Postoperative Respiratory Support Research Articles

ОЦЕНКА РЕЗУЛЬТАТОВ ПРИМЕНЕНИЯ АЛГОРИТМА ВЫБОРА ОПТИМАЛЬНОГО ХИРУРГИЧЕСКОГО ДОСТУПА К ЗАБРЮШИННОМУ ПРОСТРАНСТВУ У ПАЦИЕНТОВ С РАЗЛИЧНЫМИ ПАРАМЕТРАМИ КОНСТИТУЦИИ.

Relevance. Despite the rapid development and predominance of endovideosurgical techniques in the treatment of pathologies of organs and structures of the retroperitoneal space, the implementation of transperitoneal or retroperitoneal approaches for open surgical interventions remains a routine activity. Surgical treatment of various pathologies of retroperitoneal localization leads to the development of nonspecific life-threatening complications in 23.8% - 30% of clinical observations, and associated mortality - 7.2% - 11% of cases. Previously, our works presented the results of comparing the number of this type of complications when using laparotomy or retroperitoneal access, depending on the constitutional parameters of the patient. An assessment was made of the significance of the influence of constitutional parameters on the development of nonspecific life-threatening complications, on the basis of which an algorithm for choosing the optimal surgical access to the structures of the retroperitoneal space was developed [patent application No. 2024113445 dated May 17, 2024]. Purpose of the study. To evaluate the effectiveness of using an algorithm for selecting the optimal surgical approach in the surgical treatment of pathologies of organs and structures of retroperitoneal localization. Materials and methods. Comparative analysis of the results of surgical treatment of patients with various surgical pathologies of the retroperitoneal space. Group I (n = 167), where the choice of surgical approach was determined using the “optimal surgical approach selection algorithm.” Group II (n = 284), in which the choice of access to the structures of the retroperitoneal space was not unified and was chosen without taking into account the constitutional parameters of the patient. In the perioperative period, the duration of surgical intervention, the volume of intraoperative blood loss, the number of days of stay in the intensive care unit, the time of postoperative respiratory support, the duration of postoperative intestinal paresis and the number of postoperative bed days were assessed. Criteria assessed in the postoperative period: development of myocardial infarction, acute cardiovascular failure, ARDS with the development of respiratory failure, acute kidney injury; cases of development of ischemic colitis and small intestinal obstruction, requiring repeated interventions, as well as the phenomenon of multiple organ failure. Wound complications included failure of retroperitoneal and laparotomy wounds, including eventration. To calculate quantitative characteristics, the median (Me) and percentiles (Q0.25 - Q0.75) were determined. Calculation of statistical significance between groups was performed using the Mann-Whitney U test**, for comparison of qualitative indicators - the Chi-square test* in IBM SPSS Statistics 25 software. Results. In group I, compared with group II, there was a shorter surgical intervention time [140.8 vs 179.5] min, p = 0.031**, a smaller volume of intraoperative blood loss [280.4 vs 413.3] ml, p = 0.024* *; postoperative respiratory support [4.5 vs 8.5] hours, p = 0.041**; length of stay in the intensive care unit [1.8 vs 3.4] days, p = 0.021**; postoperative intestinal paresis [1.2 vs 4.8] days p = 0.024**; and duration of total postoperative hospital stay [9.1 vs 16.4] days p = 0.003**. The number of postoperative nonspecific life-threatening and wound complications in group I was 24 (14.4%), and in group II - 64 (22.5%) cases (p = 0.023*). The number of complications-related deaths in group I was 9 (5.4%); in group II - 32 (11.26%) cases (p = 0.037*). Conclusion. The use of an algorithm for selecting the optimal surgical approach for surgical treatment of pathologies of organs and structures of the retroperitoneal localization of the access leads to a reduction in the number of nonspecific life-threatening complications to 14.4%, and associated deaths to 5.4%.

Rationale and study design for an Individualized PeriopeRative Open lung VEntilatory approach in Emergency Abdominal Laparotomy/scopy: study protocol for a prospective international randomized controlled trial

BackgroundPostoperative pulmonary complications (PPC) are the most frequent postoperative complications, with an estimated prevalence in elective surgery ranging from 20% in observational cohort studies to 40% in randomized clinical trials. However, the prevalence of PPCs in patients undergoing emergency abdominal surgery is not well defined. Lung-protective ventilation aims to minimize ventilator-induced lung injury and reduce PPCs. The open lung approach (OLA), which combines recruitment manoeuvres (RM) and positive end-expiratory pressure (PEEP) titration, aims to minimize areas of atelectasis and the development of PPCs; however, there is no conclusive evidence in the literature that OLA can prevent PPCs. The purpose of this study is to compare an individualized perioperative OLA with conventional standardized lung-protective ventilation in patients undergoing emergency abdominal surgery with clinical signs of intraoperative lung collapse. MethodsRandomized international clinical trial to compare an individualized perioperative OLA (RM plus individualized PEEP and individualized postoperative respiratory support) with conventional lung-protective ventilation (standard PEEP of 5 cmH2O and conventional postoperative oxygen therapy) in patients undergoing emergency abdominal surgery with clinical signs of lung collapse. Patients will be randomised to open-label parallel groups. The primary outcome is any severe PPC during the first 7 postoperative days, including: acute respiratory failure, pneumothorax, weaning failure, acute respiratory distress syndrome, and pulmonary infection. The estimated sample size is 732 patients (366 per group). The final sample size will be readjusted during the interim analysis. DiscussionThe Individualized Perioperative Open-lung Ventilatory Strategy in emergency abdominal laparotomy (iPROVE-EAL) is the first multicentre, randomized, controlled trial to investigate whether an individualized perioperative approach prevents PPCs in patients undergoing emergency surgery.

Personalized Noninvasive Respiratory Support in the Perioperative Setting: State of the Art and Future Perspectives.

Background: Noninvasive respiratory support (NRS), including high-flow nasal oxygen therapy (HFNOT), noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP), are routinely used in the perioperative period. Objectives: This narrative review provides an overview on the perioperative use of NRS. Preoperative, intraoperative, and postoperative respiratory support is discussed, along with potential future areas of research. Results: During induction of anesthesia, in selected patients at high risk of difficult intubation, NIV is associated with improved gas exchange and reduced risk of postoperative respiratory complications. HFNOT demonstrated an improvement in oxygenation. Evidence on the intraoperative use of NRS is limited. Compared with conventional oxygenation, HFNOT is associated with a reduced risk of hypoxemia during procedural sedation, and recent data indicate a possible role for HFNOT for intraoperative apneic oxygenation in specific surgical contexts. After extubation, "preemptive" NIV and HFNOT in unselected cohorts do not affect clinical outcome. Postoperative "curative" NIV in high-risk patients and among those exhibiting signs of respiratory failure can reduce reintubation rate, especially after abdominal surgery. Data on postoperative "curative" HFNOT are limited. Conclusions: There is increasing evidence on the perioperative use of NRS. Use of NRS should be tailored based on the patient's specific characteristics and type of surgery, aimed at a personalized cost-effective approach.

Individualised, perioperative open-lung ventilation strategy during one-lung ventilation (iPROVE-OLV): a multicentre, randomised, controlled clinical trial

It is uncertain whether individualisation of the perioperative open-lung approach (OLA) to ventilation reduces postoperative pulmonary complications in patients undergoing lung resection. We compared a perioperative individualised OLA (iOLA) ventilation strategy with standard lung-protective ventilation in patients undergoing thoracic surgery with one-lung ventilation. This multicentre, randomised controlled trial enrolled patients scheduled for open or video-assisted thoracic surgery using one-lung ventilation in 25 participating hospitals in Spain, Italy, Turkey, Egypt, and Ecuador. Eligible adult patients (age ≥18 years) were randomly assigned to receive iOLA or standard lung-protective ventilation. Eligible patients (stratified by centre) were randomly assigned online by local principal investigators, with an allocation ratio of 1:1. Treatment with iOLA included an alveolar recruitment manoeuvre to 40 cm H2O of end-inspiratory pressure followed by individualised positive end-expiratory pressure (PEEP) titrated to best respiratory system compliance, and individualised postoperative respiratory support with high-flow oxygen therapy. Participants allocated to standard lung-protective ventilation received combined intraoperative 4 cm H2O of PEEP and postoperative conventional oxygen therapy. The primary outcome was a composite of severe postoperative pulmonary complications within the first 7 postoperative days, including atelectasis requiring bronchoscopy, severe respiratory failure, contralateral pneumothorax, early extubation failure (rescue with continuous positive airway pressure, non-invasive ventilation, invasive mechanical ventilation, or reintubation), acute respiratory distress syndrome, pulmonary infection, bronchopleural fistula, and pleural empyema. Due to trial setting, data obtained in the operating and postoperative rooms for routine monitoring were not blinded. At 24 h, data were acquired by an investigator blinded to group allocation. All analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT03182062, and is complete. Between Sept 11, 2018, and June 14, 2022, we enrolled 1380 patients, of whom 1308 eligible patients (670 [434 male, 233 female, and three with missing data] assigned to iOLA and 638 [395 male, 237 female, and six with missing data] to standard lung-protective ventilation) were included in the final analysis. The proportion of patients with the composite outcome of severe postoperative pulmonary complications within the first 7 postoperative days was lower in the iOLA group compared with the standard lung-protective ventilation group (40 [6%] vs 97 [15%], relative risk 0·39 [95% CI 0·28 to 0·56]), with an absolute risk difference of -9·23 (95% CI -12·55 to -5·92). Recruitment manoeuvre-related adverse events were reported in five patients. Among patients subjected to lung resection under one-lung ventilation, iOLA was associated with a reduced risk of severe postoperative pulmonary complications when compared with conventional lung-protective ventilation. Instituto de Salud Carlos III and the European Regional Development Funds.

High-flow nasal cannula use in pediatric patients for other indications than acute bronchiolitis—a scoping review of randomized controlled trials

The objective of the study is to summarize current literature on high-flow nasal cannula (HFNC) use for different indications in pediatric patient excluding acute bronchiolitis and neonatal care. The study design is a systematic scoping review. Pubmed, Scopus, and Web of Science databases were searched in February, 2023. All abstracts and full texts were screened by two independent reviewers. Randomized controlled trials focusing on HFNC use in pediatric patients (age < 18 years) were included. Studies focusing on acute bronchiolitis and neonatal respiratory conditions were excluded. Study quality was assessed by Cochrane risk of bias 2.0 tool. The main outcomes are patient groups and indications, key outcomes, and risk of bias. After screening 1276 abstracts, we included 22 full reports. Risk of bias was low in 11 and high in 5 studies. We identified three patient groups where HFNC has been studied: first, children requiring primary respiratory support for acute respiratory failure; second, perioperative use for either intraprocedural oxygenation or postoperative respiratory support; and third, post-extubation care in pediatric intensive care for other than postoperative patients. Clinical and laboratory parameters were assessed as key outcomes. None of the studies analyzed cost-effectiveness.Conclusion: This systematic scoping review provides an overview of current evidence for HFNC use in pediatric patients. Future studies should aim for better quality and include economic evaluation with cost-effectiveness analysis.Protocol registration: Protocol has been published https://osf.io/a3y46/.What is Known:• High flow nasal cannula has been effective in acute bronchiolitis and neonatal respiratory care.• The use of HFNC on other conditions is also common and increasing, but the evidence supporting this has not been previously summarized.What is New:• We found that HFNC has been studies in relatively few studies in children for other indication than bronchiolitis.• We indetified three main patient populations for which HFNC has been studied: perioperative patients, postintubation patients in intensive care units, and as primary support in acute respiratory failures. None of the studies have estimated possible cost-effectiveness of HFNC, compared to alternative strategies.

Impact of Preemptive Postoperative Pressure Support Ventilation and Physiotherapy on Postoperative Pulmonary Complications after Major Cervicofacial Cancer Surgery: A before and after Study.

Introduction: Complex cervicofacial cancer surgery with free flap reconstruction is known to have a high incidence of postoperative pulmonary complications (PPCs). We hypothesized that by implementing an optimized respiratory protocol, including preemptive postoperative pressure support ventilation, physiotherapy, and critical respiratory support and follow-up, we could decrease the incidence of PPCs. Patients and methods: We evaluated the incidence of PPCs over two periods in two groups of patients having a routine or optimized postoperative respiratory protocol: 156 adult patients undergoing major cervicofacial cancer surgery were assessed; 91 were in Group 1 (routine) and 65 were in Group 2 (optimized). In Group 1, no ventilatory support sessions were performed. The incidence of pulmonary complications in both groups was compared using a multivariate analysis. Mortality was also compared until one year postoperatively. Results: In Group 2 with an optimized protocol, the mean number of ventilatory support sessions was 3.7 ± 1 (minimum 2, maximum 6). The incidence of respiratory complications, which was 34% in Group 1 (routine), was reduced by 59% OR = 0.41 (0.16; 0.95), p = 0.043) to 21% for the optimized Group 2. No difference in mortality was found. Conclusions: The present retrospective study showed that using an optimized preemptive respiratory pressure support ventilation combined with physiotherapy after a major cervicofacial surgery could possibly help reduce the incidence of pulmonary complications. Prospective studies are needed to verify these findings.

Magnetic Resonance Imaging-Based Evaluation of Anatomy and Outcome Prediction in Infants with Esophageal Atresia

Introduction: There is currently no validated diagnostic modality to characterize the anatomy and predict outcomes of tracheal esophageal defects, such as esophageal atresia (EA) and tracheal esophageal fistulas (TEFs). We hypothesized that ultra-short echo-time MRI would provide enhanced anatomic information allowing for evaluation of specific EA/TEF anatomy and identification of risk factors that predict outcome in infants with EA/TEF. Methods: In this observational study, 11 infants had pre-repair ultra-short echo-time MRI of the chest completed. Esophageal size was measured at the widest point distal to the epiglottis and proximal to the carina. Angle of tracheal deviation was measured by identifying the initial point of deviation and the farthest lateral point proximal to the carina. Results: Infants without a proximal TEF had a larger proximal esophageal diameter (13.5 ± 5.1 mm vs. 6.8 ± 2.1 mm, p = 0.07) when compared to infants with a proximal TEF. The angle of tracheal deviation in infants without a proximal TEF was larger than infants with a proximal TEF (16.1 ± 6.1° vs. 8.2 ± 5.4°, p = 0.09) and controls (16.1 ± 6.1° vs. 8.0 ± 3.1°, p = 0.005). An increase in the angle of tracheal deviation was positively correlated with duration of post-operative mechanical ventilation (Pearson r = 0.83, p < 0.002) and total duration of post-operative respiratory support (Pearson r = 0.80, p = 0.004). Discussion: These results demonstrate that infants without a proximal TEF have a larger proximal esophagus and a greater angle of tracheal deviation which is directly correlated with the need for longer post-operative respiratory support. Additionally, these results demonstrate that MRI is a useful tool to assess the anatomy of EA/TEF.

The cardioprotective and anti-inflammatory effect of inhaled nitric oxide during Fontan surgery in patients with single ventricle congenital heart defects: a prospective randomized study

BackgroundFontan surgery with cardiopulmonary bypass (CPB) causes tremendous systemic stress and inflammatory responses, affecting postoperative organ function, morbidity, and mortality. Although this reaction triggers partially protective anti-inflammatory responses, it is harmful in patients with single ventricle congenital heart defects. Despite decades of research, an effective anti-inflammatory and stress defense strategy is lacking. This study investigated the influence of inhaled nitric oxide (NO) during CPB on early clinical results, including the duration of postoperative respiratory support as a primary outcome and a panel of laboratory analytes.MethodsIn this study, 115 patients were randomized to the Fontan-NO group (n = 48) and the Fontan group (n = 49). Eighteen patients were excluded from the study. The Fontan-NO group received NO inhaled directly into the oxygenator during CPB. Clinical data were collected, and blood samples were drawn for analysis at repeated intervals. Multiplex assays were used to analyze a proteome profile of molecules involved in stress response, inflammation, metabolic reactions, as well as heart and lung protection.ResultsFontan-NO patients had significantly shorter respiratory support time with a median of 9.3 h (7.0; 13,2) vs 13.9 h (3.7; 18.5) by the absolute difference of 4.6 h [95% confidence interval, − 30.9 to 12.3; (p = 0.03)]. In addition, they have a shorter time in intensive care (p = 0.04) and lower pulmonary artery pressure after CPB discontinuation (p = 0.04), 4 h (p = 0.03) and 8 h (p = 0.03) after surgery. Fontan-NO patients also had a lower concentration of lactates (p = 0.04) and glucose after separation from CPB (p = 0.02) and lower catecholamine index (p = 0.042). Plasma factors analysis has shown a significantly higher concentration of interleukin-10, and a lower concentration of interleukin-6, interleukin-8, interleukin-1β, pentraxin, matrix metalloproteinase-8, troponin-I, creatine kinase myocardial band (CK-MB), and insulin in Fontan-NO group.ConclusionsNO inhaled into the oxygenator during CPB can improve short-term clinical outcomes. It shortens intubation time and intensive care time. It reduces inflammatory response, improves myocardial and lung protection, and diminishes metabolic stress in patients with a single ventricle undergoing Fontan surgery.Trial registration number: The trial was preregistered, supervised, and supported by The Polish National Science Center (NCN/01/B/NZ5/04246).

Врожденный лордоз и лордосколиоз: состояние проблемы (обзор литературы)

the dorsal part of the vertebrae and normal growth of the ventral part. The most common nosological variant of the defect is lordoscoliotic deformity of the thoracic spine, which often occurs due to syndromic defects (spondylocostal dysostosis) and systemic diseases of the musculoskeletal system (arthrogryposis). Along with the vertebral syndrome, the pathological complex in congenital lordosis of the thoracic or thoracolumbar spine includes thoracic insufficiency syndrome, which in the overwhelming cases leads to the development of respiratory failure caused by bronchial obstruction. The purpose of the study is to summarize information and analyze literature data on a rare pathology of the spine, which is clinically manifested by the formation of thoracic lordosis due to congenital anomaly in the development of the vertebrae. Materials and methods An analysis of the literature on the diagnosis and treatment of congenital lordosis and lordoscoliosis in children was carried out. The depth of the search was more than 100 years. Inclusion criteria: presence of lordotic deformity of the thoracic, cervicothoracic or thoracolumbar spine. Results and discussion Respiratory failure in this group of patients develops due to reduction in the anteroposterior size of the chest (an increase in the chest penetration index), a decrease in the height of the thoracic spine, changes in the mechanics of rib movements, bronchial obstruction, worsening ventilation and perfusion on the convex side of the deformity. The leading component of disability and impairment of the quality of life of patients is respiratory failure syndrome. A decrease in lung function, primarily due to reduction in VC, is directly proportional to the magnitude of the deformation of the spine and chest. Surgical correction of spinal and chest deformity is the main component of treatment for this group of patients. Surgical treatment consists in the mandatory multilevel mobilization of all three columns of the spine (preferably combined access) and bilateral resection of the ribs to reduce chest rigidity. Postoperative respiratory support is critical in respiratory failure. Conclusion Congenital spinal deformities in the form of thoracic lordosis and lordoscoliosis are extremely rare. The key aspects of treatment are the fight against respiratory failure and the selective choice of surgical technologies for deformity correction with a trend towards simultaneity of interventions. The literature review confirmed the insufficient knowledge on the issues of this pathology.

263. EFFECTS OF PREHABILITATION AND POST-OPERATIVE HIGH-FLOW NASAL CANNULA AFTER OPEN ESOPHAGECTOMY ON PULMONARY COMPLICATIONS: A FEASIBILITY STUDY

Abstract Pulmonary complications (PPC) are still reported in 30% of patients also after minimally-invasive esophagectomy in high volume centers. 1–2. Prehabilitation programs are promising in ERAS protocols. 3 Open esophagectomy (OE) has the lowest anastomotic leakage rate but higher PPC.4,5. The combination of pre-habilitation and the application of High-Flow Nasal Cannula (HFNC) after OE has not been investigated yet. This is a feasibility study evaluating a pre-habilitation program and the post-operative application of HFNC on PPC after OE. We prospectively included patients undergoing OE from May 2021 to February 2022. A preoperative multimodal prehabilitation program was applied to all patients. Within 4 hours after surgery, patients were extubated and put under HFNC (50–60 lt/min with FIO2 0.4, humidifier temperature at 34°C) for the following 5 days. Chest physiotherapist applied daily post-operative respiratory exercise to all patients. Hospital stay outcomes, feasibility of HFNC and PPC were recorded by 30 days after surgery. We compared this group with an historic cohort (January 2016–March 2021) where HFNC was not applied to determine differences in baseline characteristics and post-operative complications. We included 45 patients for the final analysis, 12 in the HFNC and 33 in the historic cohort. Baseline characteristics comparisons are shown in table 1. No interruption of post-operative HFNC was recorded due to patient’s complain. PPC in the two groups were statistically comparable. No adverse event was related to HFNC application. The overall leakage rate was 9%. A prehabilitation program and HFNC use after OE seems feasible, safe and well tolerated by patients. PPC were lower in the treatment group without statistically significant difference. Pneumonia was recorded in less than 20% of patients; in the study group there weren’t severe pulmonary complications (ARDS, reintubations). HFNC looks like an interesting tool for post-operative respiratory support. Larger randomized controlled trials should be designed to evaluate HFNC efficacy after esophagectomy.

Mandibular Distraction in Neonatal Pierre Robin Sequence: Is Immediate Extubation Both Feasible and Safe?

The timing of extubation following placement of mandibular distractors in the setting of Pierre Robin sequence is variable across institutional algorithms. Postoperative maintenance of intubation allows for an improvement in airway dimension and tongue positioning before extubation, theoretically decreasing the impact of postoperative airway edema. Maintenance of intubation, however, is not without risk. The authors analyze their institutional experience with neonatal mandibular distraction followed by immediate extubation to assess feasibility and safety profiles. A 4-year retrospective review of patients diagnosed with Pierre Robin sequence who underwent mandibular distraction within the first 3 months of life was performed. Patients intubated preoperatively were excluded. Fifty-two patients met inclusion criteria. Thirty-eight patients (73 percent) were extubated immediately, whereas 14 patients (27 percent) remained intubated. No differences between these groups were found when comorbidities, cleft pathology, preoperative respiratory support, or grade of view on direct laryngoscopy were analyzed. Case duration greater than 120 minutes, operation start time after 3 pm, and the subjective designation of a difficult airway by the anesthesiologist were associated with maintaining intubation (p < 0.05). Eight patients (21 percent) in the extubated group required an increase in respiratory support in the postoperative interval. Four of these patients (11 percent) required reintubation. Increased postoperative respiratory support was more likely in patients with certain comorbidities and higher preoperative respiratory support requirements (p < 0.05). The authors' data suggest that immediate extubation following neonatal mandibular distraction is feasible in patients who are not intubated preoperatively. Careful consideration should be given to patients who require significant respiratory support preoperatively and in those with certain comorbidities. Therapeutic, III.

A Protocol for Propofol-Infusion Drug-Induced Sleep Endoscopy.

The objective of this study was to outline a protocol utilizing propofol infusion without an initial bolus during drug-induced sleep endoscopy (DISE). We define normative values for final propofol infusion rate (Pfinal ) during DISE and sedation depth values at Pfinal . Retrospective chart review. Tertiary academic hospital. A review of patients with obstructive sleep apnea who underwent DISE between 2016 and 2020 was performed. The following patient data were recorded: demographics; DISE procedure details, including Pfinal , time to Pfinal , frequency and cadence of infusion rate changes, depth of sedation as measured by Bispectral Index and SedLine values, and hemodynamics; and polysomnography details including apnea-hypopnea index severity and minimum oxygen saturation. A mixed linear model adjusted for age and body mass index was performed for the analysis of effects on Pfinal . Pearson correlation coefficients determined the strength of association between depth of sedation measured and pattern of collapse on DISE and Pfinal . There were 246 patients who met inclusion criteria. Pfinal resembled a normal distribution (mean ± SD, 156.44 ± 26.69 mcg/kg/min; median, 150 mcg/kg/min). Analysis demonstrated that Pfinal was influenced by male sex, current smoker status, time to Pfinal , and number of propofol dose changes (P < .05). Depth of sedation categories measured differently between Bispectral Index and SedLine (55-65 vs 45-55, P < .001). The pattern including severity of collapse on DISE was not associated with Pfinal (P > .05). No patients required intra- or postoperative respiratory support beyond oxygen via nasal canula. We describe a propofol slow-infusion DISE protocol that demonstrates safe and reproducible outcomes.

Does a prenatal diagnosis affect mortality and morbidity for neonatal arterial switch operation.

The effect of prenatal diagnosis on prognosis in patients with transposition of the great arteries is not clear. In this study, we compared the outcomes after arterial switch operation. Outcome of 112 patients who had arterial switch operation in the neonatal period were analysed. The patients were divided into two groups: those who had prenatal diagnosis (Group 1; n = 34) and those who did not (Group 2; n = 78). The patients were also classified based on their diagnosis: simple transposition, transposition with ventricular septal defect and/or aortic arch hypoplasia, and Taussig-Bing anomaly. In Group 1, the C-section delivery rate was higher (82% vs. 44%; p = 0.004), and it was observed that patients in Group 1 were more often intubated upon admission to the neonatal ICU (38% vs. 9%; p = 0.005). No differences were found between the two groups in terms of operation time, cardiopulmonary bypass time, post-operative invasive respiratory support duration, or extracorporeal membrane oxygenation support. It was observed that those who had Taussig-Bing anomaly had a higher mortality. Timely treatment have a positive effect on neonatal mortality and morbidity. That's why all families with prenatal diagnosis of critical CHD should be recommended to have the delivery in a tertiary care hospital. Although it could not be demonstrated in this study, prenatal diagnosis has a potential to improve surgical results especially in countries or cities, which does not have enough resources for transfer and surgical units. Further efforts are needed to improve prenatal screening programmes.

Cardiac Postoperative Use of High-Flow Nasal Cannula: A Retrospective Single-Center Study

We aimed to investigate the risk factors and reason for initiation of high-flow nasal cannula (HFNC), its benefit on re-intubation rate, mortality, and length of stay (LOS) in the postoperative cardiac surgery patient in the ICU. Methods: In a retrospective and descriptive study, 200 patients, who underwent cardiac surgery, were randomly included, and screened for initiation of postoperative respiratory support. Demographic patient data and pre-operative patient measurements were sampled. Data concerning the P/F ratio at arrival- and post-extubation, LOS at ICU and overall mortality were sampled. A comparison of those variables was performed between patients with and without need of respiratory support. Results: HFNC was initiated in approximately 22.45% in 2018, and 25% in 2020, of the patients. Comparing both years didn’t reveal a significant rise, but we saw a quicker use of HFNC in 2020. The all-case re-intubation rate and mortality was approximately 3%. The body mass index (BMI) was the only correlation with a higher chance of initiation of HFNC. Other data like age, pre-operative renal- or left ventricle function didn’t show a correlation. Conclusion: In case of respiratory insufficiency in the postoperative cardiac surgery setting, HFNC is a worthy first line treatment option which is initiated if conventional oxygen therapy doesn’t suffice. The mortality was low, and the mean LOS was 4.38 days. If respiratory support was started with HFNC mean LOS rose to 8.35 days. The BMI seems to have a correlation with the development of respiratory failure, which confirms the latest recommendation to start preventive HFNC in the post-extubation cardiac surgery setting and which could be implemented in the daily practice.

One-Stage Hybrid Total Aortic Arch and Descending Thoracic Aortic Repair is a Safe and Secure Procedure With Less Postoperative Complications for Extended Aortic Arch Aneurysms

Purpose Hybrid aortic arch repair (HAR) has been implemented for extended aortic arch and descending thoracic aortic disease since 2012 in our institution. This study aimed to estimate the early and mid-term efficacy and safety of HAR. Materials and Methods From 2007 to 2019, 56 patients underwent HAR for extended aortic arch disease, and 75 patients underwent total arch replacement (TAR) for arch-limited disease. HAR comprises 3 procedures: replacement of the aorta, reconstruction of all arch vessels, and thoracic endovascular aortic repair (TEVAR) from zone 0 to the descending aorta after cardiopulmonary bypass is off in 1 stage. The type II-1 HAR procedure, in which the ascending aorta and aortic arch distal to the brachiocephalic artery are replaced, was the most frequently selected procedure (40/56 patients). The outcomes of the type II-1 HAR procedure were compared with those of TAR using the Cox regression analysis. Results The median follow-up period was 36 months. In HAR, the operative mortality, in-hospital mortality, and postoperative permanent neurological deficits were not observed. The paraplegia rate was 1.8%. TEVAR-related complications occurred in 3 patients. Among the patients with non-ruptured atherosclerotic aortic arch aneurysm (31 type II-1 HAR patients and 36 TAR patients, the postoperative respiratory support time in those who underwent type II-1 HAR was quicker than in those who underwent TAR (p<0.01). The rate of 6 year freedom from all-cause death in type II-1 HAR (83.1%) was numerically higher than that in TAR (74.7%), and the rate of 6 year freedom from surgery-related complications in type II-1 HAR (90.3%) was numerically lower than that in TAR (96.9%) due to the occurrence of TEVAR-related complications, and the rate of 6 year freedom from reintervention to the descending thoracic aorta in type II-1 HAR (100%) seemed to be better than that in TAR (83.7%). However, Cox regression analysis did not reveal any statistical difference between the 2 procedures. Conclusions HAR, especially the type II-1 procedure, can treat extended aortic arch disease with acceptable survival outcomes. The development of TEVAR technology will further improve the outcomes of HAR in the future.

Abstracts of the Annual Congress 2021 23‐24 September 2021, virtual conference

COVID-19 has led to a reduction in beds for elective surgery requiring postoperative level 2 or 3 care such as those undergoing pancreatoduodenectomy (PD) [1]. A post-anaesthetic care unit (PACU) has been established to deliver level 2 care for up to 23 h in order to reduce the requirement for critical care services. The aim of this study is to identify factors associated with successful discharge from PACU to the ward after PD surgery. Methods We conducted a single-centre retrospective observational study that utilised a prospectively maintained database of patients undergoing PD from December 2019 to January 2020. Data regarding duration of postoperative respiratory, cardiovascular and renal support requirements, epidural status and comorbidity details were obtained. These were compared between PD alone, PD with vein resection, PD and visceral resection and PD with arterial resection. Patients were categorised as 'suitable for PACU' if they met all of the pre-specified criteria: (1) inotropic support for ≥ 20 h, (2) no respiratory support and (3) no renal support. Binomial logistic regression was used to determine the suitability for PACU using gender, age, body mass index (BMI), Charlson Comorbidity Index (CCI), epidural status, Surgical Outcome Risk Score (SORT) and length of operation as independent variables of interest. Results There were 175 patients, of which 86 (49%) were categorised as 'suitable for PACU' after PD. Suitability for PACU was more likely with shorter operating times (p < 0.001), but less likely for male patients (p = 0.003) and with epidural analgesia (p = 0.002). PD with venous resection patients had a longer period of postoperative inotropy compared with those without venous resection. Discussion The high incidence of patients requiring organ support beyond 23 h suggests that PACU admission for PD patients will require a modification of current practice. It may not be appropriate to admit PD with venous resection to PACU. Epidural analgesia may not be appropriate for patients going to PACU, but further investigations are required to determine optimal analgesic solutions [2].

Factors Associated with Respiratory Support after Cesarean Hysterectomy

Background: Cesarean hysterectomy is a major operation that causes massive hemorrhage and larger fluid resuscitation. Thus, postoperative mechanical ventilation support is required in some patients, involving longer hospital stay and high cost of hospital care. Objective: To find the predictive factors for postoperative respiratory support in pregnant women underwent cesarean hysterectomy. Materials and Methods: A retrospective review of patients underwent cesarean hysterectomy between January 2014 and June 2019 was conducted. Patient characteristics, anesthetic records and hospital length of stay were reviewed. The relationship between factors and postoperative mechanical ventilator (PMV) was also analyzed. Results: A total of 180 patients were included in the present study, wherein, 64 patients (35%) required PMV and 30 patients (16%) needed postoperative oxygen support. Multivariable logistic regression was used to identify the relationship between PMV and the associated factors. The authors found the American Society of Anesthesiologists (ASA) classification and the volume of intraoperative blood components replacement (packed red blood cells [PRC] and fresh frozen plasma [FFP]) were significantly related to PMV: ASA3 16.51 (95% CI 1.89 to 144.33), ASA4 183.25 (95% CI 2.92 to 11,500.65), p=0.003; PRC 1.0028 (95% CI 1.0008 to 1.0047), p=0.001; FFP 1.0022 (95% CI 1.0000 to 1.0043), p=0.029, respectively. Conclusion: Postoperative mechanical ventilation was found in one-third of the cesarean hysterectomy patients and associated with ICU admission along with increased in post-operative length of hospital stay. The ASA classification and intraoperative volume of blood components replacement were significantly associated with PMV. Factors associated significantly with respiratory support were ASA classification and duration surgery. Keywords: Factors associated; Respiratory support; Cesarean hysterectomy

1509. Impact of Respiratory Viral Infection on Outcomes of Congenital Heart Repair Surgery

BackgroundRespiratory viral infections are common in the pediatric population and can range from mild to life-threatening. Given the risk factors that accompany these infections, some pediatric cardiothoracic surgeons in the United States avoid performing surgery for patients with congenital heart disease when there is a possibility of concurrent viral respiratory illness. Studies in this patient population have been limited either by small study populations, or a study focus that is too narrow. The impact of respiratory infections on patient outcomes based on previous literature is also unclear.MethodsThis retrospective chart review study aimed to compare outcomes after congenital heart repair surgery in patients with positive respiratory viral testing to those with negative testing over a five-year period, to determine if there are significant differences related to post-operative hospital course or morbidity.Patient Inclusion Flowchart ResultsThis study included 120 patients, of whom 43 tested positive for respiratory viruses and 77 tested negative. Patients were additionally divided based on the presence or absence of symptoms of respiratory infection, with 79 patients demonstrating respiratory symptoms and 41 who did not. Results demonstrate that negative respiratory viral testing is associated with a significant increase in post-operative ICU LOS (p = 0.01), hospital LOS (p < 0.01), and duration of post-operative respiratory support (p < 0.01), compared to positive testing. Additionally, an absence of respiratory symptoms at the time of testing was associated with a significant increase in post-operative ICU LOS (p = 0.01) and hospital LOS (p < 0.01), compared to patients who were symptomatic.Outcomes by Positive vs. Negative FilmArray Outcomes by Symptomatic vs. Asymptomatic ConclusionThese results suggest that negative respiratory viral testing or lack of respiratory infectious symptoms should not be a reassuring factor in patients scheduled for repair of congenital heart disease, and positive testing does not appear to result in worse outcomes after surgery. Based on this data, we would recommend that respiratory viral testing should not be a routine component of preoperative planning for patients scheduled to undergo congenital heart repair surgery, which would reduce the burdens of unnecessary testing and delays in definitive heart repair.Disclosures All Authors: No reported disclosures

Risk factors for respiratory failure after heart surgery

IntroductionStudy of risk factors for prolonged mechanical ventilation and causes of respiratory failure after heart surgery with cardiopulmonary bypass.MethodsTo identify risk factors for postoperative respiratory failure, an analysis of 1,440 medical histories of cardiac surgery patients operated on in 2016 was carried out (a retrospective monocenter study). The selected medical histories were divided into the study group (with duration of hospitalization after surgery in the postoperative ICU of more than 2 days) and the control group (with duration of hospitalization in ICU less than one day). Patients of the study group were divided into 2 subgroups (with duration of CPB more than 90 minutes andless than 90 minutes). A separate statistical analysis of the effect of concomitant pathology on the duration of postoperative mechanical ventilation was performed.ResultsThe most frequent pulmonary complication after heart surgery was atelectasis (39%). A significant increase in the duration of postoperative mechanical ventilation and hospitalization in ICU is associated with both comorbidities (arterial hypertension and cerebrovascular disease) and the duration of cardiopulmonary bypass more than 90 minutes. The cardiopulmonary bypass lasting more than 90 minutes requires reliable greater infusion load during the surgery, which led to an increase in the duration of postoperative mechanical ventilation and deterioration of oxygenation. These factors increase the duration of treatment in the intensive care unit.DiscussionConservative infusion therapy may reduce the duration of postoperative respiratory support. Study of risk factors for prolonged mechanical ventilation and causes of respiratory failure after heart surgery with cardiopulmonary bypass. To identify risk factors for postoperative respiratory failure, an analysis of 1,440 medical histories of cardiac surgery patients operated on in 2016 was carried out (a retrospective monocenter study). The selected medical histories were divided into the study group (with duration of hospitalization after surgery in the postoperative ICU of more than 2 days) and the control group (with duration of hospitalization in ICU less than one day). Patients of the study group were divided into 2 subgroups (with duration of CPB more than 90 minutes andless than 90 minutes). A separate statistical analysis of the effect of concomitant pathology on the duration of postoperative mechanical ventilation was performed. The most frequent pulmonary complication after heart surgery was atelectasis (39%). A significant increase in the duration of postoperative mechanical ventilation and hospitalization in ICU is associated with both comorbidities (arterial hypertension and cerebrovascular disease) and the duration of cardiopulmonary bypass more than 90 minutes. The cardiopulmonary bypass lasting more than 90 minutes requires reliable greater infusion load during the surgery, which led to an increase in the duration of postoperative mechanical ventilation and deterioration of oxygenation. These factors increase the duration of treatment in the intensive care unit. Conservative infusion therapy may reduce the duration of postoperative respiratory support.

Minimally Invasive Aortic Valve Replacement on Minimally Invasive Extracorporeal Circulation: Going beyond Aesthetics

We present our multidisciplinary and multistep strategy in patients undergoing minimally invasive aortic valve replacement (mAVR) on minimally invasive extracorporeal circulation (MiECC) compared with control groups of a single strategy and conventional techniques. This cohort study included high-risk patients (Society of Thoracic Surgeons [STS] risk score &gt;8%) undergoing aortic valve surgery under different strategies during the period from January 2017 until March 2019. Patients were matched for age, gender, body mass index, and STS score: group 1 (MiAVR) based on a minimally invasive technique with J-mini-sternotomy, rapid deployment valve (RDV), and type IV customized MiECC; group 2 (control-mAVR) consisted of minimally invasive technique with only J mini-sternotomy and RDV on a conventional extracorporeal system; group 3 (control-MiECC): full sternotomy and type IV customized MiECC; and group 4 (control): full sternotomy on a conventional extracorporeal system. The MiAVR group had significantly less duration of x-clamp time (35.4 ± 11 minutes), postoperative respiratory support (4.1 ± 1 hour), postoperative hemorrhage (250 ± 50 mL), and intensive care unit stay (1 ± .5 days) than the control-conventional (group 4) group. Seventy-six percent of patients did not receive any blood products in MiAVR (p = .025 vs. group 4). Incidence of atrial fibrillation (8%) and low cardiac output (14%) in MiAVR were significantly better than control. Critics of minimally invasive techniques sustain that potential advantages are offset by a longer cross-clamp and cardiopulmonary bypass duration, which may translate into inferior clinical outcomes. We advocate that our multidisciplinary approach supported by multiple technologies may be associated with faster recovery and superior outcomes than conventional minimally/conventional techniques.