Median Intensive Care Unit Length Research Articles

Comparison of Neutrophil Lymphocyte Ratio combined SOFA versus APACHE IV in assessing the Prognosis of Sepsis Patients admitted to Medical Intensive Care Unit

Background Sepsis poses a significant threat in the Medical Intensive Care Unit (MICU), with high morbidity and mortality rates. Accurate prognostic tools are essential for guiding patient management. This study aims to compare the effectiveness of Neutrophil–Lymphocyte Ratio with Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) in predicting sepsis outcomes. A prospective cross-sectional design will enrol septic MICU patients, collecting baseline data and scoring systems. Patient outcomes, including mortality and length of MICU stay, will be analyzed using correlation and ROC curve analyses. This study addresses the current gap in direct comparisons of these tools. Results The results of this study are anticipated to reveal significant correlations between the Neutrophil Lymphocyte Ratio combined with SOFA and APACHE IV scores and patient outcomes. Specifically, we expected to observe strong associations between the combined scoring system and mortality rates, length of MICU stay, and the need for organ support. Furthermore, we anticipate that the Neutrophil Lymphocyte Ratio combined with SOFA will demonstrate higher predictive accuracy than APACHE IV to assess prognosis in sepsis patients admitted to the MICU. Conclusion Based on the results obtained from this prospective cross-sectional study, we can draw conclusions regarding the comparative effectiveness of NLR (Neutrophil Lymphocyte Ratio) combined with SOFA and APACHE IV in assessing the prognosis of sepsis in the MICU. We anticipate that the combined scoring system will provide a more accurate prognostic assessment and enable healthcare professionals to make well-informed choices regarding patient care and the distribution of resources. These findings will contribute to building evidence on sepsis and may have implications for improving patient outcomes in the MICU setting.

Single-session catheter-directed lysis using adjunctive clot fragmentation with power pulse spray only is a fast, safe, and effective option for acute pulmonary embolism

ObjectiveSingle-session, catheter-directed thrombolysis (CDT) with adjunctive power pulse spray (PPS) only, without thrombectomy, was evaluated for its safety and effectiveness. We performed a single-center, retrospective analysis of prospectively collected data. MethodsPatients with high-risk or intermediate-risk pulmonary embolism (PE) who met the inclusion criteria and underwent a single session of CDT-PPS were included in the study. The primary outcomes assessed were technical and clinical success and major adverse events. Secondary outcomes included effectiveness based on pre- and postintervention clinical examination, radiographic findings, and reversal of right ventricular dysfunction at 48 hours and 4 weeks after discharge on echocardiography and computed tomography pulmonary angiography. The length of stay in the intensive care unit and overall admission were also analyzed. A return to premorbid exercise tolerance was evaluated at 12 months after the procedure. ResultsBetween May 2016 and January 2023, 104 patients at the Wollongong Hospital were diagnosed with high- or intermediate-risk PE and underwent CDT-PPS. Of the 104 patients, 49 (47%) were considered to have high-risk PE and 55 (53%) intermediate-risk PE. Eleven patients (11%) had absolute contraindications and 49 patients (47%) had relative contraindications to systemic thrombolysis. Technical success was achieved in 102 patients (98%). Survival was 99% at 48 hours, 96% at 4 weeks, and 91% at 12 months. At 4 weeks, echocardiography showed 98% of patients had no evidence of right heart dysfunction, and computed tomography pulmonary angiography showed complete resolution of PE in 72%. There were no major adverse events at 48 hours. The median intensive care unit length of stay was 1 day, and the overall length of stay was 6 days. At 12 months, 96% had returned to their premorbid status. ConclusionsThe CDT-PPS technique is fast, safe, and effective in the treatment of high- and intermediate-risk PE, even in patients with a high bleeding risk, and should be considered as first-line management when the skills and resources are available. Further multicenter prospective studies are needed to corroborate these results.

Pharmacist‐led intervention to reduce inappropriate continuation of targeted medications initiated in the acute care setting at hospital and ICU discharge

AbstractPharmacist‐led interventions may reduce the inappropriate continuation of acid‐suppressive agents and antipsychotics temporarily initiated in the intensive care unit (ICU), but limited data exist for other medications. This study evaluated the impact of a pharmacist‐led intervention on the number of medications inappropriately continued upon ICU and hospital discharge. This was a single‐center, pre‐post intervention analysis conducted in the medical and surgical ICUs at a tertiary academic medical center. The pre‐ and post‐intervention groups included adults who were newly initiated on medications used for stress ulcer prophylaxis, delirium, agitation, wakefulness, sedation, and insomnia from December 1, 2021 to January 31, 2022 and December 12, 2022 to February 13, 2023, respectively. In the post‐intervention group, pharmacists identified patients who were newly initiated on a medication of interest and documented in patients' charts via an electronic handoff tool utilizing a standardized template. The appropriateness of those medications was assessed daily, and pharmacists intervened when necessary. The number of medications inappropriately continued at ICU and hospital discharge and ICU and hospital lengths of stay were compared. Overall, 399 encounters were included in the final analysis, and a total of 459 medications were newly initiated in the ICU. There was no significant difference in the number of medications inappropriately continued at hospital discharge [22 (8.4%) vs. 10 (5.1%); p = 0.17]. Significantly fewer medications were inappropriately continued at ICU discharge in the post‐intervention group [85 (32.3%) vs. 37 (18.9%); p < 0.01]. The median ICU length of stay was significantly greater in the post‐intervention group [4 (2–8) vs. 2 (1–6) days; p < 0.01]. No significant difference was found in the median hospital length of stay [14 (7–26.5) vs. 16 (9–33.75) days; p = 0.08]. Use of an electronic handoff tool was associated with a significant reduction in the number of medications inappropriately continued at ICU discharge.

Impact of direct ICU admission of pneumococcal meningitis in France: a retrospective analysis of a French medico-administrative (PMSI) database

BackgroundCurrent guidelines for adult patients with pneumococcal meningitis (PM) recommend initial management in intermediate or intensive care units (ICU), but evidence to support these recommendations is limited. We aimed to describe ICU admission practices of patients with PM.MethodsWe conducted a retrospective analysis of the French medico administrative database of consecutive adult patients with PM and sepsis criteria hospitalized between 2011 and 2020. We defined two groups, “Direct ICU” corresponding to a direct ICU admission and “Delayed ICU” corresponding to a secondary ICU admission.ResultsWe identified 4052 patients hospitalized for a first episode of PM, including 2006 “Direct ICU” patients (50%) and 2046 “delayed ICU” patients (50%). The patients were mainly males [n = 2260 (56%)] with median age of 61 years [IQR 50–71] and a median Charlson index of 1 [0–3]. Among them, median SAPS II on admission was 46 [33–62], 2173 (54%) had a neurological failure on admission with 2133 (53%) in coma, 654 (16%) with brainstem failure, 488 (12%) with seizures and 779 (19%) with focal signs without coma. PM was frequently associated with pneumonia [n = 1411 (35%)], and less frequently with endocarditis [n = 317 (8%)]. The median ICU length of stay and hospital length of stay were 6 days [2–14] and 21 days [13–38], respectively. In-hospital mortality was 27% (n = 1100) and 640 (16%) patients were secondarily transferred to rehabilitation care unit. Direct ICU group was significantly more severe but after adjustment for age, sex, comorbidities, organ failures on admission and admission from home, direct ICU admission was significantly associated with a lower mortality (Odds ratio 0.67 [0.56–0.80], p < 0.01). This corresponded to one death avoided for 11 PM directly admitted in ICU.ConclusionsAmong patients with PM and sepsis, direct ICU admission was associated with lower mortality rates when compared to delayed admission.

Impact of COVID-19 infection during the postoperative period in patients who underwent gastrointestinal surgery: a retrospective study.

The coronavirus disease 2019 (COVID-19) pandemic has led to significant global casualties. This study examines the postoperative impact of COVID-19 on patients who underwent gastrointestinal surgery, considering their heightened vulnerability to infections and increased morbidity and mortality risk. This retrospective observational study was conducted at a tertiary center and patients who underwent gastrointestinal surgery between January 2022 and February 2023 were included. Postoperative COVID-19 infection was defined as the detection of severe acute respiratory syndrome coronavirus 2 RNA by RT-PCR within 14 days after surgery. Propensity score matching was performed including age, sex, American Society of Anesthesiology physical status classification, and emergency operation between the COVID-19-negative (-) and -positive (+) groups. Following 1:2 propensity score matching, 21 COVID-19(+) and 42 COVID-19(-) patients were included in the study. In the COVID-19(+) group, the postoperative complication rate was significantly higher (52.4% vs. 23.8%, P = 0.023). Mechanical ventilator requirement, intensive care unit (ICU) admission, and readmission rate did not significantly differ between the 2 groups. The median length of ICU (19 days vs. 4 days, P < 0.001) and hospital stay (18 vs. 8 days, P = 0.015) were significantly longer in the COVID-19(+) group. Patients with COVID-19 had a 2.4 times higher relative risk (RR) of major complications than patients without COVID-19 (RR, 2.37; 95% confidence interval, 1.254-4.467; P = 0.015). COVID-19 infection during the postoperative period in gastrointestinal surgery may have adverse outcomes which may increase the risk of major complications. Preoperative COVID-19 screening and protocols for COVID-19 prevention in surgical patients should be maintained.

Patient perceptions of ICU physiotherapy: 'Your body needs to go somewhere to be recharged … '.

Patient satisfaction is an essential concept to consider for the improvement of quality care in healthcare centres and hospitals and has been linked to increased patient compliance with treatment plans, better patient safety and improved clinical outcomes. As part of a before-and-after clinical trial aimed to investigate the implementation of an evidence-based and -validated physiotherapy protocol within a surgical intensive care unit (ICU), we decided to include the patient perception of physiotherapy received in the intervention unit. A nested, exploratory, descriptive, qualitative study design was adopted. Purposively selected adult patients discharged from ICU during the implementation phase of the trial were interviewed. Eighteen patients (10 male) with a median age of 44 years and median ICU length of stay (LOS) of six days were included. Three themes and nine categories emerged: (i) linking therapy to clinical outcome (patient expectations and understanding; physiotherapy activities and the implication of mobilisation; physiotherapy benefits and progression); (ii) the importance of developing a trusting relationship (physiotherapy value; safety; continuity of care); and (iii) communication (satisfaction; interactions and patient perception and experience of physiotherapy). While confirming barriers to early mobility, patients perceived participation in mobility activities as a marked jolt in their journey to recovery following a critical incident. Effective communication and preservation of trust between physiotherapist and patient are essential for understanding expectations and can facilitate improved outcomes. Clinicians can use the information when managing critically ill patients. Including patient-reported outcomes to measure physiotherapy interventions used in the ICU is feasible and can inform the development of such outcomes. The study highlights the feasibility and importance of the use of patient-reported outcomes to measure physiotherapy interventions and informs the development of patient reported outcomes and the importance of patient centred physiotherapy care in the ICU setting.

Impact of age on mortality and transfer to long-term care in patients in an intensive care unit

BackgroundIn the global trend of population aging, age is one of the significant factors to be considered in critically ill patients. However, the impact of age on clinical outcomes and long-term prognosis in this population varies across different studies.MethodsWe conducted a retrospective cohort analysis for patients admitted to the medical intensive care unit (ICU) (30 beds) between January 2017 and December 2020 at the tertiary referral hospital in Korea. Patients were classified into three groups according to age: <65 years, old age (65–79 years), and very old age (≥ 80 years). Subsequently, enrolled patients were analyzed for acute mortality and long-term prognosis.ResultsAmong the 1584 patients, the median age was 67.0 (57.0–76.0) years, and 65.2% were male. Median ICU length of stay (LOS) (8, 9, and 10 days in < 65, 65–79, and ≥ 80 years, respectively; p = 0.006) and the proportion of patients who were transferred to long-term care hospital at the time of discharge (12.9% vs. 28.3% vs. 39.4%, respectively; p < 0.001) increased with age. Multivariable logistic analysis showed no significant difference in the 28-day mortality in the old age (adjusted odds ratio [aOR] 0.88; 95% confidence interval [CI] 0.65–1.17) and very old age (aOR 1.05; 95% CI 0.71–1.55) groups compared to that in patients with age < 65 years. However, the relevance of the proportion of ICU LOS ≥ 7 days and transfers to other hospitals after discharge increased with age.ConclusionsAge did not affect acute mortality in critical illness patients. However, surviving older age groups required more long-term care facilities compared to patients younger than 65 years after acute management. These results indicate that in an aging society, the importance of not only acute management but also long-term care facilities may increase for critical illness patients.

Comparison of Erector Spinae Plane Block and Pectointercostal Facial Plane Block for Enhanced Recovery After Sternotomy in Adult Cardiac Surgery

This study aimed to investigate and compare the effects of the pectointercostal fascial plane block (PIFPB) and the erector spinae plane block (ESPB) on enhancing the recovery of patients who undergo cardiac surgery. A randomized, controlled, double-blinded study. The operating rooms and intensive care units of university hospitals. One hundred patients who were American Society of Anesthesiologists class II to III aged 18-to-70 years scheduled for elective cardiac surgery. Patients were randomly assigned to undergo either ultrasound-guided bilateral PIFPB or ESPB. Patients shared comparable baseline characteristics. Time to extubation, the primary outcome, did not demonstrate a statistically significant difference between the groups, with median (95% confidence interval) values of 115 (90-120) minutes and 110 (100-120) minutes, respectively (p = 0.875). The ESPB group had a statistically significant reduced pain score postoperatively. The median (IQR) values of postoperative fentanyl consumption were statistically significantly lower in the ESPB group than in the PIFPB group (p < 0.001): 4 (4-5) versus 9 (9-11) µg/kg, respectively. In the ESPB group, the first analgesia request was given 4 hours later than in the PIFPB group (p < 0.001). Additionally, 12 (24%) patients in the PIFPB group reported nonsternal wound chest pain, compared with none in the ESPB group. The median intensive care unit length of stay for both groups was 3 days (p = 0.428). Erector spinae plane block and PIFPB were found to equally affect recovery after cardiac surgery, with comparable extubation times and intensive care unit length of stay.

Long-Term Outcomes of Pulmonary Embolism Requiring Intensive Care Unit (ICU) Admission

Introduction:Pulmonary embolism (PE) requiring intensive care unit (ICU) admission is associated with high in-hospital mortality, however data on long-term survival outcomes and associated contributors remains limited. We sought to further investigate this using a large binational dataset. Methods:Retrospective cohort study of adults aged &amp;gt;16 years admitted to an Australian or New Zealand (NZ) ICU between January 1, 2018 and December 31, 2022 with a primary admission diagnosis of PE using the Australian and NZ Intensive Care Society (ANZICS) Adult Patient Database (APD). Data were available on baseline characteristics - specifically age, gender, admission co-morbidities (active malignancy, chronic cardiovascular, respiratory, renal and liver disease and illness severity as per the Acute Physiology and Chronic Health Evaluation (APACHE) III scoring system. The need for ICU-specific supports (vasopressors or inotropes, invasive and non-invasive ventilation [NIV], extracorporeal membrane oxygenation [ECMO]) was also recorded. All-cause mortality from 30 days to 48 months after ICU admission was obtained. Descriptive analyses, Kaplan-Meier and Cox proportional hazards models were used to describe survival during this time period. Ethical approval was granted by the Alfred Hospital Human Research Ethics Committee (HREC). Results:6447 patients with PE who had been admitted to 193 ICUs across Australia and NZ were identified, representing 9136 patient-years of follow-up. Median age was 66.5 years (interquartile range [IQR], 53-75). 24.5% were admitted to a rural or regional ICU. Median ICU length of stay was 46.6 hours (IQR, 27-79). Median APACHE III score was 42 (IQR, 31-56). Admission co-morbidities included active malignancy (8.1%), chronic respiratory (7.0%), renal (1.4%) and liver (0.4%) disease. Systolic blood pressure was was ≤90 mmHg at time of ICU admission in 1482 patients (23.9% of those in whom this data was available). Vasopressors or inotropes were required in 986 patients (17.6%), NIV was used in 713 (12.6%), invasive ventilation in 453 (8.0%) and 24 patients (0.43%) received ECMO. The mean duration of invasive ventilation where this was required was 14.9 hours. Kaplan-Meier survival analysis is shown in Figure 1. Overall survival was 92.3% at 30 days (95% CI, 91.6-93.0%), 87.5% at 6 months (95% CI, 86.5-88.3%), 84.4% at 12 months (95% CI 83.4%-85.4%) and 73.0% at 48 months (95% CI, 71.0-74.9%). Active malignancy was the strongest independent predictor of mortality (hazard ratio [HR] 3.3, 95% CI 2.8-4.0). Other independent predictors were chronic liver (HR 2.8), renal (HR 1.7) and respiratory (HR 1.6) disease, immunosuppressive therapy (HR 1.5), and the need for NIV (HR 1.4) or vasopressor and inotropic support (HR 1.3). No significant difference in mortality was observed between rural/regional and tertiary/metropolitan ICUs, however improved survival was observed in patients admitted to Australian ICUs (n = 6032) compared to those in NZ (n = 415) (HR 0.5 [95% CI 0.4-0.8]). Conclusions:Nearly three-quarters of patients admitted to ICU due to PE remain alive 2 years later. The largest risk factor for late mortality is malignancy, along with other chronic diseases, which is similar to previous studies reporting long-term follow-up of PE survivors outside ICU, however patients who need advanced life supports (NIV, ECMO) were also at greater risk. Limitations of this study include retrospective design, broad heterogeneity in admission criteria across different ICUs due to variation in resources across both countries and lack of data therapies such as intravenous thrombolysis and anticoagulation. Further work is needed to understand if changes to acute management of at-risk patients might improve long-term survival outcomes.

Risk factors for mortality in intensive care unit patients with Stenotrophomonas maltophilia pneumonia in South Korea.

Stenotrophomonas maltophilia has been increasingly recognized as an opportunistic pathogen associated with high morbidity and mortality. Data on the prognostic factors associated with S. maltophilia pneumonia in patients admitted to intensive care unit (ICU) are lacking. We conducted a retrospective analysis of data from 117 patients with S. maltophilia pneumonia admitted to the ICUs of two tertiary referral hospitals in South Korea between January 2011 and December 2022. To assess risk factors associated with in-hospital mortality, multivariable logistic regression analyses were performed. The median age of the study population was 71 years. Ventilator-associated pneumonia was 76.1% of cases, and the median length of ICU stay before the first isolation of S. maltophilia was 15 days. The overall in-hospital mortality rate was 82.1%, and factors independently associated with mortality were age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.00-1.09; P=0.046), Sequential Organ Failure Assessment (SOFA) score (OR, 1.21; 95%; CI, 1.02-1.43; P=0.025), corticosteroid use (OR, 4.19; 95% CI, 1.26-13.91; P=0.019), and polymicrobial infection (OR, 95% CI 0.07-0.69). However, the impact of appropriate antibiotic therapy on mortality was insignificant. In a subgroup of patients who received appropriate antibiotic therapy (n=58), antibiotic treatment modality-related variables, including combination or empirical therapy, also showed no significant association with survival. Patients with S. maltophilia pneumonia in ICU have high mortality rates. Older age, higher SOFA score, and corticosteroid use were independently associated with increased in-hospital mortality, whereas polymicrobial infection was associated with lower mortality. The effect of appropriate antibiotic therapy on prognosis was insignificant.

Outcome of COVID-19 patients treated with VV-ECMO in Tyrol during the pandemic

Summary Introduction A small percentage of patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV‑2) showed severe respiratory deterioration requiring treatment with extracorporeal membrane oxygenation (ECMO). During the pandemic surges availability of ECMO devices was limited and resources had to be used wisely. The aim of this analysis was to determine the incidence and outcome of venovenous (VV) ECMO patients in Tyrol, when criteria based on the Extracorporeal Life Support Organization (ELSO) guidelines for VV-ECMO initiation were established. Methods This is a secondary analysis of the Tyrol-CoV-ICU-Reg, which includes all patients admitted to an intensive care unit (ICU) during the coronavirus disease 2019 (COVID-19) pandemic in Tyrol. Of the 13 participating departments, VV-ECMO was performed at 4 units at the University Hospital Innsbruck. Results Overall, 37 (3.4%) of 1101 patients were treated with VV-ECMO during their ICU stay. The hospital mortality rate was approximately 40% (n = 15). Multiorgan failure due to sepsis was the most common cause of death. No significant difference in survival rates between newly initiated and experienced centers was observed. The median survival time of nonsurvivors was 27 days (interquartile range, IQR: 22–36 days) after initiation of VV-ECMO. Acute kidney injury meeting the Kidney Disease: Improving Global Outcomes (KDIGO) criteria occurred in 48.6%. Renal replacement therapy (RRT) was initiated in 12 (32.4%) patients after a median of 18 days (IQR: 1–26 days) after VV-ECMO start. The median length of ICU and hospital stays were 38 days (IQR: 30–55 days) and 50 days (IQR: 37–83 days), respectively. Discussion Despite a rapidly increased demand and the resulting requirement to initiate an additional ECMO center, we could demonstrate that a structured approach with interdisciplinary collaboration resulted in favorable survival rates similar to multinational reports.

Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients.

Optimal treatment (i.e., nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment. The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with 1-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life. Mean age was 57.7 ± 17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n = 13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic nonunion. The median HLOS was 7 days (4-13 days), and median intensive care unit length of stay was 2 days (1-5 days). Mean 5-Level Quality of Life Questionnaire index value was 0.83 ± 0.18 1 year after trauma. Polytrauma patients had a median HLOS of 10 days (6-18 days), a pneumonia rate of 17.6% (n = 77) and mortality rate of 1.7% (n = 7). Elderly patients (≥65 years) had a median HLOS of 9 days (5-15 days), a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12). Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after 1 year. Future studies evaluating the benefit of operative stabilization should use contemporary outcomes to establish the therapeutic margin of rib fixation. Therapeutic/Care Management; Level III.

Characteristics of living liver donors in a national referral hospital in Indonesia: a 13-year experience with living donor liver transplantation.

Hepatocellular carcinoma and biliary atresia lead to end-stage liver disease, which requires liver transplantation and is linked to increased mortality. Dr. Cipto Mangunkusumo Hospital is the national referral center in Indonesia and is the only center that routinely performs living donor liver transplantation (LDLT). This study presents the characteristics of living liver donors (LLDs) in Indonesia. Using the LDLT registry, we conducted a retrospective analysis of all approved donors from 2010 to 2022. The variables included clinical characteristics of the donors, graft types, and intraoperative and postoperative characteristics. The LDLT rate has increased from 5.8 to 8.8 procedures/year in the last 8 years. The average age of the 76 LLDs was 31.8 years. They were predominantly female (59%) and lived within a family relationship (90%). Pediatric LDLT was more frequent than adult LDLT (88% vs. 12%, respectively). Most grafts (86%) were obtained by left lateral sectionectomy, with a median ratio of remnant liver volume to total liver volume of 79.5% (range, 47.7%-85.8%) and a mean graft-to-recipient weight ratio of 2.65%±1.21%. The median intensive care unit length of stay (LOS) was 2 days (range, 1-5 days) and the total hospital LOS was 7 days (range, 4-28 days). The complication rate was 23%. No donor mortality was reported. LDLT in Indonesia has increased over the years. The shortage of donors for adult-to-adult liver transplantation is due to cultural differences and challenges in finding eligible donors. This study aims to explain the eligibility criteria of LLDs and contribute to creating a national policy.

EXPLORING THE ROLE OF CENTRAL VENOUS OXYGEN SATURATION IN THE EVALUATION AND MANAGEMENT OF SEVERE HYPOXEMIA IN MECHANICALLY VENTILATED PATIENTS.

Background: Although central venous oxygen saturation (ScvO 2 ) has been used as an endpoint for the treatment of circulatory shock, its role in guiding the evaluation and treatment of patients with severe hypoxemia remains to be assessed. The aim of this study was to assess the incidence of low ScvO 2 in a cohort of hypoxemic patients and the association of this finding with differences in clinical management and patient outcomes. Methods: Retrospective review of data from adult intensive care unit patients with hypoxemia who required invasive mechanical ventilation for over 24 h and had at least one ScvO 2 measured within 6 h of a PaO 2 /FiO 2 ratio <200. Results: Of 442 mechanically ventilated patients with severe hypoxemia, 249 (56%) had an ScvO 2 <70%. When compared with patients with ScvO 2 ≥70%, those with low ScvO 2 had worse systemic oxygenation and hemodynamic parameters and were more likely to receive red blood cell transfusions (31.7% vs. 18.1%, P = 0.001), epinephrine (27.3% vs. 16.6%, P = 0.007), and inodilators. Outcomes such as median intensive care unit length of stay (7.5 vs. 8.3 days, P = 0.337) and hospital mortality (39.8% vs. 35.7%, P = 0.389) were not different between groups. When stratified by the central venous-to-arterial CO 2 difference (∆PCO 2 ), patients with a low ScvO 2 and normal ∆PCO 2 had lower median PaO 2 and hemoglobin levels and received more red blood cell transfusions, whereas those with an increased ∆PCO 2 had a lower pulse pressure and cardiac index and were more likely to receive epinephrine and milrinone. Conclusion: Low ScvO 2 is frequently observed in mechanically ventilated patients with severe hypoxemia, and these patients receive different interventions. Clinicians often use therapies targeting systemic oxygen delivery to correct low ScvO 2 . Prospective research is needed to identify patients with severe hypoxemia that might benefit from interventions targeting systemic oxygen delivery.

A single-center experience involving the first 50 patients of minimally invasive cardiac surgery of coronary artery bypass grafting: at district level

Aim. To examine the learning curve and results of the first 50 instances of coronary artery bypass grafting (CABG) that were done at our facility using minimally invasive cardiac surgery (MICS).Material and methods. A total of 50 patients received CABG using the left anterior thoracotomy technique between January 2021 and November 2022. We examined the MICS CABG patients' operating hours to assess our learning curve. In addition, we reviewed postoperative outcomes and compared them with those of patients who underwent sternotomy.Results. The median age was 49.5 years (the range was 27-72). Males made up 38 of the group, while females — 12. Ejection fraction (EF) before surgery averaged 40±5%. After exclusion criteria were met, all of these patients underwent CABG by left-sided thoracotomy. The radial artery and saphenous vein were the next alternate conduits, and all patients got left internal mammary artery (LIMA) to left anterior descending (LAD) artery as a conventional transplant. The average incision length was 7.08±0.5 cm. On the pump, only 1 case was completed. Per patient, there were 2.53±0.82 grafts on average. On average, the operation took 130.43±9.78 minutes. The median intensive care unit (ICU) length of stay was 2.82±0.74 days, while the median ventilation time was 5.79±1.80 hours. In our study, there were no conversions and no deaths. After the first 20 cases, we noticed a considerable decrease in operating time, which was our learning curve.Conclusion. Once the learning curve has been overcome, MICS CABG can be performed for multivessel disease with the same comfort for the operator as for a singleor double-vessel disease. Only during the learning curve, and not subsequently, there were greater operating time for MICS CABG observed as a significant difference from the sternotomy technique. While there was no difference in postoperative adverse events, there were notable advantages of MICS vs sternotomy in the parameters of immediate postoperative time such as ventilation time, mean drainage, postoperative discomfort, length of stay in ICU and hospital.

Neonatal outcomes and rationale for timing of birth in perinatal diabetes: a retrospective cohort study

The American College of Obstetricians and Gynecologists recommends delivery in the 39th week of pregnancy for patients with pregestational and medication-controlled gestational diabetes with consideration for earlier delivery among those with poor glucose control. We sought to evaluate the impact of birth before 39 weeks' gestation exclusively for diabetes-related indications on neonatal outcomes and clinician rationale for these recommendations. This was a retrospective cohort study of all singleton, nonanomalous pregnancies complicated by diabetes. Patients were identified through an obstetrical database containing information of 90,185 births from 2011 to 2021. Patients who delivered in a given week of gestation exclusively for diabetes-related indications were compared with ongoing pregnancies. Recommended births for other obstetrical indications were excluded from the diabetes-related indications cohorts. The primary outcome was neonatal intensive care unit admission. Secondary outcomes included neonatal intensive care unit length of stay, stillbirth, neonatal death, hypoglycemia, respiratory distress syndrome, and shoulder dystocia. For all births before 39 weeks' gestation, the electronic medical records were reviewed to confirm the rationale for the intervention for a diabetes-indicated condition. From the 90,185 recorded births that occurred in 2011 to 2021, 4750 patients with diabetes were identified. Of those, 30.5% (n=1449) had a recommended birth for a diabetes-related indications with 2.2% of those (n=32) occurring at 36 weeks' gestation, 7.9% (n=114) at 37 weeks' gestation, 9.7% (n=141) at 38 weeks' gestation, and 63.0% (n=913) at 39 weeks' gestation. Births that occurred at 36 and 37 weeks' gestation exclusively for diabetes-related indications had higher rates of neonatal intensive care unit admission than the respective ongoing pregnancies (62.5% vs 8.7%; P<.001 and 25.4% vs 7.2%; P<.001). There was no difference in neonatal intensive care unit admission for births at 38 or 39 weeks' gestation when compared with ongoing pregnancy. For neonates born at 36 and 37 weeks' gestation in comparison with ongoing pregnancies, the median neonatal intensive care unit length of stay was 11.0 vs 2.8 days, (P<.001) and 4.4 vs 2.6 days (P=.026), respectively. There were significantly increased rates of neonatal hypoglycemia and respiratory distress syndrome among births that occurred at 36, 37, and 38 weeks' gestation when compared with ongoing pregnancies. There were no differences in the rate of stillbirth in this cohort. Primary factors cited for early birth were poor glycemic control (71.4%), recommendation by a maternal-fetal medicine specialist (38.7%), and suspected fetal macrosomia (27.9%). Overall, 46.7%, 32.8%, and 20.6% of patients had 1, 2, or ≥3 indications, respectively, listed as rationale for early birth. Overall, few objective measures were used to recommend birth before 39 weeks' gestation owing to diabetes. In pregnancies complicated by diabetes, early birth exclusively for diabetes-related indications was associated with increased neonatal intensive care unit admission and length of stay and with neonatal morbidity. Little objective data are documented by clinicians to support their recommendations for early birth associated with diabetes. Additional clinical guidelines are needed to define suboptimal glucose control necessitating birth before 39 weeks' gestation.

Síndrome confusional agudo y confusional subsindromático en terapia intensiva: evolución intrahospitalaria y a los tres meses del alta

Background and objectiveThe characteristics and outcomes of patients with subsyndromal delirium (SSD) at hospitalization are still under discussion. The objectives were to describe the incidence of delirium and SSD in the intensive care unit (ICU), to analyze the association with risk factors and to explore outcomes of delirium and SSD at hospitalization and three months after discharge. Patients and methodsA prospective study, with telephone follow-up three months after discharge. The study included 270 patients over one year. Delirium and SSD were assessed with the CAM-ICU. Results22.96% developed delirium and 17.03% SSD. The main risk factors associated with the development of delirium were cognitive impairment (P=.000), age ≥75years (P=.019), neurological admission (P=.003), shock (P=.043), bedsores (P=.010), polypharmacy (P=.017), ARM (P=.001) and fast (P=.028), and with the development of SSD were low schooling (P=.014), Charlson >5 (P=.028), AIVD <8 (P=.001), enteral feeding (P=.000) and non-cardiovascular admission (P=.019). Overall mortality was 6% in the group without delirium (reference), 8% in SSD (P=.516) and 30% in delirium (P=.000). Median ICU length of stay was 2 (IQR, 1-2) days in the group without delirium, 3 (IQR, 2-4) days in SSD (P=.0001), and 3 (IQR, 2-7) days in delirium group (P=.0001). Three months after discharge, instrumental ADL were preserved in 50% of the group without delirium, 30% of SSD (P=.026) and 26% of delirium (P=.005). ConclusionsThe SSD group presented an intermediate prognosis between no delirium and delirium groups. It is advisable to promote its diagnosis for better risk classification.

The magnitude of mortality and its predictors among adult patients admitted to the Intensive care unit in Amhara Regional State, Northwest Ethiopia

Despite mortality in intensive care units (ICU) being a global public health problem, it is higher in developing countries, including Ethiopia. However, insufficient evidence is established concerning mortality in the ICU and its predictors. This study aimed to assess the magnitude of ICU mortality and its predictors among patients at Tibebe Ghion specialized hospital, Northwest Ethiopia, 2021. A retrospective cross-sectional study was conducted from February 24th, 2019, to January 24th, 2021. Data were collected from medical records by using pretested structured data retrieval checklist. The collected data was entered into Epi-data version 3.1 and analyzed using R version 4.0 software. Descriptive statistics computed. A simple logistic analysis was run (at 95% CI and p-value < 0.05) to identify the determinants for ICU mortality. A total of 568 study participants’ charts were reviewed. The median length of ICU stay was four days. Head trauma and shock were the leading causes of ICU admissions and mortality. The overall mortality rate of the ICU-admitted patients was 29.6% (95% CI: 26%, 33%). Admission in 2020 (AOR = 0.51; 95%CI: 0.31, 0.85), having altered mentation (AOR = 13.44; 95%CI: 5.77, 31.27), mechanical ventilation required at admission (AOR = 4.11; 95%CI: 2.63, 6.43), and stayed < 5 days in the ICU (AOR = 3.74; 95%CI: 2.31, 6.06) were significantly associated with ICU mortality. The magnitude of the ICU mortality rate was moderate. Years of admission, altered mentation, mechanical ventilation required at admission, and days of stay in the ICU were the predictors for ICU mortality. This finding underscores the importance of interventions to reduce ICU mortality.

A study on demographic and clinicopathological characteristics of severe acute pancreatitis in a tertiary-level intensive care unit in Nepal

BACKGROUND AND AIMS Severe acute pancreatitis can have serious consequences and a high mortality rate and may necessarily require intensive care unit admission. This study is to describe the demographic and clinicopathological characteristics of severe acute pancreatitis (SAP) in a tertiary-level intensive care unit (ICU). METHODS The study was designed retrospectively with a diagnosis of severe acute pancreatitis (SAP) admitted to the tertiary-level adult ICU “between” January 2019 to December 2022. RESULTS A total of 52 patients were enrolled in this study. The maximum numbers of patients were between 41 to 52 years of age, with a median age of 47.6 years. Gallstone (biliary) was identified as the most important etiological factor associated with severe acute pancreatitis. Among the known etiological factors, 52% of the cases were related to gallstone disease, 28.8% were due to alcohol, 7 (13.4%) to other causes (such as idiopathic, post-viral, post-ERCP, and drug-induced), and 5.7% were due to triglycerides. In our study, the most common symptoms were abdominal pain and vomiting. And the majority of patients recovered with conservative treatment. The majority 48 (92.3%) of patients improved, while 4 (7.6%) died. Eighteen (34.6%) patients required Mechanical ventilation (MV), while 10 (19%) with vasopressor supports. Eleven patients (21%) had evidence of an acute kidney injury on admission. Three patients (5.7%) underwent surgery, including necrosectomy and open cholecystectomy. The median length of ICU stay was 6.3 days. CONCLUSIONS The most common cause of severe acute pancreatitis was gallstone, followed by alcohol-related. SAP was seen more commonly in the male gender in the age group of 41-52 years. The most common presenting symptoms were abdominal pain and vomiting. Most SAP cases could be managed conservatively.

Enhanced Recovery After Surgery for an Uncommon Complex Urological Procedure: The Complete Primary Repair of Bladder Exstrophy.

ERAS (enhanced recovery after surgery) protocols are designed to optimize perioperative care and expedite recovery. Historically, complete primary repair of bladder exstrophy has included postoperative recovery in the intensive care unit and extended length of stay. We hypothesized that instituting ERAS principles would benefit children undergoing complete primary repair of bladder exstrophy, decreasing length of stay. We describe implementation of a complete primary repair of bladder exstrophy-ERAS pathway at a single, freestanding children's hospital. A multidisciplinary team developed an ERAS pathway for complete primary repair of bladder exstrophy, which launched in June 2020 and included a new surgical approach that divided the lengthy procedure into 2 consecutive operative days. The complete primary repair of bladder exstrophy-ERAS pathway was continuously refined, and the final pathway went into effect in May 2021. Post-ERAS patient outcomes were compared with a pre-ERAS historical cohort (2013-2020). A total of 30 historical and 10 post-ERAS patients were included. All post-ERAS patients had immediate extubation (P = .04) and 90% received early feeding (P < .001). The median intensive care unit and overall length of stay decreased from 2.5 to 1 days (P = .005) and from 14.5 to 7.5 days (P < .001), respectively. After final pathway implementation, there was no intensive care unit use (n=4). Postoperatively, no ERAS patient required escalation of care, and there was no difference in emergency department visits or readmissions. Applying ERAS principles to complete primary repair of bladder exstrophy was associated with decreased variations in care, improved patient outcomes, and effective resource utilization. Although ERAS has typically been utilized for high-volume procedures, our study highlights that an enhanced recovery pathway is both feasible and adaptable to less common urological surgeries.