Mechanical Ventilation Time Research Articles

Impact of the timing of invasive mechanical ventilation in patients with sepsis: a multicenter cohort study

BackgroundThe potential adverse effects associated with invasive mechanical ventilation (MV) can lead to delayed decisions on starting MV. We aimed to explore the association between the timing of MV and the clinical outcomes in patients with sepsis ventilated in intensive care unit (ICU).MethodsWe analyzed data of adult patients with sepsis between September 2019 and December 2021. Data was collected through the Korean Sepsis Alliance from 20 hospitals in Korea. Patients who were admitted to ICU and received MV were included in the study. Patients were divided into ‘early MV’ and ‘delayed MV’ groups based on whether they were on MV on the first day of ICU admission or later. Propensity score matching was applied, and patients in the two groups were compared on a 1:1 ratio to overcome bias between the groups. Outcomes including ICU mortality, hospital mortality, length of hospital and ICU stay, and organ failure at ICU discharge were compared.ResultsOut of 2440 patients on MV during ICU stay, 2119 ‘early MV’ and 321 ‘delayed MV’ cases were analyzed. The propensity score matching identified 295 patients in each group with similar baseline characteristics. ICU mortality was lower in ‘early MV’ group than ‘delayed MV’ group (36.3% vs. 46.4%; odds ratio, 0.66; 95% confidence interval, 0.47–0.93; p = 0.015). ‘Early MV’ group had lower in-hospital mortality, shorter ICU stay, and required tracheostomy less frequently than ‘delayed MV’ group. Multivariable logistic regression model identified ‘early MV’ as associated with lower ICU mortality (odds ratio, 0.38; 95% confidence interval, 0.29–0.50; p < 0.001).ConclusionIn patients with sepsis ventilated in ICU, earlier start (first day of ICU admission) of MV may be associated with lower mortality.

Risk Factors for Postoperative Atrial Fibrillation in Myocardial Revascularization Surgery: A 15-Year Experience.

Background: Myocardial revascularization surgery (MRV) is a revascularization therapy for coronary artery disease aimed at improving survival conditions. Elderly patients with increased comorbidities undergoing MRV face challenges in preventing postoperative complications, including atrial fibrillation (AF), a common arrhythmia occurring in 40% of cases or even in 80% of cases if the procedure is combined with valve surgery. This study aimed to determine the risk factors associated with the appearance of postoperative AF (POAF) in patients undergoing isolated MRV. Methods: This is an epidemiological, retrospective, and analytical case-control study (90 cases and 360 controls). Results: Mortality within the group of patients who presented with POAF in the study population was 15.5%, and 9.44% in the control group. Logistic regression showed an association of AF with the presurgical variables age >60 years and urgent/emergency surgery and the postsurgical variables cardiogenic shock, blood transfusion, pulmonary edema, pleural effusion, orotracheal reintubation, and mechanical ventilation time. Conclusions: Strategies should be proposed for the timely identification of risk factors and postoperative complications related to AF onset to avoid the increased morbidity and mortality associated with this type of arrhythmia during the postoperative period.

International treatment outcomes of neonates on extracorporeal membrane oxygenation (ECMO) with persistent pulmonary hypertension of the newborn (PPHN): a systematic review

BackgroundPPHN is a common cause of neonatal respiratory failure and is still a serious condition and associated with high mortality.ObjectivesTo compare the demographic variables, clinical characteristics, and treatment outcomes in neonates with PHHN who underwent ECMO and survived compared to neonates with PHHN who underwent ECMO and died.MethodsWe adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and searched ProQuest, Medline, Embase, PubMed, CINAHL, Wiley online library, Scopus and Nature for studies on the development of PPHN in neonates who underwent ECMO, published from January 1, 2010 to May 31, 2023, with English language restriction.ResultsOf the 5689 papers that were identified, 134 articles were included in the systematic review. Studies involving 1814 neonates with PPHN who were placed on ECMO were analyzed (1218 survived and 594 died). Neonates in the PPHN group who died had lower proportion of normal spontaneous vaginal delivery (6.4% vs 1.8%; p value > 0.05) and lower Apgar scores at 1 min and 5 min [i.e., low Apgar score: 1.5% vs 0.5%, moderately abnormal Apgar score: 10.3% vs 1.2% and reassuring Apgar score: 4% vs 2.3%; p value = 0.039] compared to those who survived. Neonates who had PPHN and died had higher proportion of medical comorbidities such as omphalocele (0.7% vs 4.7%), systemic hypotension (1% vs 2.5%), infection with Herpes simplex virus (0.4% vs 2.2%) or Bordetella pertussis (0.7% vs 2%); p = 0.042. Neonates with PPHN in the death group were more likely to present due to congenital diaphragmatic hernia (25.5% vs 47.3%), neonatal respiratory distress syndrome (4.2% vs 13.5%), meconium aspiration syndrome (8% vs 12.1%), pneumonia (1.6% vs 8.4%), sepsis (1.5% vs 8.2%) and alveolar capillary dysplasia with misalignment of pulmonary veins (0.1% vs 4.4%); p = 0.019. Neonates with PPHN who died needed a longer median time of mechanical ventilation (15 days, IQR 10 to 27 vs. 10 days, IQR 7 to 28; p = 0.024) and ECMO use (9.2 days, IQR 3.9 to 13.5 vs. 6 days, IQR 3 to 12.5; p = 0.033), and a shorter median duration of hospital stay (23 days, IQR 12.5 to 46 vs. 58.5 days, IQR 28.2 to 60.7; p = 0.000) compared to the neonates with PPHN who survived. ECMO-related complications such as chylothorax (1% vs 2.7%), intracranial bleeding (1.2% vs 1.7%) and catheter-related infections (0% vs 0.3%) were more frequent in the group of neonates with PPHN who died (p = 0.031).ConclusionECMO in the neonates with PPHN who failed supportive cardiorespiratory care and conventional therapies has been successfully utilized with a neonatal survival rate of 67.1%. Mortality in neonates with PPHN who underwent ECMO was highest in cases born via the caesarean delivery mode or neonates who had lower Apgar scores at birth. Fatality rate in neonates with PPHN who underwent ECMO was the highest in patients with higher rate of specific medical comorbidities (omphalocele, systemic hypotension and infection with Herpes simplex virus or Bordetella pertussis) or cases who had PPHN due to higher rate of specific etiologies (congenital diaphragmatic hernia, neonatal respiratory distress syndrome and meconium aspiration syndrome). Neonates with PPHN who died may need a longer time of mechanical ventilation and ECMO use and a shorter duration of hospital stay; and may experience higher frequency of ECMO-related complications (chylothorax, intracranial bleeding and catheter-related infections) in comparison with the neonates with PPHN who survived.

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.

Adaptive Pressure Control-Continuous Mandatory Ventilation Versus Volume Control-Continuous Mandatory Ventilation: Factors Associated With Initiation, Maintenance, and Adjustment.

Adaptive pressure control-continuous mandatory ventilation (APC-CMV) is a frequently utilized ventilator mode in ICU settings. This analysis compared APC-CMV and traditional volume control-continuous mandatory ventilation (VC-CMV) mode, describing factors associated with initiation, maintenance, and changes in settings of each mode. We analyzed ventilator data from a retrospective electronic health record data set collected as part of a quality improvement project in a single academic ICU. The majority ventilator mode was defined as the mode comprising the highest proportion of mechanical ventilation time. Multivariable logistic regression was used to identify variables associated with initial and majority APC-CMV or VC-CMV modes. Wilcoxon rank-sum tests were used to compare ventilator setting changes/d and sedation as a function of APC-CMV and VC-CMV majority modes. Among 1,213 subjects initiated on mechanical ventilation from January 2013-March 2017, 68% and 24% were initiated on APC-CMV and VC-CMV, respectively, which composed 62% and 21% of the majority ventilator modes. Age, sex, race, and ethnicity were not associated with the initial or majority APC-CMV or VC-CMV modes. Subjects initiated on APC-CMV spent 88% of the mechanical ventilation time on APC-CMV mode. Compared to VC-CMV, subjects with APC-CMV majority mode experienced more ventilator setting changes/d (1.1 vs 0.8, P < .001). There were no significant differences in sedative medications when comparing subjects receiving APC-CMV versus VC-CMV majority modes. APC-CMV was highly utilized in the medical ICU. Subjects on APC-CMV had more ventilator setting changes/d than those on VC-CMV. APC-CMV offered no advantage of reduced setting adjustments or less sedation compared to VC-CMV.

Simultaneous thoracoscopic surgery in patients with atrial fibrillation and early-stage lung cancer

ObjectivesAtrial fibrillation (AF) and early-stage lung cancer can both be treated under thoracoscopy. This study aims to evaluate the feasibility and safety of simultaneous thoracoscopic surgery for atrial fibrillation and early-stage lung cancer. MethodsThis was a single-center, retrospective study of 865 patients with paroxysmal or non-paroxysmal AF who underwent surgical ablation between October 2014 and December 2021. Patients were divided into two groups according to whether they have undergone simultaneous thoracoscopic early-stage lung cancer surgery and resulting in 24 pairs of patients. ResultsIn total, 48 patients (24 matched pairs) were analyzed. The age was 63.71 ± 8.43 years. Procedure time and postoperative mechanical ventilation time were significantly lower in the group AF than group AFLC (Atrial fibrillation and lung cancer) (140.38 ± 27.53 vs. 230.79 ± 59.06 min, P<0.001; 5 vs 6.5 h, P = 0.002). There was no significant difference between the groups in terms of operative bleeding volume (90.00 ± 29.78 vs 85.83 ± 53.56 ml, P = 0.741), total postoperative drainage volume (1020.83 ± 516.5 vs 1406.25 ± 840.33 ml, P = 0.067), ICU (intensive care unit) length of stay (LOS) (43.5 vs 44 h, P = 0.33), hospitalization LOS (9.29 ± 1.92 vs 8.58 ± 1.98 days, P = 0.214) and incidence of freedom from AF or complications. ConclusionsSimultaneous thoracoscopic surgical AF ablation and early-stage lung cancer is safe and feasible. It can be used as an alternative method for coexisting atrial fibrillation and lung cancer with acceptable operative risks.

Clinical-Epidemiological Profile of COVID-19 Patients Admitted during Three Waves of the Pandemic in a Tertiary Care Center, in Belém, Pará, Amazon Region of Brazil.

Coronavirus disease 2019 (COVID-19) is a disease with a broad clinical spectrum, which may result in hospitalization in healthcare units, intensive care, and progression to death. This study aimed to describe and compare the clinical and epidemiological profile of COVID-19 during the three waves of the disease, in patients admitted to a public hospital in the city of Belém, Pará, in the Amazon region of Brazil. This descriptive, observational, and cross-sectional study was population-based on individuals who were hospitalized with a diagnosis of COVID-19, confirmed by real-time reverse transcription-polymerase chain reaction (RT-PCR), and who were interviewed and monitored at the public hospital, from February 2020 to April 2022. The prevalence was male patients, older than 60 years. The most frequent symptoms were dyspnea, cough, and fever. Systemic arterial hypertension was the most prevalent comorbidity followed by diabetes mellitus. Less than 15% of patients were vaccinated. The nasal oxygen cannula was the most used oxygen therapy interface followed by the non-rebreathing reservoir mask. Invasive mechanical ventilation predominated and the median time of invasive mechanical ventilation ranged from 2 to 6 days among waves. As for the hospital outcome, transfers prevailed, followed by deaths and discharges. The presence of comorbidities, advanced age, and male sex were important factors in the severity and need for hospitalization of these patients, and the implementation of the vaccination policy was an essential factor in reducing the number of hospital admissions.

Predictive value of serum MED1 and PGC-1α for bronchopulmonary dysplasia in preterm infants

ObjectiveThis study aimed to predict the bronchopulmonary dysplasia (BPD) in preterm infants with a gestational age(GA) < 32 weeks utilizing clinical data, serum mediator complex subunit 1 (MED1), and serum peroxisome proliferator-activated receptor gamma coactivator-1alpha (PGC-1α).MethodsThis prospective observational study enrolled 70 preterm infants with GA < 32 weeks. The infants were categorized into two groups: non-BPD group(N = 35) and BPD group(N = 35), including 25 cases with mild BPD and 10 patients with moderate/severe subgroups. We performed multifactorial regression analysis to investigate the postnatal risk factors for BPD. Furthermore, we compared serum levels of biomarkers, including MED1 and PGC-1α, among infants with and without BPD at postnatal days 1, 7, 14, 28, and PMA 36 weeks. A logistic regression model was constructed to predict BPD’s likelihood using clinical risk factors and serum biomarkers.ResultsSerum levels of MED1 on the first postnatal day, PGC-1α on the 1st, 7th, and 28th days, and PMA at 36 weeks were significantly lower in the BPD group than in the non-BPD group (P < 0.05). Furthermore, the predictive model for BPD was created by combing serum levels of MED1 and PGC-1α on postnatal day 1 along with clinical risk factors such as frequent apnea, mechanical ventilation time > 7 d, and time to reach total enteral nutrition. Our predictive model had a high predictive accuracy(C statistics of 0.989) .ConclusionMED1and PGC-1α could potentially serve as valuable biomarkers, combined with clinical factors, to aid clinicians in the early diagnosis of BPD.

Analysis of the Efficacy of Xuebijing Combined with Antimicrobials in the Treatment of Intensive Care Unit Patients with Severe Pneumonia

Objective: To analyze the therapeutic effect of Xuebijing + antimicrobials in intensive care unit (ICU) patients with severe pneumonia. Methods: 60 ICU patients with severe pneumonia from June 2021 to June 2023 were selected and divided by the random number table method, with 30 cases in each group. The observation group received Xuebijing + antimicrobial treatment, while the control group received only antimicrobial treatment. The differences in rehabilitation indexes, test indexes, and inflammation indexes were compared between the two groups. Results: Mechanical ventilation time, fever reduction time, cough relief time, and hospitalization time of the observation group were significantly shorter than those of the control group (P &lt; 0.05); C-reactive protein, procalcitonin, and white blood cell count of the observation group were significantly lower than those of the control group (P &lt; 0.05); interleukin-6 and tumor necrosis factor-α of the observation group were significantly lower than those of the control group (P &lt; 0.05). Conclusion: The treatment of severe pneumonia patients in ICU with Xuebijing + antibacterial drugs can reduce inflammation, enhance immune function, shorten the pneumonia recovery time, and reduce the adverse reactions of severe pneumonia.

Safety and Efficacy of N-Acetylcysteine as an Adjuvant Therapy in Critically Ill COVID-19 Patients

Abstract Background COVID-19 may cause pneumonia, acute respiratory distress syndrome, cardiovascular alterations, and multiple organ failure, which have been ascribed to a cytokinestorm, a systemic inflammatory response, and an attack by the immune system. Moreover, an oxidative stress imbalance has been demonstrated to occur in COVID- 19 patients. N- Acetyl-L-cysteine (NAC) is a precursor of reduced glutathione (GSH). Aim of the Work we retrospectively will investigate safety and efficacy of NAC dose given in paracetamol toxicity as an adjuvant therapy in critically ill COVID-19 patients with acute respiratory distress and determine whether NAC in high doses can avoid respiratory failure in patients with COVID-19. Patients and Methods This was a retrospective observational study in which all cases were collected from ICU of Ain shams university hospitals during COVID-19 outbreak. All data were extracted from clinical records. All patients initially admitted to ICU with SPO2 less than 94 % were included between December 2020 to February 2022. Exclusion Criteria included Need for immediate mechanical ventilation on admission, known allergy or hypersensitivity to NAC, end stage renal and liver diseases, heart failure and pregnancy. All patients with severe COVID-19 (confirmed or suspected received standard care, according to the institutional protocol. Results Patients were randomized into two equal groups (number (n)=40 each) as the N1(NAC) group who was given intravenously, initially 150 mg/kg in 200 mL of 0.9% NaCL for 60 minutes (first bag), followed by 50 mg/kg in 500 mL of 0.9% NaCL for 4 hours (second bag), and then 100 mg/kg in 1000 mL of 0.9%NaCL for 16 hours (third bag) and N2(Non NAC) group who received intravenously N-acetylcysteine (NAC) 600mg /12hr and The primary endpoint was the need for mechanical ventilation. Secondary endpoints were time of mechanical ventilation, admission to the intensive care unit (ICU), time in ICU, and mortality. There were no statistically significant differences between the two groups (p &amp;gt; 0.05) The effect of NAC on mechanical ventilations, mortality, ICU stays, and hospital stays is a matter of controverse in ARDS patients. We found that intravenous high dose of NAC did not improve oxygenation, mortality rate and did not reduce the requirement for mechanical ventilation when administered for COVID 19 patients with ARDS. Also, the duration of ICU and hospital stays were relatively prolonged in the NAC-treated patients. These might be due to prolonged survival time with NAC-treated patients, but not to be detected with the small single centered trial.. Conclusion Use of high doses of NAC administration can not affect the need of mechanical ventilation, rate of mortality, the need, duration of ICU admission and hospital stays for patients with severe COVID-19.

Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study

BackgroundAn optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting.MethodsThis retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications.ResultsWe included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39–11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups.ConclusionImplementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA.Trials registrationThe study protocol was registered in the Australian New Zealand Clinical Trials Registry (https://www.anzctr.org.au/ACTRN12623000060640.aspx, retrospectively registered on 17/01/2023).

Initial Clinical Experience with Implantation of a New Left Ventricular Assist Device HeartCon

Objective: Heart failure is a major health problem worldwide. We report the initial experience of a new left ventricular assist device (LVAD) Heartcon—a centrifugal pump of magnetic-fluid suspension rotor integrated with the pump and machine. From September 2020 to March 2023, HeartCon was implanted in a total of 78 cases throughout China, 27 were implanted in TEDA International Cardiovascular Hospital. Methods: The patient data collected from the medical record included patient demographics, surgical and cardiopulmonary bypass (CPB) data, doses of transfused red blood cells, mechanical ventilation time (h), intensive care unit (ICU) stay time (d), and cardiac function indices assessed by echocardiography, 6-minute walk tests, and N-terminal pro brain natriuretic peptide (NT proBNP) values. Results: All patients were in New York Heart Association (NYHA) grade IV before surgery and 21 had a dilated cardiomyopathy. All patients survived the surgery. One patient underwent heart transplantation 10 months after the implantation. Eight patients reported adverse event events. The duration of mechanical ventilation after operation was 37.8 ± 52.0 h. The incidence of hemorrhagic stroke was 7.4% and the incidence of mediastinal infection was 7.4%. At 90 day followup, 25 patients were in NYHA grade I and the other 2 patients were in grade II. Conclusion: We conclude that HeartCon implantation is a safe and useful LVAD for treatment of end-stage heart failure. It provides a shorter duration of mechanical ventilation time, and a lower incidence of hemorrhagic stroke and mediastinal infection.

A comparative analysis of sivelestat sodium hydrate and ulinastatin combination therapy in the treatment of sepsis with acute respiratory distress syndrome

ObjectiveThis comparative analysis aimed to investigate the efficacy of Sivelestat Sodium Hydrate (SSH) combined with Ulinastatin (UTI) in the treatment of sepsis with acute respiratory distress syndrome (ARDS).MethodsA control group and an observation group were formed with eighty-four cases of patients with sepsis with ARDS, with 42 cases in each group. The control group was intravenously injected with UTI based on conventional treatment, and the observation group was injected with SSH based on the control group. Both groups were treated continuously for 7 days, and the treatment outcomes and efficacy of both groups were observed. The Murray Lung Injury Score (MLIS), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) were compared. Changes in respiratory function, inflammatory factors, and oxidative stress indicators were assessed. The occurrence of adverse drug reactions was recorded.ResultsThe total effective rate in the observation group (95.24%) was higher than that in the control group (80.95%) (P < 0.05). The mechanical ventilation time, intensive care unit (ICU) hospitalization time, and duration of antimicrobial medication in the observation group were shorter and multiple organ dysfunction syndrome incidence was lower than those in the control group (P < 0.05). The mortality rate of patients in the observation group (35.71%) was lower than that in the control group (52.38%), but there was no statistically significant difference between the two groups (P > 0.05). MLIS, SOFA, and APACHE II scores in the observation group were lower than the control group (P < 0.05). After treatment, respiratory function, inflammation, and oxidative stress were improved in the observation group (P < 0.05). Adverse reactions were not significantly different between the two groups (P > 0.05).ConclusionThe combination of SSH plus UTI improves lung injury and pulmonary ventilation function, and reduces inflammation and oxidative stress in patients with sepsis and ARDS.

Rigid ring vs. flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation: A systematic review and meta-analysis

Background & objectivesRigid ring and Flexible band are techniques used to repair tricuspid valve regurgitation. The comparison between both techniques' effectiveness is controversial in the literature. We conducted this systematic review and meta-analysis to compare the safety and efficacy of rigid ring versus flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation. MethodsWe conducted a PRISMA-compliant systematic review and meta-analysis. A systematic search was performed in major databases, including PubMed, Scopus, Web of Science, and Cochrane CENTRAL to identify relevant published studies. Data were extracted and analyzed using Stata (version 17 for Mac) and Revman (version 5.4 for Windows). ResultsTwelve studies were included in this meta-analysis. Total number of patients was 4259. The rigid ring wasn't superior to the flexible band in terms of postoperative tricuspid regurgitation RR 0.74, 95 % CI (0.43–1.27) (P = 0.29). However, the results were not homogeneous. After employing sensitivity analysis, the significance of the pooled effect estimate didn't change, showing no significant difference between the two annuloplasty RR 0.72, 95%CI (0.45–1.15). On the other hand, the rigid ring was associated with a higher bypass time than the flexible band (RR 4.85, P = 0.00). There were no differences between the two groups in terms of hospital stay, ICU stays, prolonged ventilation, mechanical ventilation time, annuloplasty size, stroke, concomitant mitral valve surgery, concomitant aortic valve surgery, atrial fibrillation, pacemaker implantation, low cardiac output, in-hospital death, or late death (all P > 0.05). ConclusionOur study findings suggested no difference between rigid ring compared to flexible band regarding the rates of postoperative tricuspid regurgitation; however, rigid ring may encompass a higher bypass time. Therefore, further research is required to ensure our findings.

High intraoperative fluid load associated with prolonged length of hospital stay and complications after non-cardiac surgery in neonates

Inappropriate perioperative fluid load can lead to postoperative complications and death. This retrospective study was designed to investigate the association between intraoperative fluid load and outcomes in neonates undergoing non-cardiac surgery. From April 2020 to September 2022, 940 neonates who underwent non-cardiac surgery were retrospectively enrolled and their perioperative data were harvested for further analysis. According to recorded intraoperative fluid volumes defined as ml.kg−1 h−1, patients were mandatorily divided into quintile with fluid load as restrictive (quintile 1, Q1), moderately restrictive (Q2), moderate (Q3), moderately liberal (Q4), and liberal (Q5). The primary outcomes were defined as prolonged length of hospital stay (LOS) (postoperative LOS ≥ 14 days), complications beyond prolonged LOS, and 30-day mortality. Secondary outcomes included postoperative complications within 14 days of hospital stay. The intraoperative fluid load was in Q1 of 6.5 (5.3–7.3) (median and IQR); Q2: 9.2 (8.7–9.9); Q3: 12.2 (11.4–13.2); Q4: 16.5 (15.4–18.0); and Q5: 26.5 (22.3–32.2) ml.kg−1 h−1. The odd of prolonged LOS was positively correlated with an increase fluid volume (Q5 quintile: OR 2.602 [95% CI 1.444–4.690], P = 0.001), as well as complications beyond prolonged LOS (Q5: OR 3.322 [95% CI 1.656–6.275], P = 0.001). The overall 30-day mortality rate was increased with high intraoperative fluid load but did not reach to a statistical significance after adjusted with confounders. Furthermore, the highest quintile of fluid load (26.5 ml.kg−1 h−1, IQR [22.3–32.2]) (Q5 quintile) was significantly associated with longer postoperative mechanical ventilation time compared with Q1 (Q5: OR 2.212 [95% CI 1.101–4.445], P = 0.026). Conclusion: Restrictive intraoperative fluid load had overall better outcomes, whilst high fluid load was significantly associated with prolonged LOS and complications after non-cardiac surgery in neonates. Trial registration: Chictr.org.cn Identifier: ChiCTR2200066823 (December 19, 2022).What is Known:• Inappropriate perioperative fluid load can lead to postoperative complications and even death.What is New:• High perioperative fluid load was significantly associated with an increased length of stay after non-cardiac surgery in neonates, whilst low fluid load was consistently related to better postoperative outcomes.

Pulmonary inflammation and viral replication define distinct clinical outcomes in fatal cases of COVID-19.

COVID-19 has affected more than half a billion people worldwide, with more than 6.3 million deaths, but the pathophysiological mechanisms involved in lethal cases and the host determinants that determine the different clinical outcomes are still unclear. In this study, we assessed lung autopsies of 47 COVID-19 patients and examined the inflammatory profiles, viral loads, and inflammasome activation. Additionally, we correlated these factors with the patient's clinical and histopathological conditions. Robust inflammasome activation was detected in the lungs of lethal cases of SARS-CoV-2. Experiments conducted on transgenic mice expressing hACE2 and infected with SARS-CoV-2 showed that Nlrp3-/- mice were protected from disease development and lethality compared to Nlrp3+/+ littermate mice, supporting the involvement of this inflammasome in disease exacerbation. An analysis of gene expression allowed for the classification of COVID-19 patients into two different clusters. Cluster 1 died with higher viral loads and exhibited a reduced inflammatory profile than Cluster 2. Illness time, mechanical ventilation time, pulmonary fibrosis, respiratory functions, histopathological status, thrombosis, viral loads, and inflammasome activation significantly differed between the two clusters. Our data demonstrated two distinct profiles in lethal cases of COVID-19, thus indicating that the balance of viral replication and inflammasome-mediated pulmonary inflammation led to different clinical outcomes. We provide important information to understand clinical variations in severe COVID-19, a process that is critical for decisions between immune-mediated or antiviral-mediated therapies for the treatment of critical cases of COVID-19.

Effect of early vs. delayed extubation on functional outcome among patients with acute ischemic stroke treated with endovascular thrombectomy under general anesthesia: the prospective, randomized controlled EDESTROKE trial study protocol

BackgroundRecent meta-analyses and randomized studies have shown that among patients with acute ischemic stroke undergoing endovascular thrombectomy, general anesthesia with mechanical ventilation is associated with better functional status compared to local anesthesia and sedation, and they recommend its use. But once the procedure is completed, when is the optimal moment for extubation? Currently, there are no guidelines recommending the optimal moment for extubation. Prolonged mechanical ventilation time could potentially be linked to increased complications such as pneumonia or disturbances in cerebral blood flow due to the vasodilatation produced by most anesthetic drugs. However, premature extubation in a patient who has suffered a stroke could led to complications such as agitation, disorientation, abolished reflexes, sudden fluctuations in blood pressure, alterations in cerebral blood flow, respiratory distress, bronchial aspiration, and the need for reintubation. We therefore designed a randomized study hypothesizing that early compared with delayed extubation is associated with a better functional outcome 3 months after endovascular thrombectomy treatment under general anesthesia for acute ischemic stroke.MethodsThis investigator-initiated, single-center, prospective, parallel, evaluated blinded, superiority, randomized controlled trial will include 178 patients with a proximal occlusion of the anterior circulation treated with successful endovascular thrombectomy (TICI 2b-3) under general anesthesia. Patients will be randomly allocated to receive early (< 6 h) or delayed (6–12 h) extubation after the procedure. The primary outcome measure is functional independence (mRS of 0–2) at 90 days, measured with the modified Rankin Score (mRS), ranging from 0 (no symptoms) to 6 (death).DiscussionThis will be the first trial to compare the effect of mechanical ventilation duration (early vs delayed extubation) after satisfactory endovascular thrombectomy for acute ischemic stroke under general anesthesia.Trial registrationThe study protocol was approved April 11, 2023, by the by the Santiago-Lugo Research Ethics Committee (CEI-SL), number 2023/127, and was registered into the clinicaltrials.gov clinical trials registry with No. NCT05847309. Informed consent is required. Participant recruitment begins on April 18, 2023. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.

Outcomes of lung transplantation for pleuroparenchymal fibroelastosis: A French multicentric retrospective study

BackgroundPleuroparenchymal fibroelastosis (PPFE) has no currently available specific treatment. Benefits of lung transplantation (LT) for PPFE are poorly documented. MethodsWe conducted a nation-wide multicentric retrospective study in patients who underwent lung or heart-lung transplantation for chronic end-stage lung disease secondary to PPFE between 2012 and 2022 in France. ResultsThirty-one patients were included. At transplantation, median age was 48 years [IQR 35 – 55]. 64.5% were women. Twenty-one (67.7%) had idiopathic PFFE. Sixteen (52%) had bilateral LT, 10 (32%) had single LT, 4 (13%) had lobar transplantation and one (3%) had heart-lung transplantation. Operative mortality was 3.2%. Early mortality (< 90 days or during the first hospitalization) was 32%. Eleven patients (35.5%) underwent reoperation for hemostasis. Eight (30.8%) experienced bronchial complications. Mechanical ventilation time was 10 days [IQR 2–55]. Length of stay in intensive care unit and hospital were 34 [IQR 18–73] and 64 [IQR 36–103] days, respectively. Median survival was 21 months. Post-transplant survival rates after 1, 2, and 5 years were 57.9%, 42.6% and 38.3% respectively. Low albuminemia (p=0.046), FVC (p=0.021), FEV1 (p=0.009) and high emergency lung transplantation (p=0.04) were associated with increased early mortality. Oversized graft tended to be correlated to a higher mortality (p=0.07). ConclusionLT for PPFE is associated with high post-operative morbi-mortality rates. Patients requiring high emergency lung transplantation with advanced disease, malnutrition, or critical clinical status experienced worse outcomes. ClinicalTrials.gov IdentifierNCT05044390.

Risk factors for ICU-acquired weakness in sepsis patients: A retrospective study of 264 patients

BackgroundSepsis is a common critical illness in intensive care unit (ICU) and an important risk factor for intensive care unit-acquired weakness (ICU-AW). The objective of the study is to analyze the risk factors of ICU-AW in septic patients. MethodsA total of 264 septic patients admitted to the General Hospital of the Western Theater Command from January 2018 to April 2022 were included in this study. The cohort was divided into 2 groups according to the presence or absence of ICU-AW. Clinical characteristics included age, sex, body mass index, length of ICU stay, multiple organ dysfunction syndrome, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), mechanical ventilation time, intubation, tracheotomy, protective constraint, lactic acid, fasting blood glucose, etc. The clinical characteristics of sepsis were evaluated using logistic regression analysis. ResultsA total of 114 septic patients suffered ICU-AW during their ICU stay. Multivariate binary logistic regression analysis showed that APACHE Ⅱ score, mechanical ventilation time, protective constraint, and lactic acid were independent risk factors for ICU-AW in septic patients. The areas under the receiver operating characteristic curve (AUCs) were 0.791, 0.740 and 0.812, all P < 0.05, and the optimal cut-off values were 24 points, 5 days and 2.12 mmol/L, respectively. ConclusionsA high APACHE Ⅱ score, long mechanical ventilation time, protective constraint and high lactate concentration are independent risk factors for ICU-AW in septic patients. An APACHE Ⅱ score greater than 24 points, mechanical ventilation time longer than 5 days and lactate concentration higher than 2.12 mmol/L are likely to cause ICU-AW.

Perioperative echocardiography in minimally invasive surgery for hypertrophic obstructive cardiomyopathy.

Hypertrophic obstructive cardiomyopathy (HOCM) is clinically symptomatic and prone to malignant arrhythmias and sudden cardiac death (SCD). Currently, an effective treatment is surgical resection of the hypertrophic ventricular septum to relieve the left ventricular outflow tract (LVOT) obstruction and mitral insufficiency. Our center performs an innovative, minimally invasive right infra-axillary thoracotomy for transaortic septal myectomy. Minimally invasive procedures rely more on perioperative transesophageal echocardiography (TEE). This study aimed to explore the use of echocardiography during the perioperative period of surgical intervention for HOCM. Between August 2021 and April 2022, 27 patients with HOCM underwent cardiac surgery at our hospital. Minimally invasive transaortic septal resection (Morrow myectomy) was performed from the right axilla. The extent of myectomy and need for mitral valve repair were based on perioperative TEE assessment and surgical findings. The demographic parameters and clinical data of patients were recorded. The cardiopulmonary bypass time, aortic cross-clamp, and mechanical ventilation times were calculated. TEE was used to assess ventricular wall thickening and anatomical abnormalities of mitral regurgitation, assist in intravenous catheterization, and assess the postoperative gradients of the LVOT. Among the 27 patients with HOCM who underwent transaortic septal myectomy by minimally invasive right infra-axillary thoracotomy, 16 had LVOT obstruction, 2 had mid-LV obstruction, and 9 had both LVOT and mid-LV involvement. TEE provides information about the fine structure of the LV cavity and the etiology of the obstruction. In all cases, LVOT obstruction and mitral valve systolic anterior motion were resolved postoperatively, and the degree of mitral regurgitation was significantly reduced. Perioperative echocardiography provides valuable information regarding the complex etiology of LVOT obstruction during minimally invasive right infra-axillary thoracotomy for transaortic septal myectomy. It helps determine the extent of septal resection and assess the need for concomitant mitral valve repair.