Need For Prolonged Mechanical Ventilation Research Articles

The pulmonary contusion score: Development of a simple scoring system for blunt lung injury

BackgroundPulmonary contusions (PC) are common after blunt chest trauma and can be identified with computed tomography (CT). Complex scoring systems for grading PC exist, however recent scoring systems rely on computer-generated algorithms that are not readily available at all hospitals. We developed a scoring system for grading PC to predict the need for prolonged mechanical ventilation and initial hospital admission location. MethodsA retrospective review was performed of adult blunt trauma patients with PC identified on initial chest CT during 2020. Data elements related to demographics, injury characteristics, disposition and healthcare utilization were extracted. The primary outcome was the need for mechanical ventilation for greater than 48 h. A novel scoring system, the Pulmonary Contusion Score (PCS) was developed. The maximum score was 10, with each lobe contributing up to 2 points. A score of 0 was given for no contusion present in the lobe, 1 for less than 50 % contusion, and 2 for greater than 50 % contusion. A PCS of 4 was hypothesized to correlate with need for mechanical ventilation for over 48 h. A confusion matrix of the scoring algorithm was created, and inter-rater concordance was calculated from a randomly selected 125 patients. ResultsA total of 217 patients were identified. 118 patients (54 %) were admitted to the ICU, but only 23 patients (19 %) were intubated, and only 17 patients (8 %) required mechanical ventilation > 48 h. Sensitivity of the scoring system was 20 %, while specificity was 93 %. Negative predictive value was 93 %. Inter-rater agreement was 77 %. ConclusionThe PCS is a scoring system with high specificity and negative predictive value that can be used to evaluate the need for mechanical ventilation after sustaining blunt PC and can help properly allocate hospital resources. Level of evidenceIV - diagnostic criteria

Improving Outcome in Severe Myasthenia Gravis and Guillain-Barré Syndrome.

When progressive and severe, myasthenia gravis and Guillain-Barré syndrome may have the potential for fatal and unfavorable clinical outcomes. Regardless of important differences in their clinical course, the development of weakness of oropharyngeal muscles and respiratory failure with requirement of mechanical ventilation is the main driver of poor prognosis in both conditions. The need for prolonged mechanical ventilation is particularly relevant because it immobilizes the patient and care becomes extraordinarily complex due to daily risks of systemic complications. Additionally, patients with myasthenia gravis often require long-term immunosuppressive treatments with associated toxicity and infectious risks. Unlike myasthenia gravis, the recovery period is prolonged in Guillain-Barré syndrome, but often favorable, even in the more severely affected patients. Outcome, for a large part, is determined by expert neurocritical care.

Prognostic value of combined central venous oxygen saturation and lactate in pediatric patients after cardiac surgery

ObjectivesThis study assessed the value of measuring both arterial lactate levels and central venous oxygen saturation (ScvO2) in predicting cardiac surgery outcomes in pediatric patients.MethodsA prospective cohort study was conducted on 73 patients who underwent surgery for congenital heart disease. Vasoactive-inotropic score (VIS), serial mean arterial blood pressures (MAP), lactate levels, and ScvO2 were measured immediately and 3, 6, 12, 18, and 24 h after admission to the pediatric intensive care unit (PICU). To test the prognostic values of these markers, we calculated the areas under the receiver operating characteristic curves (AUCs). Binary logistic regression was used to identify the determinants of postsurgical complications.ResultsThe most common complications after cardiac surgery were the prolonged need for mechanical ventilation (38.36%), chest infection (30.14%), prolonged stay in the PICU (24.66%), and sepsis (9.59%). ScvO2 6 h after admission was most predictive of complications (AUC = 85.5%), followed by ScvO2/lactate (AUC = 83.0%), lactate level 12 h after admission (AUC = 75.0%), MAP (AUC = 73.6%), and VIS (AUC = 63.4). In multivariate analysis, body weight and ScvO2 6 h after PICU admission were the main predictors of complications (OR = 0.01, 95% CI 0.001–0.689, p = 0.033), and (OR = 0.87, 95% CI 0.798–0.948, p = 0.002) respectively.ConclusionsTo predict complications after pediatric cardiac surgery, lactate measurement does not add value to ScvO2 measurement 6 h after admission.The Cochrane TRNPACTR202104905893217.Date of registration 12 April 2021.

Retrospective Analysis of Our Experience with Percutaneous Tracheostomy in Our Intensive Care Unit

Aim: Percutaneous tracheostomy (PT) application has advantages such as being able to be applied at the bedside in a short time and less bleeding. It is frequently preferred in intensive care units with indications such as prolonged artificial respiration requirement, facilitating weaning, and providing emergency airway. It is an alternative method to surgical tracheostomy. In this study, we aimed to retrospectively evaluate the percutaneous tracheostomy cases we performed in the Intensive Care Unit (ICU) in the last three years.
 Material and Methods: Patients who underwent percutaneous tracheostomy in the 3rd Level our Hospital between January 2018 and December 2022 were examined. Demographic data of the patients, diagnosis of hospitalization, Acute Physiology and Chronic Health Evaluation II Score (APACHE II score), hospitalization time, intubation time, time from intubation to tracheostomy, early and late complications of tracheostomy were retrospectively analyzed.
 Results: Ninety-seven patients were analyzed. The mean age of the patients was 77.6±10.9 (range, 41-100) years and the female-male ratio was 40/57. The most common hospitalization diagnosis was neurological reasons (54.6%). The patients were intubated for 20.3±7.9 (range, 7-48) days and the total length of stay in the ICU 65.3±30.3 (range, 17-175) days. The number of patients who developed complications related to the PT procedure was 17 (12.9%).
 Conclusion: Percutaneous tracheotomy, which is performed in the ICU with indications such as the need for prolonged mechanical ventilation, facilitating weaning, and providing an emergency airway, is a simple, minimally invasive procedure with a low complication rate.

A case report on attempted suicide by self-slitting resulting in laryngeal fracture

Introduction: Laryngeal fractures cause significant problems with airway patency, vocal production, and swallowing function. The mechanism of injury can be sharp or blunt and can occur in the supraglottic, glottic, or infraglottic regions. Blunt external trauma to the neck caused by motor vehicle accidents, sports-related trauma, assault, and strangulation are the most frequent causes of laryngeal ruptures and fractures. Penetrating trauma is the second leading cause, often due to gunshot or stab wounds to the neck. The immediate goal in patients presenting to the emergency department with laryngeal rupture is to secure the airway. One of the indications for tracheostomy placement includes acute respiratory failure with the need for prolonged mechanical ventilation.

The Effect of Therapeutic Hypothermia on Prognosis in Patients Receiving Continuous Renal Replacement Therapy.

Continuous renal replacement therapy (CRRT) is a commonly used therapeutic modality in the pediatric intensive care unit (PICU) for the treatment of severe acute kidney injury, as well as for addressing metabolic abnormalities, fluid-electrolyte imbalances, and acid-base disorders. According to reports, therapeutic hypothermia treatment has demonstrated the ability to decrease cellular metabolism, oxygen consumption, formation of free radicals, cell death, and inflammatory signals. The study encompassed all individuals who underwent CRRT at both Manisa City Hospital and Manisa Celal Bayar University Hospital throughout the period from February 2021 to November 2022. A total of 14 patients who received CRRT were subjected to a warming procedure utilizing an external blanket and an external heater attached to the CRRT venous return line, resulting in the attainment of a body temperature exceeding 36°C. Therapeutic hypothermia was implemented on 12 patients to maintain their body temperature within the range of 32-35°C. The study population exhibited a median age of 24.5 months, with males comprising 61.5% of the sample. A therapeutic hypothermia treatment was administered to a cohort of 12 patients. The patients who had therapeutic hypothermia exhibited a significantly reduced vasoactive-inotropic score (p = 0.038). Patients who did not receive therapeutic hypothermia exhibited a prolonged need for mechanical ventilation (p = 0.020). The duration of stay in the PICU for patients who underwent therapeutic hypothermia was shown to be considerably shorter compared to those who did not receive therapeutic hypothermia (p = 0.047). The potential efficacy of moderate therapeutic hypothermia appears promising, particularly in the context of patients who are receiving CRRT for severe sepsis and acute respiratory distress syndrome. This is attributed to the anti-inflammatory properties and hypometabolic effects associated with this intervention. To the best of our current understanding, this study represents the initial investigation showcasing the effectiveness of combining therapeutic hypothermia with CRRT in the pediatric population.

The Effect of Birth Hour on Neonatal Morbidity and Mortality in Very-Low Birth Weight Infants in a Teaching Hospital.

With the increase in the preterm birth rate, the factors influencing mortality and morbidity in very-low-birth weight neonates have gained importance in recent years. The results of available studies on the influence of birth hour on the mortality and morbidity rates of preterm infants are contradictory. Moreover, no study on this topic has been conducted in our region. This retrospective cohort study was conducted on 127 very-low-birth weight newborns based on birth hour. The newborns were divided into 2 groups, the first born during working hours (7:00 am to 11:59 pm) and the second born during after-hours care (12-6:59 am). Mortality and major diseases were compared using Statistical Package for the Social Sciences by Fisher's exact tests, Pearson's chi-squared test, and independent t-tests. The statistical significance level for all analyses was set at P < .05 and the CI at 95%. Based on the results of this study in terms of neonatal mortality and major morbidities such as intraventricular hemorrhage and the need for prolonged mechanical ventilation, no significant difference was found between the 2 groups, but the difference in appearance, pulse, grimace, activity, respiration (APGAR) score at the fifth minute was statistically significant and was lower at the working hours. The results of the study may be due to appropriate allocation of resources, assignment of tasks, and professionalism of care in our study area. Further study is needed to determine the differences in clinical care processes that cause these results.

Tracheotomy as a life-saving procedure - overview of the current knowledge

Tracheotomy as a life-saving procedure has been known for many thousands of years. Tracheotomy remains one of the most frequently performed surgical procedures in the course of acute respiratory failure. Tracheostomy is traditionally performed as an open surgical procedure, performed both in the operating room and at the patient's bedside. Before performing the procedure, the thyroid cartilage and soft tissues are palpated. Before the operation, the patient lies on his back with a roller placed under the shoulder blades and his head tilted back. Direct and indirect laryngotracheoscopy is performed, and in doubtful situations we use computed tomography.General indications for tracheostomy are acute respiratory failure with anticipated need for prolonged mechanical ventilation and inability to wean off from mechanical ventilation, upper airway obstruction, and profuse secretions. Tracheostomy may have a beneficial effect on refractory obstructive sleep apnea. The percentage of late complications after the procedure reaches even 65%. The aim of the article is to present information on tracheostomy: its techniques, indications, contraindications, possible complications and decannulation of the patient.

Association of intraoperative lactate elevation and postoperative mortality and morbidity in patients undergoing craniotomy: retrospective analysis.

Intraoperative lactate levels increase in patients undergoing craniotomy, but the reason is not yet fully known. High levels of intraoperative lactate are associated with mortality and morbidity in patients with septic shock and abdominal and cardiac surgery. Investigate whether intraoperative lactate elevation is associated with postoperative systemic and neurological complications and mortality in craniotomy. Retrospective study SETTING: University hospital in Turkey. In this study, we included patients who underwent elective intracranial tumor surgery in our hospital between 1 January 2018, and 31 December 2018. According to the level of intraoperative lactate, patients were divided into two groups: high (≥2.1 mmol/L) and normal (<2.1 mmol/L). The groups were compared by the presence of postoperative new neurological deficits, postoperative surgical and medical complications, mechanical ventilation duration, 30-day mortality, in-hospital mortality, and hospital stay length. Cox regression analysis was performed for the 30-day mortality outcome. Association between intraoperative lactate levels and postoperative 30-day mortality. 163 patients with lactate data. While no significant difference was found between the groups regarding age, gender, ASA score, tumor location, operation time and pathology results, preoperative neurologic deficits were higher in the high intraoperative lactate group (P=.017). No statically significant difference was found between the groups for postoperative neurological deficit, need for prolonged mechanical ventilation, and hospital stay length. The postoperative 30-day mortality rate was higher in the group with high intraoperative lactate (P=.028). High lactate and medical complications were significant in the Cox analysis. Intraoperative lactate elevation was associated with postoperative 30-day mortality in patients undergoing craniotomy. The intraoperative level of lactate is an important mortality predictor in patients undergoing craniotomy. Retrospective design and single-centered, missing most data for several variables. None.

A Hemodynamic Echocardiographic Evaluation Predicts Prolonged Mechanical Ventilation in Septic Patients: A Pilot Study.

Prolonged mechanical ventilation (PMV) is common among critically ill septic patients and leads to serious adverse effects. Transthoracic echocardiography (TTE) is an efficient tool for the assessment of septic shock. Our study investigated the relationship between TTE parameters and PMV in mechanically ventilated septic shock patients. TTE was performed in the first 24 h of intensive care unit admission, acquiring data on cardiac output (CO), cardiac index (CI), s' wave (s'), E wave (E), e' wave (e') and E/e' ratio. We compared data on patients who met the criteria for PMV with data on patients who did not. Sixty-four patients were included, 26 of whom met the criteria for PMV. CO, CI and s' were higher in patients who required PMV (5.49 vs. 4.20, p=0.02; 2.95 vs. 2.34, p=0.04; and 12.56 vs. 9.81, p=0.01, respectively). CI correlated with s' (r=0.37, p < 0.01). The areas under the receiver operating characteristic curves for CO, CI and s' in assessing the need for PMV were, respectively, 0.7 (fair results), 0.69 and 0.68 (poor results). Despite a lack of a prognostic model, the observed differences suggest that hemodynamic TTE could provide information on the risk of PMV in septic shock.

Senile asthenia as a predictor of the severity of the perioperative period in elderly and senile patients

The aim. To evaluate the effectiveness of the diagnosis of senile asthenia using the Edmonton Frail scale in emergency abdominal surgery and to determine its impact on the severity of the perioperative period. Materials and methods. The study included 81 patients with acute cholecystitis on the background of gallstone disease, who were assessed for senile asthenia using the Edmonton Frail scale. For the reliability of the obtained results, only patients who were urgently hospitalized to the surgical department with gynecology beds of the emergency hospital with clinical symptoms of acute cholecystitis were included. All patients received treatment in only one department and according to the standards and clinical protocols of this clinic. Based on the Edmonton Frail score, all patients were divided into two groups. The comparison group included 50 (61.7 %) patients who did not have senile asthenia. The main group included 31 (38.3 %) patients diagnosed with senile asthenia. Results. Surgical treatment in both groups was carried out on an urgent basis using total intravenous anesthesia with artificial lung ventilation. According to the type of surgical intervention in both groups, preference was given to minimally invasive methods. Laparoscopic cholecystectomy in the comparison group was performed in 49 (98.0 %) patients, and only one patient (2.0 %) was converted and operation continued from the mini-access. In the main group, all surgical interventions were performed by the laparoscopic method, U = 759.50, P = 0.8841. Analyzing the results of the duration parameters and the need for prolonged mechanical ventilation, it can be seen that it progressively increases in patients with asthenia: in the comparison group 61.50 (48.00; 75.00) minutes, and in the main 93.84 (60.00; 80.00), U = 513.50, P = 0.0112. Also, we noted that in patients with senile asthenia, the number of postoperative complications increases: in the comparison group, there were only 2 (4.0 %) postoperative complications, while in the main group – 7 (22.6 %), U = 556.00, Р = 0.0337. Summarizing the results, it can be seen that due to increase of the frequency of postoperative complications and increase of the need for prolonged artificial ventilation of the lungs, the length of hospital stay of patients with senile asthenia increased: in the comparison group it was 7.9 ± 2.2 days, and in the main group 9.7 ± 3.2 days, U = 530.50, P = 0.0177. Conclusions. In our opinion, the Edmonton Frail scale is effective in diagnosing the severity of senile asthenia in elderly and senile patients in emergency abdominal surgery due to its simplicity and speed of use. The overall severity of the condition, heart failure in patients with senile asthenia lead to increase in the duration of surgery and the total duration of artificial lung ventilation: in the comparison group 39.52 (30.00; 45.00) minutes, while in the main group 49.19 (35.00; 50.00) minutes, U = 482.50, P = 0.0046. The duration of mechanical ventilation also differed significantly, in the comparison group 61.50 (48.00; 75.00) minutes, and in the main – 93.84 (60.00; 80.00), U = 513.50, P = 0.0112. The severity of senile asthenia negatively affects the course of the perioperative period, the frequency of postoperative complications increases: 2 (4.0 %) patients in the comparison group, while in the main group of 7 (22.6 %) patients, U = 556.00, P = 0.0337 and, as a consequence, the duration of inpatient treatment increases: in the comparison group it was 7.9 ± 2.2 days, in the main – 9.7 ± 3.2, U = 530.50, P = 0.0177. Modification of the approaches to preoperative preparation and postoperative management of elderly and senile patients diagnosed with senile asthenia will reduce the frequency of postoperative complications and reduce the length of hospital stay.

Elective Tracheostomy During Covid-19 Pandemic- A Tertiary Care Centre Experience.

: The aim of our study was to present an experience of elective tracheostomy in COVID-19 patients at our institute. The present prospective study was conducted, after approval by Institutional Ethics Committee, in the Department of ENT, SMGS Hospital, GMC Jammu from May 2020 to March 2021 over 60 patients having need for prolonged mechanical ventilation and having tested positive for COVID-19 with nasopharyngeal swab on rtPCR assay testing. Detailed information regarding following aspects was gathered :Age, Gender, Comorbidities (Diabetes, Cardiovascular disease, Pulmonary disease, Malignancy), time of endotracheal intubation to tracheostomy, time to wean sedation after tracheostomy, time to wean mechanical ventilation after tracheostomy, surgical complications, mortality, any health care worker in operating team getting infected by SARS-CoV-2. All 60 patients underwent Elective Open Tracheostomy Bed-side in the ICU section of our institute. The mean age of presentation was 55.9 ± 2.34 years, with male preponderance. The most common indication for tracheostomy was ARDS (Acute Respiratory Distress Syndrome) (56.6%). Out of 60 patients, co-morbidities were present in 44 patients (73.3%). The mean time between endotracheal intubation and tracheostomy was 12.2 ± 4.9 days. The mean time to wean mechanical ventilation after tracheostomy was 10.4 ± 2.31 days. The mean time to wean sedation was 2.2 ± 0.83 days. There were no deaths during the procedure. Out of 60 patients, 5 patients (8.3%) died due to complications of COVID-19. Our study provides important clinical data (such as timing of tracheostomy, pre-operative evaluation of patients, recommendations during procedure, outcomes of tracheostomy and postoperative care) on this threatening issue of tracheostomy in COVID-19 patients and might be of immense help to various Otorhinolaryngologists who are dealing with the same situation.

Weaning from prolonged mechanical ventilation on a specialised weaning unit: a retrospective comparison of patients with and without SARS-CoV-2 infection

Available data on patients requiring prolonged mechanical ventilation due to severe COVID-19 are sparse. Here we compare patients with ARDS related or not related to SARS-CoV-2 infection treated in a specialised weaning unit. A retrospective analysis of all patients with prolonged mechanical ventilation associated with an ARDS admitted from the 21st November 2013 to the 23rd July 2021 to the weaning unit of the University Hospital RWTH Aachen was performed. ARDS patients with COVID-19 (cARDS) were compared to patients with ARDS not related to COVID-19 (ncARDS). In total, n=129 patients in prolonged need for mechanical ventilation after ARDS were treated in the weaning unit, of whom n=38 had been suffering from ARDS related to COVID-19. Both patients groups were similar in terms of demographic parameters, underlying chronic illnesses, severity of ARDS and the duration of mechanical ventilation before being admitted to the weaning unit. During ICU stay, prone positioning and therapy with systemic corticosteroids was used more frequently in cARDS patients. Furthermore, therapy with vasoconstrictors was needed more often (cARDS: 42.1% vs. ncARDS 12.1%; p=0.0003) and urinary output was lower (cARDS: 1980 ml vs. ncARDS: 2600 ml; p=0.0037) in this patient group. The clinical course of the weaning process was similar in patients with cARDS and ncARDS, there were no significant differences in the occurrence of complications and the duration of mechanical ventilation. There were n=5 deaths (13.2%) in the cARDS and n=15 deaths (16.5%) in the ncARDS group. After hospital discharge, n=4 patients required non-invasive ventilation whereas out-of-hospital invasive ventilation was only necessary in one patient (all in the ncARDS group). After having survived the acute phase, the disease prognosis of patients with severe COVID-19 is favourable and most patients can be successfully weaned from mechanical ventilation. In addition, there were only minor differences compared to patients with ARDS unrelated to COVID-19.

Effects of mechanical ventilation during cardiopulmonary bypass on postoperative pulmonary complications

Introduction. It is common practice in on-pump cardiac surgery to stop mechanical ventilation when extracorporeal circulation is started or to continue with low tidal volumes. The aim of this study was to investigate whether patients ventilated with low tidal volumes had a lower percentage of postoperative pulmonary complications compared to patients who were not ventilated during cardiopulmonary bypass. Material and Methods. This retrospective study included patients who underwent coronary artery bypass graft surgery over a period of 14 months. Patients with lung diseases and those with an ejection fraction &lt; 30% were excluded from the study. Results. A total of 499 patients were included in the study. Of these, 398 were ventilated with low tidal volumes, while 101 patients were not ventilated during extracorporeal circulation. The groups did not differ in baseline characteristics, comorbidities, and intraoperative data. Pulmonary complications were equally prevalent in both groups (ventilated 16%, not ventilated 17.8%). The most frequent were the need for prolonged mechanical ventilation (ventilated 5.8%, not ventilated 5.9%), and pleural effusions (ventilated 4.8%, not ventilated 5.9%). The incidence of pneumonia was identical in both groups (2%). Other complications were less frequent. Duration of mechanical ventilation after surgery, stay in the intensive care unit, and in-hospital mortality did not differ significantly between the groups. Conclusion. Pulmonary complications after cardiac surgery are still common. The experience at our clinic showed that the choice of mechanical ventilation strategy during cardiopulmonary bypass does not affect postoperative pulmonary complications.

959: TRACHEOSTOMY IN PEDIATRIC ONCOLOGY AND HEMATOPOIETIC STEM CELL TRANSPLANT POPULATIONS

Introduction: Children with oncologic diagnoses and those who undergo hematopoietic stem cell transplantation (HSCT) have infrequent but high intensity utilization of critical care services, including need for prolonged mechanical ventilation (MV). While tracheostomy has been shown to be a safe procedure with increasing incidence in other pediatric populations, there is no overall consensus on optimal timing, patient selection, or relative contraindications. This study describes the HSCT and oncology cohorts from multiple pediatric centers who underwent tracheostomy. Methods: The Pediatric Health information System database (2009-2020) was used for a retrospective, descriptive cohort study of all patients with an oncologic diagnosis and/or SCT code and underwent tracheotomy. Results: 1,061 patients were included, 217 (20%) of whom had undergone HSCT. The annual incidence in tracheostomy did not change significantly over the study period. The majority (62%) underwent tracheostomy early (< 30 days) in the admission. Complications reported included tracheostomy site bleeding (< 1%) and infection (24%). The overall rate of MV at discharge was 26% and was significantly associated with preexisting chronic lung disease (adjusted odds ratio [OR] 2.1; 95% CI 1.19- 3.7), and acute lung disease ([OR] 1.63; 95% CI 1.12-2.35). Those who underwent the procedure late (>90 days) had a significant increase in MV at discharge (52% vs 25%, p< 0.001) and in hospital mortality (53% vs 18%, p< 0.001) compared to the early subgroup. The overall rate of mortality was 28% within the cohort and significantly associated with HSCT ([OR] 2.04; 95% CI 1.17- 3.56), diagnosis of sepsis ([OR] 2.09; 95% CI 1.36- 3.19), and requirement for renal replacement therapy ([OR] 2.86; 95% CI 1.71- 4.79). Conclusions: This is the first study describing pediatric oncology and HSCT patients who undergo tracheostomy. Despite implicit concerns for immunocompromised or thrombocytopenic status, complication rates are not disproportionate. Significantly higher need for MV at discharge and mortality, however, is seen in patients who undergo the procedure late in a hospitalization, with certain chronic conditions. and other ICU specific comorbidities. Further understanding of this vulnerable cohort, however, is needed to inform timing and patient selection.

EVALUATION OF THE IMPLEMENTATION OF ROTATIONAL THROMBOELASTOMETRY GUIDED COAGULATION MANAGEMENT IN ADULT CARDIAC SURGERY

<h3>Objective</h3> To evaluate changes in the administration of blood products and hemostatic drugs following the implementation of rotational thronboelastometry (ROTEM) in cardiac surgery in adult patients. To analyze changes in the rate of reintervention and perioperative complications. Economic analysis on the consumption of blood products, hemostatic drugs and ROTEM cartridges. <h3>Design and method</h3> Single-center retrospective cohort study. Exclusion criteria: interventions without cardiopulmonary bypass (CPB), emergent surgery, circulatory assist devices, heart transplant, ascending aortic dissection, Jehovah's Witness patients, congenital hemostasis disorders, and severe liver disease. In group 1 (before ROTEM), blood products and hemostatic drugs were administered empirically at the anesthesiologist's discretion. Activated clotting time, point-of-care prothrombin time testing, standard laboratory tests and clinical variables were used to guide therapeutic management. In group 2 (after ROTEM), blood products and hemostatic drugs were administered according to the Gorlinger algorithm modified. Variables preoperative period: age, sex, weight, height, BMI, BSA, hemoglobin level, number of platelets, creatinine, glomerular filtration rate, previous cardiac surgery. Variables intraoperative period: type of surgery, duration of CPB, administration of packed red blood cells (PRBC), platelet concentrates (PC), fresh frozen plasma (FFP), fibrinogen concentrate (FC), prothrombin complex concentrate (PCC) and rFVIIa. Variables postoperative period: reintervention (first 24h), mechanical ventilation >24h, acute lung injury (ALI), infection, thrombotic events, death, ICU and hospital length of stay. <h3>Results</h3> 759 patients were included, 438 in group 1 and 321 in group 2. There were no significant differences in age, sex, weight, height, BMI, BSA, preoperative anemia, thrombocytopenia, renal failure, previous cardiac surgery, type of surgey or interventions with CPB time >120 minutes. A significant reduction was observed in the number of patients who received PRBC (19% vs 29.2%; p = 0.001), FFP (1.6% vs 7.5%; p < 0.001), FC (23.4% vs 30.6%; p = 0.028) and rFVIIa (0.3% vs 2.7%; p = 0.011). A significant decrease was observed in the total quantity of PRBC, PC, FFP, FC and rFVIIa administered per patient. A significant reduction was observed in the incidence of postoperative infection (5.3% vs 10.3%; p = 0.013), ICU stay (median of 3 d vs 4 d; p < 0.001) and hospital stay (median of 8 d vs 11 d; p <0.001). There were no significant differences in the need for prolonged mechanical ventilation, surgical revision, incidence of ALI, thrombotic events or death. The economic analysis showed a total cost of 403,394.99 euros for group 1 and 203,292.97 euros for group 2. The average cost per patient was 921.00 euros in group 1 and 633.31 euros in group 2 (reduction of 30%). <h3>Conclusions</h3> Thromboelastometry reduces the administration of blood products and hemostatic drugs, in addition to lowering costs. The decreases in the incidence of infections and ICU and hospital stays cannot be solely attributed to the ROTEM technique as there are other factors that may have contributed.

Importance of Preventing Inadvertent Perioperative Hypothermia During Liver Transplant

Inadvertent perioperative hypothermia (IPH) leads to a series of deleterious effects that can be especially in complex procedures such as liver transplant. The implementation of a protocol is key to ensure the patient's normothermia. A cohort of 209 patients who underwent liver transplant in a tertiary hospital in a period between January 2016 and December 2018 was retrospectively analyzed. The patients were divided into 2 groups: group 1, patients with normothermia (core body temperature ≥ 36°C) and group 2, patients with hypothermia (core body temperature < 36°C). Mortality between both groups at 1 month, 1 year, and 3 years is compared. Postoperative morbidity is also compared. The incidence of IPH is 21.5%. Patients with normothermia present with statistical significance: a lower mortality at 1 year; a lower need for transfusion of platelets, plasma, fibrinogen consumption, or massive polytransfusion; and lower primary graft dysfunction, graft and surgical complications, rejection, hemodynamic complications, and metabolic and surgical reintervention. No significant differences were found in mortality at 1 month or 3 years in the need for prolonged mechanical ventilation; hospital readmission; length of stay in the intensive care unit or in hospital stay; rate of red blood cell transfusion; vascular, biliary, respiratory, or digestive complications; refractory ascites; or neurologic, kidney, hematological, endocrine, thrombotic, nutritional, or infectious issues. The incidence of IPH is relatively low in our patients, based on what is described in the literature, and in most cases it is mild. There is a reduction in complications fundamentally related to the consumption of blood products and the graft.

Impact of the Acute and Chronic Liver Failure–Sequential Evaluation of Organ Failure Scoring System on the Prognosis of Liver Transplant

The use of the Model of End-Stage Liver Disease (MELD) to predict morbidity and mortality after orthotopic liver transplant (OLT) is controversial. Acute and chronic liver failure-sequential evaluation of organ failure (CLIF-SOFA) is a new score that assess the patient's global status and that have been developed exclusively for patients with end-stage liver disease. The objective is to evaluate whether the CLIF-SOFA system predicts postoperative morbidity and mortality in the short and medium term. A cohort of 123 patients who underwent OLT in a tertiary care hospital between January 2016 and December 2017 was retrospectively analyzed. The patients were divided into 2 groups: group 1 with a CLIF-SOFA score <7 and group 2 with a score CLIF-SOFA ≥7. Patients with a CLIF-SOFA ≥7 present, with statistical significance, had higher mortality at 1 and 3 years; longer duration of admission to the critical care unit; longer hospital stay; need for prolonged mechanical ventilation; surgical reintervention; higher rate of transfusion of blood products; pulmonary, neurologic, hemodynamic, surgical, infectious, kidney, metabolic, thrombotic, vascular, and graft complications; and need for kidney replacement therapy. However, no statistically significant differences were found in mortality in the first month, the need for hospital readmission, retransplant, digestive, endocrine, nutritional, hematologic, or biliary complications, and the presence of ascites. The role of CLIF-SOFA as a prognostic factor for mortality after OLT must be taken into account. Our results should be taken with caution, and more studies are necessary.

Pediatric intensive care unit tracheostomy experiences in Ondokuz Mayıs University Faculty of Medicine

In this study; patients who underwent conventional tracheostomy while being followed up on a mechanical ventilator with endotracheal intubation in their pediatric intensive care unit were evaluated retrospectively. It was aimed to share the positive changes observed in clinical-mechanical ventilator parameters with the literature. Study data were obtained from the hospital information management system and recorded in the "Child Patient Evaluation Form with Tracheostomy" as follows: Demographic data, diagnosis of admission to pediatric intensive care unit, indications for mechanical ventilation and tracheostomy, changes in post-procedure mechanical ventilation parameters, tracheostomy complications, decannulation, survival and death rates etc. Post-discharge medical records were created by telephone interviews with parents. IBM SPSS 21 (Statistical Package for Social Sciences) program was used for statistical analysis. In our study; the most common indication (67.0%) for tracheostomy was the need for prolonged mechanical ventilation. Peak inspiratory pressure requirement on mechanical ventilator decreased statistically and tidal volume increased significantly in those who underwent tracheostomy due to prolonged mechanical ventilation requirement (both p&lt;0.001). On the other hand, the mean length of stay in the pediatric intensive care unit after the procedure was statistically significantly shorter (p&lt;0.001). Decannulation success was statistically significantly higher in those who underwent tracheostomy due to upper airway obstruction (p&lt;0.02). In our study; only four (6.2%) patients died due to tracheotomy (cannula occlusion, unplanned decannulation, etc.). Clinicians should consider tracheostomy if extubation cannot be achieved in children and adolescents who have been given mechanical ventilation for a long time (&gt;2-4 weeks) due to progressive primary disease. Tracheotomy should definitely be performed within appropriate medical indications in order to shorten the length of stay in the hospital/Pediatric intensive care unit and to provide medical care outside the hospital (e.g.; a suitable home environment) in order to create general psychosocial-physical well-being in the patients.

Predictors of Early Deterioration of Renal Function in Patients Older Than 70 Years Undergoing Valvular Surgery.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is the most common clinically important complication in adult patients undergoing open-heart surgery, with an incidence between 8.9% and 39%. Studies have shown that even a slight increase in serum creatinine levels after cardiac surgery significantly affects the mortality and morbidity of these patients. This study sought to determine the predictors and incidence of acute kidney injury (AKI) in patients older than 70 years undergoing elective valvular surgery. Prospective study included 156 patients scheduled for elective cardiac surgery requiring cardiopulmonary bypass (CPB) at Dedinje Cardiovascular Institute between January and September 2019. Isolated valvular surgery was performed in 87 patients, while the remaining 69 patients underwent combined coronary and valvular surgery. The development and stage of CSA-AKI were diagnosed, according to Kidney Disease Improving Global Outcome (KDIGO) criteria. Predictors and incidence of CSA-AKI development were assessed using univariate binary logistic regression analysis. The incidence of CSA-AKI was 17.3%. CSA-AKI stage 1 was diagnosed in 25 patients (16.02%). CSA-AKI stage 2 was noted in one patient (0.64%), as well as stage 3 (0.64%). In six patients (3.85%), renal replacement therapy (RRT) was required. Using univariate binary logistic analysis, the following parameters were identified as predictors for CSA-AKI development: duration of cardiopulmonary bypass (OR 1.01; CI 95% (1.01-1.02); P = .002), duration of aortic clamping (OR 1.02; CI 95% (1.01-1.03); P = .002), lactate levels during the intensive care unit (ICU) stay (OR 1.33; CI 95% (1.04-1.70); P = .026), duration of mechanical ventilation (MV) (OR 1.03; CI 95% (1.1-1.07); P = .014), the use of inotropic drugs (adrenaline, dobutamine) (OR 0.38: CI 95% (0.16-0.9); P = .026; and OR 0.23; CI 95% (0.1-0.56); P = .0019, respectively), and the use of diuretics (OR 0.24; CI95% (0.06-095); P = .041). Using Mann-Whitney U test for independent samples show that the group of patients who developed CSA-AKI had significantly longer duration of hospitalization (Z = -2.751); P = .006), prolonged ICU stay (Z = -4.160; P < .001), and need for prolonged mechanical ventilation (Z = -4.411; P < .001). Independent predictors for AKI development after valvular surgery in patients older than 70 years are prolonged mechanical ventilation and increased lactate values, while the use of diuretics after surgery reduces the incidence of AKI. Also, the development of CSA-AKI is associated with prolonged ICU stay and a longer duration of hospitalization.