Noncardiac Patients Research Articles

Marcadores de daño miocárdico en la predicción del pronóstico a corto plazo de los pacientes con COVID-19

Introduction and objectivesCOVID-19 is currently causing high mortality and morbidity worldwide. Information on cardiac injury is scarce. We aimed to evaluate cardiovascular damage in patients with COVID-19 and determine the correlation of high-sensitivity cardiac-specific troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) with the severity of COVID-19. MethodsWe included 872 consecutive patients with confirmed COVID-19 from February to April 2020. We tested 651 patients for high-sensitivity troponin T (hs-TnT) and 506 for NT-proBNP on admission. Cardiac injury was defined as hs-TnT> 14 ng/L, the upper 99th percentile. Levels of NT-proBNP> 300 pg/mL were considered related to some extent of cardiac injury. The primary composite endpoint was 30-day mortality or mechanical ventilation (MV). ResultsCardiac injury by hs-TnT was observed in 34.6% of our COVID-19 patients. Mortality or MV were higher in cardiac injury than noncardiac injury patients (39.1% vs 9.1%). Hs-TnT and NT-proBNP levels were independent predictors of death or MV (HR, 2.18; 95%CI, 1.23-3.83 and 1.87 (95%CI, 1.05-3.36), respectively) and of mortality alone (HR, 2.91; 95%CI, 1.211-7.04 and 5.47; 95%CI, 2.10-14.26, respectively). NT-ProBNP significantly improved the troponin model discrimination of mortality or MV (C-index 0.83 to 0.84), and of mortality alone (C-index 0.85 to 0.87). ConclusionsMyocardial injury measured at admission was a common finding in patients with COVID-19. It reliably predicted the occurrence of mortality and need of MV, the most severe complications of the disease. NT-proBNP improved the prognostic accuracy of hs-TnT.

Abstract 245: Dispatcher Assisted Cardiopulmonary Resuscitation in Patients Not in Cardiac Arrest: A Multi-Center, Observation Study

Background: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) can increase bystander CPR rates and improve outcomes in out-of-hospital cardiac arrest (OHCA). Protocols used by dispatchers are designed to provide a quick assessment for prompt initiation of CPR. However, there are instances where non-cardiac arrest cases are falsely recognised by dispatchers to be in cardiac arrest. These patients may go on to receive chest compressions and potentially suffer from complications of unnecessary CPR, though the clinical implications of starting DA-CPR on these non-cardiac arrest cases have not been studied. Hence, the objectives of this study are to find the prevalence and clinical outcomes of DA-CPR in patients not in cardiac arrest in the Singapore population. Methods: This was a multi-center, observational study of all dispatcher-recognized cardiac arrests cases between January to December 2017 involving three tertiary hospitals in Singapore. Data was collected through audio review of dispatch calls from the national emergency ambulance service and information about patients’ clinical outcomes were prospectively collected from health records. Results: During the study period, dispatchers recognised 821 patients as having cardiac arrest. Of these, 40.0% (328/ 821) were not in cardiac arrest. 52.7% (173/ 328) of the non-cardiac arrest patients had chest compressions initiated under dispatcher assistance. No complications from chest compressions were reported. The top diagnoses of non-cardiac arrest patients found were cerebrovascular accidents (CVA), syncope and infection. A multiple logistic regression model with estimates adjusted for the presence or absence of chest compressions revealed that only final diagnoses of CVA (OR 20.68), infection (OR 17.34) and myocardial infarction (OR 32.19) were associated with in-hospital mortality. Conclusion: In this study, chest compressions initiated due to false recognition of cardiac arrest by dispatchers did not result in any reported complications and was not associated with in-hospital mortality. This provides reassurance for the continued implementation of DA-CPR.

Abstract 17068: Do Post-Operative Nitrates Increase Mortality in Non-Cardiac Surgery Patients With Perioperative Myocardial Injury?

Introduction: Myocardial injury after noncardiac surgery (MINS) is strongly associated with 30-day mortality, and data on its management is scarce. We hypothesized that postoperative nitrates (Isosorbide mononitrate, Isosorbide dinitrate, and scheduled Nitroglycerine) increase mortality in MINS patients. Methods: We used data from the Wake-Up T2MI registry, which is a single center, retrospective cohort of adults with elevated troponin (cTn) I (>0.04 ng/dL) during hospitalization without acute coronary syndrome in a 2-year period (2009-2010). Cardiac procedures were excluded. Kaplan-Meier curves and a multivariate-adjusted Cox-proportional hazard models were performed to assess all-cause mortality at 90-days and 1-year among patients with and without nitrates upon discharge. Results: Total of 457 MINS patients were included in the final analysis. There was no significant difference in baseline characteristics and peak cTn among patients stratified by nitrates status. Prevalence of mortality in the nitrates group was significantly higher at 90-days (35.7% vs 10%, p = 0.002) and non-significantly higher at 1-year (42.9% vs. 22.4%, p = 0.073) compared to non-nitrates group. Survival benefit was significantly lower in the nitrates group at 90-days (log-rank p = 0.002) and at 1-year (log-rank p = 0.031) (Figure 1). In a multivariate-adjusted model, nitrates had a HR of 3.032 (1.018 - 9.026; p = 0.046) at 90-days and HR of 2.022 (0.809 - 5.054; p = 0.132) at 1-year (Figure 2). Conclusion: Nitrates on discharge were associated with increased mortality at 3-months and at 1-year in MINS patients. Further large-scale studies are required to validate our results.

Abstract 14045: The Incidence and Associated Risk Factors of New-onset Atrial Fibrillation in the Medical Intensive Care Unit

Introduction: New-onset AF (NOAF) in the medical ICU is associated with worse patient outcomes. The research on NOAF in this setting compared to that in the post-cardiothoracic and non-cardiac surgery patients is not as robust. For example, a 2019 literature review found that the reported incidence of NOAF in the medical ICU ranges between 1.7% and 43.9%. This retrospective single-center observational study examines the incidence and associated risk factors of this relatively understudied population. Methods: The total study population is comprised of 2682 consecutive patients with medical ICU stays in 2018. Post-operative patients as well as patients with preexisting AF were excluded. ICD-10 codes were used in conjunction with i2b2 to identify patients. Manual chart review confirmed those with NOAF during a 2018 ICU stay. These patients were compared with a control group comprised of 106 randomly-selected patients from the study population. Demographics and diagnoses were collected, along with length of stay (LOS), mortality at discharge and mortality after one year. Results: 90 patients of the 2682 patient cohort (3.4%) developed NOAF during their ICU stay. Patients with NOAF were more likely to be older (67.7 vs. 56.5 years), have hypertension (75.6% vs. 62.3%) and have peripheral vascular disease (41.1% vs. 26.4%) compared to the control group. More importantly, NOAF was associated with an increased LOS of 16.5 days relative to 9.6 days in the control group. No significant difference was found in mortality between the two groups. The results of this preliminary analysis are summarized in Table 1 . Conclusions: We found the incidence of NOAF in patients admitted to the medical ICU was 3.4%, and NOAF was associated with a significant increase in LOS. Upon completion of data extraction and multivariate analysis for the entire study population, we hope that this study will contribute to our understanding of the significance of NOAF in critically ill patients.

Vulnerability to cardiac arrest in patients with ST elevation myocardial infarction: Is it time or patient dependent? Results from a nationwide observational study.

Cardiac arrest is a common complication of ST elevation myocardial infarction and is associated with high mortality. We evaluated whether vulnerability to cardiac arrest follows a circadian rhythm and whether it is related to specific patient characteristics. A total of 24,164 ST elevation myocardial infarction patients who were admitted to 60 Belgian hospitals between 2008-2017 were analysed. The proportion of patients with cardiac arrest before initiation of reperfusion therapy was calculated for different time periods (hour of the day, months, seasons) and related to patient characteristics using stepwise logistic regression analysis. Cardiac arrest occurred in 10.8% of the ST elevation myocardial infarction patients at a median of 65 min (interquartile range 33-138 min) after onset of pain. ST elevation myocardial infarction patients with cardiac arrest showed a biphasic pattern with one peak in the morning and one peak in the late afternoon. Multivariate analysis identified the following independent factors associated with cardiac arrest: cardiogenic shock (odds ratio=28), left bundle branch block (odds ratio=3.7), short (<180 min) ischaemic period (odds ratio=2.2), post-meridiem daytime presentation (odds ratio=1.4), anterior infarction (odds ratio=1.3). Overall in-hospital mortality was 30% for cardiac arrest patients versus 3.7% for non-cardiac arrest patients (p<0.0001). In the present study population, cardiac arrest in ST elevation myocardial infarction showed an atypical circadian rhythm with not only a morning peak but also a second peak in the late afternoon, suggesting that cardiac arrest and ST elevation myocardial infarction triggers are, at least partially, different. In addition, specific patient characteristics, such as short ischaemic period, cardiogenic shock and left bundle branch block, increase the vulnerability to cardiac arrest.

Novel low-delta value troponin algorithms have good precision for rule-out of NSTE-ACS

Abstract Background Rapid rule-out algorithms for non-ST-elevation infarction (NSTEMI) may be beneficial for logistics in the emergency room. Current algorithms are designed to rule-out NSTEMI, but do not differentiate between unstable angina (UAP) in need of revascularization and non-cardiac chest pain patients (NCCP) who could be discharged. Recent improvements in analytical precision of high sensitivity troponin (cTn) assays allow for trialing algorithms with very small delta values. Purpose Could the use of lower delta values produce rule-out algorithms for NSTE-ACS with a false negative rate of ≤5%, and a sufficient high rule-out rate of patients with NCCP. Method 927 patients with suspected NSTE-ACS were consecutively included. Serum samples were collected at 0, 3 and 8–12 hours. The final diagnosis was adjudicated by two independent cardiologists based on all clinical data including routine cTnT. The 0- and 3-hour samples were additionally measured for cTnIand cTnI from Singulex Clarity System (cTnI(sgx)). The diagnostic performance to rule-out NSTE-ACS was compared between one low-delta value algorithm from each assay (cTnT, cTnI and cTnT). Results The prevalence of NSTEMI was 13.4%, UAP 11.4% and NCCP 60%. Median age was 63 years, 60% males. Fig. 1 shows baseline and 3-hour delta cTn values for the UAP and NCCP patients for the three different assays. The baseline cTn value differed significantly between UAP and NCCP for all assays, p value &amp;lt;0.001. The novel low-delta cTnT algorithm (Table 1) ruled out 8 NSTE-ACS patients (3.5%), the cTnI algorithm and cTnI (sgx) algorithm ruled out 11 (4.8%) and 12 (5.2%) patients with NSTE-ACS, respectively. Moreover, the cTnT algorithm allocated 35.3% of the NCCP patients to discharge. Respective numbers for the cTnI(sgx) and cTnI algorithm were 30.6% and 33.5%. Comparing the ROC curves, the cTnT algorithm had significantly higher AUC compared to the cTnI(sgx) algorithm (p value =0.005, DeLong test). Conclusion The low-delta value algorithms correctly ruled in ≥95% of the NSTE-ACS patients whilst &amp;gt;30% of NCCP patients were ruled out. The cTnT algorithm had the best performance with a significant higher AUC compared to the cTnI(sgx) algorithm. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority, Haukeland and Stavanger University hospital

Association Between Preoperative Statin Use and Respiratory Complications After Noncardiac Surgery: A Retrospective Cohort Analysis.

Statins possess pleiotropic effects, which potentially benefit noncardiovascular conditions. Previous work suggests that statins reduce inflammation and prevent acute respiratory distress syndrome and infections. However, there is a paucity of data regarding potential benefits of statins on respiratory and infectious complications, particularly after noncardiac surgery. We therefore evaluated respiratory and other complications in noncardiac surgery patients taking or not taking statins preoperatively. We obtained data from the Cleveland Clinic Perioperative Health Documentation System and evaluated medical records of 92,139 inpatients who had noncardiac surgery. Among these, 31,719 patients took statins preoperatively. Statin patients were compared to nonstatin patients on incidence of intraoperative use of albuterol and postoperative respiratory complications for primary analysis. Infectious complications, cardiovascular complications, in-hospital mortality, and duration of hospitalization were compared for secondary analyses, using inverse probability of treatment weighting to control for potential confounding. Statin use was associated with lower odds of intraoperative albuterol treatment (odds ratio [OR] = 0.89; 97.5% confidence interval [CI], 0.82-0.97; P = .001; number needed to treat [NNT] = 216). Postoperative respiratory complications were also less common (OR = 0.82; 98.75% CI, 0.78-0.87; P < .001). Secondarily, statin use was associated with lower odds of infections, cardiovascular complications, in-hospital mortality, and shorter duration of hospitalization. The interaction between statin use and sex was significant (with significance criteria P < .10) for all primary and secondary outcomes except intraoperative use of albuterol. Preoperative statin use in noncardiac surgical patients was associated with slightly reduced odds of postoperative respiratory, infectious, and cardiovascular complications. However, the NNTs were high. Thus, despite the fact that statins appeared to be associated with lower odds of various complications, especially cardiovascular complications, our results do not support using statins specifically to reduce noncardiovascular complications after noncardiac surgery.

Association between postoperative haemoglobin and myocardial injury after noncardiac surgery: a retrospective cohort analysis

BackgroundMyocardial injury after noncardiac surgery (MINS) is common, mostly silent, and a strong predictor of postoperative mortality. MINS appears to result from myocardial supply–demand mismatch. Recent data support restrictive perioperative transfusion strategies that can result in low postoperative haemoglobin concentrations. Whether low postoperative haemoglobin is associated with myocardial injury remains unknown. We therefore tested the hypothesis that anaemia is associated with an increased risk of myocardial injury in adults having noncardiac surgery. MethodsWe conducted a retrospective analysis of adults ≥45 yr old who had routine postoperative troponin T (TnT) monitoring after noncardiac surgery at the Cleverland Clinic (including those enrolled in the PeriOperative ISchemic Evaluation-2 Trial [POISE-2], the Safety of Addition of Nitrous Oxide to General Anaesthesia in At-risk Patients Having Major Non-cardiac Surgery [ENIGMA-II], Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study [VISION], and Anaesthetic Depth and Complications After Major Surgery [BALANCED] trial). Patients with baseline increase in TnT and non-ischaemic aetiologies for TnT increase were excluded. The association between postoperative haemoglobin concentration during the 3 initial postoperative days and the incidence of MINS (fourth-generation TnT ≥0.03 ng ml−1 judged as attributable to ischaemia) was assessed using a time-varying covariate Cox proportional hazards survival analysis. ResultsAmong 6141 patients, 4480 were analysed. The incidence of MINS was 155/4480 (3.5%), ranging from 0/345 (0%) among patients whose lowest postoperative haemoglobin exceeded 13 g dl−1 to 52/611 (8.5%) in patients whose minimum postoperative haemoglobin was <8 g dl−1. The confounder-adjusted hazard ratio [95% confidence interval] for having MINS was 1.29 [1.16–1.42] for every 1 g dl−1 decrease in postoperative haemoglobin in a time-varying covariate analysis. Similar associations were identified in sensitivity analyses. ConclusionLower postoperative haemoglobin values are associated with MINS. Whether this association is modifiable by prevention or treatment of anaemia remains to be determined.

Incidence, Characteristics and Outcomes of Cardiac Tamponade in Patients on Extracorporeal Membrane Oxygenation for the Treatment of Refractory Cardiogenic Shock

Background Extracorporeal membrane oxygenation(ECMO) for the treatment of refractory cardiogenic shock has gained popularity over the last decade. Cardiac tamponade(CT), a life threatening condition, has been reported to occur in patients after the initiation of ECMO therapy. However, there is a scarcity of data pertaining to the incidence, characteristics and outcomes of pericardial tamponade in non-cardiac surgery patients undergoing ECMO for the treatment of refractory cardiogenic shock. Methodology This is a single center retrospective review of all patients developing CT post ECMO for refractory cardiogenic shock presenting between January 1999-January 2020. Patients were excluded if they were on ECMO post cardiac surgery, aged less than 18 years or had a moderate to large pericardial effusion prior to ECMO initiation. Results Out of 220 patients presenting with cardiogenic shock, 8(3.6%) patients developed CT after being treated with ECMO. Patients were mostly male (7,78%) and 66±12.8 years old. 7(77.5%) patients were on VA ECMO, 1(12.5%) patient on VAV ECMO, all of which were accessed peripherally . 5(62.5%) patients were on additional mechanical support devices: Impella(2,25%), IABP(2,25%) and tandem heart with impella(1,12.5%). 6(75%) patients were supratherapeutic whilst on systemic anticoagulation preceding CT. Initial ECMO pump flow rates were 4±0.68ml/min, mean sheath size of 22±3.1 F. 5(62.5%) patients developed CT 24 hours after ECMO initiation, 3(37.5%) patients before 24 hours. Average size of pericardial effusion was 2.1±0.1cm. None of the patients had any evidence of myocardial/great vessel perforation. 4(50%) patients were treated with pericardiocentesis, 2(25%) patients required pericardial window, and 2(25%) required both. Fluid analysis in 6(87.5%) patients revealed hemorrhagic pericardial fluid, 1(12.5%) with serosanguinous fluid and 1(12.5%) with serous fluid .6(75%) of patients died during hospitalization, but not directly from CT. Conclusion 3.6% of patients on ECMO for refractory cardiogenic shock develop CT, with most cases occurring after 24 hours of therapy initiation. Most patients who develop this are coagulopathic and are on additional mechanical support devices. CT can occur in patients without evidence of cardiac/great vessel perforation. CT should be considered in all patients on ECMO with unexplained reductions in flow rates, and this should immediately be addressed to optimize cardio-pulmonary support. Although treatable, CT in this subset of patients is reflective of an overall grave prognosis.

Markers of myocardial injury in the prediction of short-term COVID-19 prognosis

Introduction and objectivesCOVID-19 is currently causing high mortality and morbidity worldwide. Information on cardiac injury is scarce. We aimed to evaluate cardiovascular damage in patients with COVID-19 and determine the correlation of high-sensitivity cardiac-specific troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) with the severity of COVID-19. MethodsWe included 872 consecutive patients with confirmed COVID-19 from February to April 2020. We tested 651 patients for high-sensitivity troponin T (hs-TnT) and 506 for NT-proBNP on admission. Cardiac injury was defined as hs-TnT> 14ng/L, the upper 99th percentile. Levels of NT-proBNP> 300 pg/mL were considered related to some extent of cardiac injury. The primary composite endpoint was 30-day mortality or mechanical ventilation (MV). ResultsCardiac injury by hs-TnT was observed in 34.6% of our COVID-19 patients. Mortality or MV were higher in cardiac injury than noncardiac injury patients (39.1% vs 9.1%). Hs-TnT and NT-proBNP levels were independent predictors of death or MV (HR, 2.18; 95%CI, 1.23-3.83 and 1.87 (95%CI, 1.05-3.36), respectively) and of mortality alone (HR, 2.91; 95%CI, 1.211-7.04 and 5.47; 95%CI, 2.10-14.26, respectively). NT-ProBNP significantly improved the troponin model discrimination of mortality or MV (C-index 0.83 to 0.84), and of mortality alone (C-index 0.85 to 0.87). ConclusionsMyocardial injury measured at admission was a common finding in patients with COVID-19. It reliably predicted the occurrence of mortality and need of MV, the most severe complications of the disease. NT-proBNP improved the prognostic accuracy of hs-TnT.

Recommendations and Alerting for Delirium Alleviation in Real-Time (RADAR): Protocol for a pilot randomized controlled trial.

Background: Delirium is a common and serious complication of major surgery for older adults. Postoperative social and behavioral support (e.g., early mobilization, mealtime assistance) may reduce the incidence and impact of delirium, and these efforts are possible with proactive patient-care programs. This pilot trial tests the hypothesis that a multicomponent decision support system, which sends automated alerts and recommendations to patient-care programs and family members for high-risk patients, will improve the postoperative environment for neurocognitive and clinical recovery. Methods: This will be a randomized, controlled, factorial pilot trial at a large academic medical center. High-risk, non-cardiac surgery patients (≥70 years old) will be recruited. Patients will be allocated to a usual care group (n=15), Hospital Elder Life Program (HELP)-based paging system (n=15), family-based paging system (n=15), or combined HELP- and family-based system (n=15). The primary outcome will be the presence of delirium, defined by positive long-form Confusion Assessment Method screening. Secondary outcomes will include additional HELP- and family-based performance metrics along with various neurocognitive and clinical recovery measures. Exploratory outcomes include the incidence of positive family-based delirium assessments post-discharge, 36-item Short Form Survey, PROMIS Cognitive Function Abilities Subset 4a, and 30-day readmission rates. Ethics and dissemination: This trial has received approval by the University of Michigan Medical Institutional Review Board (IRBMED). Dissemination plans include presentation at scientific conferences, publication in medical journals, and distribution via educational and news media. Registration: ClinicalTrials.gov Identifier NCT04007523, registered on 7/3/2019.

Recommendations and Alerting for Delirium Alleviation in Real-Time (RADAR): Protocol for a pilot randomized controlled trial

Background: Delirium is a common and serious complication of major surgery for older adults. Postoperative social and behavioral support (e.g., early mobilization, mealtime assistance) may reduce the incidence and impact of delirium, and these efforts are possible with proactive patient-care programs. This pilot trial tests the hypothesis that a multicomponent decision support system, which sends automated alerts and recommendations to patient-care programs and family members for high-risk patients, will improve the postoperative environment for neurocognitive and clinical recovery. Methods: This will be a randomized, controlled, factorial pilot trial at a large academic medical center. High-risk, non-cardiac surgery patients (≥70 years old) will be recruited. Patients will be allocated to a usual care group (n=15), Hospital Elder Life Program (HELP)-based paging system (n=15), family-based paging system (n=15), or combined HELP- and family-based system (n=15). The primary outcome will be the presence of delirium, defined by positive long-form Confusion Assessment Method screening. Secondary outcomes will include additional HELP- and family-based performance metrics along with various neurocognitive and clinical recovery measures. Exploratory outcomes include the incidence of positive family-based delirium assessments post-discharge, 36-item Short Form Survey, PROMIS Cognitive Function Abilities Subset 4a, and 30-day readmission rates. Ethics and dissemination: This trial has received approval by the University of Michigan Medical Institutional Review Board (IRBMED). Dissemination plans include presentation at scientific conferences, publication in medical journals, and distribution via educational and news media. Registration: ClinicalTrials.gov Identifier NCT04007523, registered on 7/3/2019.

The importance of oral hygiene for patients on mechanical ventilation.

The importance of oral hygiene for patients on mechanical ventilation.

Intraoperative Data Enhance the Detection of High-Risk Acute Kidney Injury Patients When Added to a Baseline Prediction Model.

Aspects of intraoperative management (eg, hypotension) are associated with acute kidney injury (AKI) in noncardiac surgery patients. However, it is unclear if and how the addition of intraoperative data affects a baseline risk prediction model for postoperative AKI. With institutional review board (IRB) approval, an institutional cohort (2005-2015) of inpatient intra-abdominal surgery patients without preoperative AKI was identified. Data from the American College of Surgeons National Surgical Quality Improvement Program (preoperative and procedure data), Anesthesia Information Management System (intraoperative data), and electronic health record (postoperative laboratory data) were linked. The sample was split into derivation/validation (70%/30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or >50% within 7 days of surgery. Forward logistic regression fit a baseline model incorporating preoperative variables and surgical procedure. Forward logistic regression fit a second model incorporating the previously selected baseline variables, as well as additional intraoperative variables. Intraoperative variables reflected the following aspects of intraoperative management: anesthetics, beta-blockers, blood pressure, diuretics, fluids, operative time, opioids, and vasopressors. The baseline and intraoperative models were evaluated based on statistical significance and discriminative ability (c-statistic). The risk threshold equalizing sensitivity and specificity in the intraoperative model was identified. Of 2691 patients in the derivation cohort, 234 (8.7%) developed AKI. The baseline model had c-statistic 0.77 (95% confidence interval [CI], 0.74-0.80). The additional variables added to the intraoperative model were significantly associated with AKI (P < .0001) and the intraoperative model had c-statistic 0.81 (95% CI, 0.78-0.83). Sensitivity and specificity were equalized at a risk threshold of 9.0% in the intraoperative model. At this threshold, the baseline model had sensitivity and specificity of 71% (95% CI, 65-76) and 69% (95% CI, 67-70), respectively, and the intraoperative model had sensitivity and specificity of 74% (95% CI, 69-80) and 74% (95% CI, 73-76), respectively. The high-risk group had an AKI risk of 18% (95% CI, 15-20) in the baseline model and 22% (95% CI, 19-25) in the intraoperative model. Intraoperative data, when added to a baseline risk prediction model for postoperative AKI in intra-abdominal surgery patients, improves the performance of the model.

Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport.

The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency. This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record. Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals. These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.

Assessing the impact of a combination of sofosbuvir and daclatasvir treatment for hepatitis C virus infection on heart rate, rhythm and heart rate variability using 24-hour ECG monitoring

BackgroundDirect-acting antiviral agents (DAAs) cure patients with hepatitis C virus (HCV) infection. Concerns have arisen the occurrence of significant bradyarrhythmias during treatment with DAAs. The aim of this study was to assess the impact of a DAA combination for the treatment of HCV infection on heart rate, rhythm, and heart rate variability (HRV) using 24-h ECG monitoring.ResultsA prospective randomized study of 50 treatment-naïve patients with HCV infection treated with a combination of sofosbuvir 400 mg daily and daclatasvir 60 mg daily for 12 weeks. Surface ECG and 24-h ECG monitoring were performed at baseline and after completion of therapy to assess PR interval, corrected QT interval (QTc), minimum heart rate (HR), maximum HR, average HR, HRV time-domain and frequency-domain measures, significant pauses, tachycardias, bradycardias, premature atrial contractions (PACs), and premature ventricular contraction (PVCs).No differences were detected in all examined parameters between baseline and after completion of treatment. PR interval was 154 ± 25.95 vs 151.4 ± 23.82 ms, respectively (p = 0.124). QTc interval was 397.34 ± 29.38 vs 395.04 ± 30.23 ms, respectively (p = 0.403). No differences were detected for minimum HR, maximum HR, average HR, HRV time-domain and frequency-domain measures, the occurrence of significant pauses, sinus tachycardia episodes, sinus bradycardia episodes, PACs, and PVCs. No episodes of bradyarrhythmias, syncope, and atrial fibrillation, supraventricular, or ventricular tachycardias were reported or detected.ConclusionIn non-cardiac patients receiving no cardioactive medications, the combination of sofosbuvir and daclatasvir for the treatment of HCV infection has no effect on HR, rhythm, conductivity, or HRV. No symptomatic bradycardias, tachycardias, or syncope were reported or detected using 24-h ECG monitoring.

Diagnosed in operating room with hypertension: a widespread but unseen affliction

The present study aims to describe a widely held misconception in the literature concerning preoperative hypertension diagnosis. The blood pressure elevation occurring in the operative room is seen commonly even in subjects considered hitherto fully normotensive. As these patients have a condition which - similar to White Coat Hypertension (WCH) - indicates the presence of hypertension, and thus necessitates more frequent intraoperative checks. We have named a condition 'Diagnosed in Operating Room (DIOR) with Hypertension', following the preoperative stage at which it is detected. Our observational study evaluated 718 elective noncardiac surgery adult patients, finding 28% of them (n = 204) to be 'DIOR-tensive' and thus at risk for suboptimal intraoperative care. In addition to recommending a modification to the domain's best practices, we provide a preliminary description of DIOR hypertension patient identifying characteristics (older, higher body weight and BMI, and higher rates of chronic obstructive pulmonary disease, hypothyroidism and obesity), so that DIOR hypertension patients may be more readily identified, and that future research may build on the findings, and that the operating team may remain generally aware that this problem can occur and be dealt with regardless of the patient's medical history.

Predictive Role of Cardiac Troponin I, Creatine Kinase-Mb and Electrocardiogram in Early Assessment of Acute Cardiotoxicity in Patients Poisoned by Cardiotoxic Drugs and Toxins

Background: In spite speedy development of clinical toxicology researches and protocols cardiovascular failure in severe acute intoxication remains a leading cause of death. Early cardiovascular risk assessment in acutely intoxicated patients is a must nowadays.&#x0D; This study aims to evaluate the role of ECG, serum cardiac troponin I (cTnI) and creatine kinase myocardial band (CK-MB) for early detection of cardio-toxicity in acutely poisoned patients.&#x0D; Methods: Prospective study was carried on100 patients with acute cardiotoxicity by drugs and toxins known to cause cardiac injury admitted to Sohag University hospitals, informed written consent has been obtained from each patient; ECG and biochemical analysis of serum cTnI and CK-MB were estimated in all studied patients.&#x0D; Results: (90%) of studied patients had complete free recovery, (4%) discharged with complications and (6%) of patients died. ECG test can be used as a predictor of mortality and had sensitivity 100%, specificity 46.8% and negative predictive value (NPV) 100%. Serum cTnI was highly significantly increased with death hence could be used as predictors of outcome. While serum CK-MB couldn't be used as an outcome predictor. ROC curve analysis to assess serum cTnI as a predictor of mortality of acute cardiovascular toxicity with cut off &gt; 1.0 ng/ml had sensitivity 100%, specificity 89.4% and NPV 100% with excellent diagnostic characteristic (accuracy rate 96.4%). There is no significant difference of serum CK-MB and serum cTnI among cardiac drugs toxicity patients and non-cardiac toxins patients.&#x0D; Conclusion: the study concluded that ECG and serum cTnI can be used as a predictor of mortality. Also, the protocol of management will be same in acute cardiotoxicity by cardiac drugs and non-cardiac drugs and toxins.&#x0D; Recommendation: the study recommends combining of ECG changes and serum cTnI as they can early detect acute cardiovascular effects in acutely poisoned patients.

Early Diagnosis of Brain Natriuretic Peptide (Pro-BNP) and Ischemia Modified Albumin (IMA) Levels in Acute Coronary Syndrome Patients with ST Segment Elevation Myocardial Infarction (STEMI) and Non ST Segment Elevation Myocardial Infarction (NSTEMI)

Background: Acute coronary syndrome (ACS) can be classified to ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina. The challenging in acute coronary syndrome remains, as it does not detect the myocardial ischemia by cardiac troponin and creatine kinase-MB. Pro brain-type natriuretic peptide (pro-BNP) was released when the heart need to hard works, which leads of retention fluid and expansion of veins and arteries. Therefore, this hormone release in the response of the changes of pressure in the heart especially for patients with ACS, which be benefit to use as an indicator to evaluate health problem that related with heart. Ischemia modified albumin (IMA) is a form of human serum albumin in which the N-terminal amino acids have been modified by ischemia as the result of acidosis, damaging occurs by free radicals, fatty acids releasing, exposures to free copper and iron, and disturbance of calcium pump. The aim of this study was to estimate the brain natriuretic peptide (Pro-BNP) and Ischemia Modified Albumin (IMA) Levels as early diagnostic markers and correlated with conventional cardiac markers at admission to the emergency department in Acute Coronary Syndrome Patients with ST segment elevation myocardial infarction (STEMI) and Non ST segment elevation myocardial infarction (NSTEMI). Methods: Eighty ACS patients who arrived at the emergency department ED within 6h of clinical symptoms divided to STEMI and NSTEMI, and another 40 of noncardiac chest pain patients (NCCP) as control were enrolled in this study. pro-BNP was measured using a Cobas e 411 Roche, Germany, and IMA was measured using enzyme linked immunosorbent assay (ELISA) kits. Tukey HSD Post hoc ANONA test and One-way ANOVA were used to compare differences of mean between groups. Pearson Correlation was calculated to assess the relation between the biomarkers of this study. Receiver Operating Characteristics (ROC) curve was calculated to estimate the sensitivity and specificity for the use of pro-BNP and IMA as biomarker in the diagnosis and discriminatory ability of ACS. Results: pro-BNP and Ischemia modified albumin were significantly higher in acute coronary syndrome patients (STEMI & NSTEMI) compared to NCCP as controls (1359.82± 995.00 and 2698.22±1604.69 vs 180.07±90.24) (p

Anemia and perioperative mortality in non-cardiac surgery patients: a secondary analysis based on a single-center retrospective study

BackgroundEvidence regarding the relationship between anemia and perioperative prognosis is controversial. The study was conducted to highlight the specific relationship between anemia and perioperative mortality in non-cardiac surgery patients over 18 years of age.MethodsThis study was a retrospective analysis of the electronic medical records of 90,784 patients at the Singapore General Hospital from January 1, 2012 to October 31, 2016. Multivariate regression, propensity score analysis, doubly robust estimation, and an inverse probability-weighting model was used to ensure the robustness of our findings.ResultsWe identified 85,989 patients, of whom75, 163 had none or mild anemia (Hemoglobin>90g/L) and 10,826 had moderate or severe anemia (Hemoglobin≤90g/L). 8,857 patients in each study exposure group had similar propensity scores and were included in the analyses. In the doubly robust model, postoperative 30-day mortality rate was increased by 0.51% (n = 219) in moderate or severe anemia group (Odds Ratio, 1.510; 95% Confidence Interval (CI), 1.049 to 2.174) compared with none or mild anemia group (2.47% vs.1.22%, P<0.001). Moderate or severe anemia was also associated with increased postoperative blood transfusion rates (OR, 5.608; 95% CI, 4.026 to 7.811, P < 0.001). There was no statistical difference in Intensive Care Unit (ICU) admission rate among different anemia groups within 30 days after surgery (P=0.104).DiscussionIn patients undergoing non-cardiac surgery over 18 years old, moderate or severe preoperative anemia would increase the occurrence of postoperative blood transfusion and the risk of death, rather than ICU admission within 30 days after surgery.