Inotropic Score Research Articles

Comparison of Immediate Outcomes of Pulmonary Valve-Sparing and Transannular Patch Techniques for Correction of Tetralogy of Fallot.

This study primarily aimed to compare the mechanical ventilation durations between pulmonary valve-sparing and transannular patch repair techniques in the surgical correction of Tetralogy of Fallot. Secondary objectives included comparison of demographic characteristics, cardiopulmonary bypass parameters, postoperative vasoactive inotrope requirements, incidence of cardiac conduction abnormalities, echocardiographic findings, intensive care unit and hospitalisation durations, reoperations rates, morbidity and mortality between the 2 approaches. This retrospective cohort study was conducted at the Royal Hospital, Muscat, Oman, between January 2016 and December 2019. This study included 102 paediatric patients who underwent complete surgical correction of Tetralogy of Fallot over 3 years, either by a pulmonary valve-sparing technique (Group 1, n = 43) or by transannular patch repair (Group 2, n = 59). Data for both primary and secondary outcomes were extracted from hospital records. Mechanical ventilation duration was significantly shorter in Group 1 (P = 0.039). Patients in Group 1 were generally older, with shorter cardiopulmonary bypass and aortic clamp times, lower inotrope scores, and shorter chest tube retention, intensive care unit and hospitalisation periods. Junctional ectopic tachycardia and severe pulmonary regurgitation were significantly more common in Group 2, while right ventricular outflow tract peak pressure gradients were higher in Group 1. Multivariate analysis identified patient weight as the only independent predictor of mechanical ventilation duration. Pulmonary valve preservation was associated with better early outcomes, including reduced mechanical ventilation duration, lower vasoactive inotrope scores, decreased postoperative arrhythmias and shorter hospital stay.

Nutritional Intake in Venovenous ECMO Patients: A Single-Center Study in a North American PICU.

Multiple independent variables were analyzed to determine total nutritional intake (caloric and protein), while reviewing vasoactive inotrope scores (VISs). Retrospective data were collected for nutritional intake (N = 64), daily VISs, extracorporeal membrane oxygenation (ECMO) complications, delays in nutritional intake (>48 h), reason for delay, and interruptions in nutrition support. VISs and ECMO characteristics analyzed by box-whisker plots demonstrated that ECMO complications prior to 24 h, cardiac arrest 24 h prior to ECMO, pediatric ECMO patients, venoarterial ECMO type, having a cardiac ECMO indication, and ECMO centrifugal pump had higher VISs. A regression analysis revealed that venovenous ECMO patients and the centrifugal pump type had higher caloric and protein intake; subsequently, for each increase in VIS, caloric intake decreased by -0.54. Sixteen patients did not receive nutritional support while on ECMO (9/16; 56% cardiac); 12/48 (25%) had a delay, with the cardiac patients nearing statistical significance. Venovenous ECMO (non-cardiac) correlated with higher nutritional intake. The enteral administration of nutrition had a lower VIS on average compared to the other three groupings, namely enteral vs. parenteral; enteral vs. both enteral and parenteral; enteral vs. no nutrition. This study provides additional clinical insight on nutritional intake in ECMO patients.

PP147 Topic: AS14–Infections: Sepsis and Septic Shock/Antimicrobial Stewardship/Tropical and Parasite Infections/Other: VASOACTIVE INOTROPIC SCORE TO PREDICT MORTALITY OF PEDIATRIC PATIENTS WITH SEPTIC SHOCK

PP147 Topic: AS14–Infections: Sepsis and Septic Shock/Antimicrobial Stewardship/Tropical and Parasite Infections/Other: VASOACTIVE INOTROPIC SCORE TO PREDICT MORTALITY OF PEDIATRIC PATIENTS WITH SEPTIC SHOCK

Peri-Interventional Hemodynamic Management Strategies for Percutaneous Chemosaturation of the Liver in Metastatic Cancer.

Background: Hepatic chemosaturation for inoperable liver tumors is a palliative treatment option with a beneficial effect on survival. However, the procedure regularly leads to circulatory failure during the filtration phase, and hemodynamic management is challenging. Our study aimed to compare two different strategies for hemodynamic management during chemosaturation to develop hypotheses for improving patient care and reducing peri-interventional morbidity. Methods: We conducted a single-center retrospective cohort study including 66 procedures of chemosaturation between May 2016 and March 2024. Procedures were divided into two groups: group 1 was managed with norepinephrine as the only vasopressor and liberal use of hydroxyethyl starch (HES). Group 2 was managed with norepinephrine and vasopressin and the preferred use of balanced crystalloids. We compared these two groups with respect to hemodynamic parameters, laboratory values, and post-interventional complications. Results: The heart rate was highest and the mean arterial pressure (MAP) was lowest during the filtration phase in both groups (p = 0.868, p = 0.270). The vasoactive inotropic score (VIS) was significantly higher in group 2 during the filtration phase (31.5 vs. 89, p < 0.001). Group 1 received significantly more HES overall (1000 mL vs. 0 mL, p < 0.001). Lactate levels at admission to the ICU were higher in group 1 (22.9 vs. 14.45 mg/dL, p = 0.041). Platelet counts were lower in group 2 from directly after chemosaturation through day 2 (p = 0.022, p = 0.001, p = 0.032). The INR differed significantly directly after chemosaturation (1.13 vs. 1.26, p = 0.015). Overall, group 1 received significantly more blood products peri-interventionally. There were two bleedings and one ischemic stroke in the overall cohort. There was no peri-interventional mortality. Conclusions: Advanced hemodynamic management ensures low peri-interventional mortality and morbidity. High-dose vasopressors, including vasopressin and the preferred use of balanced crystalloids, are sufficient to stabilize circulatory function during chemosaturation.

Electrical cardiometry significance in postoperative cardiac ICU; a single center study

BackgroundHemodynamic monitoring is a cornerstone of critical care; in fact, the techniques available for this purpose are either unreliable or operator-dependent or intermittent (echocardiography) and invasive (thermodilution). Objectives: To evaluate the effectiveness of electrical cardiometry (EC) in assessing hemodynamics in pediatric postoperative cardiac intensive care unit (ICU) and the agreement between EC and trans-thoracic echocardiography (TTE) as bedside tools for hemodynamic monitoring and early diagnosis of cardiovascular compromise. We included 70 pediatric patients from the postoperative cardiac ICU. All participants underwent history-taking and clinical examination. emphasising vital signs, manifestations or signs of hemodynamic instability, calculation of RACH score and vasoactive inotropic score. EC was applied for all patients, and TTE.ResultsThe study included 40 males and 30 females with a mean age of 2.6 ± 3.49 years, ranging between 2 weeks and 13 years, with a male to female ratio of 1.3:1. The median of EC parameters were comparable to TTE parameters stroke volume (SV) (9 vs. 8 p = 0.2), stroke index (SI) (23.5 vs. 22 p = 0.2), cardiac output (CO) (1.25 vs. 1.1 p = 0.3), and cardiac index (CI) (3.2 vs. 3.15 p = 0.2). Hemodynamic parameters correlated significantly between EC and echocardiography, with significantly observed agreement between them. Four equations were postulated successfully based on a linear regression model to predict echocardiographic hemodynamic parameters in comparable groups of children, i.e., SV, SI, CO, and CI.ConclusionEC is an excellent alternative to echocardiography in hemodynamic assessment of cardiac patients in the postoperative ICU.

Effect of vasopressin infusion in refractory neonatal shock

To evaluate the effect of vasopressin infusion in refractory neonatal shock. Method This was a cohort study involving retrospective review of medical records of all neonates who received intravenous vasopressin infusion for at least 6 h for treatment of refractory shock in a level 3B neonatal intensive care unit of northern India between Jan 2016 to May 2021. Outcome measures assessed were systolic, diastolic, and mean blood pressure, heart rate, urine output, serum sodium level, inotrope score, and oxygenation index at 6, 12, 24, 48, and 72 h of vasopressin therapy. Outcome measures were compared before (T1) and 48 h (T2) after initiation of vasopressin. Results A total of 32 neonates received vasopressin. The mean (SD) systolic, diastolic, and mean blood pressure improved significantly between T1 and T2 from 54 (9) to 64 (11) mm Hg (MD (95% CI) = 10.3 (4.2–16.6), p = 0.003), 36 (8) to 42 (10) mm Hg (MD (95% CI) = 6.2 (1.3–11.3), p = 0.01), and 43 (8) to 51 (10) mm Hg (MD (95% CI) = 8.5 (2.3–14.6), p = 0.01), respectively. Median (IQR) urine output improved from 1.25 (0–3.2) to 2.1 (1.6–7) ml/kg/hr, p = 0.004. There was a significant fall in serum sodium from 139 (9) to 134 (8) mEq/l, p = 0.01. Out of 32 infants, 19 (59.4%) survived, while 6 (18.8 %) were transferred out and 7 (21.8%) died. Conclusion Vasopressin improved hemodynamic parameters in refractory neonatal shock and can be used as a rescue therapy. Vasopressin therapy is associated with a fall in serum sodium.

Evaluating Impact of Surgical Myocardial Revascularization on Global Left Ventricular Systolic Function and Immediate Postoperative Outcome using Transesophageal Echocardiography

Abstract Background and Aims: Surgical myocardial revascularization is supposed to improve the global left ventricular (LV) function by improving the blood supply in significantly occluded coronary arteries. Transesophageal echocardiography (TEE) provides an excellent opportunity to evaluate cardiac function in operating room. Present study was aimed at evaluating impact of surgical myocardial revascularization on global LV systolic function. Comparison of LV fractional shortening (LV-FS), fractional area change (LV-FAC), ejection fraction (LV-EF), indexed LV volumes (indexed LV volumes at end diastole, LV volumes at end systole) and “Tei” (Myocardial performance) index obtained prior and after surgical myocardial revascularization was done for quantitative analysis. Also, the determinants of immediate postoperative outcome were evaluated based on need of pharmacological and/or mechanical cardiovascular support, mechanical ventilation, intensive care unit (ICU) stay, morbidity and mortality in immediate postoperative period. These outcome measures were correlated with baseline values of TEE derived echo indices. Methods: One hundred and ten subjects with significant coronary artery disease scheduled for elective myocardial revascularization surgery. Fourteen subjects were excluded due to presence of either hemodynamic instability requiring either pharmacological or mechanical cardiovascular support, before coronary revascularization (n = 6), presence of Grade III mitral regurgitation (MR) in baseline TEE (n = 2) and arrythmias (n = 6). Ninety six subjects were evaluated for global LV systolic function using TEE before and after surgical revascularization. Subjects were followed in ICU for the outcome. Immediate postoperative outcome was measured as “good” or “poor” based on vasoactive inotropic score, requirement of Intra-aortic balloon counter pulsation (IABP) and mechanical cardiovascular support (VA-ECMO) to maintain cardiac output, duration of mechanical ventilation, postoperative ICU stay, morbidity and mortality. Results: In 96 subjects analyzed, there was a significant improvement in TEE derived LV-FS (38.60 ± 16.38 vs. 31.31 ± 13.14) (P = 0.002), FAC (51.94 ± 16.06 vs. 43.99 ± 16.02) (P ≤ 0.001), EF (53.08 ± 9.97 vs. 46.71 ± 7.53) (P &lt; 0.00001), LV end diastolic volume index (34.84 ± 13.43 vs. 40.08 ± 17.22) (P = 0.0188) and “Tei” index (0.47 ± 0.13 vs. 0.53 ± 0.13) (P = 0.0007). Thirty three subjects required either prolonged stay in ICU (&gt;7 days), (n = 20) and/or mechanical ventilatory support (&gt;24 h), (n = 10) and/or mechanical cardiovascular support (IABP/VA ECMO placement), (n = 7) and/or suffered mortality (n = 2) in postoperative period were categorized as “poor” outcome. Presence of type II diabetes mellitus, Chronic obstructive pulmonary disease (COPD), higher grade of ischemic MR, larger LV end diastolic volume, use of cardiopulmonary bypass and allogenic blood transfusion during surgery were the determinants of “poor” outcome. Conclusion: Surgical myocardial revascularization improved global LV systolic function irrespective of baseline LV EF. Immediate postoperative outcome was strongly determined by presence of diabetes, COPD, higher grade of ischemic MR and larger LV end diastolic volumes. Preoperative (Baseline) LV EF and myocardial performance index did not determine “poor” postoperative outcome following surgical myocardial revascularization in subjects with LVEF &gt;35%.

Mixed venous to arterial pCO2-gap is poorly correlated to cardiac index in 1526 pulmonary artery catheter monitored critically ill patients

Abstract Background The CO2 gap is the difference between mixed venous and arterial CO2, and can be estimated by the difference in partial pressure in CO2 (Pv-aCO2 or ∆PCO2). ∆PCO2 is affected by cardiac output (CO), CO2 production and solubility. The central venous-to-arterial CO2 gap has been proposed as a less invasive surrogate for P(v-a)CO2 and has been investigated as a measure of adequacy of resuscitation, and to guide sepsis management. Nevertheless, the CO2-gap as determinant of CO has never been thoroughly investigated in large cohort of critically ill ICU-patients. This study aims to investigate the relationship between ∆PCO2 and cardiac index (CI) in a retrospective cohort of critically ill patients in a large quaternary cardiothoracic intensive care unit. Methods Over 62 months, pulmonary artery catheter monitored critically ill patients were identified and their case files reviewed in retrospect. Extracorporeal membrane oxygenation (ECMO) patients were excluded. P(v-a)CO2 measurements were defined as mixed venous and arterial pCO2 measurements drawn simultaneously or within maximum 30 minutes together with PA-measurements. Correlation coefficients were calculated between P(v-a)CO2 and CI, serum lactate, mixed venous saturations (SvO2), cardiac power index (CPI), inotropic score (IS), central venous pressure (CVP) and minute expiratory volume (MV)(Table 1). We used receiver operator characteristic (ROC) curves to assess the diagnostic performance of P(v-a)CO2 as a surrogate for CI lower than 2,2L/min/m2. Multivariate linear regression analysis was performed with P(v-a)CO2 as an dependent variable. Results 4414 P(v-a)CO2 measurements were identified from 1526 patients. Median P(v-a)CO2 was 0,86 kPa (0,66-1,1) or 6.45 mmHg (4.95-8.25), and mean CI was 2.7l/min/m2 (2.2-3.2). Correlation coefficients of P(v-a)CO2 with the other variables remained poor (&amp;gt; 0,35). The area under the ROC curve for P(v-a)CO2 as a predictor of CI&amp;lt;2.2l/min/m2 was 0.65, p&amp;lt;0.0001 (Fig. 1B). A value of P(v-a)CO2 &amp;gt; 6.9 mmHg was found to have the highest sensitivity and specificity, with a poor performance of 61.21% sensitivity and 62.73% specificity. Conclusion This large retrospective study in 1526 critically ill cardiac ICU-patients did not demonstrate a strong relationship between P(v-a)CO2 and CI, nor with any other hemodynamic variable found in the ICU patient cohort studied (Table 1). This raises scepticism regarding the efficacy of P(v-a)CO2 as a physiological goal in guiding resuscitation and management of this precarious patient group. Therefore, we argue that the PA-catheter remains the cornerstone in assessing critically ill (cardiothoracic) ICU patients.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational monocentric prospective study

Abstract Background Although temporary mechanical circulatory support (MCS) devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process and decision although there are no standardized protocols for the trial nor accordance on the parameters to apply. Purpose We sought to evaluate the overall accuracy of echocardiographic indices in predicting successful weaning from VA ECMO in patients with CS. Specifically, we tested total isovolumic time (tIVT), an index of ventricular performance, and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Monocentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Weaning trials were performed daily, starting 48 hours after VA-ECMO institution, when patients were hemodynamically stable: mean arterial pressure &amp;gt;65 mmHg, no or minimum adrenergic support (vasoactive inotropic score &amp;lt;10), heart rate &amp;lt;110 bpm, lactate &amp;lt;2 mmol/L, and no signs of respiratory distress. Weaning trials were performed with a stepwise decrease of VA-ECMO blood flow until reaching 1 or 1.5 L/min under adequate anticoagulation. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (table): stroke volume &amp;gt;13.9 mL (p 0.002), tIVT &amp;gt;23.6 min/sec (p 0.053), LV VTI &amp;gt;6.6 cm (p&amp;lt;0.001), MAPSE &amp;gt;6.15 mm (p 0.001), TAPSE &amp;gt;11 mm (p 0.023), RV S’ &amp;gt;10 cm/s (p 0.012). LVEF did not reach the statistical significance. Figure shows Kaplan-Meier analysis on echocardiographic indices collected at time of cannulation (panel A) and during the last weaning trial (panel B). Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Considering the known limitations of LVEF (heart rate, loading and left ventricular dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation of patients in the acute setting.TableFigure

Is it useful to washing stored red blood cells in cardiopulmonary bypass priming fluid for neonatal cardiac surgery

Abstract Background The small blood volume and immature physiology of neonates necessitate careful consideration of the priming fluid composition during cardiopulmonary bypass (CPB) surgery, as it has a substantial impact on their physiologic stability. This study aimed to investigate the impact of allogeneic stored RBCs processed by an autotransfusion system into the CPB priming fluid for neonatal cardiac surgery. Methods This retrospective cohort study investigated the effects of incorporating unwashed (n=56) or washed (n=45) RBCs into the CPB priming fluid for elective neonatal cardiac surgery. We compared perioperative blood parameters, inflammatory mediators, coagulation indicators, vasoactive inotrope score (VIS), other relevant blood parameters and clinical outcomes between the two groups. The regression models were employed to evaluate the independent association between RBCs washing and prognostic outcomes. Results The autotransfusion system can effectively improve the quality of stored RBCs. During CPB, washed group exhibited higher peak hematocrit (P &amp;lt; 0.01), peak hemoglobin (P = 0.04), increased oxygen delivery index during rewarming (P &amp;lt; 0.05). The washed group exhibited significantly lower early postoperative lactate levels and VIS scores (P &amp;lt; 0.05). Despite demonstrating fluctuations in inflammatory (IL-6, IL-8, IL-10）and coagulation parameters(DD, FIB, FDP) compared to baseline, the two groups exhibited no significant divergence. Notably, the washed group experienced a lower incidence of hyperlactacidemia and delayed sternal closure at weaning from CPB. Conclusions The addition of washed allogeneic stored RBCs to neonatal CPB priming fluid significantly attenuated postoperative lactate elevation and lowered VIS without improving early alterations in the inflammatory and coagulation systems.

A Prospective Comparative study to assess the effect of modified del Nido versus standard del Nido on Myocardial protection in Adults

Objective. This comparative observational study aimed to assess the efficacy and safety of modified del Nido cardioplegia (MDN) prepared using Ringer Lactate [Group R] compared to the standard del Nido cardioplegia (SDN) with Plasmalyte–A [Group P] in adult patients undergoing cardiac surgery with cardioplegic arrest. Materials and Methods. A total of 88 patients were evaluated. The primary outcome of myocardial injury was measured by specific markers viz cardiac Troponin I (cTnI), Creatine Phosphokinase–MB (CPK–MB), and Coronary Sinus (CS) Lactate at various time points. Secondary outcomes were postoperative left ventricular ejection fraction, inotropic score, and duration of intensive care unit (ICU) stay. The differences in primary and secondary outcomes between the groups were measured and analysed. Results. Two primary outcome parameters showed significant differences between the two groups viz. the CS lactate levels measured immediately after the removal of the aortic cross–clamp (group–R 3.23 ± 1.07, group–P 2.58 ± 0.99, p–0.004) and troponin–I levels measured at 24 hours post–surgery (group–R 6.45 ± 4.89, group–P 4.64 ± 3.98, p–0.012). However other primary and secondary parameters did not exhibit significant differences between the two groups. Conclusion. Although there were no significant differences in the secondary outcome parameters, two of the primary outcome parameters associated with myocardial injury showed significant difference. Hence modified del Nido should be used with caution unless the safety is validated by large multi–centric RCTs.

Vasopressin as adjunctive therapy in pulmonary hypertension associated with refractory systemic hypotension in term newborns.

The use of vasopressin as an adjunctive therapy in pulmonary hypertension associated with refractory systemic hypotension has increased. The objective of our study is to describe its effects on term infants. Retrospective observational study. Setting in a referral level IV neonatal intensive care unit from a middle-income region. The patients are term neonates admitted to our NICU who required vasopressin due to severe Pulmonary Hypertension and refractory hypotension during a 49-month period (December 2019 and December 2023). We identified 68 term infants, all in mechanical ventilation, receiving inhaled nitric oxide (iNO), and a phased protocol management for hypotension. Vasopressin was a started at a mean of 2 days with a mean duration of 80 h. Regarding hemodynamic outcome: diastolic, systolic, and median systemic pressure significantly increased during the first 4 h of treatment, as well as arterial pH and urine output. Accordingly, lactate and Vasoactive Inotropic Score (VIS) score decreased after 4 and 8 h, respectively, after vasopressin was started. Regarding oxygenation markers: oxygen requirements and mean airway pressure decreased significantly (and therefore the oxygenation index decreased in concordance) after 4 h of vasopressin. Echocardiographic indices of pulmonary hypertension progressively improved after vasopressin infusion with a significant decrease of tricuspid ingurgitation velocities and the rate of right-to- left ductal shunt through the ductus arteriosus. In the same way, left and right ventricular output increased after the initiation of vasopressin. This study showed that the use of vasopressin in neonates with persistent pulmonary hypertension was associated with a rapid and significant improvement in oxygenation and hemodynamic markers of perfusion, including blood pressure. Its effects begin early during the first hours of treatment.

Perioperative hemodynamic parameters monitored by three noninvasive technologies in children with congenital heart disease: A prospective study

AbstractThis study aims to compare the efficiencies of three noninvasive technologies in monitoring the perioperative hemodynamics of children with congenital heart disease (CHD) including ventricular septal defects with or without atrial septal defects. Three noninvasive technologies included transthoracic echocardiography (TTE), electrical cardiometry (EC), and vasoactive inotropic score (VIS). Parameters included left ventricular ejection fraction (LVEF) and cardiac index (cardiac index monitored by ultrasound, uCI) in TTE, cardiac index (cardiac index monitored by electrical cardiometry, eCI) and systemic vascular resistance index (SVRI) in EC, and VIS. Seventy‐four children were eligible. Three types of adverse events (AEs) related to disease activity and prognosis were observed, including cardio‐pulmonary resuscitation in five cases (5/74, 6.76%), hypoxic‐ischemic brain damage in four cases (4/74, 5.41%) and hemopurification in four cases (4/74, 5.41%). Except for LVEF, eight parameters (VISmax [maximum VIS], VISmea [mean VIS], uCImea [mean uCI], uCImin [minimum uCI], eCImea [mean eCI], eCImin [minimum eCI], SVRImea [mean SVRI], and SVRImin [minimum SVRI]) showed predictive value for any AE (p &lt; 0.05). VISmea, uCImea, and eCImea demonstrated the highest accuracy and linear associations (AUROC &gt; 0.9, p = 0.00). Linear associations also existed between the three groups of parameters and the duration of mechanical ventilation (MV) and the length of stay (LOS) in the intensive care unit (ICU). The duration of MV and the LOS in the ICU increased as VISmea rose, or uCImea and eCImea fell (p &lt; 0.05). LVEF in TTE could not predict any AE (p &gt; 0.05) and not fully reflect the cardiovascular function. Therefore, most parameters obtained in TTE, EC, and VIS can reflect the perioperative hemodynamics of children with CHD, with VISmea, uCImea, and eCImea being most accurate.

Correlation between elevated neutrophil lymphocyte ratio, vasotropic inotropic score, cumulative fluid balance and level of reactive oxygen species in septic patients

Introduction. Reactive oxygen species (ROS) serve as a biomarker in sepsis, while neutrophil lymphocyte ratio (NLR), vasotropic inotropic score (VIS), and cumulative fluid balance (CFB) correlate with inflammation and mortality. Understanding the correlation between elevated ROS levels and these markers aids in prognostication.The objective is to study the correlation between the increased level of neutrophil/lymphocyte ratio, vasotropic and inotropic index, total fluid balance and reactive oxygen species level in patients with sepsis.Materials and methods. A prospective cohort study in RSUD Dr. Moewardi’s ICU/HCU from June to August 2023 employed univariate, bivariate (Spearman correlation), and multivariate logistic regression analyses.Results. Among 34 sepsis patients, NLR and VIS showed significant positive correlations on day one, and NLR, VIS, and FB on day three. Delta changes in NLR and VIS significantly correlated with ROS.Conclusion. NLR and VIS changes predict ROS levels, while CFB exhibits weak correlations, which deserve additional investigation. This underscores the importance of NLR and VIS as prognostic indicators in sepsis.

Out of the ice age: Preservation of cardiac allografts with a reusable 10 °C cooler

ObjectiveStatic cold storage with ice has been the mainstay of cardiac donor preservation. Early preclinical data suggest that allograft preservation at 10 °C may be beneficial. We tested this hypothesis by using a static 10 °C storage device to preserve and transport cardiac allografts. MethodsIn total, 52 allografts were recovered between July 2023 and March 2024 and transported using a 10 °C storage cooler. Results were compared to a 3:1 propensity match of allografts transported on ice. Patients were excluded for the following reasons: dual viscera transplant, previous heart transplant, complex congenital heart disease, or allograft injury during procurement. ResultsAmong the 10 °C cooler cohort, median total ischemic time was 222 minutes at 10 °C versus 193 minutes on ice (P < .0001). Intraoperative change in lactate was statistically lower at 10 °C (3.6 vs 5.1 mmol/L, P = .0016). Cardiac index score was greater in 10 °C cooler hearts at 24 (3.2 vs 3.0, P = .016) and 72 hours (3.3 vs 2.9, P = .037), despite similar vasoactive inotrope scores. There was no difference in severe primary graft dysfunction (1.9 vs 2.6%, P > .99). 10 °C hearts demonstrated less change in lactate but no difference in vasoactive inotrope scores or cardiac index. In hearts with extended ischemic time, delta lactate was lower in 10 °C cooler hearts. There was no statistical difference in outcomes for donor hearts >40 years old. ConclusionsThis is an early experience of static preservation in a 10 °C cooler. Postoperative allograft function was excellent, and lactate profiles lower in those allografts with extended ischemic times. Static cold storage targeting 10 °C may offer an inexpensive method for extended heart preservation. Further investigation is needed to assess long-term outcomes of 10 °C storage.

Perioperative Modulation of Left Ventricular Systolic Performance: A Retrospective Study on Ionized Calcium and Vitamin D in Cardiac Surgery Patients.

Background: The perioperative impact of calcium and vitamin D on left ventricular (LV) performance during major cardiac surgery remains unexplored. We aimed to assess the relation of calcium and vitamin D measured at different time points with the LV ejection fraction (EF), and to investigate whether changes in EF correlate with postoperative outcomes. Methods: We enrolled 83 patients, in whom ionized calcium was measured before, during, and after surgery (until discharge), vitamin D preoperatively, and EF pre- and postoperatively at 24 h. The postoperative outcomes were cardiopulmonary bypass (CPB) time, aortic cross-clamp time, mechanical ventilation time, vasoactive inotropic score (VIS) (intraoperative, day 0, day 1), and ICU stay time. Results: The mean age was 64.9 ± 8.5 years, with 21 of the patients (25%) having an EF < 50%. The median change from preoperative to postoperative EF was -2.0 (-10.0-0.0) % (p < 0.001). At the baseline, the EF < 50% group had significantly lower preoperative vitamin D levels than the EF ≥ 50% group (p = 0.048). The calcium trend did not differ across the groups. Preoperative EF was significantly associated with CPB time (r = 0.22, p = 0.044) and aortic cross-clamp time (r = 0.24, p = 0.031). Postoperative EF was significantly and inversely associated with intraoperative VIS (r = -0.28, p = 0.009), VIS day 0 (r = -0.25, p = 0.020), VIS day 1 (r = -0.23, p = 0.036), and ICU length of stay (r = -0.22, p = 0.047). Finally, the change in ejection fraction was significantly and inversely associated with CPB time (r = -0.23, p = 0.037), aortic cross-clamp time (r = -0.22, p = 0.044), intraoperative VIS (r = -0.42, p < 0.001), VIS day 0 (r = -0.25, p = 0.024), mechanical ventilation time (r = -0.22, p = 0.047), and ICU length of stay (r = -0.23, p = 0.039). Conclusions: The fluctuations in perioperative ionized calcium levels were not associated with the evolution of LVEF, although preoperative vitamin D levels may affect those with low EF. Correspondingly, a reduced EF significantly impacted all the studied postoperative outcomes. Further investigation into biomarkers affecting cardiac inotropic function is warranted to better understand their significance.

Impact of early myocardial injury on patients with severe pneumonia.

Pneumonia often causes myocardial damage. This study sought to understand how early myocardial injury affects severe pneumonia patients' prognoses. This multi-center prospective cohort study from March 2020 to October 2023 comprised severe pneumonia patients. Binary logistic regression analysis examined how myocardial damage affects cardiac complications and acute renal injury (AKI). We used Spearman correlation analysis to examine the relationship between troponin I levels and the vasoactive inotropic score (VIS) in shock patients with myocardial injury. We used the Kaplan-Meier survival curve to evaluate the impact of myocardial injury on 30-day and 1-year survival rates. Mediation investigations examined how AKI and cardiac complications mediate myocardial injury and death. This study included 363 severe pneumonia patients, of whom 204 (56.2%) developed myocardial damage, 132 (36.4%) had cardiac problems, and 146 (40.2%) had AKI. Myocardial damage independently elevated the incidence of cardiac complications (OR = 2.548, 95% CI = 1.404-4.303, P = 0.002) and AKI (OR = 1.946, 95% CI = 1.177-3.219, P = 0.009). There was a positive link between troponin I and VIS in myocardial injury and shock patients (r = 0.43, P < 0.001). COX regression found myocardial injury to be a death risk (HR = 1.472, 95% CI = 1.043-2.077, P = 0.028). Adjusted Kaplan-Meier survival analysis showed significantly decreased short-term and long-term survival rates with myocardial injury (log-rank test P < 0.05). The mediation study showed that cardiac complications and AKI mediated myocardial injury and death by 19.30% and 17.18%, respectively. Early myocardial injury in severe pneumonia patients raises the likelihood of cardiac problems, AKI, and refractory shock, reducing short- and long-term survival.

Donation After Circulatory Death Cardiac Recovery Technique: Single-Center Observational Outcomes

BackgroundRecovery of hearts from donation after circulatory death donors has been performed either with direct procurement and perfusion (DPP) using the TransMedics Organ Care System or with normothermic regional perfusion (NRP) with subsequent cold storage. It remains unclear which of these 2 strategies yields optimal posttransplant outcomes. MethodsAll heart transplant recipients from donors after circulatory death donors at the Vanderbilt University Medical Center (Nashville, TN) were reviewed (February 2020 to January 2023). Recipients were stratified into an NRP or DPP cohort. All DPP recoveries were performed using the TransMedics Organ Care System. The key outcome was severe primary graft dysfunction at 24 hours, defined by the need for postoperative extracorporeal membrane oxygenation. ResultsA total of 118 hearts were transplanted (NRP, 87; DPP, 31). Donors recovered using NRP were younger (25 years [interquartile range {IQR}, 21-31 years] vs 31 years [IQR, 24-37 years]; P = .008) and had shorter distance traveled (292 miles [158-516 miles] vs 449 miles [IQR, 248-635 miles]; P = .02). Recipient preoperative risk factors were similar between the groups. There was no difference in the incidence of severe primary graft dysfunction at 24 hours (NRP, 5.8%; and DPP, 12.9%; P = .24). However, ejection fraction at 7 days after transplantation was higher in the NRP group (65% [IQR, 60%-65%] vs 60% [IQR, 60%-68%]; P = .005). There was no difference in inotrope scores at 24 hours (P = 1.00) or 72 hours (P = .87) or in 30-day (NRP, 95% vs DPP, 97%; P = .75) and 1-year (NRP, 94% vs DPP, 86%; P = .19) survival. ConclusionsNRP and DPP strategies for recovery of cardiac allografts yield comparable early allograft outcomes. Future studies are needed to confirm these findings in larger prospective cohorts.

Comparison Between Histidine-Tryptophan-Ketoglutarate Cardioplegia and Cold Blood Cardioplegia for Myocardial Protection in Tetralogy of Fallot Patients Undergoing Surgical Repair: A Randomized Clinical Trial

ObjectivesThis study was conducted to compare the efficacy of histidine-tryptophan-ketoglutarate (HTK) cardioplegia and cold blood cardioplegia (CBC), especially for postoperative right ventricle (RV) function after Tetralogy of Fallot (TOF) repair. DesignRandomized, double-blinded, parallel group, controlled, clinical trial. SettingAin Shams University Hospitals.) ParticipantsA total of 100 children (1-5 years-old) scheduled for TOF repair. InterventionsPatients were allocated (double blinded one: one allocation ratio), to either HTK Group that received HTK cardioplegia (30 ml/kg by antegrade route) or CBC Group that received cold blood cardioplegia with blood to Ringer solution (4:1) in volume of 20 ml/kg. Measurements and Main ResultsThe HTK group showed a statistically significant reduction of the vasoactive inotropic score on admission to pediatric intensive care unit (13.0±4.1) in comparison to CBC (15.5±5.4) with P-value of 0.011 but after 24 hours Vasoactive-Inotropic Score was comparable. Lactate level during the first 24 hours in HTK group (6.2±0.7) mmol/l and (6.9±0.4) mmol/l in CBC group with P-value < 0.0001. Serial troponin measurements were lower in the HTK group (1.49 ± 0.45) in comparison to the CBC group (1.69 ± 0.18) with P-value of 0.005 at the first 72 hours postoperatively. Postoperative echocardiographic assessment of RV function by mean of tricuspid annular plane systolic excursion and myocardial performance index were better in HTK than CBC (P-value<0.05). ConclusionsHTK cardioplegia may offer better cardiac protection to pediatric patients undergoing TOF repair than our institutional standard CBC with better recovery for the hypertrophic RV.

A retrospective observational study evaluating the association between vasoactive–inotropic score and mortality after major abdominal surgery

The relationship between VISmax and mortality in patients undergoing major abdominal surgery remains unclear. This study aims to evaluate the association between VISmax and both short-term and long-term all-cause mortality in patients undergoing major abdominal surgery, VISmax was calculated (VISmax = dopamine dose [µg/kg/min] + dobutamine dose [µg/kg/min] + 100 × epinephrine dose [µg/kg/min] + 10 × milrinone dose [µg/kg/min] + 10,000 × vasopressin dose [units/kg/min] + 100 × norepinephrine dose [µg/kg/min]) using the maximum dosing rates of vasoactives and inotropics within the first 24 h postoperative ICU admission. The study included 512 patients first admitted to the intensive care unit (ICU) who were administered vasoactive drugs after major abdominal surgery. The data was extracted from the medical information mart in intensive care-IV database. VISmax was stratified into five categories: 0–5, > 5–15, > 15–30, > 30–45, and > 45. Compared to patients with the lowest VISmax (≤ 5), those with the high VISmax (> 45) had an increased risk of 30-day mortality (hazard ratio [HR] 3.73, 95% CI 1.16–12.02; P = 0.03) and 1-year mortality (HR 2.76, 95% CI 1.09–6.95; P = 0.03) in fully adjusted Cox models. The ROC analysis for VISmax predicting 30-day and 1-year mortality yielded AUC values of 0.69 (95% CI 0.64–0.75) and 0.67 (95% CI 0.62–0.72), respectively. In conclusion, elevated VISmax within the first postoperative 24 h after ICU admission was associated with increased risks of both short-term and long-term mortality in patients undergoing major abdominal surgery.