Postoperative Ventilation Research Articles

Bilateral lung transplantation for pediatric pulmonary arterial hypertension: perioperative management and one-year follow-up.

Bilateral lung transplantation (LuTx) remains the only established treatment for children with end-stage pulmonary arterial hypertension (PAH). Although PAH is the second most common indication for LuTx, little is known about optimal perioperative management and midterm clinical outcomes. Prospective observational study on consecutive children with PAH who underwent LuTx with scheduled postoperative VA-ECMO support at Hannover Medical School from December 2013 to June 2020. Twelve patients with PAH underwent LuTx (mean age 11.9 years; age range 1.9-17.8). Underlying diagnoses included idiopathic (n = 4) or heritable PAH (n = 4), PAH associated with congenital heart disease (n = 2), pulmonary veno-occlusive disease (n = 1), and pulmonary capillary hemangiomatosis (n = 1). The mean waiting time was 58.5 days (range 1-220d). Three patients were bridged to LuTx on VA-ECMO. Intraoperative VA-ECMO/cardiopulmonary bypass was applied and VA-ECMO was continued postoperatively in all patients (mean ECMO-duration 185 h; range 73-363 h; early extubation). The median postoperative ventilation time was 28 h (range 17-145 h). Echocardiographic conventional and strain analysis showed that 12 months after LuTx, all patients had normal biventricular systolic function. All PAH patients are alive 2 years after LuTx (median follow-up 53 months, range 26-104 months). LuTx in children with end-stage PAH resulted in excellent midterm outcomes (100% survival 2 years post-LuTx). Postoperative VA-ECMO facilitates early extubation with rapid gain of allograft function and sustained biventricular reverse-remodeling and systolic function after RV pressure unloading and LV volume loading.

Intraoperative fluid administration volumes during pediatric liver transplantation and postoperative outcomes: A multicenter analysis.

Fluid administration is an important aspect of the management of children undergoing liver transplantation and may impact postoperative outcomes. Our aim was to evaluate the association between volume of intraoperative fluid administration and our primary outcome, the duration of postoperative mechanical ventilation following pediatric liver transplantation. Secondary outcomes included intensive care unit length of stay and hospital length of stay. We conducted a multicenter, retrospective cohort study using electronic data from three major pediatric liver transplant centers. Intraoperative fluid administration was indexed to weight and duration of anesthesia. Univariate and stepwise linear regression analyses were conducted. Among 286 successful pediatric liver transplants, the median duration of postoperative mechanical ventilation was 10.8 h (IQR 0.0, 35.4), the median intensive care unit length of stay was 4.3 days (IQR 2.7, 6.8), and the median hospital length of stay was 13.6 days (9.8, 21.1). Univariate linear regression showed a weak correlation between intraoperative fluids and duration of ventilation (r2 = .037, p = .001). Following stepwise linear regression, intraoperative fluid administration remained weakly correlated (r2 = .161, p = .04) with duration of postoperative ventilation. The following variables were also independently correlated with duration of ventilation: center (Riley Children's Health versus Children's Health Dallas, p = .001), and open abdominal incision after transplant (p = .001). The amount of intraoperative fluid administration is correlated with duration of postoperative mechanical ventilation in children undergoing liver transplantation, however, it does not seem to be a strong factor. Other modifiable factors should be sought which may lead to improved postoperative outcomes in this highly vulnerable patient population.

Utility of Pre-operative Glasgow Coma Scale and SKALE Scoring System to Predict need for Post-operative Ventilator Support in Intracranial Tumour Patients

Objective: To evaluate the feasibility of GCS and SKALE in predicting post-operative requirement of ventilator support in intracranial tumour patients. Methods: Seventy patients undergoing intracranial tumour resection surgery were assessed pre-operatively using GCS and SKALE scoring systems to predict their post-operative requirement of ventilator support. The data was analysed using SPSS software and ShapiroWilk test and Chi-Square tests were apllied to compare the obtain data. Results: The study included 70 patients, of whom 88.6% had good GCS of 13-15 and 72.9% had good SKALE score of >8. We found that all patients with poor GCS ≤8 required post -operative ventilator support, while only 4 out 62 patients with GCS 13-15 required ventilator support post-operatively (p value <0.05). Patients with SKALE score ≤8 also had higher incidence of post-operative ventilator requirement (31.6%) as against those with SKALE score >8 (11.8%). Conclusion: GCS is a good predictor of post-operative ventilator requirement. SKALE scoring system requires further studies to prove its utility.

Results of Lung Transplantation for Cystic Fibrosis With Selected Donors Over 65Years Old.

Lung transplantation is limited by the shortage of suitable donors. Many programs have begun to use extended criteria donors. Donors over 65years old are rarely reported, especially for young cystic fibrosis recipients. This monocentric study was conducted for cystic fibrosis recipients from January 2005 to December 2019, comparing two cohorts according to lung donor age (<65years or ≥65years). The primary objective was to assess the survival rate at 3years using a Cox multivariable model. Of the 356 lung recipients, 326 had donors under 65years, and 30 had donors over 65years. Donors' characteristics did not differ significantly in terms of sex, time on mechanical ventilation before retrieval, and partial pressure of arterial oxygen/fraction of inspired oxygen ratio. There were no significant differences in post-operative mechanical ventilation duration and incidence of grade 3 primary graft dysfunction between the two groups. At 1, 3, and 5years, the percentage of predicted forced expiratory volume in 1s (p = 0.767) and survival rate did not differ between groups (p = 0.924). The use of lungs from donors over 65years for cystic fibrosis recipients allows extension of the donor pool without compromising results. Longer follow-up is needed to assess the long-term effects of this practice.

Clinical Observations and Outcomes in Advanced Low-Grade Serous Carcinoma of the Ovary: Case Series from a Tertiary Cancer Center.

Low-grade serous carcinoma (LGSC) is a rare histologic subtype of ovarian cancer. We present detailed management of 15 cases of advanced LGSC from a tertiary cancer center of India. Fifteen cases of advanced LGSC who underwent cytoreductive surgery (CRS) were analyzed from a prospectively maintained database. Baseline demographic characteristics, surgical details, and chemotherapy details were recorded. Descriptive statistics were summarized, and progression-free survival (PFS) and overall survival (OS) were estimated. The median age was 37years. Nine patients had received NACT. All cases were FIGO stage III. Mean PCI was 15. Eleven patients had a completeness of cytoreduction score of 0-1. The median surgical time was 7.5h; nine patients required multiple gastrointestinal resections. Median blood loss was 2500ml. Median postoperative ventilation, ICU stay, and hospital stays were 1, 2, and 16days, respectively. One patient had a grade III complication. Four patients received adjuvant chemotherapy. There was no postoperative mortality at the end of 90days of surgery. All the patients except one were offered hormonal maintenance therapy. At a median follow-up of 43months, 4 patients were disease-free, 9 had a recurrence, one died of disease progression, and one was lost to follow-up. Most recurrences were locoregional in the peritoneal cavity or pelvis. Four-year OS and PFS were 71.8% and 29.7%, respectively. Advanced LGSCs occur mostly in young premenopausal women with favorable oncologic outcomes. Optimal CRS is the mainstay of treatment. Relative chemo-resistance and hormone receptor positivity provide an excellent therapeutic opportunity for endocrine therapy.

PEDS2: Impact of Mechanical Ventilation Duration on Outcomes in Children after Ventricular Assist Device Placement: A linked analysis from the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) and Pediatric Cardiac Critical Care Consortium (PC4) Registries.

Background: Placement of a ventricular assist device (VAD) has improved outcomes in children with advanced heart failure (HF), but adverse events, such as stroke and mortality, remain important consequences. It is unknown what impact prolonged post-operative mechanical ventilation (MV) has on these outcomes. Methods: ACTION and PC4 are audited, comprehensive, encounter-based registries of patient course and outcomes for pediatric HF and pediatric cardiac critical care, respectively. Data from initial VAD placement in each registry from 8/2014-7/2020 were linked using indirect patient identifiers with 98% match concordance. Patient demographics, heart disease, pre- and post-op ICU courses and outcomes were compiled. Descriptive and univariate statistics assessed association of patient factors with prolonged post-op MV. Multivariable logistic regression sought independent associations with outcomes. Results: Overall, 248 ACTION subjects were linked to a matching patient in PC4. Median age was 7.7 years (1.5-15.5), weight 21.3kg (9.1-58), 56% male. Primary diagnosis was congenital heart disease (CHD) in 35%. Pre-VAD variables that independently predicted prolonged post-op MV included age (IRR=0.95 [95%CI: 0.93-0.96], p<0.01); renal dysfunction: eGFR 30-60 (IRR=3.28 [95%CI: 1.11-9.68], p=0.032), eGFR 60-90 (IRR=3.87 [95%CI: 1.35-11.07], p=0.012); pre-op MV within 48 hours (IRR=2.76 [95%CI: 1.59-4.79], p<0.01), 2-7 days (IRR=1.82 [95%CI: 1.15-2.89], p=0.011), and >7days before implant (IRR=2.35 [95%CI: 1.62-3.4], p<0.01); and CHD (IRR=1.96 [95%CI: 1.48-2.59], p<0.01). Each additional day of post-op MV was associated with increased risk of death (OR 1.09 per day, p<0.01) in the full cohort. Association of post-operative MV duration with mortality is presented in Figure 1. By device type, duration of post-op MV had no association with outcomes in extracorporeal devices (n=77), but remained strongly associated with risk of death in intracorporeal devices (n=102) (OR=1.24 [95%CI: 1.04-1.48], p=0.014). Conclusion: There is increased risk of death per day of MV after VAD placement, however, this did not hold true with extracorporeal devices. Further studies are warranted.

A study on the perioperative effects of obesity on minimally invasive coronary artery bypass grafting and its surgical techniques.

The aim of this study was to discuss the perioperative effects of obesity on minimally invasive coronary artery bypass grafting (CABG) and its surgical techniques. A total of 582 patients with multivessel lesion who underwent off-pump CABG by our medical group of Beijing Anzhen Hospital between January 2017 and January 2021 were divided into the minimally invasive cardiac surgery (MICS) group and the conventional group (median sternotomy) according to the surgical method used. The body mass index of the patients was calculated, based on which both groups were divided into obese (≥28 kg/m2) and non-obese subgroups (<28 kg/m2). First, the perioperative data of the obese subgroups of both MICS and conventional groups were compared. Second, the obese and non-obese subgroups were compared in the MICS group. Despite a higher proportion of diabetes in the MICS group, there was no significant difference in preoperative baseline nor in the incidence of major complications within 30 days after surgery between obese subgroups of the MICS and conventional groups. The MICS group had a significantly lower rate of poor wound healing, along with a higher predischarge Barthel Index. Also, the preoperative baseline between the obese and non-obese subgroups of the MICS group exhibited no statistical differences. The obese subgroup had longer postoperative ventilator assistance, while other intraoperative data and postoperative observation indexes exhibited no significant differences. MICS CABG method is safe and feasible for obese patients with multivessel lesion. Minimally invasive surgery is beneficial to wound healing in obese patients. However, it requires a thorough preoperative evaluation and adequate surgical experience and skills.

Pterional Approach for Anterior Skull Base Midline Meningiomas against "The More The Merrier" Approach: An Institutional Experience.

Objective Anterior midline skull base meningiomas involving olfactory groove, planum sphenoidale, and tuberculum sellae were usually managed with bifrontal craniotomy until the dawn of advanced microsurgical techniques. With the emergence of microsurgical techniques, midline meningiomas could be tackled solely from a unilateral pterional approach. We present our experience with pterional approach in managing anterior skull base midline meningiomas, including the technical nuances and outcomes. Methods Fifty-nine patients who underwent excision of anterior skull base midline meningiomas through a unilateral pterional craniotomy between 2015 and 2021 were retrospectively analyzed. The surgical technique and patient outcomes in the context of visual, behavioral, olfaction, and quality of life were evaluated during the follow-up. Results A total of 59 consecutive patients were assessed over an average follow-up period of 26.6 months. Twenty-one (35.5%) patients had planum sphenoidale meningioma. Olfactory groove and tuberculum sellae meningioma groups consist of 19 (32%) patients each. Visual disturbance was the predominant symptom with almost 68% of patients presented with it. A total of 55 (93%) patients had complete excision of the tumor with 40 patients (68%) achieving Simpson grade II excision, and 11 (19%) patients had Simpson grade I excision. Among operated cases, 24 patients (40%) had postoperative edema among which 3 (5%) patients had irritability and 1 patient had diffuse edema requiring postoperative ventilation. Only 15 (24.6%) patients had contusion of the frontal lobe and were managed conservatively. Five patients (50%) with seizures had an association with contusion. Sixty-seven percent of patients had improvements in vision and 15% of patients had a stable vision. Only eight (13%) patients had postoperative focal deficits. Ten percent of patients had new-onset anosmia. The average Karnofsky score was improved. Only two patients had recurrence during follow-up. Conclusion A unilateral pterional craniotomy is a versatile approach for the excision of anterior midline skull base meningioma, even for the larger lesions. The ability of this approach in the visualization of posterior neurovascular structures at the earlier stages of surgery while avoiding the opposite frontal lobe retraction and frontal sinus opening makes this approach more preferable over the other approaches.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study.

A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

Anesthetic Management of Wilms’ Tumor Patient Using Thoracal Epidural Block: A Case Report

Introduction: Wilms’ tumor or nephroblastoma is an embryonal tumor that develops from the remaining immature kidney and is the fourth most common primary renal tumor malignancy in children. An asymptomatic abdominal mass is present in more than 90% and hematuria in 30% of patients. Preoperative workup includes complete laboratory blood tests and imaging to ensure intrarenal mass. This study aimed to describe the anesthetic management of Wilms’ tumor patients.&#x0D; Case presentation: A two-year-old girl was diagnosed with Wilms' tumor with the main complaint of intermittent hematuria. An abdominal CT scan showed an enlargement mass in the right kidney with a size of +/- 7.4 x 5.9 x 9.5 cm. The patient was planned for radical nephrectomy. In addition to general anesthesia, an epidural catheter is placed at the 10th-11th thoracic level (T10-T11).&#x0D; Conclusion: Epidural placement in pediatrics undergoing abdomen surgery have various beneficial considerations, such as superior analgesia, minimal opioid use, reduced intraoperative bleeding, and decreased postoperative ventilator requirements.

Failed Extubation in Neonates After Cardiac Surgery: A Single-Center, Retrospective Study.

To describe factors associated with failed extubation (FE) in neonates following cardiovascular surgery, and the relationship with clinical outcomes. Retrospective cohort study. Twenty-bed pediatric cardiac ICU (PCICU) in an academic tertiary care children's hospital. Neonates admitted to the PCICU following cardiac surgery between July 2015 and June 2018. None. Patients who experienced FE were compared with patients who were successfully extubated. Variables associated with FE ( p < 0.05) from univariate analysis were considered for inclusion in multivariable logistic regression. Univariate associations of FE with clinical outcomes were also examined. Of 240 patients, 40 (17%) experienced FE. Univariate analyses revealed associations of FE with upper airway (UA) abnormality (25% vs 8%, p = 0.003) and delayed sternal closure (50% vs 24%, p = 0.001). There were weaker associations of FE with hypoplastic left heart syndrome (25% vs 13%, p = 0.04), postoperative ventilation greater than 7 days (33% vs 15%, p = 0.01), Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 5 operations (38% vs 21%, p = 0.02), and respiratory rate during spontaneous breathing trial (median 42 vs 37 breaths/min, p = 0.01). In multivariable analysis, UA abnormalities (adjusted odds ratio [AOR] 3.5; 95% CI, 1.4-9.0), postoperative ventilation greater than 7 days (AOR 2.3; 95% CI, 1.0-5.2), and STAT category 5 operations (AOR 2.4; 95% CI, 1.1-5.2) were independently associated with FE. FE was also associated with unplanned reoperation/reintervention during hospital course (38% vs 22%, p = 0.04), longer hospitalization (median 29 vs 16.5 d, p < 0.0001), and in-hospital mortality (13% vs 3%, p = 0.02). FE in neonates occurs relatively commonly following cardiac surgery and is associated with adverse clinical outcomes. Additional data are needed to further optimize periextubation decision-making in patients with multiple clinical factors associated with FE.

The delaying of elective surgeries after COVID-19 infection decreases postoperative complications

Huge controversy surrounds delaying elective surgeries after COVID-19 infection. Although two studies evaluated the issue, several gaps still exist. A propensity score matched retrospective single center cohort design was used to evaluate the optimum time of delaying elective surgeries after COVID-19 infection and the validity of the current ASA guidelines in this regard. The exposure of interest was a previous COVID-19 infection. The primary composite included the incidence of death, unplanned Intensive Care Unit admission or postoperative mechanical ventilation. The secondary composite included the occurrence of pneumonia, acute respiratory distress, or venous thromboembolic. The total number of patients was 774, half of them had a history of COVID-19 infection. The analysis revealed that delaying surgeries for 4 weeks was associated with significant reduction in primary composite (AOR=0.02; 95%CI: 0.00-0.33) and the length of hospital stay (B=3.05; 95%CI: 0.41-5.70). Furthermore, before implementing the ASA guidelines in our hospital, a significant higher risk for the primary composite (AOR=15.15; 95%CI: 1.84-124.44; P-value=0.011) was observed compared to after applying it. Our study showed that the optimum period of delaying elective surgery after COVID-19 infection is four weeks, with no further benefits from waiting for longer times. This finding provide further support to the current ASA guidelines about delaying elective surgeries. Further large-scale prospective studies are needed to give more evidence-based support to the appropriateness of the 4-week waiting time for elective surgeries after COVID-19 infection and to investigate the effect of type of surgery on the required delay.

Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use, ventilation days, and intensive care days

BackgroundIntercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF). MethodsSSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation. Results241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05). ConclusionIntercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.

Postoperative Pulmonary Complications and Perioperative Strategies: A Systematic Review.

The occurrence of postoperative pulmonary complications (PPCs) is frequently observed and has been linked to elevated levels of morbidity and mortality, which have adverse effects on both clinical and financial outcomes in healthcare settings. This systematic review aims to present the evidence that supports our comprehension of PPCs and emphasize the circumstances that necessitate the use of postoperative noninvasive ventilation (PNIV) or re-intubation with postoperative mechanical ventilation (POMV). A search was conducted on the National Library of Medicine's Pubmed database and Cochrane Library until November 29, 2020, to find published reports of randomized control trials (RCTs) that assessed postoperative pulmonary complications. Data related to the prevalence of PPCs and the use of PNIV, POMV, and length of hospital stay were extracted from all the studies. For the analysis, a total of 13 studies involving 6,609 patients were included, and out of these, four RCTsreported statistically significant results. The use of protective lung ventilation (PLV) with low tidal volume and positive end-expiratory pressure (PEEP) during intraoperative ventilation, along with pressure-controlled (PCV) ventilation, as well as the postoperative ventilation strategy of continuous positive airway pressure (CPAP) combined with standard oxygen therapy were the only techniques that demonstrated a clear reduction in the incidence of PPCs. Furthermore, the use of PLV with low tidal volume and PEEP and intraoperative mechanical ventilation with a vital capacity maneuver followed by 10 cm H2O of PEEP were found to decrease the requirement for postoperative noninvasive ventilation. CPAP with standard oxygen therapy was the only intervention that reduced the need for reintubation. Various ventilation strategies are available for both intraoperative and postoperative periods with the goal of decreasing the need for postoperative noninvasive ventilation (PNIV) or re-intubation with postoperative mechanical ventilation (POMV).

Postoperative prolonged mechanical ventilation in patients with surgically treated pyogenic spondylodiscitis: a surrogate endpoint for early postoperative mortality

Surgical procedures with spinal instrumentation constitute a prevalent and occasionally highly indicated treatment modality in patients with pyogenic spondylodiscitis (PSD). However, surgical therapy might be associated with the need of prolonged postoperative intensive care medicine which in turn might impair intended operative benefit. Therefore, we analyzed prolonged mechanical ventilation (PMV) as an indicator variable for such intensive care treatment with regard to potential correlations with mortality in this vulnerable patient cohort. Between 2012 and 2018, 177 consecutive patients received stabilization surgery for PSD at the authors’ neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 h. A multivariable analysis was performed to identify independent predictors for 30-day mortality. Twenty-three out of 177 patients (13%) with PSD suffered from postoperative PMV. Thirty-day mortality rate was 5%. Multivariable analysis identified “spinal empyema” (p = 0.02, odds ratio (OR) 6.2, 95% confidence interval (CI) 1.3–30.2), “Charlson comorbidity index (CCI) > 2” (p = 0.04, OR 4.0, 95% CI 1.0–15.5), “early postoperative complications (PSIs)” (p = 0.001, OR 17.1, 95% CI 3.1–96.0) and “PMV > 24 hrs” (p = 0.002, OR 13.0, 95% CI 2.7–63.8) as significant and independent predictors for early postoperative mortality. The present study indicates PMV to significantly correlate to elevated early postoperative mortality rates following stabilization surgery for PSD. These results might entail further scientific efforts to investigate PMV as a so far underestimated negative prognostic factor in the surgical treatment of PSD.

Factors influencing the need for post operative ventilation in patients with aneurysmal subarachnoid hemorrhage

Introduction: Patients with aneurysmal subarachnoid hemorrhage (aSAH) frequently require monitoring, however planned ventilatory support may not be necessary in the post-operative period. In resource constraints scenarios, reserving an intensive care unit (ICU) bed and ventilator may lead to problems like delay in surgery and definite care. With this study, we aim to identify the factors that influence the need for post-operative ventilation in patients with aSAH. Methodology: A retrospective study over a period of six years of patients who underwent surgical clipping of aneurysm and were not intubated pre-operatively was conducted. Aneurysm was confirmed by Digital Subtraction Angiography (DSA) or Computerized Tomographic Angiography (CTA). Demographic data and clinico-radiological factors like Hunt and Hess grade, Modified Fischers Grade and aneurysm location were collected. Results: Of the 62 patients identified in the study period, 17 patients were excluded as they were intubated in the preoperative period. Of the 45 patients included, there were 15 male patients. Of these only 23 (51.11%) patients failed to be successfully extubated. Clinical factors such as Hunt and Hess score ≥ 3 (p value&lt;0.001), WFNS grade ≥3 (p value&lt;0.001) and intraoperative blood loss ≥ 425 ml (p value=0.001) were associated with higher chances of failure to extubate. Presenting GCS score of ≥14 (p value&lt;0.001) had higher chances of extubation postoperatively. However, radiological factors like Modified Fischers Grade and aneurysm location had no significant association. Conclusion: The demand for post-operative ICU and ventilatory support in aneurysmal SAH is over estimated. Simple clinical factors can better predict the need for post-operative ventilation and reduce the burden of reserving ICU bed.

Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-AGerman nationwide survey study

Malignant middle cerebral artery infarction is apotentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization. This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting. From 20 September 2021 to 31 October 2021, 43members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in astandardized anonymous online survey. Descriptive data analysis was performed. Out of 43centers 29 (67.4%) participated in the survey, including 24university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored astandardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3days in 30.8%, ≤ 5days in 19.2%, > 5days in 15.4%). Early tracheotomy (≤ 7days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14days. Hyperosmolar treatment is used on aregular basis in 53.9% and 22 centers (84.6%) agreed to participate in aclinical trial addressing the duration of postoperative sedation and ventilation. The results of this nationwide survey among neurointensive care units in Germany reflect aremarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. Arandomized trial in this matter seems warranted.

Factors associated with malnutrition in infants with congenital heart disease within one year after surgery

Objective: To explore the risk factors of malnutrition in infants with congenital heart disease within one year after surgery. Methods: This retrospective cohort study selected 502 infants with congenital heart disease who underwent surgical treatment in Guangzhou Women and Children's Medical Center from February 2018 to January 2019. Their basic information and clinical data were analyzed, and their nutrition status after the surgery was followed up by questionnaire survey. Weight-for-age Z score (WAZ)≤-2 one year after operation was defined as malnutrition group, and WAZ>-2 was non-malnutrition group. The perioperative indicators and complementary food advancement were compared between the two groups by chi-square test, t-test, and Kruskal-Wallis test. The risk factors of malnutrition were analyzed by Logistic regression. Results: A total of 502 infants were selected, including 301 males and 201 females, with the age of 4.1 (2.0, 6.8) months. There were 90 cases in malnutrition group and 412 cases in non-malnutrition group. The body length and weight at birth in the malnutrition group were lower than those in the non-malnutrition group ((47.8±3.8) vs. (49.3±2.5) cm, (2.7±0.6) vs.(3.0±0.5) kg, both P<0.001). The proportion of paternal high school education or above and the proportion of family per capita income of 5 000 yuan or above in the malnutrition group were lower than those in the non-malnutrition group ((18.9% (17/90) vs. 30.8% (127/412), 18.9% (17/90) vs. 33.7% (139/412), both P<0.05). Compared to the non-malnutrition group, the proportion of complex congenital heart disease in the malnutrition group was higher (62.2% (56/90) vs. 47.3% (195/412), P<0.05). The postoperative mechanical ventilation time, postoperative intensive care unit (ICU) stay time, postoperative hospital stay, total length of ICU stay and total hospital stay in the malnutrition group were significantly longer than those in non-malnutrition group (all P<0.05). The proportion of egg and fish supplementation over 2 times/week within one year after the surgery was also lower in the malnutrition group (both P<0.05). Logistic regression analysis showed that mother's weight at delivery (OR=0.95,95%CI 0.91-0.99), the pre-operative WAZ≤-2 (OR=6.04, 95%CI 3.13-11.65), the complexity of the cardiac disease (OR=2.23, 95%CI 1.22-4.06), the hospital stay after the surgery over 14 days (OR=2.61, 95%CI 1.30-5.26), the types of complementary food<4 (OR=2.57, 95%CI 1.39-4.76), and the frequency of meat and fish<2 times/week (OR=2.11, 95%CI 1.13-3.93) were the risk factors associated with malnutrition within one year after the surgery. Conclusion: Mother's weight at delivery pre-operative nutritional status, complexity of cardiac disease, postoperative hospital stay, types of daily supplements and frequency of fish are risk factors associated with malnutrition within one year after surgery in children with congenital heart disease.

Comparison of valvuloplasty and replacement for surgical treatment of tricuspid infective endocarditis

BackgroundOwing to the increase in both intravenous drug injections and intracardiac and vascular interventional treatments among drug users, the incidence of infective endocarditis (IE) involving the tricuspid valve, which sits between the two right heart chambers, has gradually increased. This study aimed to compare the clinical outcomes of different surgical procedures for tricuspid infective endocarditis (TIE).MethodsWe retrospectively analyzed fifty-six patients who underwent tricuspid valve surgery at our hospital from January 2006 to August 2019. All patients were diagnosed with TIE and indicated a need for surgery. Perioperative and follow-up data were collected to summarize and analyze the clinical outcomes of different surgical approaches, including tricuspid valvuloplasty (TVP) and tricuspid valve replacement (TVR) for TIE.ResultsCardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, postoperative mechanical ventilation time, and intensive care unit (ICU) stay time were shorter in the TVP group than in the TVR group. Additionally, the incidence of red blood cell transfusion and postoperative complications was lower in the TVP group than in the TVR group. The postoperative 30-day mortality rates were similar between both the groups. Fifty-two patients were followed up for an average of 5.50 ± 3.79 years. The postoperative 3-, 5-, and 7-year survival rates were 100%, 100%, and 95.5% in the TVP group and 96.7%, 96.7%, and 96.7% in the TVR group, respectively. The 5-year and 10-year reoperation rates were 0% and 0% in the TVP group and 6.7% and 20% in the TVR group, respectively.ConclusionBoth TVR and TVP for TIE significantly improved the functional status of the heart with satisfactory efficacy. TVP was found to be superior to TVR in reducing the need for postoperative blood transfusions, reducing the risk of postoperative complications, and reducing the need for long-term reoperations.

Airway Complications after Lung Transplantation-A Contemporary Series of 400 Bronchial Anastomoses from a Single Center.

(1) Objective: To determine whether recent advances in lung transplantation (LT) have reduced the incidence and changed the risk factors for airway complications (AC). (2) Methods: Retrospective analysis of patients receiving a lung transplant between January 2007 and January 2019. An AC was defined as a bronchoscopic abnormality in the airway, either requiring or not requiring an endoscopic or surgical intervention. Both univariable and multivariable analyses were performed to identify risk factors for AC. (3) Results: 285 lung transplants (170 single and 115 bilateral lung transplants) were analysed, comprising 400 anastomoses at risk. A total of 50 anastomoses resulted in AC (12%). There were 14 anastomotic and 11 non-anastomotic stenoses, 4 dehiscences, and 3 malacias. Independent predictors for AC were: gender male (OR: 4.18; p = 0.002), cardiac comorbidities (OR: 2.74; p = 0.009), prolonged postoperative mechanical ventilation (OR: 2.5; p = 0.02), PaO2/FiO2 < 300 mmHg at 24 h post-LT (OR: 2.48; p = 0.01), graft infection (OR: 2.16; p = 0.05), and post-LT isolation of Aspergillus spp. (OR: 2.63; p = 0.03). (4) Conclusions: In spite of advances in lung transplantation practice, the risk factors, incidence, and lethality of AC after LT remains unchanged. Graft dysfunction, an infected environment, and the need of prolonged mechanical ventilation remain an Achilles heel for AC.