidney injury (AKI) is common among critically ill children and these children are at risk of developing acute kidney disease (AKD). A prospective cohort study was conducted on children aged > 1month to ≤ 18years old admitted to the pediatric intensive care unit (ICU) of Hong Kong Children's Hospital from 6/2020 to 6/2021. The incidences and risk factors of both AKI and AKD were determined. There were 254 eligible admissions (58.3% inmales, with a median age of 4.9 [9.7] years). The overall AKI incidence was 41.7% and 56% of children who remained hospitalized inthe pediatric ICU for ≥ 7days after acquiring AKI developed AKD. Cardiac surgery, bone marrow transplantation and requirement of inotropes were risk factors for both AKI and AKD. The requirement of non-invasive ventilation [relative risk (RR): 2.625 (1.361, 5.064)], total medication dose [RR 1.006 (1.002, 1.010)] and maximal medication intensity [RR 1.154 (1.038, 1.283)] were additional determinants of AKI. Factors indicating more severe AKI and AKI progression were predictive of AKD development. The overall mortality in the pediatric ICUwas 3.1%. AKI was significantly associated with mortality (p < 0.001), longer length of hospitalization in the pediatricICU (p < 0.001) and hospital stay (p < 0.001). AKD was associated with a lower estimated glomerular filtration rate at dischargefrom the pediatric ICU (p = 0.036). AKI and AKD were common among critically ill children, and were associated with significant morbidity and mortality. Few modifiable risk factors, especially those related to nephrotoxic medication exposure, were associated with AKI development and AKD progression.

Venoarterial extracorporeal membrane oxygenation for cardiac support in human immunodeficiency virus-positive patients: a case report and review of a multicentre registry

BackgroundHuman immunodeficiency virus (HIV) is associated with increased risk of heart failure via multiple mechanisms both in patients with and without access to highly active antiretroviral therapy (HAART). Limited information is available on outcomes among this population supported on Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO), a form of temporary mechanical circulatory support.MethodsWe aimed to assess outcomes and complications among patients with HIV supported on VA ECMO reported to a multicentre registry and present a case report of a 32 year old male requiring VA ECMO for cardiogenic shock as a consequence of his untreated HIV and acquired immune deficiency syndrome (AIDS). A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) registry data from 1989 to 2019 was performed in HIV patients supported on VA ECMO.Results36 HIV positive patients were reported to the ELSO Database who received VA ECMO during the study period with known outcomes. 15 patients (41%) survived to discharge. No significant differences existed between survivors and non-survivors in demographic variables, duration of VA ECMO support or cardiac parameters. Inotrope and/or vasopressor requirement prior to or during VA ECMO support was associated with increased mortality. Survivors were more likely to develop circuit thrombosis. The patient presented was supported on VA ECMO for 14 days and was discharged from hospital day 85.ConclusionsA limited number of patients with HIV have been supported with VA ECMO and more data is required to ascertain the indications for ECMO in this population. HIV should not be considered an absolute contraindication to VA ECMO as they may have comparable outcomes to other patient groups requiring VA ECMO support.

Fulminant colitis due to Clostridium Difficile in a patient with a history of liver transplantation: a severe life-threatening complication.

Clostridium difficile´s fulminant colitis is characterized by the development of severe acute inflammation of the colon, associated with systemic toxicity. Fulminant colitis is the most serious form of acute colitis with a mortality of up to 80%. We present the case of a 45-year-old man who presented to the emergency department with acute abdominal pain, diarrhea and fever. Computed tomography showed circumferential diffuse parietal thickening of the colon, including the rectum, associated with striation of the surrounding tissues and ganglionic formations. In the following hours the patient evolved with worsening of the general condition, increased inotropic requirements and lactic acidosis. Emergency laparotomy was decided and total colectomy was performed. Fulminant Clostridium difficile colitis is a potentially deadly disease. The lability of the pathology in many occasions forces quick decision making, therefore fulminant colitis represents a medical surgical emergency being time crucial.

Five-Year Outcomes and Predictors of Mortality following Sepsis in a Large Cohort of Patients in a General Medical Ward: A Cohort Study from South India

Background: Although sepsis is a well-known cause of in-hospital mortality, data on long term outcomes are scarce. Aim: This study aims to estimate the cumulative 5-year mortality among patients with infection requiring admission. Methods: This was a cohort study done in tertiary care center in South India, with recruitment of those admitted with an infection between January 1st, 2009 and July 31st, 2014 in a medical unit. The patients were followed up by telephonic call or case record review. Kaplan–Meier survival curve was plotted and Cox-proportional hazard model was used as multivariable analysis to identify the independent risk factors of long-term mortality. Results: One thousand four hundred and fifty three patients were followed up in this cohort study. The mean survival by Kaplan–Meier survival analysis was 3.78 years (95% confidence interval [CI] 3.33, 4.22) in quick sepsis-related organ failure assessment (qSOFA) score positive patients and 6.07 years (95% CI 5.73, 6.41) in qSOFA negative patients which was statistically significant by the log-rank test. The cumulative 1-year mortality was 44.9% and 21.8% for qSOFA score of 2 or more and nonsepsis patients, respectively. The median survival of qSOFA score of 2 or more patients was 0.75 years (95% CI 0–2.1 years). The mortality among sepsis patients at discharge, 1 year, 5 and 8 years was 38.2%, 44.9%, 47.4%, and 47.8%, respectively. Cox regression analysis showed age hazard ratio (HR) 1.02 (1.01, 1.04), male gender 1.45 (1.03, 2.04), &gt;qSOFA score HR 1.89 (1.32, 2.72), Charlson Comorbidity Index HR 1.29 (1.14, 1.46), respiratory tract infection HR 1.81 (1.10, 2.95), and inotrope requirement HR 3.24 (1.98, 5.29) were the independent predictors of long-term mortality. Conclusions: The median survival of patients with possible infection with qSOFA score of 2 or more patients was 0.75 years (95% CI 0–2.1 years). Older age, male gender, qSOFA score of 2 or more, Charlson Comorbidity Index, respiratory tract infection, and inotrope requirement HR 3.24 were the independent predictors of long-term mortality.

Advanced heart failure in adult congenital heart disease: the role of renal dysfunction in management and outcomes.

Previous studies in adult congenital heart disease (CHD) have demonstrated a link between renal dysfunction and mortality. However, the prognostic significance of renal dysfunction in CHD and decompensated heart failure (HF) remains unclear. We sought to assess the association between renal dysfunction and outcomes in adults with CHD presenting to our centre with acute HF between 2010 and 2021. This retrospective analysis focused on the association between renal dysfunction, pre-existing and on admission, and outcomes during and after the index hospitalization. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2. Cox regression analysis was used to identify the predictors of death post-discharge. In total, 176 HF admissions were included (mean age 47.7 ± 14.5 years, 43.2% females). One-half of patients had a CHD of great complexity, 22.2% had a systemic right ventricle, and 18.8% had Eisenmenger syndrome. Chronic kidney disease was present in one-quarter of patients. The median length of intravenous diuretic therapy was 7 (4-12) days, with a maximum dose of 120 (80-160) mg furosemide equivalents/day, and 15.3% required inotropic support. The in-hospital mortality rate was 4.5%. The 1- and 5-year survival rates free of transplant or ventricular assist device (VAD) post-discharge were 75.4% [95% confidence interval (CI): 69.2-82.3%] and 43.3% (95% CI: 36-52%), respectively. On multivariable Cox analysis, CKD was the strongest predictor of mortality or transplantation/VAD. Highly complex CHD and inpatient requirement of inotropes also remained predictive of an adverse outcome. Adult patients with CHD admitted with acute HF are a high-risk cohort. CKD is common and triples the risk of death/transplantation/VAD. An expert multidisciplinary approach is essential for optimizing outcomes.

Analgesia and Sedation at Terminal Extubation: A Secondary Analysis From Death One Hour After Terminal Extubation Study Data.

To describe the doses of opioids and benzodiazepines administered around the time of terminal extubation (TE) to children who died within 1 hour of TE and to identify their association with the time to death (TTD). Secondary analysis of data collected for the Death One Hour After Terminal Extubation study. Nine U.S. hospitals. Six hundred eighty patients between 0 and 21 years who died within 1 hour after TE (2010-2021). Medications included total doses of opioids and benzodiazepines 24 hours before and 1 hour after TE. Correlations between drug doses and TTD in minutes were calculated, and multivariable linear regression performed to determine their association with TTD after adjusting for age, sex, last recorded oxygen saturation/F io2 ratio and Glasgow Coma Scale score, inotrope requirement in the last 24 hours, and use of muscle relaxants within 1 hour of TE. Median age of the study population was 2.1 years (interquartile range [IQR], 0.4-11.0 yr). The median TTD was 15 minutes (IQR, 8-23 min). Forty percent patients (278/680) received either opioids or benzodiazepines within 1 hour after TE, with the largest proportion receiving opioids only (23%, 159/680). Among patients who received medications, the median IV morphine equivalent within 1 hour after TE was 0.75 mg/kg/hr (IQR, 0.3-1.8 mg/kg/hr) ( n = 263), and median lorazepam equivalent was 0.22 mg/kg/hr (IQR, 0.11-0.44 mg/kg/hr) ( n = 118). The median morphine equivalent and lorazepam equivalent rates after TE were 7.5-fold and 22-fold greater than the median pre-extubation rates, respectively. No significant direct correlation was observed between either opioid or benzodiazepine doses before or after TE and TTD. After adjusting for confounding variables, regression analysis also failed to show any association between drug dose and TTD. Children after TE are often prescribed opioids and benzodiazepines. For patients dying within 1 hour of TE, TTD is not associated with the dose of medication administered as part of comfort care.

Evaluation of the Effects of the Heart-Lung Machine on the Plasma Beta-2 Microglobulin Level

Purpose: In this study, it was aimed to investigate whether beta-2 microglobulin (β2M) blood plasma level is affected by cardiopulmonary bypass (CPB) and its effects on prognosis in surgeries performed using a heart-lung machine.&#x0D; &#x0D; Material and Methods: The study was carried out on 33 patients who underwent cardiac surgery using a heart-lung machine in the cardiovascular surgery department of Sivas Cumhuriyet University. Plasma β2M levels were evaluated in peripheral venous blood samples taken just before the operation, thirty minutes after connecting to the heart-lung machine, and at the twenty-fourth postoperative hour.&#x0D; &#x0D; Results: It was observed that a high β2M level was associated with long intensive care and hospital stay, prolonged intubation, increased inotrope requirement, and blood product use (P

Invasive Pulmonary Aspergillosis in Patients with and without SARS-CoV-2 Infection

The recent European Confederation of Medical Mycology (ECMM) and the International Society for Human and Animal Mycology (ISHAM) 2020 consensus classification proposes criteria to define coronavirus 2019 (COVID-19)-associated invasive pulmonary aspergillosis (CAPA), including mycological evidence obtained via non-bronchoscopic lavage. Given the low specificity of radiological findings in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this criterion makes it difficult to differentiate between invasive pulmonary aspergillosis (IPA) and colonization. This unicenter and retrospective study includes 240 patients with isolates of any Aspergillus species in any respiratory samples during a 20-month study (140 IPA and 100 colonization). Mortality was high in the IPA and colonization groups (37.1% and 34.0%, respectively; p = 0.61), especially in patients with SARS-CoV-2 infection, where mortality was higher in colonized patients (40.7% vs. 66.6.%; p: 0.021). Multivariate analysis confirmed the following variables to be independently associated with increased mortality: age > 65 years, acute or chronic renal failure at diagnosis, thrombocytopenia (<100,000 platelets/µL) at admission, inotrope requirement, and SARS-CoV-2 infection, but not the presence of IPA. This series shows that the isolation of Aspergillus spp. in respiratory samples, whether associated with disease criteria or not, is associated with high mortality, especially in patients with SARS-CoV-2 infection, and suggests an early initiation of treatment given its high mortality rate.

Effect of intraoperative haemoadsorption therapy on cardiac surgery for active infective endocarditis with confirmed Staphylococcus aureus bacteraemia.

Sepsis caused by infective endocarditis (IE), due to Staphylococcus aureus, is associated with significant morbidity and mortality. Blood purification using haemoadsorption (HA) may attenuate the inflammatory response. We investigated the effect of intraoperative HA on postoperative outcomes in S. aureus IE. Patients with confirmed S. aureus IE undergoing cardiac surgery were included in a dual-centre study between January 2015 and March 2022. Patients treated with intraoperative HA (HA group) were compared to patients not treated with HA (control group). The primary outcome was vasoactive-inotropic score within the first 72 h postoperatively and secondary outcomes were sepsis-related mortality (SEPSIS-3 definition) and overall mortality at 30 and 90 days. No differences in baseline characteristics were observed between groups (haemoadsorption group, n = 75, control group, n = 55). Significantly decreased vasoactive-inotropic score was observed in the haemoadsorption group at all time points [6 h: 6.0 (0-17) vs 17 (3-47), P = 0.0014; 12 h: 2 (0-8.3) vs 5.9 (0-37), P = 0.0138; 24 h: 0 (0-5) vs 4.9 (0-23), P = 0.0064; 48 h: 0 (0-2.1) vs 0.1 (0-13), P = 0.0192; 72 h: 0 (0) vs 0 (0-5), P = 0.0014]. Importantly, sepsis-related mortality (8.0% vs 22.8%, P = 0.02) and 30-day (17.3% vs 32.7%, P = 0.03) and 90-day overall mortality (21.3% vs 40%, P = 0.03) were also significantly lower with haemoadsorption. Intraoperative HA during cardiac surgery for S. aureus IE was associated with significantly lower postoperative vasopressor and inotropic requirements and resulted in lower sepsis-related and overall 30- and 90-day mortality. In this high-risk population, improved postoperative haemodynamic stabilization by intraoperative HA appears to improve survival and should be further tested in future randomized trials.

Randomized controlled trial to evaluate the effect of prophylactic amiodarone versus dexmedetomidine on reducing the incidence of postoperative junctional ectopic tachycardia after pediatric open heart surgery.

Junctional ectopic tachycardia (JET) is the most common arrhythmia after pediatric open-heart surgeries (OHS), causing high morbidity and mortality. As diagnosis is often missed in patients with minimal hemodynamic instability, its incidence depends on active surveillance. A prospective randomized trial evaluated the efficacy and safety of prophylactic amiodarone and dexmedetomidine to prevent and control postoperative JET. Consecutive patients aged under 12 years were randomized into amiodarone, dexmedetomidine (initiated during anesthetic induction) and control groups. Outcome measures included incidence of JET, inotropic score, ventilation, and intensive care unit (ICU) duration and hospital stay, as well as adverse drug effects. Two hundred and twenty-five consecutive patients with a median age of 9 months (range 2 days-144 months) and a median weight of 6.3 kg (range 1.8 kg-38 kg) were randomized with 70 patients each to amiodarone and dexmedetomidine groups, and the rest were controls. Ventricular septal defect and Fallot's tetralogy were the common defects. The overall incidence of JET was 16.4%. Syndromic patients, hypokalemia, hypomagnesemia, longer bypass, and cross-clamp duration were the risk factors for JET. Patients with JET had significantly prolonged ventilation (P = 0.043), longer ICU (P = 0.004), and hospital stay (P = 0.034) than those without JET. JET was less frequent in amiodarone (8.5%) and dexmedetomidine (14.2%) groups compared to controls (24.7%) (P = 0.022). Patients receiving amiodarone and dexmedetomidine had significantly lower inotropic requirements, lower ventilation duration (P = 0.008), ICU (P = 0.006), and hospital stay (P = 0.05). Adverse effects such as bradycardia and hypotension after amiodarone and ventricular dysfunction after dexmedetomidine were not significantly different from controls. Prophylactic amiodarone or dexmedetomidine started before OHS is effective and safe for the prevention of postoperative JET.