Mean Intensive Care Unit Length Research Articles

Robotic Totally Endoscopic Off-Pump Unroofing of Myocardial Bridge: Early Experience and Midterm Outcomes.

Myocardial bridging (MB) occurs when a coronary artery, commonly the left anterior descending (LAD), has an intramyocardial course. In symptomatic patients who fail medical therapy, surgical unroofing can provide symptomatic relief by improving coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing. There were 34 patients with an LAD-MB who failed medical therapy and underwent robotic totally endoscopic, off-pump unroofing between January 2017 and October 2023. Patients were evaluated by a multidisciplinary team and underwent provocative coronary angiography to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients for midterm follow-up, including completion of a modified Seattle Angina Questionnaire (SAQ). The mean age was 48 ± 8 years, and 56% were female patients. One patient had prior septal myectomy via sternotomy. All patients had significant dobutamine Pd/Pa reduction on preoperative coronary angiography. One patient had atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. The mean procedure time was 140 ± 69 min. All were completed totally endoscopically off-pump without intraoperative conversions. The mean MB length was 4.5 ± 1.4 cm, and the mean depth was 1.6 ± 0.9 cm. Of the patients, 76% were extubated in the operating room. The mean intensive care unit and hospital length of stay were 0.97 ± 0.58 and 1.73 ± 1.1 days, respectively. There were no mortalities or strokes. There was 1 postoperative take-back for bleeding. At midterm follow-up (19 ± 14 months), 28 patients completed the SAQ; 86% reported "much less angina" during activity compared with before surgery, and 93% reported taking no antianginal medication since surgery. In appropriate patients with hemodynamically significant LAD-MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. Further studies are warranted.

Comparison of different surgical approaches for ascending aortic surgery with or without aortic valve involvement: Right anterior minithoracotomy versus conventional median sternotomy

ObjectivesMinimally invasive approach to cardiac surgery has been steadily developing and increasingly being performed since the early 1990s. We aimed to present our initial clinical experience and show the feasibility and safety of the right anterior minithoracotomy (RAT) approach for ascending aorta surgery with or without aortic valve involvement. MethodsThis single-center study included 112 patients who underwent ascending aortic replacement with or without aortic valve intervention, between September 2018 and March 2024. RAT was performed for 48 (42.9%) patients (RAT Group) and conventional median sternotomy (CS) was performed in the remaining 64 (57.1%) (CS Group). The primary end points included operative variables, reoperation for bleeding, transfusion requirements, extubation time, length of intensive care unit stay, hospital stay, and postoperative complications. ResultsThe mean age was 67.63 ± 6.67 years, and 65.1% of patients were men. Total operation time was significantly lower in the CS group (237.84 ± 24.87 minutes vs 259.57 ± 27.41 minutes, respectively; P = .0001). The mean ventilation time (12.73 ± 2.96 hours vs 19.43 ± 4.21 hours) and the mean intensive care unit length of stay (1.71 ± 0.86 days vs 3.6 ± 1.71 days) were both shorter in the RAT group (P < .0001 for both). Wound infection was significantly lower in the RAT group (P = .036). The length of the hospital stay was significantly shorter in the RAT group compared with the sternotomy group (7.48 ± 0.91 days vs 10.6 ± 1.43 days; P < .0001). ConclusionsRAT is a novel and promising approach for ascending aortic surgery with or without aortic valve involvement. This study confirms that this approach is feasible and safe.

Bilateral internal thoracic artery grafting in robotic beating-heart totally endoscopic coronary artery bypass: 10-year outcomes.

Multi-arterial grafting (MAG) with bilateral internal thoracic arteries (BITAs) is superior to single internal thoracic artery (ITA) and veins, however, sternal wound infection (SWI) is a deterrent to using BITA, especially in diabetic and obese patients. Sternal-sparing approaches, including robotic totally endoscopic coronary artery bypass (TECAB), may mitigate this risk. We reviewed outcomes of robotic TECAB with BITA grafting. A total of 871 patients underwent robotic TECAB at our institution from 7/2013 to 4/2024. Of these, 406 patients received BITA grafts and are the subject of this review. Early and mid-term clinical outcomes were reviewed and angiographic patency in those undergoing hybrid revascularization with percutaneous coronary intervention (PCI) after TECAB. All cases were performed via a beating-heart robotic approach, with standard TECAB port placement. The mean age of the cohort was 67±9 years and 16% were female. The mean Society of Thoracic Surgeons (STS) risk was 1.47%±2.2%. Thirty-nine percent were diabetic (15% insulin-dependent) and 39% had a body mass index (BMI) ≥30 kg/m2. Twenty percent had an ejection fraction (EF) ≤40%. Ninety-eight percent of cases were completed off-pump and there were no conversions to sternotomy. The mean number of grafts per patient was 2.2±0.4. The mean intensive care unit (ICU) and hospital length of stay (LOS) were 1.22±0.62 and 2.44±0.83 days, respectively. Postoperative complications included atrial fibrillation in 13%, acute kidney injury (AKI) in 3.4%, return to theatre for bleeding in 0.7%, postoperative myocardial infarction (MI) in 0.2%, and stroke in 0.2%. Thirty-day mortality was 1.2% [observed/expected (O/E): 0.89]. Return to full activities and work occurred at mean of 14±8.6 and 17±13 days, respectively. Two hundred and two patients (50%) had 'advanced' hybrid revascularization (with at least two arterial grafts and stents). ITA early graft patency in this cohort of patients was 271/278 (98%) with 100% left ITA to left anterior descending artery (LITA-LAD) patency. Mid-term follow-up was complete in all patients at mean of 51±36 months (longest follow-up at 10 years). All-cause mortality was 13% and cardiac-mortality was 2.5%. Freedom from angina was 96%, and freedom from repeat revascularization was 94%. Use of the beating-heart robotic TECAB approach facilitates BITA grafting to achieve multi-vessel arterial revascularization of the left coronary system, with excellent 10-year outcomes.

Exploring the impact of arginine-supplemented immunonutrition on length of stay in the intensive care unit: A retrospective cross-sectional analysis.

Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to pinpoint; however, all cumulate in the body's response to illness and injury. The study objective was to compare health outcomes between different immunonutrition formulas. Real-world data from October 2015 -February 2019 in the PINC AI™ Healthcare Database (formerly the Premier Healthcare Database) was reviewed for patients with an intensive care unit (ICU) stay and ≥3 days exclusive use of either higher L-arginine formula (HAF), or lower L-arginine formula (LAF). Multivariable generalized linear model regression was used to check associations between formulas and ICU length of stay. 3,284 patients (74.5% surgical) were included from 21 hospitals, with 2,525 receiving HAF and 759 LAF. Inpatient mortality (19.4%) and surgical site infections (6.2%) were similar across groups. Median hospital stay of 17 days (IQR: 16) did not differ by immunonutrition formula. Median ICU stay was shorter for patients receiving HAF compared to LAF (10 vs 12 days; P<0.001). After adjusting for demographics, visit, severity of illness, and other clinical characteristics, associated regression-adjusted ICU length of stay for patients in the HAF group was 11% shorter [0.89 (95% CI: 0.84, 0.94; P<0.001)] compared to patients in the LAF group. Estimated adjusted mean ICU length of stay was 9.4 days (95% CI: 8.9, 10.0 days) for the HAF group compared to 10.6 days (95% CI: 9.9, 11.3 days) for the LAF group (P<0.001). Despite formulas being isocaloric and isoproteic, HAF use was associated with significantly reduced ICU length of stay, compared to LAF. Higher arginine immunonutrition formula may play a role in improving health outcomes in primarily surgical critically ill patients.

Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques

Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage—essentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained significant traction within neurosurgical practice, alternatives—including the retroauricular (RA) and Kempe incisions—have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. We queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus “alternative” scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited.

Pediatric Digit Replantation: A Nationwide Analysis of Failure Rate, Complications, and Potential Factors Affecting Failure

Function and cosmesis may be improved by replantation following digital amputation in pediatric patients. However, accurate failure and complication rate estimates may be limited as most pertinent studies reflect single center/surgeon experience and therefore are limited by small sample sizes. The primary aim of this study was to assess the rate of failure (amputation) following pediatric digital replantation. Secondary aims include evaluating the rate of complications and associated resource utilization (intensive care unit stays, readmission rate, and hospital length of stay). Digital replantation patients were identified from 47 pediatric hospitals using the 2004 to 2020 Pediatric Health Information System nationwide database. Using applicable International Classification of Disease 9/10 and Current Procedural Terminology codes, we identified complications after replantation, including revision amputation, infection, surgical complications, medical complications, admission to intensive care unit (ICU), and length of stay. Of the 348 patients who underwent replantation the mean age was 8.3 ± 5.1 years, and 27% were female. Mean hospital length of stay was 5.8 ± 4.7 (range, 1-28) days. Of the 53% of patients who required ICU admission, the mean ICU length of stay was 2.4 ± 3.3 days. Failure/amputation after replantation occurred in 71 (20.4%) patients, at a mean of 9.7 ± 27.2 days postoperatively. Surgical complications occurred in 58 (17%) patients, 30-day hospital readmissions occurred in 5.7% of patients, and 90-day readmissions occurred in 6.3% patients. The estimated rate of failure following pediatric digit replantation was 20%. Our data on failure and complication rates and associated resource utilization may be useful in counseling pediatric replantation patients and their families and provide an update on prior literature. IV, Prognosis.

Long-term functional outcomes of upper extremity civilian vascular trauma

ObjectiveCivilian analyses of long-term outcomes of upper extremity vascular trauma (UEVT) are limited. Our goal was to evaluate the management of UEVT in the civilian trauma population and explore the long-term functional consequences. MethodsA retrospective review and analysis was performed of patients with UEVT at an urban Level 1 trauma center (2001-2022). Management and long-term functional outcomes were analyzed. ResultsThere were 150 patients with UEVT. Mean age was 34 years, and 85% were male. There were 42% Black and 27% White patients. Mechanism was penetrating in 79%, blunt in 20%, and multifactorial in 1%. Within penetrating trauma, mechanism was from firearms in 30% of cases. Of blunt injuries, 27% were secondary to falls, 13% motorcycle collisions, 13% motor vehicle collisions, and 3% crush injuries. Injuries were isolated arterial in 62%, isolated venous in 13%, and combined in 25% of cases. Isolated arterial injuries included brachial (34%), radial (27%), ulnar (27%), axillary (8%), and subclavian (4%). The majority of arterial injuries (92%) underwent open repair with autologous vein bypass (34%), followed by primary repair (32%), vein patch (6.6%), and prosthetic graft (3.3%). There were 23% that underwent fasciotomies, 68% of which were prophylactic. Two patients were managed with endovascular interventions; one underwent covered stent placement and the other embolization. Perioperative reintervention occurred in 12% of patients. Concomitant injuries included nerves (35%), bones (17%), and ligaments (16%). Intensive care unit admission was required in 45%, with mean intensive care unit length of stay 1.6 days. Mean hospital length of stay was 6.7 days. Major amputation and in-hospital mortality rates were 1.3% and 4.6% respectively. The majority (72%) had >6-month follow-up, with a median follow-up period of 197 days. Trauma readmissions occurred in 19%. Many patients experienced chronic pain (56%), as well as motor (54%) and sensory (61%) deficits. Additionally, 41% had difficulty with activities of daily living. Of previously employed patients (57%), 39% experienced a >6-month delay in returning to work. Most patients (82%) were discharged with opioids; of these, 16% were using opioids at 6 months. ConclusionsUEVT is associated with long-term functional impairments and opioid use. It is imperative to counsel patients prior to discharge and ensure appropriate follow-up and therapy.

Machine Learning to Detect Disparities in ICU Mortality Among Patients Receiving Direct Oral Anticoagulants

INTRODUCTION The current prescribing practices of direct oral anticoagulants (DOACs) in intensive care unit (ICU) patients and the associated clinical outcomes, including the incidence of major bleeding episodes and mortality, are significant clinical challenges. There is a need for early detection and intervention among patients taking DOACs to prevent adverse clinical outcomes. We hypothesized that machine-learning algorithms could be used to create a more precise and user-friendly diagnostic tool that incorporates a variety of clinical and laboratory data and takes complex interactions into account. METHODS This was an observational, retrospective study using routine clinical practice data from MIMIC-IV, a freely accessible electronic health record database. The study included patients who were admitted to the ICU with a DOAC (apixaban, rivaroxaban, dabigatran, or edoxaban) listed as one of the active medications at the time of hospital admission. ICD-9 and ICD-10 codes were utilized to identify cases (Z7901, V5861). Descriptive statistics were reported for all variables of interest. Various machine-learning models were utilized to predict the outcome variable of ICU mortality after accounting for variables from the demographic, laboratory, comorbidity, etc. domains. Model performance was evaluated by comparing the accuracy and Area Under the Receiver Operating Characteristic Curve (AUROC) values. RESULTS Overall, there were 3597 cases that met the inclusion criteria. Among these, 1517 (42.2%) were female. The majority of the sample was White (70.5%), and 2093 (58.2%) cases had Medicare insurance. The median [Q1, Q3] age of the sample was 74 [65, 83] years. ICU mortality was reported in 297 cases (8.2%). The mean ( SD) ICU length of stay was 3.5 (4.6) days among those cases who were discharged alive and 4.2 (4.7) days among those who expired (p &amp;lt; 0.012). The median blood urea nitrogen among those discharged alive and expired was 20.0 and 29.5 (p&amp;lt;0.001), respectively. Intracranial hemorrhage was reported in 186 (5.6%) and 59 (19.9%) of those discharged alive and expired, respectively (p&amp;lt;0.001). The machine learning model results showed that the Random forest classifier performed best in predicting mortality in the ICU, with an AUROC value of 85.3%. The top ten variables associated with ICU mortality by feature importance were pH, WBC count, platelet count, blood urea nitrogen, heart rate, anion gap, partial pressure of carbon dioxide, oxygen saturation, age, and respiratory rate. CONCLUSION The Random forest classifier algorithm improved discrimination and calibration compared to other ML models for predicting mortality in the ICU among patients taking DOACs. It has the potential to reduce delayed diagnosis and overtreatment in clinical practice. Future studies will validate this model in broader clinical settings.

Nasal Iodophor Antiseptic vs Nasal Mupirocin Antibiotic in the Setting of Chlorhexidine Bathing to Prevent Infections in Adult ICUs

Universal nasal mupirocin plus chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) prevents methicillin-resistant Staphylococcus aureus (MRSA) infections and all-cause bloodstream infections. Antibiotic resistance to mupirocin has raised questions about whether an antiseptic could be advantageous for ICU decolonization. To compare the effectiveness of iodophor vs mupirocin for universal ICU nasal decolonization in combination with CHG bathing. Two-group noninferiority, pragmatic, cluster-randomized trial conducted in US community hospitals, all of which used mupirocin-CHG for universal decolonization in ICUs at baseline. Adult ICU patients in 137 randomized hospitals during baseline (May 1, 2015-April 30, 2017) and intervention (November 1, 2017-April 30, 2019) were included. Universal decolonization involving switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline). ICU-attributable S aureus clinical cultures (primary outcome), MRSA clinical cultures, and all-cause bloodstream infections were evaluated using proportional hazard models to assess differences from baseline to intervention periods between the strategies. Results were also compared with a 2009-2011 trial of mupirocin-CHG vs no decolonization in the same hospital network. The prespecified noninferiority margin for the primary outcome was 10%. Among the 801 668 admissions in 233 ICUs, the participants' mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, -0.9% [95% CI, -9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]). Nasal iodophor antiseptic did not meet criteria to be considered noninferior to nasal mupirocin antibiotic for the outcome of S aureus clinical cultures in adult ICU patients in the context of daily CHG bathing. In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin. ClinicalTrials.gov Identifier: NCT03140423.

Correlation of urinary neutrophil gelatinase-associated lipocalin levels as an early diagnostic marker for acute kidney injury in patients with sepsis

Background. The exact association between urinary neutrophil gelatinase-associated lipocalin (uNGAL) and acute kidney injury (AKI) is unknown in a critical care setting, in which the population is heterogeneous and the aetiology of AKI is unclear. Aim of this study is to clarify if uNGAL level is an early diagnostic marker for AKI in patients with sepsis. Materials and methods. The current study was conducted on 86 sepsis patients. The prevalence of AKI was identified among them. The role of uNGAL in predicting AKI development, mortality rate and length of the intensive care unit (ICU) stay were analyzed. Sensitivity and specificity were calculated, and the area under the receiver operating characteristic curve was considered as the optimal uNGAL cut-off level for detecting all classifications of AKI. Results. Most patients belonged to the age group of 51–60 years and their mean age was 54.6 years. Most patients (65.11 %) were males. 26.75 % had both type 2 diabetes mellitus and hypertension. AKI was detected in 89 % of subjects in the current study, as per KDIGO definition. 15.12 % of patients had stage 1 CKD, 15.12 % had stage 2 CKD, and stage 3 CKD was diagnosed in 4.65 % of cases. Mortality rate was 11 %, and 89 % of patients were discharged. The mean ICU length of stay among patients with AKI is 8.9 days. There is significant association between the mean ICU length of stay and AKI presence (p = 0.03). 17.4 % (n = 15) of patients required renal replacement therapy. There is a very significant difference in mean baseline uNGAL in patients with and without AKI: 149.9 and 73.2 ng/ml, respectively (p = 0.0006). This indicated that baseline uNGAL levels predict AKI. The mean uNGAL in people with AKI was 356 ng/ml and in those without AKI, it was 95 ng/ml. There is a very significant difference in mean uNGAL 48 hours after in patients with and without AKI (p &lt; 0.0001). At a cut-off value of 120, there were 69 true positive cases, 9 true negative cases, 0 false positive cases, and 8 false negative cases. Based on these, the sensitivity of uNGAL at baseline in detecting AKI is 89.61 %, specificity is 100 %, and accuracy is 90.70 %. At a cut-off point of 120, there were 77 true positive cases, 8 true negative cases, 1 false positive case, and 0 false negative cases. Based on these, the sensitivity of uNGAL 48 hours after was 100 %, specificity 88.89 %, and accuracy was 98.84 %. There is a significant association between uNGAL levels and the ICU length of stay (p = 0.00). Conclusions. Sensitivity analysis was done in cut-off value of 120 for urinary NGAL in predicting AKI. From these results we conclude that urinary NGAL at the time of ICU admission is a reliable marker of renal function in sepsis patients. There is a significant correlation between AKI presence and urinary NGAL, and the ICU length of stay. We recommend not to use uNGAL alone in predicting AKI. It should be combined with glomerular filtration rate to reliably detect AKI development. Study findings indicate that sepsis patients with elevated uNGAL require proper management with close monitoring of blood pressure, urine output and appropriate doses of diuretics to avoid the development of AKI.

10 Years of Pericardiectomy at a Tertiary New Zealand Hospital: Clinical Characteristics and Outcomes

Pericardiectomy is an effective treatment for pericardial constriction but is infrequently performed. This study assessed outcomes and clinical characteristics of a consecutive series of pericardiectomy patients. Clinical coding was used to identify all patients who had a pericardiectomy at a tertiary hospital between 2011 and 2021. Patients who had a pericardial window or partial pericardiectomy as part of tumour resection were excluded. Clinical data were collected from electronic medical records. Thirty-six patients met inclusion criteria: 30 were male, 23 NZ European, two Māori, and six Pacific Islanders. The mean age was 53.2 years (range 7–78). The aetiology of the pericardial disease was 17 idiopathic (47%), eight post-surgical (22%), three viral (8%), three tuberculosis (8%), two rheumatological (5%), two post-radiotherapy (5%), and one pyogenic (3%). Cardiopulmonary bypass was used in 20 patients (55%) with a median operative time of 189 minutes. Ten patients (28%) had concomitant cardiac surgery. The mean intensive care unit and hospital length of stay was 4.3 days and 11.7 days, respectively. Twenty-five patients (48%) required postoperative inotropic/vasopressor support. Mean New York Heart Association functional class was 2.3 before pericardiectomy and 1.6 postoperatively. Two patients (5%) died within the hospital admission, and three (8%) died during longer follow-up, with a mean follow-up of 5.4 years. Pericardiectomy was associated with a low to moderate risk of in-hospital and 5-year mortality. Functional status improved after surgery in most patients. Larger multicentre studies are needed to reliably identify predictors of short- and medium-term adverse outcomes in patients considered for pericardiectomy.

294 Outcomes in Stevens-johnson Syndrome/toxic Epidermal Necroylsis Patients Treated Without Admission to a Verified Burn Center

Abstract Introduction The care of patients with Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necroylsis (TEN) has traditionally been delivered within a burn center. Our burn center utilizes a multi-disciplinary approach which involves admission to the medicine service, with support from the burn team. The aim of this study is to determine whether SJS/TEN patients cared for with our system, including burn involvement but not burn admission, demonstrate equivalent outcomes. Methods A retrospective review of all SJS/TEN patients admitted to the medicine service at a single academic medical center from 2009 to 2021 was conducted. Demographic characteristics and outcome measures such as mortality, length of intensive care unit (ICU) stay and total length of hospitalization were collected. The Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) was used to calculate expected mortality rates within the cohort [2]. The observed mortality rates were then compared to the expected mortality rates. Results 126 patients who were admitted for SJS/TEN were included (70 SJS, 40 SJS/TEN overlap, 16 TEN). The mortality rate for the entire cohort was 10.32% as compared to a 22.33% expected mortality rate (p=0.010). The observed and expected mortality rates for SJS, SJS/TEN overlap, and TEN sub-groups were 1.43% observed versus 10.22% expected (p=0.029), 20.00% observed versus 35.83% expected (p=0.133), and 25.00% observed version 44.06% expected (p=0.264) respectively. The mean ICU length of stay was 3.58 days, and the mean length of total hospitalization was 11.69 days. Conclusions Mortality rates in SJS/TEN patients admitted to medicine units are equivalent or decreased as compared to SCORTEN predicted mortality rates. Applicability of Research to Practice Admission of SJS/TEN patients to a medicine unit is appropriate as long as there is burn team involvement in their care, which may be more suitable for patients who require management of complex medical comorbidities.

Debilidad pulmonar asociada a COVID-19 (DPAC): revisión sistemática y metaanálisis

ObjectivesTo assess mortality and different clinical factors derived from the development of atraumatic pneumothorax (PNX) and/or pneumomediastinum (PNMD) in critically ill patients as a consequence of COVID-19-associated lung weakness (CALW). DesignSystematic review with meta-analysis. SettingIntensive care unit (ICU). ParticipantsOriginal research evaluating patients, with or without the need for protective invasive mechanical ventilation (IMV), with a diagnosis of COVID-19 who had developed atraumatic PNX or PNMD on admission or during their hospital stay. InterventionsData of interest were obtained from each article and analysed and assessed by the Newcastle-Ottawa Scale. The risk of the variables of interest was assessed by data derived from studies including patients who developed atraumatic PNX or PNMD. Main variables of interestMortality, mean ICU length of stay and mean PaO2/FiO2 at diagnosis. ResultsData were collected from 12 longitudinal studies. Data from a total of 4,901 patients were included in the meta-analysis. A total of 1,629 patients had an episode of atraumatic PNX and 253 patients had an episode of atraumatic PNMD. Despite finding significantly strong associations, the high heterogeneity between studies means that interpretation of the results should be made with caution. ConclusionsMortality of COVID-19 patients was higher in those who developed atraumatic PNX and/or PNMD compared to those who did not. The mean PaO2/FiO2 index was lower in patients who developed atraumatic PNX and/or PNMD. We propose to group these cases under the term CAPD.

Ex Vivo Heart Perfusion for Cardiac Transplantation Allowing for Prolonged Perfusion Time and Extension of Distance Traveled for Procurement of Donor Hearts: An Initial Experience in the United States.

We retrospectively reviewed consecutive patients who received HT at our institution in the post-Food and Drug Administration approval period from May 1 to October 15, 2022. Patients were divided into 2 groups: OCS versus conventional technique. Baseline characteristics and outcomes were compared. A total of 21 patients received HT during this period, 8 using OCS and 13 conventional techniques. All hearts were from donation after brain death donors. The indication for OCS was an expected ischemic time of >4 h. Baseline characteristics in the 2 groups were comparable. The mean distance traveled for heart recovery was significantly higher in the OCS group (OCS, 845 ± 337, versus conventional, 186 ± 188 mi; P < 0.001), as was the mean total preservation time (6.5 ± 0.7 versus 2.5 ± 0.7 h; P < 0.001). The mean OCS time was 5.1 ± 0.7 h. In-hospital survival in the OCS group was 100% compared with 92.3% in the conventional group (P = 0.32). Primary graft dysfunction was similar in both groups (OCS 12.5% versus conventional 15.4%; P = 0.85). No patient in the OCS group required venoarterial extracorporeal membrane oxygenation support after transplant compared with 1 in the conventional group (0% versus 7.7%; P = 0.32). The mean intensive care unit length of stay after transplant was comparable. OCS allowed utilization of donors from extended distances that otherwise would not be considered because ischemic time would be prohibitive by conventional technique.

Evaluation of pediatric renal transplant recipients admitted to the intensive care unit: A retrospective cohort study

Background/Aim: The best course of treatment for children with end-stage kidney disease (ESKD) is renal transplantation (RT), but some pediatric RT recipients are admitted to an intensive care unit (ICU) post-transplant. In the early and late post-operative phases, clinical data about pediatric RT recipients who are admitted to ICU are available. In this study, we aimed to evaluate demographic features, main reasons, and outcomes of pediatric RT patients admitted to the ICU during the early and late post-operative phases. Methods: This study was a cohort study. We analyzed the medical records of pediatric RT recipients (&lt;18 years of age) who were admitted to the ICU between May 30, 2011, and October 16, 2021, at our center, retrospectively. Patients ≥18 years of age and those without available data were excluded. We obtained the following data from ICU follow-up records and hospital medical records. The median (minimum-maximum) for continuous variables, frequencies, and percentages for categorical variables were used. The Chi-square test was used to compare categorical variables. We created graphs using percentages and frequencies to summarize the results. Results: Nineteen (16.5%) of the 115 pediatric patients who underwent RT were admitted to the ICU during the study period. Thirteen patients (68.4%) were male, and the mean age was 10.2 (4.9) years. Hypertension (21.2%) was the most common comorbidity. Eighteen (94.7%) received transplants from living donors. Cystic-hereditary-congenital disorders (42.1%, n=8) and congenital anomalies of the kidney and urinary tract (26.3%, n=5) were among the etiologies of ESKD. Ten patients (52.6%) were admitted to the ICU &gt;6 months after transplantation. Epileptic seizure (n=6, 31.6%), respiratory failure (n=4, 21.1%), and cardiac diseases (n=2, 10.5%) were among the main reasons for ICU admission. During ICU follow-up, invasive mechanical ventilation was needed for five patients (26.3%), and renal replacement treatment was needed for four patients (21.1%). The mean length of ICU was 12.4 (28.5), and the mean hospital stay was 25.8 (29.4) days. The ICU and hospital survival rates were 78.9% and 97%, respectively, while 3.5% was the hospital mortality rate. Hemorrhagic cerebrovascular disease, acute hepatic failure, and cardiogenic shock secondary to pericardiocentesis were the causes of death in the ICU. Conclusion: Patients mostly had ICU admissions because of epileptic seizures and acute respiratory failure. A multidisciplinary approach involving pediatric nephrologists, transplant surgeons, and an intensive care team successfully manages pediatric RT recipients admitted to the intensive care unit.

The Fontan procedures – early outcomes and predictive factors

Objectives: the aim of this study was to describe the early outcomes after the extracardiac conduit Fontan procedure and evaluate predictive factors related to these results.&#x0D; Methods: a cross – sectional study. We retrospectively reviewed the perioperative medical records of 71 patients with Fontan surgery at Hanoi Heart Hospital between January 2017 and December 2020. Data processing using SPSS 22 software&#x0D; Results: the early mortality and early failure rates with Fontan circulation were 4.2%. High postoperative pulmonary artery pressure was a risk factor for early mortality and early Fontan failure. The mean duration of mechanical ventilation was 62.86±108.17 hours; female, short height, and common atrioventricular valve or double­inlet atrioventricular connection increased the risk of prolonged mechanical ventilation. The mean intensive care unit (ICU) length of stay was 6.46±6.32 days, female, short height, and moderate to severe postoperative atrioventricular valve regurgitation increased the risk of prolonged duration in ICU. The mean time of pleural drainage was 16.96±10.23 days, low weight was a risk factor for prolonged pleural drainage. The mean postoperative hospital stay was 23.89±11.83 days, age at the Fontan surgery, preoperative oxygen saturation, concomitant atrioventricular valve repair, and postoperative atrioventricular valve regurgitation were factors associated with prolonged postoperative hospital stay.&#x0D; Conclusion: the early outcomes after Fontan surgery have been consistent with our condition. There have been many risk factors that influenced early results after surgery, and identifying those factors may help with our treatment.

Ventricular Fibrillatory Arrest: A Safe Option in Robotic Totally Endoscopic Intracardiac Surgery

BackgroundModerate hypothermic ventricular fibrillatory arrest during heart surgery is an alternative to cardioplegic arrest in selected patients. We reviewed our experience using a ventricular fibrillatory arrest technique in robotic totally endoscopic intracardiac surgery. MethodsFrom February 2014 through July 2022, 128 patients who underwent robotic totally endoscopic intracardiac surgical procedures performed using moderate hypothermic ventricular fibrillatory arrest were reviewed. Patients were chosen based on the risk of aortic manipulation, complexity of the procedure, grade of aortic valve insufficiency and comorbidities, including history of prior cardiac surgery and peripheral vascular disease. ResultsPatients were a mean age of 65 ± 14 years, and the mean The Society of Thoracic Surgeons score was 2.7 ± 2.9. Fourteen patients (11%) had a history of previous cardiac surgery. The intracardiac procedures were mitral valve surgery in 84 patients (66%), isolated cryomaze procedure in 27 (21%), and other in 17 (13%). The mean ventricular fibrillatory arrest time was 79 ± 26 minutes, and the mean cardiopulmonary bypass time was 174 ± 49 minutes. There was no conversion to sternotomy. Seven patients (5.5%) required inotropic support, and 2 patients (1.6%) needed an intra-aortic balloon pump. There was no incidence of postoperative stroke or clinical myocardial infarction. The mean hospital and intensive care unit lengths of stay were 3.1 ± 1.7 and 1.4 ± 0.7 days, respectively. One death (0.78%) occurred due to respiratory failure. ConclusionsModerate hypothermic ventricular fibrillatory arrest in robotic intracardiac surgery may be a safe and effective alternative in selected patients.

505: FACTORS ASSOCIATED WITH INTENSIVE CARE UTILIZATION AFTER ADULT SPINAL DEFORMITY SURGERY

Introduction: Adult spinal deformity surgery (SDS) has a higher morbidity and mortality relative to other elective spinal procedures, and patients often require post-operative intensive care unit (ICU) admission. The goal of this study is to describe the type and frequency of ICU-specific needs after SDS and identify risk factors for these interventions. Methods: This was a single center, retrospective analysis of adult patients admitted to the ICU after elective SDS over a 6-year period. Demographics and ICU interventions (vasoactive medications, mechanical ventilation (MV), etc.) were recorded. Chi-square test and two sample t-tests were performed to determine risk factors for ICU needs. Results: 236 patient records were analyzed (mean age 68 + 9 years; 65% women). The most common surgery was long-segment thoracolumbar fusion for scoliosis (86%). Mean ICU and hospital lengths of stay (LOS) were 1.6 and 6.2 days, respectively; 2 (0.85%) patients died in the ICU. 42 (18%) required vasoactive medications and 17 (7%) needed MV (15 returned from the operating room (OR) intubated, 1 was re-intubated in the OR, 1 was re-intubated in the ICU for bronchospasm); all patients were extubated safely within 24 hours of ICU admission. Post-operative blood product transfusion was common (65%); 140 (59%) patients received red blood cells (mean units 1.28 + 1.4, max 8). Other ICU events included symptomatic arrhythmias in 14 (6%), acute kidney injury in 8 (3.4%), and acute pulmonary edema in 11 (4.7%). 75% of patients used continuous analgesic or sedative infusions. Age and gender were not significantly different in those requiring ICU interventions versus those who did not. Estimated blood loss (EBL) was associated with post-operative MV (p< 0.0001) and vasopressors (p = 0.04), while length of segmental fusion was associated with MV (p = 0.0001) only. Conclusions: ICU interventions (MV, vasopressors) were required in 53 (22%) patients undergoing SDS, suggesting that ICU destination after SDS is warranted. Intensivists should expect a moderate number of patients to need critical care interventions in the absence of intra-operative complications, however, most patients have a short ICU LOS. In this study, EBL and spinal fusion length was associated with the need for ICU-specific care.

209: EFFECT OF MIDODRINE IN COVID-19 PATIENTS WITH SEPTIC SHOCK ON TIME TO VASOPRESSOR DISCONTINUATION

Introduction: Patients with COVID-19 in the intensive care unit (ICU) often require prolonged use of intravenous (IV) vasopressors which become a barrier to intensive care unit (ICU) discharge. The goal of this study is to describe the effect of midodrine, an alpha-1 agonist, on time to IV vasopressor discontinuation in COVID-19 patients in the ICU. Methods: This study was an IRB-approved retrospective chart review conducted at a community, tertiary care hospital between January 2020 until November 2021. Eligible participants included hypotensive patients aged 18 years or older who were admitted to an ICU on at least 0.1 mcg/kg/min of norepinephrine for 24hrs with a diagnosis of septic shock and COVID-19. Pearson Chi-Square and Independent-Samples Mann-Whitney U Test were used to analyze baseline characteristics, ICU length of stay, and time to IV vasopressor discontinuation in patients that received at least one dose of midodrine and patients on comparable IV vasopressors not started on midodrine. Results: 70 patients were included in the study with 35 patients in the midodrine group and 35 patients in the control group. The median time to IV vasopressor discontinuation was 13 days for the midodrine group and 8 days for the control group (p < 0.001), but there were less patients started on a second IV vasopressor in the midodrine group. Median time of initiation of midodrine was 9 days and IV vasopressors were discontinued at a median of 4 days after starting midodrine. The mean ICU length of stay and Hospital length of stay were 26 days & 32 days in the midodrine group and 15 days & 21 days in the control group (p < 0.001). The average dose of midodrine was 10 mg per day. Conclusions: The initiation of midodrine in COVID-19 patients with septic shock was not found to decrease total time to IV vasopressor discontinuation. Although, there were less patients started on a second IV vasopressor in the midodrine group.

Mortality trends and length of stays among hospitalized patients with COVID-19 in Ontario and Québec (Canada): a population-based cohort study of the first three epidemic waves

BackgroundEpidemics of COVID-19 strained hospital resources. We describe temporal trends in mortality risk and length of stays in hospital and intensive care units (ICUs) among patients with COVID-19 hospitalized through the first three epidemic waves in Canada. MethodsWe used population-based provincial hospitalization data from the epicenters of Canada's epidemics (Ontario and Québec). Adjusted estimates were obtained using marginal standardization of logistic regression models, accounting for patient-level and hospital-level determinants. ResultsUsing all hospitalizations from Ontario (N = 26,538) and Québec (N = 23,857), we found that unadjusted in-hospital mortality risks peaked at 31% in the first wave and was lowest at the end of the third wave at 6–7%. This general trend remained after adjustments. The odds of in-hospital mortality in the highest patient load quintile were 1.2-fold (95% CI: 1.0–1.4; Ontario) and 1.6-fold (95% CI: 1.3–1.9; Québec) that of the lowest quintile. Mean hospital and ICU length of stays decreased over time but ICU stays were consistently higher in Ontario than Québec. ConclusionsIn-hospital mortality risks and length of ICU stays declined over time despite changing patient demographics. Continuous population-based monitoring of patient outcomes in an evolving epidemic is necessary for health system preparedness and response.