Need For Inotropes Research Articles

Not Rocket Science: A Pragmatic Checklist to Assess Readiness for Oral Feeding in Very Preterm Infants

Background and Rationale Successful transition to oral feeding is a crucial milestone for preterm infants. Our unit uses a pragmatic 5-point checklist to assess the readiness of preterm infants for oral feeding. Methods This prospective observational study included very preterm infants (<32 weeks at birth). They were assessed for readiness at ≥33 weeks postmenstrual age (PMA), and pre-defined physiological stability for oral feed readiness. Oral feeds were started when all parameters of the checklist were satisfied. The proportion of those who succeeded (measured as no apnoea/choking on oral feed for 48 hours) after commencement of transitioning from orogastric to oral feeds was measured, weight gain over 1 week and PMA at attainment of full oral feeds were also analysed. Results Thirty-three eligible neonates were included, of which 26(78.8%) had no apnoea/choking within the first 48 hours of transition. Twelve infants needed to be reassessed since they ‘failed’ the first time over. The median PMA of attainment of full oral feeds was 34(34,37) weeks, weight gain over 1 week of oral feeds was 145(117,170) g. Among risk factors analysed for choking, stress signs during non-nutritive sucking [RR6(1.7–20.1), P = .002], those with initial sick newborn period (FiO2 need>0.3 beyond 72 hours/any inotrope need)[RR9.2(1.2–68.1), P = .004], and bronchopulmonary dysplasia (BPD) [RR4.2(1.3–13.3)], P = .02] were significant. Conclusion The transition to oral feeding of preterm neonates can be assessed by a practicable, easy-to-use scale; it predicted success in 78.8% infants. Those who were initially sick exhibited stress signs on assessment and BPD infants can be transitioned with due caution and monitored for choking events more closely.

Impact of social determinants of health on the outcomes of Latin American children with Multisystem Inflammatory Syndrome (MIS-C).

There is growing understanding that Social Determinants of Health (SDH) impact on the outcomes of different pediatric conditions. We aimed to determine whether SDH affect the severity of MIS-C. Retrospective cohort study, 2021-2023. Children and adolescents with MIS-C younger than 18 years of age fulfilling the MIS-C CDC definition within the REKAMLATINA network were invited to participate. We assessed the impact of SDH on the risk of children with MIS-C to be diagnosed with shock, need of inotropes, respiratory support, transfusion, and death. Two hundred and seventy seven patients from 30 centers in 13 countries were included. Of them, 241 children from the four most-represented countries were included in the final analysis. Food insecurity, higher distance from a health center, not possessing a private vehicle to transport the patient to hospital, and having a home in poor condition, were associated with low LVEF, need of transfusion, shock, and need for respiratory support, when controlling for age, BMI, and ethnicity. The Score of Social Disadvantage was associated with Shock (OR: 1.35, P: 0.011, 95% CI: 1.07-1.71), Respiratory support (OR: 1.39, P: 0.005, 95% CI: 1.1-1.75), Transfusion (OR: 1.63, P0.013, 95% CI 1.1-2.41), but not death (OR: 0.76, P: 0.38, 95% CI: 0.41-1.40). Among a large cohort of Latin American children with MIS-C, SDH negatively affect outcomes. These findings reinforce the need for better investigation of the role of SDH in MIS-C and other inflammatory conditions and may guide public health interventions.

Estado de Vitamina D y gravedad de la enfermedad en pacientes pediátricos críticamente enfermos

Objectives: The objective of this study was to evaluate Vitamin D (VD) status and its asso-ciation with disease severity in critically ill pediatric patients.Methods: An observational follow-up study was conducted on a prospective cohort of pe-diatric patients admitted to the intensive care units (ICU) of two health institutions. All admitted patients underwent measurement of 25-OH-VD, which were categorized as defi-ciency, insufficiency, or normal. The outcome variables were mechanical ventilation, the need for inotropes, renal replacement therapy, and mortality.Results: One-hundred seventy-five pediatric patients were followed up. The mean VD was (25.43 mg/dl, SD = 10.17). The prevalence of deficiency was 26.29 % (n= 46), and for insuf-ficiency, 48 %. Patients with VD deficiency (adjusted RR 2.07 CI95 1.12 – 3.82) had a higher risk of requiring inotropes. 746Vitamin D Status and Disease Severity in Critically Ill Pediatric PatientsDerly Gómez Sandoval, Iván José Ardila-Gómez, Darling Carvajal-Duque, Pilar Pérez-López, Jorge Andres Ramos-CastanedaVol. 40(3), 2024, 744-758Barranquilla (Col.) Conclusion: VD deficiency was associated with the need for inotropic medication during ICU stay

Intravascular Lithotripsy in Acute Coronary Syndromes: Procedural and One-Year Clinical Outcomes From the BENELUX-IVL Registry.

Despite the excellent success and safety of intravascular lithotripsy (IVL) in heavily calcified lesions, evidence in acute coronary syndromes (ACS) remains limited. This study aimed to evaluate the procedural and clinical outcomes of IVL in heavily calcified ACS. Patients who underwent IVL between 2019 and 2024 from the ongoing prospective BENELUX registry were eligible for inclusion. Patients were therefore classified in ACS and chronic coronary syndrome (CCS) groups. The primary technical endpoint was angiographic success < 30%, defined as the successful delivery of the IVL catheter across the target lesion and delivery of IVL pulses without angiographic complications and residual target lesion less than 30%. The primary clinical endpoint was in-hospital major adverse cardiac events (MACE), including cardiac death, nonfatal myocardial infarction, or target lesion revascularization. A total of 454 patients underwent IVL, with 251 (55.3%) treated for CCS and 203 (44.7%) for ACS. The median SYNTAX score (p-value 0.17), the need for inotropes (p-value 0.09), and the use of mechanical circulatory support (p-value 0.71) were similar between CCS and ACS groups. Comparable angiographic success (< 30% residual stenosis) was observed between CCS and ACS groups (90.1% vs. 91.1%, p = 0.69). MACE were similar across groups during hospital stays (CCS 1.6% vs. ACS 3.0%, p = 0.33), at 30 days (CCS 3.2% vs. ACS 3.9%, p = 0.86), and at 12-month follow-up (CCS 8.4% vs. ACS 7.9%, p = 0.91). IVL provides high procedural success and consistent clinical outcomes in both CCS and ACS cases.

Arterial Cannulation Through Aneurysm and Aortic Anastomosis During Proximal Thoracic Aortic Aneurysm Surgery

Background: Proximal aortic aneurysm surgery involving the aortic root and ascending aorta represents a specific surgical intervention in terms of the number of surgical incisions, arterial cannulation methods as well as anastomosis technique and cerebral protection. This study aims to present a case series of a new surgical technique for proximal aortic aneurysm surgery exclusively through midsternal approach and consisting of arterial cannulation from the aneurysmatic segment and through aortic anastomosis. Methods: This retrospective study included 90 patients who were operated for proximal thoracic aortic aneurysm using a new surgical technique mainly consisting of single standard midsternal approach without extension of the incision, arterial cannulation through the aneurysmatic segment and aortic anastomosis, deep hypothermic circulatory arrest, and open distal anastomosis without cerebral perfusion. Results: Ascending aorta replacement (replacement) and ascending aorta replacement plus aortic root replacement (ARR) was performed in 60 (66.7%) and 30 (33.3%) patients, respectively. Intraoperative courses were uneventful. The mean durations for deep hypothermic circulatory arrest (DHCA), cross-clamp, and cardiopulmonary bypass were 24.9 ± 3.2 min, 169.7 ± 52.8 min, and 235.3 ± 57.6 min, respectively. Most common postoperative complication was atrial fibrillation (18.9%) followed by inotropic need (10%) and wound infection (7.8%). Three patients died (3.3%) during hospitalization. Conclusions: This new method for the treatment of proximal aortic aneurysms offers a viable and safe alternative with only midsternal surgical incision, without damaging any segment of the healthy aortic tree for arterial cannulation, without prolonging the operation time, and avoiding complications related to additional incisions and cannulation of the healthy aortic tree.

Abstract 4137198: Cardiac Index At The Time Of Pulmonary Artery Pressure Monitor Implantation And Inotrope Requirement Within 1 Year

Introduction: Pulmonary artery pressure monitoring with an implantable device (PAPM) improves heart failure hospitalizations (HFH) in patients with symptomatic heart failure. We sought to explore whether cardiac index (CI) predicted need for initiation of inotrope within 1 year of PAPM. Purpose: To examine the association between CI at PAPM implantation and need for inotropes within 1 yr. Methods: We retrospectively analyzed 277 consecutive HF patients who underwent PAPM from 1/1/19 through 10/31/22 with at least 1 yr post-implant follow-up. Demographic and clinical characteristics were compared between those who required inotropes within 1 yr (n=60) vs those who did not (n=217) (Figure 1). Independent samples t-test was used for continuous data and chi-square analysis for categorical data. Logistic regression was used to examine CI as a predictor of inotrope requirement within 1 yr, controlling for age, ejection fraction and glomerular filtration rate. Results: The average age was 69 (12) yr, 54% were male and 60 required inotropes. Patients requiring inotropes had significantly lower CI (2.2±0.6 L/min/m 2 vs 2.6±0.7 L/min/m 2 , p &lt; 0.001). CI was a significant independent predictor of inotrope requirement within 1 yr [odds ratio (OR)=0.3, 0.2-0.6; P&lt;.001). Every increase in CI by 1 L/min/m 2 resulted in 70% lower odds of requiring inotropes (Figure 2). After adjustment, CI remained a significant predictor of inotrope need (OR=0.4, 0.2-0.7; p&lt;0.001); every increase in CI by 1 L/min/m 2 reduced odds of inotrope requirement by 60%. Conclusion: Lower cardiac index at the time of PAPM implantation in symptomatic heart failure patients was associated with an increased need for inotrope within one year. This may identify a cohort of patients at risk of progressing to advanced heart failure. Prospective studies should examine the role of PAPM in management of HF patients with a low presenting cardiac index as well as patients with a PAPM and on inotrope.

The illness severity scores can predict the need for respiratory and inotropic support in newborns with critical congenital heart malformations

Background and objectives. The illness severity scoring systems have been developed and validated to assess mortality risks based on clinical conditions and aid critical patient decision-making. Dextro-transposition of the great arteries (D-TGA) and coarctation of the aorta (CoA) are critical congenital heart defects that require medical treatment from birth and surgical repair in the neonatal period. The study aimed to compare the values of three scoring systems in predicting the need for respiratory and inotropic support for newborns with D-TGA and CoA. Materials and methods. An observational study was conducted on inborn infants diagnosed with D-TGA and CoA admitted to the newborn intensive care unit (NICU) within 12 hours of birth at a referral unit for congenital heart disease between January 2018 and December 2020. Newborns with D-TGA and CoA who died within the first 24 hours of birth, outborn infants, and those with a late diagnosis were excluded. For each patient, the Clinical Risk Index of Babies (CRIB-II), Score for Neonatal Acute Physiology-II (SNAP-II), and Score for Neonatal Acute Physiology-Perinatal Extension-II (SNAPPE-II) were calculated. Results. A total of 69 newborns were included in the current study, 30 (43.48 %) of whom were infants with D-TGA (D-TGA Group) and 39 (56.52 %) with CoA (CoA group). Newborns who required respiratory support had significantly higher CRIBII scores (3.03 ± 0.63 vs. 1.34 ± 0.19; p = 0.001), SNAP-II scores (26.61 ± 13.96 vs. 12.43 ± 9.98; p = 0.001), and SNAPPE-II scores (33.04 ± 2.91 vs. 14.47 ± 12.35; p = 0.001) compared to those who did not require it. Significantly higher CRIB-II (3.22 ± 0.67 vs. 1.56 ± 0.23; p = 0.003), SNAP-II (22.91 ±14.57 vs. 14.28 ± 1.58; p = 0.003), and SNAPPE-II (28.82 ± 17.95 vs. 16.58 ± 13.85; p = 0.003) scores were also associated with the need for inotropic support. When comparing the predictive efficiency of illness severity scores for detecting the risk of needing respiratory and inotropic support, they are more effective at predicting the need for ventilation and less effective at predicting the need for inotropes. Conclusions. The illness severity scores can effectively predict the need for pre-surgery interventions. Their simplicity makes them suitable for routine use.

Minimal invasive extracorporeal circulation: A bibliometric network analysis of the global scientific output.

Minimal Invasive Extracorporeal Circulation (MiECC) has recently emerged as a more 'physiologic' alternative to conventional extracorporeal circulation. However, its adoption is still limited due to lack of robust scientific evidence and ongoing debate about its potential benefits. This bibliometric analysis aims to analyze the scientific articles on MiECC and identify current research domains and existing gaps to be addressed in future studies. Pertinent articles were retrieved from the Web of Science (WOS) database. The search string included 'minimal invasive extracorporeal circulation' and its synonyms. The VOSviewer (version 1.6.17) software was used to conduct comprehensive analyses. Semantic and research networks, bibliographic coupling and journal analysis were performed. Of the 1777 articles identified in WOS, 292 were retrieved. The trend in publications increased from 1991 to date. Most articles focused on transfusion requirements, acute kidney injury, inflammatory markers and cytokines, inflammation and delirium, though the impact of intraoperative optimal fluid and hemodynamic management as far as the occurrence of postoperative complications were poorly addressed. The semantic network analysis found inter-connections between the terms "cardiopulmonary bypass", "inflammatory response", and "cardiac surgery". Perfusion contributed the highest number of published documents. The most extensive research partnerships were between Germany, Greece, Italy, and England. Notwithstanding the scientific community's growing interest in MiECC, crucial topics (i.e., the best anesthetic management and intraoperative need for inotropes, vasopressors and fluids) still require more comprehensive exploration. This investigation may prove to be a useful tool for clinicians, scientists, and students concerning global publication output and for the use of MiECC in cardiac surgery.

PASS: A scoring system to evaluate persistent kidney injury in critically ill ICU adult patients.

We evaluated if the course of recovery from sepsis-induced acute kidney injury (AKI) can be predicted using variables collected at admission. A total of 63 patients admitted for sepsis-induced AKI in our Mangalore ICU were evaluated and baseline demographic and clinical/laboratory parameters, including serum creatinine (SCr), base excess (BE), Plethysmographic Variability Index (PVI), Caval Index, R wave variability index (RVI), mean arterial pressure (MAP) and renal resistivity index (RI) using renal doppler and need for inotropes were assessed on admission. Patients were managed as per standard protocol. After six hours of fluid resuscitation, patients were classified as volume responders or non-responders. Re-assessment was done at 24 hours and 72 hours after admission. Primary outcome was persistent AKI after 72 hours. Secondary outcome was initiation of dialysis or death within 15 days of admission. A total of 34 subjects recovered from AKI, of whom 32 patients were volume responders and 31 were non-responders. Response to fluid, MAP at admission and six hours, BE at admission, inotrope requirement, and PVI at admission did not correlate with recovery. Multiple logistic regression showed that SCr < 2.36 mg%, RVI > 14.45 and RI < 0.8 on admission correlated with recovery and they were evaluated further to model AKI recovery and develop PASS. PASS score = (SCr points × 5.4) + (RVI points × 4.0) + (RI points × 6.2). One point each was allotted if SCr was < 2.36, RVI was > 14.45 and RI was <0.8, and 0 otherwise. A score > 7.8 predicted recovery with a sensitivity of 79.4%, specificity of 72.4%, PPV 81.8%, NPV 76.7% and AuROC of 0.85. The PASS score can be used to identify salvageable cases of sepsis-AKI, guiding fluid resuscitation and aiding early referral from rural to tertiary care centers for better management.

Left atrial appendage emptying velocity and left ventricular function as predictors of inotropic support in patients undergoing elective off-pump coronary artery bypass grafting

Abstract Background: Patients undergoing elective off-pump coronary artery bypass grafting (CABG) are at risk of hemodynamic instability, ischemia, arrhythmia, and dysfunction. These events need to be managed by pharmacological supports or relieving of mechanical obstruction (octopus) of the heart to maintain the hemodynamic stability. There is a paucity of data on the effect of left ventricular (LV) dysfunction on left atrial appendage (LAA) emptying velocity. We evaluated the relationship between LV function and LAA emptying velocity and requirement of inotropic support perioperatively. Materials and Methods: In this prospective open-label all-comer study, fifty patients undergoing elective off-pump CABG under general anesthesia, we measured LAA emptying velocity by pulsed wave Doppler and evaluated if it could predict the need for inotropes perioperatively. It is a case series of 50 patients without a comparator arm. We measured pulsed wave Doppler across the mitral valve leaflet and early mitral inflow velocity (Evel) and late mitral inflow velocity, tissue Doppler at the lateral annulus of the mitral valve (e’) and also calculated the ratio of Evel and e’. Need for inotrope in the intraoperative and postoperative period was captured perioperatively. Vasoactive-inotropic score (VIS) was calculated for all the patients. Results: The VIS was significant (P &lt; 0.0001, with odds ratio of 131.6 and confidence interval of 95% (0.9–1). However, there was no significant correlation between ejection fraction (EF) and VIS (P = 0.87). In patients with the need of inotropes, LAA emptying velocity was significantly increased in the postgrafting period as compared to the pregrafting period (75.64 cm/s vs. 57.9 cm/s, P &lt; 0.001). Conclusion: The assessment of LAA emptying velocity value was a useful predictor of the need of inotropic support during off-pump surgery, especially during Obtuse marginal and Ramus grafting. This study paves the need of larger case–control studies to validate the findings.

Etiology, Characteristics, and Outcomes of Neonatal Liver Failure: Lessons Learned Over the Last 3 Decades

To evaluate trends in etiology and outcomes of neonatal liver failure (NLF) over 30years retrospectively at a single institution. Inclusion criteria for this retrospective cohort study were babies presenting at a chronological age of ≤28days between 1991 and 2020 with prothrombin time≥20seconds and biochemical liver injury. Demographics, etiology, laboratory investigations, need for extrahepatic organ support, acute kidney injury, and intervention with liver transplant (LT) were recorded. Survival outcomes were measured as discharge from the hospital alive with native liver or LT. The study period was stratified into 3 10-year blocks. Trends were analyzed for hospital admissions, etiology, and survival outcomes. One hundred twenty-six babies met the NLF criteria. Admissions to the hospital increased from 21 in 1991-2000 to 65 in 2011-2020. An increasing trend in infectious and metabolic causes, while a decreasing trend in indeterminate etiology, was noted. Survival with native liver improved from 23.8% in 1991-2000 to 55.4% in 2011-20 (P=.021), and mortality reduced from 52.4% to 35.4% during the same periods (P=.213). Twenty-three (18.2%) neonates received LT. Post-LT survival outcomes were 100% for gestational alloimmune liver disease, 66.6% in the indeterminate group, and 25% for herpes simplex virus. Specific etiologies (gestational alloimmune liver disease, OR=0.07 [0-0.77, P=.048]), presence of acute kidney injury (OR=6.22 [1.45, 29.38, P=.015]) and need for inotropes (OR=6.22 [1.45, 29.38, P=.028]) influenced mortality in multivariable logistic regression analysis. In the last 30years, advances in diagnosis, treatment, and increasing experience with LT have improved survival in NLF.

Utilizing Fetal Echocardiography to Risk Stratify and Predict Neonatal Outcomes in Fetuses Diagnosed with Congenital Heart Disease.

Risk stratification of fetuses diagnosed with congenital heart disease (CHD) helps provide a delivery plan and prepare families and medical teams on expected course in the delivery room. Our aim was to assess the accuracy of echocardiographically determined risk-stratification assignments in predicting postnatal cardiac outcomes beyond the delivery room. This was a retrospective study at a single center evaluating all fetuses with CHD who were risk-stratified by echocardiographically determined level of care (LOC) assignment, ranging from 1a (lowest risk) to 4 (highest risk). All data were collected from January 1, 2017, to November 1, 2021. Outcomes included any unexpected cardiac interventions and neonatal clinical outcomes including in-hospital mortality, the need for prostaglandins or inotropes, and defined critical illness. These outcomes were assessed for each LOC assignment by Fisher's exact test. Out of 817 patients assigned a LOC, a total of 747 fetuses were included in our final cohort with a separate subanalysis of 70 fetuses diagnosed with coarctation of the aorta. The sensitivity and specificity were high for all LOC levels in predicting delivery room needs (93-100%). Higher LOC levels (3-4) had a lower positive predictive value (66-67%) indicating a high false-positive rate. Subjects with higher LOC assignments had a greater frequency of critical illness, hospital mortality, need for inotropes, need for neonatal surgical or catheterization interventions, and need for prostaglandins (p < 0.001 for all outcomes). A post-hoc analysis reviewing LOC assignments revealed a greater tendency to over-assign LOC at higher assignments (19% for LOC 3 and 4) compared to lower assignments (4% for LOC 1 and 2). Risk stratification based on fetal echocardiography can predict neonatal clinical outcomes and acuity of postnatal management needs. However, there is greater variability in expected clinical events and an expected degree of false positives for those with higher LOC assignments. · Risk stratification utilizing fetal echocardiography can be used to predict neonatal needs.. · Complex heart disease has lower positive predictive value in predicting postnatal clinical needs.. · There is a tendency to over-assign risk of acute hemodynamic instability for complex heart disease.. · False positives are expected when planning high-risk deliveries to avoid compromising situations..

The Outcomes of Surgical Pulmonary Embolectomy for Pulmonary Embolism: A Meta-Analysis.

Objectives: The purpose of this study is to assess the efficacy, short- and long-term cardiovascular and non-cardiovascular mortalities and postoperative morbidities of surgical pulmonary embolectomy (SPE) for patients with massive or submassive pulmonary embolism. Methods: A comprehensive literature review was performed to identify articles reporting SPE for pulmonary embolism. The outcomes included in-hospital and long-term mortality in addition to postoperative morbidities. The random effect inverse variance method was used. Cumulative meta-analysis, leave-one-out sensitivity analysis, subgroup analysis and meta-regression were performed. Results: Among the 1949 searched studies in our systematic literature search, 78 studies met our inclusion criteria, including 6859 cases. The mean age ranged from 42 to 65 years. The percentage of males ranged from 25.6% to 86.7%. The median rate of preoperative cardiac arrest was 27.6%. The percentage of contraindications to preoperative systemic thrombolysis was 30.4%. The preoperative systemic thrombolysis use was 11.5%. The in-hospital mortality was estimated to be 21.96% (95% CI: 19.21-24.98); in-hospital mortality from direct cardiovascular causes was estimated to be 16.05% (95% CI: 12.95-19.73). With a weighted median follow-up of 3.05 years, the late cardiovascular and non-cardiovascular mortality incidence rates were 0.39 and 0.90 per person-year, respectively. The incidence of pulmonary bleeding, gastrointestinal bleeding, surgical site bleeding, non-surgical site bleeding and wound complications was 0.62%, 4.70%, 4.84%, 5.80% and 7.2%, respectively. Cumulative meta-analysis showed a decline in hospital mortality for SPE from 42.86% in 1965 to 20.56% in 2024. Meta-regression revealed that the publication year and male sex were associated with lower in-hospital mortality, while preoperative cardiac arrest, the need for inotropes or vasopressors and preoperative mechanical ventilation were associated with higher in-hospital mortality. Conclusions: This study demonstrates acceptable perioperative mortality rates and late cardiovascular and non-cardiovascular mortality in patients who undergo SPE for massive or submassive pulmonary embolism.

Clinical spectrum and short-term outcome of post-COVID multisystem inflammatory syndrome in children after the 2019 pandemic: a longitudinal cohort study

Background As a post-COVID complication in children, multisystem inflammatory syndrome in children (MIS-C) is important because of its varied and life-threatening manifestations. With this background, this study attempts to focus on MIS-C cases in an underprivileged rural setting in north-eastern India, with most patients being treated with methylprednisolone rather than intravenous immunoglobulin due to financial constraints. Methods In this prospective longitudinal cohort study at MGM Medical College, 27 MIS-C cases diagnosed following WHO criteria were included. Laboratory and radiological investigations, including echocardiography, were performed as required for diagnosis and to assess prognosis. Most patients were treated with methylprednisolone. A follow-up assessment was done six weeks after discharge for any residual impairment. Results The most frequently affected age group was 5–10 years (59.28%), while respiratory (48.14%) and cardiac (40.74%) were the most commonly involved systems. Logistic regression studies established a significant association between serum ferritin level and prolonged hospital stay (coefficient 0.0674, p=0.0041), possibly due to greater complications in cases with high ferritin levels. Organ impairment was found to increase the need for inotrope use (coefficient 3.8797, p=0.00584). Most cases were treated with methylprednisolone alone (85.18%) with a favourable response and no death occurred. Conclusion The favourable response in cases treated with methylprednisolone only affirms the effectiveness of the drug as a cheaper alternative in a resource-poor setting. The study highlights that higher ferritin levels in complicated cases leads to prolonged hospitalisation and the increased need for inotropes in cases with organ impairment.

#2334 Elevated serum admission creatinine in acute heart failure hospitalizations: lifting the veil to understand outcome differences

Abstract Background and Aims Organ crosstalk in heart failure and kidney dysfunction is prevalent and is associated to a high event rate. In this setting elevated serum creatinine (sCr) at acute decompensated heart failure (ADHF) admissions is a strong risk factor for poor outcomes. Current accepted cardiorenal syndrome (CRS) classification is based on timing and initial organ dysfunction and fails at capturing its nature and prognosis. We sought to describe patient (P) profile and outcomes in P hospitalized for ADHF with high admission sCr in function of current CRS classification and assess for stratifying predictors. Method We conducted an observational, analytical and cross-sectional study, with prospective and consecutive data acquisition. We included P over 18 years-old, who were admitted to the Intensive Care Telemetry Unit in our Hospital between July, 2011 and Dec, 2023 due to ADHF. P who received a heart transplant during index admission or those on chronic dialysis were excluded. Clinical, epidemiological and biochemical variables were registered. Renal dysfunction was defined under admission sCr &amp;gt;1.4 mg/dl and divided according to Ronco et al classification, as initially cardiac (type 2) or renal (type 4) origin. We constructed multivariate logistic and survival regression models, with selection of relevant predictors by resampling and regularization of a Lasso regression model. Statistical significance was considered with a 5% of alpha error level. Analysis was conducted using R (R Core Team, 2023). Results A total of 1868 consecutive P were included. P population consisted in type 2: 124 and type 4: 258 P, respectively. We found no differences in gender (p = 0.47), while type 4 were older (75 ± 12 vs 71 ± 12; p &amp;lt; 0.01). Ventricular dysfunction was more severe in type 2 (left ventricular ejection fraction 34 ± 17 vs 41 ± 16%; p &amp;lt; 0.001). While ischaemic heart disease was more prevalent in type 4 (32.8 vs 23.5%; p = 0.001), idiopathic cardiomyopathy was more frequent in type 2 (18.8 vs 7.2%; p = 0.001). Clinical phenotypes differed between groups, being clinical hypoperfusion more frequent in type 2 (32.4 vs 12.3%; p &amp;lt; 0.001). Admission sCr was higher in type 4 (1.9 [0.8] vs 1.6 [0.58] mg/dl; p &amp;lt; 0.001), as was 1st day natriuresis (81 vs 67 mEq; p = 0.01). Both groups experienced a similar diuretic resistance rate (21.2 vs 17.1%; p = 0.34), while type 4 received rescue ultrafiltration more frequently (11.3 vs 3.5%; p &amp;lt; 0.01). Type 2 received a higher inotropic support rate (47.1 vs 19.5%; p &amp;lt; 0.01) and had a longer length of stay (9 vs 7 days; p = 0.01). In-hospital (11.8 vs 11.3%; p = 0.99); 6-month and 1-year mortality rates (66.8 vs 72.8% and 55.1 vs 64.6% respectively; p = 0.3). In a similar way, 1-month (94.8 vs 94.7%), 6-month (72 vs 74.7%) and 1-year readmission rates (59.2 vs 60.9%; p = 0.6) were similar in both groups. A multiple logistic regression model (AUCROC 0.82) identified admission sCr (OR 2.6; CI 95% 2.2-3.2; p &amp;lt; 0.001), inotropic need (OR 1.87; CI 95% 1.4-2.6; p &amp;lt; 0.001), anasarca phenotype (OR 1.63; CI 95% 1.06-2.5; p = 0.02), moderate to severe right ventricular dysfunction (OR 1.4; CI 95% 1.03-1.9; p = 0.03) as independent predictors for a descending sCr behavior during hospitalization, while the lower T3 levels were associated with less probability for a descent of sCr (OR 0.21; CI 95% 0.1-0.46; p &amp;lt; 0.001). Conclusion Organ crosstalk in ADHF hospitalizations was associated with a high event rate. One-year mortality and readmission rates were similar in both groups. Renal support therapies were more frequent under lower kidney reserve conditions. Ventricular dysfunction and systemic congestion phenotype are relevant to a better understanding for potential reversibility at the admission time and may promote actions for outcome enhancing.

Cardiorespiratory Instability after Percutaneous Patent Ductus Arteriosus Closure: A Multicenter Cohort Study

ObjectiveTo evaluate post-procedural clinical characteristics of preterm infants undergoing transcatheter patent ductus arteriosus (PDA) closure, including oxygenation/ventilation failure and cardiovascular compromise Study designMulticenter retrospective cohort study of preterm infants who were ≤2 kg at the time of percutaneous PDA closure between August 2018 and July 2021. Indices of cardiorespiratory stability were collected pre-closure, immediately post-closure, and subsequently averaged every 4 hours for the first 24 hours post-procedure. The primary outcome was incidence of post-transcatheter cardiorespiratory syndrome: composite of: (i) hemodynamic instability (defined by systemic hypotension, systemic hypertension, or use of new inotropes/vasopressors in the first 24 hours after catheterization and at least one of the following: (i)ventilation failure or (ii) oxygenation failure. ResultsA total of 197 patients were included with a median [IQR] age and weight at catheterization of 34 [25, 43] days and 1090 [900, 1367] grams, respectively. The primary composite outcome was reported in 46 (23.3%) patients and subcomponents of oxygenation and/or ventilation failure, systolic hypotension or systolic hypertension were noted in 81 (41.1%), 3 (1.5%) and 86 (43.6%) respectively. Logistic regression models showed weight at catheterization and respiratory severity score pre-closure to be significantly associated with post-transcatheter cardiorespiratory syndrome. ConclusionPost-transcatheter cardiorespiratory syndrome is characterized primarily by systemic hypertension and oxygenation failure, with a very low incidence of hypotension and need for inotropes.

Optimizing Anesthetic Selection in Transcatheter Aortic Valve Replacement: Striking a Delicate Balance between Efficacy and Minimal Intervention.

Patients with severe calcific native aortic valve stenosis (AS) who require valve replacement have two options, surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). TAVR was approved in late 2011 for extremely high-risk patients and was subsequently approved for high-risk (2012), intermediate-risk (2016), and low-risk (2019) patients. In 2019, TAVR procedures surpassed SAVR procedures for the first time in the United States. The approach to anesthesia for this procedure has also evolved. Initially, general anesthesia (GA) was preferred, but currently, conscious sedation (CS) is favored. This review aims to clarify the indications and contraindications for both approaches, as well as the advantages of one approach over the other. Recent studies show that conscious sedation has better outcomes in terms of all-cause mortality, procedure complications such as stroke, myocardial infarction, infection requiring antibiotics, acute kidney injury, and the need for inotropes or vasopressors.

PASS: A scoring system to evaluate persistent kidney injury in critically ill ICU adult patients

Background We evaluated if the course of recovery from sepsis-induced acute kidney injury (AKI) can be predicted using variables collected at admission. Methods A total of 63 patients admitted for sepsis-induced AKI in our Mangalore ICU were evaluated and baseline demographic and clinical/laboratory parameters, including serum creatinine (SCr), base excess (BE), Plethysmographic Variability Index (PVI), Caval Index, R wave variability index (RVI), mean arterial pressure (MAP) and renal resistivity index (RI) using renal doppler and need for inotropes were assessed on admission. Patients were managed as per standard protocol. After six hours of fluid resuscitation, patients were classified as volume responders or non-responders. Re-assessment was done at 24 hours and 72 hours after admission. Primary outcome was persistent AKI after 72 hours. Secondary outcome was initiation of dialysis or death within 15 days of admission. Results A total of 34 subjects recovered from AKI, of whom 32 patients were volume responders and 31 were non-responders. Response to fluid, MAP at admission and six hours, BE at admission, inotrope requirement, and PVI at admission did not correlate with recovery. Multiple logistic regression showed that SCr &lt; 2.36 mg%, RVI &gt; 14.45 and RI &lt; 0.8 on admission correlated with recovery and they were evaluated further to model AKI recovery and develop PASS. PASS score = (SCr points × 5.4) + (RVI points × 4.0) + (RI points × 6.2). One point each was allotted if SCr was &lt; 2.36, RVI was &gt; 14.45 and RI was &lt;0.8, and 0 otherwise. A score &gt; 7.8 predicted recovery with a sensitivity of 79.4%, specificity of 72.4%, PPV 81.8%, NPV 76.7% and AuROC of 0.85. Conclusions The PASS score can be used to identify salvageable cases of sepsis-AKI, guiding fluid resuscitation and aiding early referral from rural to tertiary care centers for better management.

The early use of bisoprolol in patients with severe sepsis and its impact on the patients outcome

Objectives To explore the hypothesis that beta 1 adrenergic receptor blockage might be protective through attenuation of destructive sympathetic activity and catecholaminergic inflammatory effects in severe sepsis patients. Design Prospective, randomized, controlled study. Settings Critical care department in Alexandria main university hospital. Patients and methods The study was conducted on 50 adult patients who were admitted to the Department of Critical Care Medicine in the Alexandria Main University Hospital who fulfilled the criteria for severe sepsis according to The American College Of Chest Physicians, patients were randomly assigned into two groups, group I: Included 25 patients receiving Bisoprolol 2.5 to 10 mg enterally for a target heart rate 80–90 beat/minute within the first 24 h according to the effect on hemodynamic stabilization and group II: Included 25 patients, as a control group, who received routine management of severe sepsis. Both groups were followed up and compared regarding the primary end points (discharge from the intensive care unit after recovery, septic shock or death) and the secondary end points (length of ICU stay, days of mechanical ventilation and need for inotropes). Results The heart rate at the end of the study was significantly lower in survived patients in group I with mean value of 80.06+9.05 beats/minute compared to mean value of 102.22+7.58 beats/minute in the died patients in the same group (P=0.003). The mean arterial blood pressure (mmHg) in studied patients, was not significantly different between the two groups on admission (P=0.099) and on the 1st day (P=0.172) the significant differences started to appear on the 2nd day (P=0.003), and over the whole period of observation till the end point of the study as the mean value of 83.31+16.90 in group I compared to mean value of 72.0+16.07 in group II (P=&lt;0.021), regarding the comparison between the survived and died patients in group I, on admission there was no statistically significant difference between them (p 0.213) while by the end point of the study, there was a statistically significant difference being higher in survived patients with mean value of 95.38+3.38 compared to mean value of 61.44+2.70 in died patients (P&lt;0.001). Regarding the occurrence of septic shock, it was less in group I as 40% compared to 72% in group II (P=0.023), group I had longer ICU stay (5.0 to 24.0 days) compared to group II (7.0 to 20.0 days), with a statistically significant difference (P=0.029). The duration of mechanical ventilation days (P=0.001), as longer in group II compared group I (group I= 8.37±3.43 days, group II=12.0±3.21 days). The mortality was lower in group I about 36% compared to 68% in group II with a statistically significant difference between the two groups (P= 0.024). Conclusion The administration of bisoprolol to patients with severe sepsis decrease the mortality, length of stay in ICU, days of mechanical ventilation and improves tissue perfusion without significant effect on hemodynamics.

Predictors of outcomes in patients with candidemia in an Intensive Care Unit

Objective: Candidemia is a life-threatening infection that causes high mortality rates in intensive care units (ICUs). This study aims to&#x0D; evaluate predictors of the outcome of patients with candidemia in ICU.&#x0D; Patients and Methods: This observational, retrospective study included patients with Candida bloodstream infection (BSI) in ICUs&#x0D; between 6 years of the episode. A binary logistic regression analysis was conducted to inspect the association with mortality.&#x0D; Results: The median age of 74 patients was 68.5, and 53.8% were men. C. parapsilosis was the most frequently isolated fungal species.&#x0D; The 30-day mortality rate was 50%. In the logistic regression model the Acute Physiology and Chronic Health Evaluation (APACHE)&#x0D; II score, positive blood culture on the seventh day, inotropes needed on the day of blood culture positivity, and ventilator-associated&#x0D; pneumonia (VAP) were significant risk factors for the outcome of patients. There was no difference in mortality between an early start&#x0D; of antifungal treatment or central venous catheter removal time.&#x0D; Conclusion: A shift to C. parapsilosis is observed in this study. Host-related factors such as APACHE II score, need for mechanical&#x0D; ventilation or need for inotropes affect mortality more than early treatment and source control in patients with Candida BSI.