Need For Prolonged Ventilation Research Articles

The anemia conundrum in contemporary redo cardiac surgery

Abstract Aims Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known on its prognostic value in the setting of redo procedure. This study aimed to investigate whether preoperative anemia is an independent determinant of adverse events in this augmented risk patients subset. Methods A retrospective, observational, cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020 (mean age of 62 ± 12.7 years, octogenarians 5.6%, female sex 52.8%, diabetes 19.5%, chronic kidney disease 30%, urgent/emergent status 34.8%, third-time sternotomy 9.8%). The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. The prevalence of preoperative anemia (according to World Health Organization definition) and its relationships with postoperative morbidity were obtained. Selection bias was assessed with propensity-adjustment method. Results The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and non-anemic group emerged in the risk of postoperative stroke (0.6% vs 4.4%, p = 0.023), postoperative renal dysfunction (29,7% vs 15.6%, p = 0.001), need for prolonged ventilation (18.1% vs 7.2%, p = 0.002), high dosage inotropes (53.1% vs 32.9%, p < 0.001) along with both length of ICU and hospital stay (8.2±15.9 vs 4.3±5.4 days, p=0.003 and 18.8±17.4 vs 14.9±11.1, p=0.012 ). After propensity matching (143 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke and need for high dosage inotropes cardiac morbidity. Anemia proved also a significant predictor of acute kidney injury at univariate analysis. Conclusions Preoperative anemia is significantly associated with acute kidney injury, stroke and need for high dosage inotropes in patients referred for redo procedures. Further studies are warranted to determine whether preoperative low hemoglobin concentration is a marker of severity of illness or a modifiable risk factor.

Factors associated with tracheostomy decannulation in infants with bronchopulmonary dysplasia

ObjectivePremature infants represent a unique subset of patients who may require tracheostomy. Bronchopulmonary dysplasia (BPD) is among one of the most common sequelae of prematurity contributing to the need for prolonged ventilation requiring tracheostomy after other airway options have been exhausted. Our objective is to understand socioeconomic barriers to decannulation and identify factors that accelerate safe decannulation, focusing on patients with BPD. MethodsAn existing internal database from a tertiary pediatric hospital of patients undergoing tracheostomy prior to one year old was reviewed. Data from January 1, 2005 through December 31, 2020 was used to compare patients who were successfully decannulated to those who were not. A further subset of infants with BPD were identified and analyzed. Of those decannulated, survival analysis was used to identify factors associated with decreased time to decannulation. ResultsWe identified 303 infants who underwent tracheostomy at less than one year old with 125 of those infants having a diagnosis of BPD. Of the 125 infants with BPD, 44 (35.2 %) were decannulated and 81 (64.8 %) were not. There was no significant difference in sex, race, ethnicity, insurance status, comorbidities, or presence of syndromes between those patients with BPD who were decannulated and those who were not. Those who were not decannulated had a significantly longer length of hospital stay, prolonged ventilator requirements after tracheostomy, and were more likely to be discharged home on the ventilator (p = 0.030; 0.020; 0.002, respectively). Of the 44 decannulated patients, mean and median time to decannulation were 37.9 and 27.8 months respectively (range 10.8–160.6 months). There was an inverse association with decannulation and both Black race (HR: 0.30) and neurological comorbidity (HR: 0.37) on multivariate analysis. Black race, presence of syndrome, and length of ventilator dependence were significantly associated with increased time to decannulation. Time to decannulation from time off the ventilator was not significantly influenced by sex, race, ethnicity, state of residence, or insurance status, but was significantly influenced by age (95 % CI: −6.9, −0.1; P = 0.044). While time from discharge to first follow up visit did not significantly impact time to decannulation, every additional follow up visit increased time to decannulation by 3.78 months when adjusting for confounding variables. ConclusionIn infants with BPD under one year requiring tracheostomy, socioeconomic factors were not found to influence likelihood of decannulation, however Black race, presence of underlying syndrome, and increased length of ventilator dependence were associated with prolonged timing. Children with more frequent follow up visits similarly had an increased time to decannulation, illustrating a vital point in the process. Ventilator weaning protocols and standardized decannulation protocols in patients with BPD, along with caregiver education, can safely expedite and facilitate decannulation.

C37 PROGNOSTIC IMPLICATION OF PREOPERATIVE ANEMIA IN REDO CARDIAC SURGERY: A SINGLE CENTER PROPENSITY MATCHED ANALYSIS

Abstract Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known on its prognostic value in the setting of redo procedure. This study aimed to investigate whether preoperative anemia is an independent determinant of adverse events in this augmented risk patients’ subset. A retrospective, observational, cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020 (mean age of 62 ± 12.7 years, octogenarians 5.6%, female 52.8%, diabetes 19.5%, chronic kidney disease 30%, urgent/emergent status 34.8%, third–time sternotomy 9.8%). The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. The prevalence of preoperative anemia (according to World Health Organization definition) and its relationships with postoperative morbidity were obtained. Selection bias was balanced with propensity–matching method. The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and non–anemic group emerged in the risk of postoperative stroke (0.6% vs 4.4%, p = 0.023), postoperative renal dysfunction (29,7% vs 15.6%, p = 0.001), need for prolonged ventilation (18.1% vs 7.2%, p = 0.002), high dosage inotropes (53.1% vs 32.9%, p < 0.001) along with both length of ICU and hospital stay (8.2±15.9 vs 4.3±5.4 days, p=0.003 and 18.8±17.4 vs 14.9±11.1, p=0.012 ). After propensity matching (143 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke and need for high dosage inotropes. Preoperative anemia is significantly associated with acute kidney injury, stroke and need for high dosage inotropes in patients referred for redo procedures. Further studies are warranted to determine whether preoperative low hemoglobin concentration is a marker of severity of illness or a modifiable risk factor.

Prognostic Implication of Preoperative Anemia in Redo Cardiac Surgery: A Single-Center Propensity-Matched Analysis.

Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known about its prognostic value in the setting of redo procedure. A retrospective, observational cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020. The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. Selection bias was assessed with the propensity-adjustment method. The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and nonanemic groups emerged in the risk for postoperative stroke (0.6% vs. 4.4%, p = 0.023), postoperative renal dysfunction (29.7% vs. 15.6%, p = 0.001), a need for prolonged ventilation (18.1% vs. 7.2%, p = 0.002), and high-dosage inotropes (53.1% vs. 32.9%, p < 0.001) along with both length of ICU and hospital stay (8.2 ± 15.9 vs. 4.3 ± 5.4 days, p = 0.003 and 18.8 ± 17.4 vs. 14.9 ± 11.1, p = 0.012). After propensity matching (145 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke, and the need for high-dosage inotrope cardiac morbidity. Preoperative anemia is significantly associated with acute kidney injury, stroke, and the need for high-dosage inotropes in patients referred for redo procedures.

Preterm prelabor rupture of membranes in singletons: maternal and neonatal outcomes.

To determine the effect of gestational age at delivery on maternal and neonatal outcomes in preterm prelabor rupture of membranes (PPROM) and assess various predictors of neonatal and infant mortality in these pregnancies. United States birth data from CDC-National Center for Health Statistics natality database for years 2004-2008 was used to identify singleton pregnancies with PPROM and delivery from 32 0/7 to 36 6/7weeks. Controls were singletons at 37-40weeks, without PPROM. Maternal and neonatal complications reported by all states were analyzed along with neonatal outcomes such as chorioamnionitis and hyaline membrane disease, reported by a subgroup of states. OR (95% CI) were calculated after adjusting for preeclampsia, diabetes, chronic hypertension, maternal race, and infant sex. There were 134,502 PPROM cases and similar number of controls. There was a significant decrease in need for prolonged ventilation, hyaline membrane disease, 5min Apgar score <7, and NICU admission with advancing gestational age. Placental abruption decreased and chorioamnionitis and cord prolapse were not different between 34 and 37weeks. We found reductions in early death, neonatal death, and infant mortality with advancing gestational age (p<0.001 for each). Gestational age at delivery was the strongest predictor for early death,neonatal death, and infant mortality in PPROM. These differences persisted after adjusting for antenatal steroid use. We provide population-based evidence showing a decrease in neonatal complications and death with advancing gestational age in PPROM. Gestational age at delivery in pregnancies with PPROM is the strongest predictor of mortality risk.

Evaluation and Neurodevelopmental Outcomes of Infants with Hypoxic Ischemic Encephalopathy Treated with Therapeutic Hypothermia: A Single Center Experience

Hypoxic ischemic encephalopathy (HIE) is an important cause of mortality and morbidity in newborns. Our study aimed to determine the neurodevelopmental outcomes, risk factors, and the relationship between risk factors and prognosis of cases followed up with HIE diagnosis and who were treated with hypothermia treatment. Medical records of 23 patients who were followed up with HIE diagnosis in the pediatric neurology outpatient clinic between January 1, 2018, and December 31, 2021, and treated with therapeutic hypothermia in the newborn period were retrospectively reviewed. Denver Developmental Screening Test II was used in the developmental evaluation. Neurodevelopment was normal in 12 (52.2%) of 23 cases and retarded for age in 11 (47.8%) cases. Variables such as Sarnat encephalopathy score in the neonatal period, need for prolonged ventilation, presence of severe acidosis at birth, Apgar scores at the 1st and 5th minutes, and abnormal cranial magnetic resonance (Mrg) findings were determined to be major factors in determining neurodevelopmental prognosis in asphyxic cases. The male gender was found to be riskier in terms of prognosis. Of the patients with HIE, retardation was determined for fine motor skills in 52.2%, speaking in 39.1%, gross motor skills in 26.1%, and personal development in 21.7%. Epilepsy, cerebral palsy, and speech disorders were the most common chronic period problems in patients with HIE. Despite therapeutic hypothermia treatment, neurodevelopmental problems are still observed in newborns with HIE. We found that male gender, low Apgar score, severe acidosis, and abnormal cranial Mrg findings in the neonatal period are risk factors in determining the neurodevelopmental prognosis of newborns with HIE. Monitoring and supporting the development of HIE cases with risk factors from the first months of life and intervening in developmental problems promptly are crucial in order to improve long-term outcomes.

Factors Associated with Mortality in Patients with COVID-19 Receiving Prolonged Ventilatory Support.

Background: Since its emergence in early 2020, coronavirus disease 2019 (COVID-19)-associated pneumonia has caused a global strain on intensive care unit (ICU) resources with many intubated patients requiring prolonged ventilatory support. Outcomes for patients with COVID-19 who receive prolonged intubation (>21 days) and possible predictors of mortality in this group are not well established. Patients and Methods: Data were prospectively collected from adult patients with COVID-19 requiring mechanical ventilation from March 2020 through December 2021 across a system of 11 hospitals. The primary end point was in-hospital mortality. Factors associated with mortality were evaluated using univariable and multivariable logistic regression analyses. Results: Six hundred six patients were placed on mechanical ventilation for COVID-19 pneumonia during the study period, with in-hospital mortality of 40.3% (n = 244). Increased age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03-1.09), increased creatinine (OR, 1.40; 95% CI, 1.08-1.82), and receiving corticosteroids (OR, 2.68; 95% CI, 1.20-5.98) were associated with mortality. Intubations lasting longer than 21 days (n = 140) had a lower in-hospital mortality of 25.7% (n = 36; p < 0.001). Increasing Elixhauser comorbidity index (OR, 1.12; 95% CI, 1.04-1.19) and receiving corticosteroids (OR, 1.92; 95% CI, 1.06-3.47) were associated with need for prolonged ventilation. In this group, increased age (OR, 1.06; 95% CI, 1.01-1.08) and non-English speaking (OR, 3.74; 95% CI, 1.13-12.3) were associated with mortality. Conclusions: In-hospital mortality in mechanically ventilated patients with COVID-19 pneumonia occurs primarily in the first 21 days after intubation, possibly related to the early active inflammatory process. In patients on prolonged mechanical ventilation, increased age and being non-English speaking were associated with mortality.

Minimally Invasive Direct Coronary Artery Bypass: An Evolving Paradigm Over the Past 25 Years.

We have routinely utilized minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending (LAD) coronary artery. We examined how this procedure has evolved. A retrospective review was undertaken of 2,283 consecutive patients who underwent MIDCAB between 1997 and 2021. Patients were divided into 3 groups: group A from 1997 to 2002 (n = 751, 32.9%), group B from 2003 to 2009 (n = 452, 19.8%), and group C from 2009 to 2021 (n = 1,080, 47.3%). Risk profiles and short-term outcomes were analyzed for the entire cohort and for 293 propensity-matched patients drawn from each group. The left internal mammary artery was harvested open in group A but with robotic assistance in group C. Thirty-day mortality was higher in group A versus group C (12 deaths, 1.6% vs 5 deaths, 0.5%, P = 0.044); this difference was negated after propensity matching. Group A had more comorbidities than group C, including peripheral vascular disease (17.7% vs 10.0%, P < 0.001), congestive heart failure (39.6% vs 18.0%, P < 0.001), and a history of stroke (17.9% vs 10.0%, P < 0.001), although diabetes mellitus was more common in group C (51.4% vs 31.0%, P < 0.001). Stroke was greater in group A (1.2% vs 0.0% vs 0.2%, respectively, P = 0.004), as was the need for prolonged ventilation (3.6% vs 0.2% vs 0.9%, respectively, P < 0.001), before and after propensity matching. MIDCAB patients had less comorbidities than in the past. Robot-assisted MIDCAB was associated with lower stroke risk.

Accuracy of Risk Estimation for Surgeons Versus Risk Calculators in Emergency General Surgery

IntroductionSurgical risk calculators have expanded in both number and sophistication of their predictive approach. These calculators are gaining popularity as validated tools to help surgeons estimate mortality and complications following emergency general surgery (EGS). However, the accuracy of risk estimates generated by these calculators compared to risk estimation by practicing surgeons has not been explored. MethodsAcute care surgeons at a quaternary care center prospectively estimated 30-d mortality and complications for adult EGS patients (2019-2021). Surgeon predictions were compared to Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) and NSQIP estimates. Observed-to-expected (O:E) ratios of median aggregate estimates were calculated. C-statistics for surgeon and calculator estimations were utilized to quantify predictive accuracy. ResultsAmong 150 patients (median 61 y, 45% male), 30-d mortality was 15% (n = 23). Observed rates of prolonged mechanical ventilation and acute renal failures were 30% and 10%, respectively. Overall, surgeon predictions were similar to risk calculator estimates for mortality (c-statistics 0.843 [surgeon] versus 0.848 [POTTER] and 0.815 [NSQIP]) and need for prolonged ventilation (c-statistics 0.801 versus 0.722 and 0.689, respectively). Surgeons tended to overestimate complication risks. Surgeon experience was not significantly associated with mortality prediction in an adjusted model. ConclusionsAcute care surgeons at a quaternary care center predicted postoperative mortality and complications with similar discrimination when compared to surgical risk calculators. Surgeon expertise should be utilized in conjunction with risk calculators when counseling EGS patients regarding anticipated postoperative outcomes. Surgeons should be cognizant of patterns in overestimation or underestimation of complications.

Postoperative decline in ambulatory function after lower extremity bypass is associated with higher short- and long-term mortality

ObjectiveAlthough the importance of preexisting functional and ambulatory status among patients undergoing lower extremity bypass (LEB) has been increasingly recognized, a paucity of reported data is available on the significance of a postoperative decline in ambulatory status after LEB surgery. The purpose of the present analysis was to determine the effects of a new decline in ambulatory status after LEB surgery on the postoperative short- and long-term outcomes. MethodsThe Vascular Quality Initiative infrainguinal bypass dataset was queried from 2003 to 2021 for patients with peripheral arterial disease (PAD) who had undergone LEB. Information on ambulatory status at admission and discharge from the hospital was recorded. Patients with a decline in ambulatory status at discharge from the hospital were included in group I, and those who had maintained their ambulatory status at discharge were included in group II. The primary outcomes were mortality, amputation, and a composite outcome of mortality or amputation at 30 days and 1 year postoperatively. The secondary outcomes were major adverse cardiovascular events, myocardial infarction, congestive heart failure, stroke, dysrhythmia, pneumonia, and the need for prolonged ventilation. ResultsA total of 40,478 patients were included in the present study, of whom 16,032 (39.6%) were included in group I and 24,446 (60.4%) were included in group II. The patients in group I were more often aged >70 years, women, African American, transferred from another hospital or rehabilitation facility, prior or current smokers, or had an American Society of Anesthesiologists classification of III or IV compared with those with unchanged ambulatory status (P < .05 for all). Patients with a decline in ambulatory status had had a greater incidence of mortality at 30 days (2.4% vs 0.6%; P < .001) and 1 year (9.7% vs 7%; P < .001) postoperatively. Patients with a decline in ambulatory status had had a greater occurrence of major adverse cardiovascular events, myocardial infarction, stroke, dysrhythmia, and the need for prolonged ventilation. The following factors were associated with a decline in postoperative ambulatory status: older age (70-79 years: adjusted odds ratio [aOR], 1.20; 95% confidence interval [CI], 1.07-1.34; P = .001; and ≥80 years: aOR, 1.18; 95% CI, 1.05-1.35; P = .007), female sex (aOR, 1.06; 95% CI, 1.00-1.11; P = .019), African-American race (aOR, 1.15; 95% CI, 1.07-1.21; P < .001), transfer from another hospital or rehabilitation unit (aOR, 1.30; 95% CI, 1.18-1.41; P < .001), and a history of diabetes mellitus (aOR, 1.12; 95% CI, 1.06-1.17; P = .004). The magnitude of decline in ambulatory function was associated with worse primary outcomes. Patients whose ambulatory function had declined from ambulatory to bedridden after LEB surgery had had the highest mortality (aOR, 21 at 30 days and 15 at 1 year). ConclusionsA new decline in ambulatory function at discharge from the hospital after LEB surgery was associated with increased short- and long-term mortality and the composite outcome of mortality or amputation. It was also associated with reduced amputation-free survival at 30 days and 1 year postoperatively.

Surgical Rib Fixation in Isolated Flail Chest Improves Survival

BackgroundThe presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study examined the impact of fixation in patients with isolated flail chest. MethodsAll patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an another hospital, or had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively, and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation. ResultsOf 287,947 patients with rib fractures, there were 12,110 patients (4.2%) with flail chest. After exclusion, 5293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%), and 4718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, P = .001). On multivariate analysis, rib fixation was associated with improved mortality (odds ratio, 0.355; P = .002). The timing of the operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days). ConclusionsOperative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation.

Tracheostomy is Safe in Patients with Prolonged Intubation After Coronavirus Disease 2019 Infection

BackgroundTracheostomy improves outcomes for critically ill patients requiring prolonged mechanical ventilation. Data are limited on the use and benefit of tracheostomies for intubated, critically ill coronavirus disease 2019 (COVID-19) patients. During the surge in COVID 19 infections in metropolitan New York/New Jersey, our hospital cared for many COVID-19 patients who required prolonged intubation. This study describes the outcomes in COVID-19 patients who underwent tracheostomy. MethodsWe present a case series of patients with COVID-19 who underwent tracheostomy at a single institution. Tracheostomies were performed on patients with prolonged mechanical ventilation beyond 3 wk. Patient demographics, medical comorbidities, and ventilator settings prior to tracheostomy were reviewed. Primary outcome was in-hospital mortality. Secondary outcomes included time on mechanical ventilation, length of ICU and hospital stay, and discharge disposition. ResultsFifteen COVID-19 patients underwent tracheostomy at an average of 31 d post intubation. Two patients (13%) died. Half of our cohort was liberated from the ventilator (8 patients, 53%), with an average time to liberation of 14 ± 6 d after tracheostomy. Among patients off mechanical ventilation, 5 (63%) had their tracheostomies removed prior to discharge. The average intensive care length of stay was 47 ± 13 d (range 29-74 d) and the average hospital stay was 59 ± 16 d (range 34-103 d). ConclusionsThis study reports promising outcomes in COVID-19 patients with acute respiratory failure and need for prolonged ventilation who undergo tracheostomy during their hospitalization. Further research is warranted to establish appropriate indications for tracheostomy in COVID-19 and confirm outcomes.

Emergency Tracheotomy: Nine Years Experiences in National Center Hospital of Nouakchott, Mauritania

Introduction: Tracheotomy is a commonly performed procedure, but with very large disparities according to the teams, both in terms of frequency and modality (percutaneous or surgical), tracheotomy has been evolved with medical advances. The objective of this study was to clarify the indications and complications of emergency tracheotomies at the National hospital center (CHN) in Nouakchott Mauritania. Materials and Methods: It is a retrospective study of tracheotomies performed in the ENT department of the CHN during the period from January 1, 2010 to December 31, 2018. The indications and complications were noted, as well as the modalities and time of decannulation. Results: Tracheotomy was motivated by upper airway obstruction (UAO) in 139 (94%) cases (mean age 32.5 years), or the need for prolonged ventilation in 8 patients (median age 46 years). Sixteen (7%) early complications were noted with 5 untimely decannulations including one fatal and 5 obstructive plug responsible for another death. Six pneumothorax was observed. Fifteen (26%) late complications required additional surgery; 7% (n = 11) of patients were decannulated with a mean duration of tracheotomy 26 months. In 19 (28%) cases of decannulations, the persistence of a tracheocutaneous fistula required surgery. Conclusion: Emergency tracheotomy is a survival gesture that is sure to be effective. A tracheotomy is not deprived of complications. Familiarity with the technique, the right choice of equipment, perfect knowledge of the anatomical relationships of the trachea, rigorous monitoring and postoperative care represent the main conditions for minimizing the risk of complications.

Tracheostomy in critically ill liver disease patients with coagulopathy: A retrospective study at a tertiary center

Introduction:Critically ill patients with liver disease commonly present to the intensive care unit (ICU) with need for prolonged ventilation, difficult weaning, and refractory coagulopathy. These patients experience both bleeding and thrombotic complications with a precariously balanced state of coagulopathy. The purpose of this study was to assess the bleeding complications of tracheostomy in critically ill patients with liver disease.Methods:A retrospective study was conducted in liver ICU of a tertiary teaching institute. Medical records were analyzed to assess postprocedure complication rate among 73 critically ill liver disease patients who had undergone tracheostomy during the period of October 2017 to September 2018.Results:Ten out of 73 patients (13%) required transfusion of blood products after 12 h of procedure, despite thromboelastography (TEG)-based correction prior to procedure. Of these, 7 patients (9%) underwent surgical tracheostomy (ST) and three patients (4%) underwent percutaneous tracheostomy. Statistically no significant difference in bleeding was seen among the two groups, but a rising trend was seen with the ST group (P = 0.52). None of the patients experienced procedure-related pneumothorax and subcutaneous emphysema, as observed in the chest X-ray.Conclusion:We conclude that coagulopathy should not be deterrence for the performance of tracheostomy in critically ill patients with liver disease. Adequate clotting support guided by the global tests of coagulation, such as TEG, ensures lesser incidence of bleeding.

Percutaneous Dilatational Tracheostomy and Modifications in Intensive Care Unit Patients

Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically ill patients [1]. It can be safely performed bedside. This has resulted in decline in the use of surgical tracheostomy except in few selected cases. Over the last 10 years data on newer methods of insertion, timing, safety profile and complication rates has been published, which has greatly improved our understanding of this procedure [2]. The most common indication of tracheostomy in the ICU is the need for prolonged ventilation. Less complication occur with an increase in skills. Many methods of performing PDT have been discovered recently [3]. Bronchoscopy has been found to be beneficial procedural aides the PDT [4]. In our study, a brief overview about the use of PDT in ICU and, different percutaneous techniques will be discussed. The conclusion is that percutaneous tracheostomies offer benefits for some of the outcomes when compared with surgical tracheostomies.

The Role of Right Ventricular Strain in Women and Men Following Left Ventricular Assist Device Implantation

BackgroundWomen and men have different perioperative hemodynamics, adverse event rates, and pump thrombosis-related mortality following left ventricular assist device (LVAD) implantation. However, gender differences in the subsequent development of right ventricular (RV) failure are not well defined. We evaluated the impact of gender on RV failure following LVAD implantation by speckle-tracking analysis of pre- and postoperative echocardiograms (echo).MethodsPre- and post-operative clinical, echo, and hemodynamic parameters were recorded in patients receiving LVADs from 2008-2018. Retrospectively, a subgroup of 74 women and 74 men were propensity score-matched 1:1 and chi square, t-tests, nonparametric tests, regression analysis, and Kaplan-Meier analysis were used to compare event rates. RV free-wall longitudinal strain (RV-FLS) and RV Fractional Area Change (RV-FAC) were calculated retrospectively using speckle-tracking, Tomtec Arena. All echo and RV strain measurements were blinded to gender outcomes.ResultsPreoperative hemodynamic parameters were not different between the two groups. However, women were more likely to have non-ischemic cardiomyopathy (81% vs 65%; p<0.001) and higher CHADS2VASC scores (3.0 vs 2.5; p<0.001), while men were more likely to have ischemic cardiomyopathy (35% vs 19%; p<0.026). Postoperative ICU stays were longer for women than men (149 vs 98 hours, respectively; p<0.016), as was the need for prolonged ventilation (61% vs 41%, respectively; p=0.014) and blood products (77% vs 62%, respectively; p=0.049). All echo parameters are presented in the table. The delta between pre and post-op RV free wall strain was not significant. Two year survival was 66.4% for the female group and 70.2% for the male group and 5-year survival was 55.3% for males and 63.6% for females (Fig 1).ConclusionsRV strain analysis tracks standard hemodynamic and echo parameters and does not add to the assessment of RV function in women and men undergoing LVAD implantation. Women and men have different perioperative hemodynamics, adverse event rates, and pump thrombosis-related mortality following left ventricular assist device (LVAD) implantation. However, gender differences in the subsequent development of right ventricular (RV) failure are not well defined. We evaluated the impact of gender on RV failure following LVAD implantation by speckle-tracking analysis of pre- and postoperative echocardiograms (echo). Pre- and post-operative clinical, echo, and hemodynamic parameters were recorded in patients receiving LVADs from 2008-2018. Retrospectively, a subgroup of 74 women and 74 men were propensity score-matched 1:1 and chi square, t-tests, nonparametric tests, regression analysis, and Kaplan-Meier analysis were used to compare event rates. RV free-wall longitudinal strain (RV-FLS) and RV Fractional Area Change (RV-FAC) were calculated retrospectively using speckle-tracking, Tomtec Arena. All echo and RV strain measurements were blinded to gender outcomes. Preoperative hemodynamic parameters were not different between the two groups. However, women were more likely to have non-ischemic cardiomyopathy (81% vs 65%; p<0.001) and higher CHADS2VASC scores (3.0 vs 2.5; p<0.001), while men were more likely to have ischemic cardiomyopathy (35% vs 19%; p<0.026). Postoperative ICU stays were longer for women than men (149 vs 98 hours, respectively; p<0.016), as was the need for prolonged ventilation (61% vs 41%, respectively; p=0.014) and blood products (77% vs 62%, respectively; p=0.049). All echo parameters are presented in the table. The delta between pre and post-op RV free wall strain was not significant. Two year survival was 66.4% for the female group and 70.2% for the male group and 5-year survival was 55.3% for males and 63.6% for females (Fig 1). RV strain analysis tracks standard hemodynamic and echo parameters and does not add to the assessment of RV function in women and men undergoing LVAD implantation.

A Pilot Study on Neonatal Surgical Mortality: A Multivariable Analysis of Predictors of Mortality in a Resource-Limited Setting.

Purpose:The aim of this research is to study the predictors of neonatal surgical mortality (NSM)-defined as in-hospital death or death within 30 days of neonatal surgery.Materials and Methods:All neonates operated over the study period of 18 months were included to evaluate NSM. The evaluated preoperative and intraoperative variables were birth weight, gestation age, age at presentation, associated anomalies, site and duration of surgery, intraoperative blood loss, and temperature after surgery. Assessed postoperative variables included the need for vasopressors, postoperative ventilation, sepsis, reoperations, and time taken to achieve full enteral nutrition. Univariate and multivariate logistic regression was applied to find the predictors of mortality.Results:Based on patient's final outcome, patients were divided into two groups (Group 1-survival, n = 100 and Group 2-mortality, n = 50). Incidence of NSM in this series was 33.33%. Factors identified as predictors of NSM were duration of surgery >120 min (P = 0.007, odds ratio [OR]: 9.76), need for prolonged ventilation (P = 0.037, OR: 5.77), requirement of high dose of vasopressors (P = 0.003, OR: 25.65) and reoperations (P = 0.031, OR: 7.16 (1.20–42.81).Conclusion:NSM was largely dependent on intraoperative stress factors and postoperative care. Neonatal surgery has a negligible margin of error and warrants expertize to minimize the duration of surgery and complications requiring reoperations. Based on our observations, we suggest a risk stratification score for neonatal surgery.

Clinical significance of chronic obstructive pulmonary disease in patients undergoing elective total arch replacement: analysis based on the Japan Adult Cardiovascular Surgery Database.

We investigated the impact of chronic obstructive pulmonary disease (COPD) on in-hospital outcomes of patients undergoing conventional total aortic arch replacement (TAR), based on the Japan Adult Cardiovascular Surgery Database. A total of 12 590 patients who underwent elective TAR between 2008 and 2013 were retrospectively reviewed. Patients were divided into 4 categories: normal respiratory function (control), with ratio of forced expiratory volume of air in 1 s (FEV 1 ) to forced vital capacity (FVC) of 76% or greater (TAR, n = 10 040); mild COPD, with FEV 1 /FVC ratio 60-75% and/or use of bronchodilator (TAR, n = 1890); moderate COPD, FEV 1 /FVC ratio 50 to 59% and/or use of steroids (TAR, n = 504); and severe COPD, FEV 1 /FVC ratio less than 50% and/or presence of respiratory failure (TAR, n = 156). In-hospital mortality was 5.7% (5.2% in controls, 7.0% in mild COPD, 9.3% in moderate COPD and 9.0% in severe COPD). A significant trend towards the severity of COPD was noted ( P < 0.0001). A higher incidence of postoperative pneumonia (6.0% in control, 11.0% in mild COPD, 12.3% in moderate COPD and 15.4% in severe COPD; P < 0.0001) and a greater need for prolonged ventilation (17.5% in control, 22.0% in mild COPD, 26.6% in moderate COPD and 29.5% in severe COPD; P < 0.0001) were observed in cases of more severe COPD. The odds ratio of moderate/severe COPD for in-hospital mortality was 1.44 with confidence interval of 1.08-1.91 ( P = 0.012). There was a significant increase in in-hospital mortality and morbidity with increasing severity of COPD in patients who underwent TAR.

Percutaneous tracheostomy.

Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically sick patients. It can be safely performed bedside by intensivists. This has resulted in decline in the use of surgical tracheostomy in intensive care unit (ICU) except in few selected cases. Most common indication of tracheostomy in ICU is need for prolonged ventilation. About 10% of patients requiring at least 3 days of mechanical ventilator support get tracheostomised during ICU stay. The ideal timing of PDT remains undecided at present. Contraindications and complications become fewer with increase in experience. Various methods of performing PDT have been discovered in last two decades. Preoperative work up, patient selection and post tracheostomy care form key components of a successful PDT. Bronchoscopy and ultrasound have been found to be useful procedural adjuncts, especially in presence of unfavorable anatomy. This article gives a brief overview about the use of PDT in ICU.

The Role of Blood Transfusion in the Development of Atrial Fibrillation after Coronary Artery Bypass Grafting.

Objectives Atrial fibrillation (AF) is the most common complication after coronary artery bypass grafting (CABG). It is associated with prolonged hospital stay and increased cost. The aim of this study is to investigate the relationship between transfusion of blood derivatives and occurrence of postoperative paroxysmal AF. Materials and Methods From June 2012 to February 2014, 446 patients undergoing CABG with cardiopulmonary bypass (CPB) were prospectively evaluated for occurrence of postoperative AF. Patients and procedural variables were recorded and were associated with the development of new-onset AF with logistic regression analysis. Results AF developed in 111 patients (24.9%). Preoperative factors associated with the development of new-onset AF included age (p < 0.05), higher EuroSCORE II (p < 0.05), carotid disease (p = 0.01), peripheral vascular disease (p = 0.02), chronic obstructive pulmonary disease (p = 0.03), renal failure (p = 0.05), and cardiac failure (p = 0.01). Intraoperative and postoperative parameters included duration of CPB (p < 0.05), number of grafts (p = 0.009), intubation time (p = 0.001), occurrence of postoperative stroke (p = 0.01), transient ischemic attack (p = 0.02), need for prolonged ventilation (p = 0.002), development of respiratory tract infection (p = 0.02), need for noninvasive ventilation (p = 0.001), reintubation (p = 0.02), development of postoperative acute kidney injury (p = 0.002), and postoperative neurocognitive dysfunction (p = 0.002). The number of red blood cell (RBC) units transfused during surgery (p = 0.7) and the total number of RBC units transfused (p = 0.2) as well as units of fresh frozen plasma (p = 0. 7) and platelets units transfused in total (p = 0.3) were not found to increase the risk of postoperative AF. Conclusion Intraoperative and postoperative blood products transfusion in patients operated for CABG is not associated with increased risk of developing postoperative AF.