Physiological Instability Research Articles

About the global strategy for the prevention of influenza in 2019–2030

The development of modern methods of epidemiological control, on the one hand, and the creation of modern methods of diagnosis, prevention, and treatment, which will be available to all strata of society, on the other hand, is the key to preventing the pandemic spread of influenza in the world. Today, influenza is a serious threat to human health globally, which covers all countries of the world. Thus, according to the World Health Organization estimates, about 1 billion cases of influenza are registered annually worldwide, of which 3–5 million are severe cases and 290,000–650,000 are cases of death due to severe complications of respiratory dysfunction caused by influenza. Children are more susceptible to acute respiratory viral infections and influenza in the general population due to the physiological instability of the immune system, being mostly in crowded places and in large social groups (kindergartens, schools, entertainment centers), which increases the probability of infection. The risk group consists of patients with chronic pathology, particularly affecting the heart and lungs, who have problems with the immune system.

Encapsulation of 4-oxo-N-(4-hydroxyphenyl) retinamide in human serum albumin nanoparticles promotes EZH2 degradation in preclinical neuroblastoma models.

Neuroblastoma is the most prevalent and aggressive solid tumor that develops extracranially in children between the ages of 0-14 years, which accounts for 8-10% of all childhood malignancies and ∼15% of pediatric cancer-related mortality. The polycomb repressive complex 2 (PRC2) protein, EZH2, is overexpressed in neuroblastoma and mediates histone H3 methylation at lysine 27 (K27) positions through its methyl transferase activity and is a potential epigenetic silencer of many tumor suppressor genes in cancer. Phosphorylation of EZH2 decreases its stability and leads to proteasomal degradation. The 4-oxo-N-(4-hydroxyphenyl) retinamide (4O4HPR) promotes EZH2 degradation via activation of PKC-δ, but its limited solubility and physiological instability limit its application. In the current study, the encapsulation of 4O4HPR in Human Serum Albumin Nanoparticles (HSANPs) enhanced the solubility and physiological stability of the nanoformulation, leading to improved therapeutic efficacy through G2-M cell cycle arrest, depolarization of mitochondrial membrane potential, generation of reactive oxygen species and caspase 3 mediated apoptosis activation. The molecular mechanistic approach of 4O4HPR loaded HSANPs has activated caspase 3, which further cleaves PKC-δ into two fragments wherein the cleaved fragment of PKC-δ possesses the kinase activity that phosphorylates EZH2 and decreases the protein stability leading to its further ubiquitination in SH-SY5Y cells. Co-immunoprecipitation experiments revealed the direct interaction between PKC-δ and EZH2 phosphorylation, followed by ubiquitination. Moreover, 4O4HPR loaded HSANPs demonstrated improved in vivo biodistribution, greater dispersibility, and biocompatibility and exhibited enhanced protein instability and degradation of EZH2 in the neuroblastoma xenograft mouse model.

High‐performance aminosilane‐infused alginate capsules for sustained drug release

AbstractSodium alginate (AlgNa) is often used to prepare oral drug capsules, offering the advantages of facile carrier formation and pH sensitivity. However, these capsules suffer from high porosity, large pore size, and mechanical and physiological instabilities. Although the performance of AlgNa in oral drug carriers can be enhanced through hybridization with other substances, this results in increased complexity and additional preparation steps. To address this problem, organic–inorganic hybrid capsules are herein prepared via the one‐step incorporation of aminosilanes (3‐aminopropyltriethoxysilane and 3‐(2‐aminoethylamino)propyltrimethoxysilane) into AlgNa and evaluated as delivery vehicles for the sustained release of a model drug, diclofenac sodium. The hybrid capsules show elevated drug encapsulation efficiencies (up to 92.7%) and pH responsiveness and outperform pure alginate capsules, exhibiting contraction and low release rates (<10%) in a simulated stomach environment (pH 1.2) and swelling and sustained release (10 h) in a simulated intestinal environment (pH 7.4). The formation of siloxane bonds between the aminosilane molecules results in stronger and more compact capsule membranes contributing to sustained drug release. Thus, our results demonstrate the potential of the proposed capsules, fabricated using a simple ecofriendly method, as carriers for sustained drug release.

Continuous improvement of non-emergent neonatal intubations in a level IV NICU.

We sought to improve practices and outcomes related to non-emergent neonatal intubations in a level IV academic Neonatal Intensive Care Unit. A multidisciplinary team created guidelines for non-emergent neonatal intubations. In period 1, premedication practices were standardized. In period 2, paralytic use and video laryngoscope use were recommended. Premedication and video laryngoscopy practices were assessed along with number of intubation attempts and frequency of bradycardia and desaturation. 636 intubations performed by neonatology fellows and neonatal advanced practice providers were reviewed over six academic years. Two academic years were included in each of the following study periods: baseline, period 1, and period 2. In our unit, compliance with recommended premedication practices and administration of paralytic medication has increased considerably, and video laryngoscopy is now utilized in most of our procedures. The frequency of intubation success on the first attempt has increased, and the frequency of both bradycardia and desaturation during intubation has decreased. In our analysis, paralytic use (AOR 2.41, 95 CI (1.53, 3.81)) and the combination of paralytic and video laryngoscopy (AOR 4.07, 95 CI (2.09, 7.92)) are associated with increased odds of intubating successfully on the first attempt. This initiative increased the use of standardized premedication, paralytic medication and video laryngoscopy for non-emergent neonatal intubations with temporally associated improvement in patient outcomes including fewer intubation attempts and reduction in physiologic instability.

Predictors of successful neonatal intubation in inexperienced operators: a secondary, non-randomised analysis of the SHINE trial

ObjectiveNeonatal endotracheal intubation is a lifesaving but technically difficult procedure, particularly for inexperienced operators. This secondary analysis in a subgroup of inexperienced operators of the Stabilization with nasal High flow...

A Prospective Study Evaluating Gender Differences of Serious Outcomes through Difficult Airway Physiological Score (DAPS) in the Emergency Department.

Gender variation in critically ill adults after resuscitation is reported in many studies. However, this variation is not well established when evaluating the physiological instability in this population. This study aimed to prospectively evaluate the gender variation in serious outcomes by the difficult airway physiological score (DAPS) among critically ill patients requiring endotracheal intubation (ETI). This is a cohort study conducted from August 2021 to December 2022 in the emergency department of Aga Khan University. The prospective validity of the difficult airway physiological score was derived using retrospective data and includes 12 variables: sex, age, time of intubation, hypotension, respiratory distress, vomiting, shock index >0.9, pH < 7.3, fever, anticipated decline, Glasgow Coma Scale (GCS) < 15, and agitation. The serious outcomes were cardiac arrest, mortality (within 1 hour after intubation in emergency), hypotension (systolic blood pressure <90 mmHg), and oxygen desaturation (SpO2 < 92%). The difference between males and females was assessed using the chi-square test, and the association of gender and serious outcomes was explored using Cox and logistic regression analysis. ROC curve analysis and area under the curve assessed score validity separately in males and females with serious outcomes. We enrolled 326 patients with a mean age of 50.3 (±17.8), with 123 (33.7%) females and 203 (62.2%) males. 198 (60.7%) patients were >45 years old, of which 136 (67%) were male and 62 (50.4%) female. Cardiac arrest was observed in 56 (17.2%), with 24 (19.5%) females and 32 (15.8%) males, p value 0.348. Hypotension after intubation was observed in 132 (40.5%) patients, 56 (45.5%) females and 76 (37.4%) males, p value 0.149. Oxygen saturation (<92%) was observed in 80 (24.5%) patients, 32 (26%) females and 48 (23.6%) males, p value 0.630. In females, the DAPS of 11 had an area under the curve of 0.863 (0.74-0.91). The sensitivity of the score was 84.8%, the specificity was 71.9%, the PPV was 77.8%, and the NPV was 80.4% with an accuracy of 78.9%. In males, the DAPS score of 14 had an area under the curve of 0.892 (0.57-0.75). The sensitivity of the score was 67%, the specificity 93.8%, the PPV 92.2%, and the NPV 72.2% with an accuracy of 79.8%. The Difficult Airway Physiological Score (DAPS) predicts the risk of serious outcomes after intubation with high precision and reliability with different score cutoffs between the two sexes, highlighting the gender variation of a difficult airway.

Altered Serum Proteins Suggest Inflammation, Fibrogenesis and Angiogenesis in Adult Patients with a Fontan Circulation.

Previous omics research in patients with complex congenital heart disease and single-ventricle circulation (irrespective of the stage of palliative repair) revealed alterations in cardiac and systemic metabolism, inter alia abnormalities in energy metabolism, and inflammation, oxidative stress or endothelial dysfunction. We employed an affinity-proteomics approach focused on cell surface markers, cytokines, and chemokines in the serum of 20 adult Fontan patients with a good functioning systemic left ventricle, and we 20 matched controls to reveal any specific processes on a cellular level. Analysis of 349 proteins revealed 4 altered protein levels related to chronic inflammation, with elevated levels of syndecan-1 and glycophorin-A, as well as decreased levels of leukemia inhibitory factor and nerve growth factor-ß in Fontan patients compared to controls. All in all, this means that Fontan circulation carries specific physiological and metabolic instabilities, including chronic inflammation, oxidative stress imbalance, and consequently, possible damage to cell structure and alterations in translational pathways. A combination of proteomics-based biomarkers and the traditional biomarkers (uric acid, γGT, and cholesterol) performed best in classification (patient vs. control). A metabolism- and signaling-based approach may be helpful for a better understanding of Fontan (patho-)physiology. Syndecan-1, glycophorin-A, leukemia inhibitory factor, and nerve growth factor-ß, especially in combination with uric acid, γGT, and cholesterol, might be interesting candidate parameters to complement traditional diagnostic imaging tools and the determination of traditional biomarkers, yielding a better understanding of the development of comorbidities in Fontan patients, and they may play a future role in the identification of targets to mitigate inflammation and comorbidities in Fontan patients.

Current diagnosis and management of necrotizing soft tissue infections: What you need to know.

Necrotizing soft tissue infections are rare bacterial infections of the skin and soft tissues with a high morbidity and mortality rate, requiring prompt diagnosis and surgical intervention. These represent a spectrum of disease resulting in tissue necrosis that is rapidly progressive; however, they remain a diagnostic challenge because the average surgeon or emergency medicine provider may only see one or two over the course of their career. Diagnosis is largely clinical and based on subtle physical examination findings, physiologic instability, and laboratory derangements. Aids to diagnosis such as scoring systems and cross-sectional imaging may be used; however, the findings are not specific, so management should not be based on these alone. The most common cause of necrotizing soft tissue infection is polymicrobial infection; however, specific bacteria such as clostridial species, group A streptococcal, methicillin resistant Staphylococcus aureus , and aquatic bacteria may also be causative. Initial management includes broad spectrum antibiotics, fluid resuscitation for severe sepsis, and early aggressive surgical debridement. Often, these patients require multiple operative debridement to achieve source control, and a low threshold for repeat debridement should be maintained because these infections can progress rapidly. Once source control is achieved, patients may be left with extensive wounds requiring multidisciplinary care and wound management. Necrotizing infections have long been viewed based on mortality outcomes alone because of their rarity and severity. Over recent years, more reports have shown a decrease in the mortality rates from those previously reported, allowing for a focus on methods to improve morbidity of these infections.

Validation of Difficult Airway Physiological Score (DAPS) in Critically Ill Adults Undergoing Endotracheal Intubation in the Emergency Department.

Critically ill patients have increased risk of cardiovascular collapse following endotracheal intubation due to physiological instability. This study aims to validate the Difficult Airway Physiological Score (DAPS) in adults to predict the risk of serious outcomes in the emergency department of a tertiary care private hospital. This is a cohort study conducted in the emergency department (ED) from 2021 to 2022. Difficult Airway Physiological Score (DAPS) was derived from a sample of 1021 patients through a retrospective study. The variables in the score were age, gender, time of intubation, vitals and vomiting at presentation, pH <7.3, fever, physician's anticipation for patient decline, and agitation. The model performance was assessed prospectively on a separate dataset (n = 326) using train-test split method. Postintubation desaturation, hypotension, cardiac arrest, and mortality postintubation were the serious outcomes. ROC analysis, sensitivity, specificity, PPV, and NPV were used to assess score validity. Our study includes 326 patients, of which 123 (37.7%) were males and 203 (62.2%) were females. The sample was divided into high-risk (DAPS ≥10) group, n = 194 with mean age of 52 (SD = ±18) years, and low-risk (DAPS <10) group, n = 132 with mean age of 47.7 (SD = ±17.4) years. The shock index ≥0.9 was in 128 (66%), while it was <0.9 in low-risk n = 111 (84%), p value <0.001. Similarly, pH <7.3 was seen in 70 (36.1%) in high-risk group compared to 4 (3%) in low-risk group, p value <0.001. Cardiac arrest was observed in 56 (17.2%) patients, of which 45 (23.2%) were in high-risk and 11 (8.3%) in low-risk groups (p < 0.001). Hypotension was the primary outcome in the high-risk group 100 (51.5%) versus 32 (24.2%) in low-risk group (p < 0.001). The DAPS of 10 had an area under the curve of 0.865 (0.71-0.84). The sensitivity of DAPS was 78.5%, specificity 77.9%, and accuracy 78.2%. The score can accurately predict serious outcomes in critically ill adult patients with physiologically difficult airway demonstrating good sensitivity and specificity.

Porphyrin Metal-organic Framework Sensors for Chemical and Biological Sensing.

Porphyrins and porphyrin derivatives have been intensively explored for a number of applications such as sensing, catalysis, adsorption, and photocatalysis due to their outstanding photophysical properties. Their usage in sensing applications, however, is limited by intrinsic defects such as physiological instability and self-quenching. To reduce self-quenching susceptibility, researchers have developed porphyrin metal-organic frameworks (MOFs). Metal-organic frameworks (MOFs), a unique type of hybrid porous coordination polymers comprised of metal ions linked by organic linkers, are gaining popularity. Porphyrin molecules can be integrated into MOFs or employed as organic linkers in the production of MOFs. Porphyrin-based MOFs are a separate branch of the huge MOF family that combines the distinguishing qualities of porphyrins (e.g., fluorescent nature) and MOFs (e.g., high surface area, high porosity) to enable sensing applications with higher sensitivity, specificity, and extended target range. The key synthesis techniques for porphyrin-based MOFs, such as porphyrin@MOFs, porphyrinic MOFs, and composite porphyrinic MOFs, are outlined in this review article. This review article focuses on current advances and breakthroughs in the field of porphyrin-based MOFs for detecting a variety of targets (for example, metal ions, anions, explosives, biomolecules, pH, and toxins). Finally, the issues and potential future uses of this class of emerging materials for sensing applications are reviewed.

A novel approach to retrograde autologous priming for infant, pediatric and adult populations undergoing congenital heart surgery.

Retrograde Autologous Priming (RAP) of cardiopulmonary bypass (CPB) circuits is an effective way to reduce prime volume, commonly through the transfer of prime into separate reservoirs or circuit manipulation. We describe a simple and safe technique for RAP without the need for any circuit modifications or manipulations. For this technique, a separate roller pump for ultrafiltration (UF) is used. After adequate heparinization and arterial cannulation, the UF pump is initiated slowly, removing prime through the effluent of the UF, replacing with the patient's blood from the aortic cannula. Once the arterial line and UF circuit are autologous primed, the arterial head displaces reservoir crystalloid toward the UF circuit at a flow rate equal to the UF pump, displacing the crystalloid prime with blood from the UF circuit, autologous priming the boot and oxygenator with blood, crystalloid again being removed by the effluent. After venous cannulation, the venous line prime is replaced with autologous blood, the crystalloid removed by the effluent of the UF circuit via the arterial head. During RAP, if the patient becomes hypovolemic, either autologous volume is transfused back to the patient, or CPB is initiated, without the need for circuitry modifications. The patient population in this sample consisted of 63 patients ranging between 6.1kg and 115.6kg. The smaller the patient, the less blood volume available for RAP and therefore the less prime volume able to be removed. Overall percent removal increases as our patients size increases compared to total circuit volume. This RAP technique is a safe and effective way to achieve a standardized asanguinous prime for many regardless of patient or circuit size in the absence of contraindications such as low starting hematocrit, emergency surgery or physiologic instability. Most importantly, this potentially reduces the amount of hemodilution patients see from CPB initiation and therefore the lowest nadir hematocrit and consequently the amount of required homologous blood products needed during surgery.

Derivation of the Difficult Airway Physiological Score (DAPS) in adults undergoing endotracheal intubation in the emergency department

BackgroundPrediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation.MethodThis single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model’s performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset’s instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden’s J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined.ResultsThe mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%.ConclusionDAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration.

Association between Intermittent Hypoxemia and NICU Length of Stay in Preterm Infants

Introduction: Length of hospitalization varies widely in preterm infants and can be affected by multiple maternal and neonatal factors including respiratory instability. Therefore, we aimed to determine the association between postnatal intermittent hypoxemia (IH) and prolonged hospitalization. Methods: This prospective single-center cohort study followed infants born at <31 weeks of gestational age through 2 years corrected age with detailed oxygen saturation data captured from days 7 to 30 of age. Results: 51/164 (31%) of infants were discharged after 400/7 weeks of corrected gestational age (CGA). A greater average daily number of IH events (OR per 10 events/day 1.33 [95% CI 1.03–1.72]), duration of events (OR per minute 1.14 [1.07–1.21]), and percent time with oxygen saturation <80% (OR per percent 1.88 [1.25–2.85]) on days 7–30 of age were all significantly associated with prolonged hospitalization past 400/7 weeks CGA. In survival analyses, infants with a greater average daily number of IH events (HR per 10 events/day 0.89 [0.81–0.98]), percent time with oxygen saturation <80% (HR per percent 0.79 [0.67–0.94]), and duration of events (HR per minute 0.93 [0.91–0.95]) on days 7–30 of age all had significantly lower probability of earlier discharge. In addition, there was a significant interaction with gestational age; the association between IH and prolonged hospitalization was stronger in more mature infants (p = 0.024). Conclusions: Physiological instability on days 7–30 of age, as manifested by IH, is significantly associated with prolonged hospitalization. IH likely represents both a marker of initial severity of illness and the beginning of biological cascades, leading to prematurity-associated morbidities.

Vibratory Impact of 3 Different Ambulance Suspension Systems on the Simulated Neonate and Health Care Provider During Normal Driving Conditions

ObjectivePatients and health care providers experience varying degrees of vibration during interfacility ground transport. The impact of vibration on term and preterm neonates may result in physiologic instability and increased risk of intracranial hemorrhage, whereas the impact on health care providers has been shown to include an increase in perceived and physiologic stress levels and may contribute to chronic back and neck pain. This study aimed to evaluate 3 common ambulance suspension systems and the corresponding vibratory impact produced during typical interfacility driving conditions on adult caregiver and neonatal patient mannequins. MethodsType 3 ambulances with air, liquid, and traditional suspensions were evaluated using various driving tests to simulate typical road conditions. Vibrations were measured using triaxial accelerometers placed on the chassis, upon the head of a seated caregiver mannequin in the ambulance bench seat, and the head of a neonatal mannequin supine and secured in an isolette. Data analysis included the average vibration frequency, root mean square values, and maximum vibration amplitudes. ResultsThe results showed that the supine neonatal mannequin experienced the highest vibration frequency and amplitude in the vertical (x) direction, whereas the adult caregiver mannequin experienced higher vibration frequencies in both parallel (y) and lateral (z) directions and the highest vibration amplitude in the y direction. The liquid suspension system consistently demonstrated the lowest vibration levels in all driving conditions and directions, whereas traditional suspension had the highest values. ConclusionThis study provides important insights into the vibrations incurred by simulated neonatal patients and health care providers during ambulance transport. The directional vibration frequency and amplitude differ between a neonatal mannequin and an adult mannequin when placed in typical positions with typical restraints during varied ambulance driving conditions. In all directional movements and driving conditions, a liquid suspension system decreases vibration frequency and amplitude more than air or traditional systems. The live patient and caregiver impact of these results should be further investigated.

Nursing Training for Early Clinical Deterioration Risk Assessment: Protocol for an Implementation Study.

During the hospitalization period, it is possible to observe considerable changes in the vital parameters of patients, which may require emergency interventions or intensive treatment. The alteration of signs and symptoms that lead to physiological instability that can worsen the clinical picture with progression to shock, respiratory failure, or cardiorespiratory arrest is currently defined as clinical deterioration. Identifying signs of clinical deterioration at an early stage can lead to substantial decreases in mortality rates, the need for emergency interventions, and unscheduled treatments in intensive care units. Identifying and appropriately referring patients who show signs of clinical deterioration can be facilitated by applying early warning systems that provide rapid responses. The nursing team is usually the first to identify clinical changes in patients. Although the literature demonstrates that early recognition of clinical deterioration is the key to early intervention and leads to better outcomes, we only sometimes pursue the most appropriate intervention. This study aims to implement and evaluate an evidence-based professional training program designed for nurses and coordinated by a nurse using the "just-in-time" methodology and the National Early Warning Score 2 (NEWS2) to assess the risk of early clinical deterioration and appropriate referral in inpatient units of a public university hospital in southeastern Brazil. This intervention protocol is structured according to the recommendations of the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) Declaration 2013. The type of training to be offered, "Just-in-Time Training," consists of a teaching modality that facilitates the delivery of a time-based and work-based education, with greater emphasis on providing on-the-job learning as needed. A qualitative stage will also be conducted through focus groups and interviews with nurses to verify the factors that influence the professional practice related to the early evaluation of the clinic. A script of previously tested questions will guide and standardize the different groups. The data will define the intervention's elements: the strategy, the type of training, the location, the teaching methodology, and the teaching material. The study has received authorization from the ethics committee, and participants will be recruited in July 2023. Data collection should be completed in October of the same year. The results obtained at the end of this research will be shared with the participating nursing team through the presentation of reports. In addition, the research results will be submitted to scientific journals and presented at international scientific conferences. This study will support nurses and possibly other clinicians to improve their approach to early recognition of clinical deterioration in patients. Brazilian Registry of Clinical Trials RBR-5hq9y3k; https://ensaiosclinicos.gov.br/rg/RBR-5hq9y3k. PRR1-10.2196/47293.

ThTP8.8 Ambulatory management of acute pancreatitis

Abstract Aim Acute pancreatitis is a common pathology with a spectrum of disease from mild to life-threatening. It is standard practice for all patients to be admitted due the inability to accurately predict severity. However, both considering the wellbeing of patients and pressures on acute hospitals, it may be the time to consider the role of ambulatory care. We retrospectively reviewed patients with pancreatitis managed ambulatorily, and assessed for trends in their presentation. Methods Retrospective review of a prospectively maintained database between 2019-2022 identifying patients with acute pancreatitis with initial ambulatory management. Results There were 19 cases of pancreatitis with planned ambulatory management, with only one representing and requiring admission for 36 hours for symptom control. Of those who had successful ambulatory management, 12 were male (67%). Median age was 55 (range 24-81). Median duration of symptoms at time of review was 5 days (range 1-21). Median number of comorbidities was 1 (0-6), with only a third (6/18) reporting no comorbidities. Median CRP was 11 (&amp;lt;1-153) and WCC 9 (3-25); no patients had acute kidney injury. All patients had a NEWS&amp;lt;2. All but two patients (with a background of pancreatitis) had imaging performed in an ambulatory setting; five had CT scans. Conclusion Patients successfully managed ambulatory were a very heterogeneous group. Our data would support that trial of ambulatory management can be considered in the absence of organ failure (renal function, or physiological instability). This should be supported by adequate safety netting, and plans for further review as appropriate.

Adult corrosive ingestions in the Pietermaritzburg Metropolitan Surgical Service.

There is a paucity of data around corrosive ingestion in South Africa over the last three decades. As such, we set out to review our experience with adult corrosive ingestion in our tertiary gastrointestinal surgical service. A retrospective, quantitative review was performed. The parameters analysed were demographics, substance ingestion, ingestion time to first presentation to a healthcare facility, clinical presentation, severity of injury based on endoscopic classification, computed tomography (CT) findings, management and outcomes. Patients presenting within 72 hours with alarm symptoms underwent flexible upper endoscopy and injury severity grading. In patients presenting after 72 hours, a water-soluble contrast study was obtained prior to upper endoscopy. Patients with signs of sepsis, surgical emphysema or physiological instability were referred for urgent CT to exclude oesophageal perforation and mediastinitis. Between January 2012 and January 2019, a total of 64 patients presented with a history of corrosive ingestion - 40 (31%) were males and 24 (19%) females. The average time from ingestion to presentation was 72 hours. In 78% of patients, the agents were intentionally ingested, whilst 22% claimed accidental ingestion. A quarter of the patients (21%) presented to the unit clinically unstable, requiring emergent cardiorespiratory support. Eight (12%) patients required urgent surgical intervention due to the extent of injury. Nine (14%) patients demised during the acute admission. Of this group, three patients had undergone surgical intervention, and six were managed conservatively. Eighty-five per cent of all patients survived their initial admission. This paper has highlighted the problem of corrosive ingestion in our setting. It remains a complicated problem to manage associated with significant morbidity and mortality rates. The current trend in the assessment of these patients is increased use of CT scan to assess the extent of transmural necrosis. Our algorithms should change to reflect this contemporary approach.

O088 Is it possible to predict which patients need prolonged intensive care support after elective oesophageal surgery?

Abstract Introduction Oesophagectomy for oesophageal cancer is associated with post-operative complications and physiological instability, with cardio-respiratory disturbance in up to 30% of patients. Oesophagectomy patients are regularly admitted to an intensive care unit (ICU) for the first 24 hours after surgery. Increased demand for ICU beds has sparked interest in identifying patients who could be managed in lower intensity environments. We examined pre-operative features potentially associated with increased complication risk. Methods Data from 526 patients who underwent elective oesophagectomy 07/01/2015 - 10/12/2019 was reviewed with basic demographic data available for 485. From 211 patients, data relating to past medical history, American Society of Anesthesiology score (ASA), prescription drug history, and pre-operative blood tests was retrospectively analysed [SPSS v.28; IBM, Chicago] to identify features associated with prolonged ICU stay. Results Median length of post-operative ICU stay was 31 hours. 327 (67.4%) remained on ICU &amp;lt;48 hours, and 158 (32.6%) ≥48 hours. Age &amp;gt;70, ASA ≥3, and female sex were associated with stay ≥48 hours (p=0.044; p=0.036; p&amp;lt;0.001). Increased pre-operative white cell count and serum urea were associated with prolonged ICU stay (p=0.002; p=0.007), as was lower sodium and albumin (p=0.002; p=0.02). Conclusion Predicting which patients are more likely to require prolonged ICU support after oesophagectomy may allow others to be admitted to lower dependency beds. The associations identified could be used in future multivariate analysis to derive a pre-operative scoring system.

Alcohol use disorder treatment delivered outside hepatology clinic.

Alcohol use disorder treatment delivered outside hepatology clinic.

Use of Temporary Abdominal Closure in Non-Trauma Surgery: A Cohort Study.

Damage control surgery in trauma is widely used but the evidence for the use of laparostomy in non-trauma abdominal emergencies is limited. This study aimed to characterise outcomes in emergency abdominal surgery by comparing laparostomy to one-stage laparotomy for patients of similar illness severity. A retrospective study of adult patients requiring emergency abdominal surgery and post-operative intensive care stay was performed between 2016 and 2020 at a major Australian metropolitan hospital. Case selection was from a prospectively maintained database, and case notes were reviewed. Patients having delayed abdominal closure were compared with those having one-stage abdominal closure. The primary outcome was odds of in-hospital mortality. The secondary outcomes included intensive care unit length of stay (LOS), overall hospital LOS, definitive stoma rate and discharge destination. Multivariable logistic regression analysis was performed to adjust for potentially confounding variables. Two hundred and eighteen patients met inclusion criteria (80 laparostomy and 138 non-laparostomy). The most common indications for laparostomy were bowel ischaemia (41.3%), sepsis (26.3%) and physiological instability (22.5%). There was no evidence of difference in odds of in-hospital mortality between groups (adjusted OR = 1.67, CI: 0.85-3.28; p = 0.138). Patients requiring laparostomy had a slightly longer median ICU LOS (4 vs. 3days; p < 0.001), similar median hospital LOS (19 vs. 14days, p = 0.245) and similar discharge destination. There was no difference in stoma rate (35.0% vs. 35.5%). Compared with standard one-stage laparotomy, laparostomy resulted in similar odds of in-hospital mortality in emergency abdominal surgery patients requiring intensive care.