Prolonged ICU Research Articles

Risk factors, time to onset and recurrence of delirium in a mixed medical-surgical ICU population: A secondary analysis using Cox and CHAID decision tree modeling.

A retrospective secondary analysis of 4,200 patients was collected from two academic medical centers. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in all patients. Univariate and multivariate Cox models, logistic regression analysis, and Chi-square Automatic Interaction Detector (CHAID) decision tree modeling were used to explore delirium risk factors. Increased delirium risk was associated with exposed only to artificial light (AL) hazard ratio (HR) 1.84 (95 % CI: 1.66-2.044, P<0.001), physical restraint application 1.11 (95 % CI: 1.001-1.226, P=0.049), and high nursing care requirements (>8 hours per 8-hour shift) 1.18 (95 % CI: 1.048-1.338, P=0.007). Delirium incidence was inversely associated with greater family engagement 0.092 (95 % CI: 0.014-0.596, P=0.012), low staff burnout and anticipated turnover scores 0.093 (95 % CI: 0.014-0.600, P=0.013), non-ICU length-of-stay (LOS)<15 days 0.725 (95 % CI: 0.655-0.804, P<0.001), and ICU LOS ≤15 days 0.509 (95 % CI: 0.456-0.567, P<0.001). CHAID modeling indicated that AL exposure and age <65 years were associated with a high risk of delirium incidence, whereas SOFA score ≤11, APACHE IV score >15 and natural light (NL) exposure were associated with moderate risk, and female sex was associated with low risk. More rapid time to delirium onset correlated with baseline sleep disturbance (P=0.049), high nursing care requirements (P=0.019), and prolonged ICU and non-ICU hospital LOS (P<0.001). Delirium recurrence correlated with age >65 years (HR 2.198; 95 % CI: 1.101-4.388, P=0.026) and high nursing care requirements (HR 1.978, 95 % CI: 1.096-3.569), with CHAID modeling identifying AL exposure (P<0.001) and age >65 years (P=0.032) as predictive variables. Development of ICU delirium correlated with application of physical restraints, high nursing care requirements, prolonged ICU and non-ICU LOS, exposure exclusively to AL (rather than natural), less family engagement, and greater staff burnout and anticipated turnover scores. ICU delirium occurred more rapidly in patients with baseline sleep disturbance, and recurrence correlated with the presence of delirium on ICU admission, exclusive AL exposure, and high nursing care requirements.

Clinical Outcomes of Adult Living Donor Liver Transplantation in High MELD Recipients: A Systematic Review and Meta-Analysis

Introduction: There is a clear survival advantage of living donor liver transplantation (LDLT) over waiting for deceased donor liver transplantation (DDLT) for patients with low Model for End-Stage Liver Disease (MELD) score. Results from several centers suggest that the outcomes following LDLT in patients with high-MELD(HM) and low-MELD(LM) are comparable. The aim of study was to verify this observation by performing a meta-analysis of available literature to determine patient survival and graft survival and postoperative outcomes. Methods: Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for literature published between 1990-2021. Ten studies with 2,183 LDLT recipients were identified (N=490 HM group and N=1,693 LM group) and meta-analysis was performed using RevMan 5.3 and STATA/SE-16. Results: Patients in the HM group had comparable mortality at 1, 3 and 5 years post-transplant compared to patients LM group (5-year Hazard Ratio(HR)1.19; 95%CI 0.79-1.79; P-value 0.40). Graft survival was also comparable (5-year HR1.08; 95%CI 0.72-1.63; P-value 0.71.) No statistically significant difference was observed in terms of major morbidity, hepatic artery thrombosis, biliary complications, intraabdominal bleeding, wound infection and rejection. However, HM group had statistically significant higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay(Figure 1, Table 1). Conclusions: HM patients submitted to LDLT had overall comparable survival, graft survival and major morbidity rate compared to LM group despite higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.Tabled 1FP13-4Table1 Post transplant outcomesA. OutcomesOdds ratio95%CIP-valueI2 (%)Major morbidity1.530.92-2.540.10$41%Hepatic artery thrombosis1.180.52-2.670.70$0%Biliary complications1.060.72-1.570.75$14%Wound infections1.460.51-4.240.48$0%Intraabdominal bleeding1.870.98-3.540.06$0%Pulmonary infections2.071.05-4.080.04**40%Abdominal fluid collections2.261.21-4.240.01**0%B. OutcomesMean difference95%CIP-valueI2 (%)Length of ICU stay1.140.43-1.840.00∗∗29%Strength: I2 --Mild to moderate heterogeneity, $: non-significant difference or comparable outcomes, *: significant difference Open table in a new tab Strength: I2 --Mild to moderate heterogeneity, $: non-significant difference or comparable outcomes, *: significant difference

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity. The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces. Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions. This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

Managing subglottic stenosis with Montgomery tube - Our experience.

The purpose of this retrospective study is to evaluate the outcome of Montgomery T-tube insertion in our institution (AIIMS, Raipur). This study also throws light on its indications and complications. This is a retrospective study of 10 patients who presented with laryngotracheal stenosis and managed by Laryngofissure with Montgomery Tube insertion in the Department of Otorhinolaryngology, Head and Neck Surgery atAll India Institute of Medical Sciences (AIIMS) Raipur, India, during the period of January 2018- JUNE 2020. The most common cause of laryngotracheal stenosis was prolonged intubation as seen in 80% patients.Majority of patients (40%) in this study were in the 3rd decade. In this study all the patients underwent tracheostomy prior to treatment for stenosis. The most common complication seen was surgical emphysema in post-operative period seen in 6 patients (60%) followed by crusting in 4 patients (40%), secondary granulation tissue formation in 4 patients (40%). Montgomery tube reinsertion had to be done in 2 patients (20%). Laryngotracheal stenosis (LTS) has always been and will remain a challenge to the otolaryngologistsand a multidisciplinary approach is required to tackle it.A multitude of surgeries have been described for the management of Laryngotracheal stenosis ranging from Endoscopic dilatation and cricotracheal resection with anterior and posterior grafting and anastomosis but many of them require specialized training and expertise,prolonged ICU care and have morbidity and mortality. 'Laryngofissure and Montgomery Tube stenting provides a safe and easy treatment option which can be done at most centres provided appropriate case selection has been done.

Unvaccinated Non-Elderly Adult Population Hospitalized for COVID-19: Risk for Severe Disease and Poor Outcomes.

Introduction:Vaccination offers significant protection against hospitalization and death due to severe COVID-19. However, a significant portion of the nonelderly U.S. adult population remains unvaccinated.Methods:This retrospective analysis of adult patients aged under 65 years hospitalized with PCR-confirmed SARS-CoV-2 between March and November 2021 assessed the age-biased risk for severe disease and outcome in non-elderly unvaccinated adults hospitalized for COVID-19. Main measures included predisposing risk factors, disease severity and progression, and outcomes in non-elderly adults compared between (1) vaccinated and unvaccinated individuals and (2) unvaccinated individuals grouped by 10-year age increment.Results:Two hundred nineteen non-elderly adults were included; of whom, 82.6% were unvaccinated. Overall, unvaccinated patients were more likely to be obese (60% vs 29%, P < .001) while vaccinated patients were more likely to have cardiovascular disease (50% vs 29%, P = .03). Unvaccinated individuals had prolonged ICU stay (11 vs 2 days, P = .002) and overall length of stay (6 vs 5 days, P < .0001), and higher proportion requiring oxygen at discharge (54% vs 29%, P < .0001). An age-stratified analysis of the unvaccinated cohort found that the time to discharge increased with age (P = .003). Compared to unvaccinated patients aged <46 years, unvaccinated patients aged ≥46 years demonstrated 1.47- and 3.49-times higher likelihood of oxygen dependency upon discharge (P = .002) and requiring higher level of care or worse at discharge (P = .004), respectively.Conclusion:Results from our non-elderly cohort affirm the benefit of vaccination despite a subset requiring hospitalization for breakthrough infection. In unvaccinated non-elderly adults, risk for worse outcomes and severe disease increased substantially from middle age onward and provides strong support for vaccination efforts in this population.

Thoracoabdominal Aneurysms—Operative Steps for Crawford Extent II Repair

Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA), aiming to replace the whole length of the diseased distal aorta while protecting the spinal cord and visceral organs to limit ischemia-related complications. This surgery carries significant risks, including death, paraplegia, renal failure requiring permanent dialysis and respiratory complications leading to prolonged ICU stay, but these still outweigh the natural history of TAAA with conservative treatment. We describe in detail our current approach to open extent II TAAA repair by a step-by-step illustration of the technique and the surgical adjuncts. We routinely use left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor-evoked potentials (MEPs), cerebral, paraspinal and lower limbs oxygen saturations by near-infrared spectrometry as well as selective visceral perfusion via the coeliac, superior mesenteric and renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft and when possible and we selectively reattach one or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in absence of a significant reduction on the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft. Favorable early outcomes and a durable repair can be achieved at experienced high-volume centers, with standardized pre-operative selection and multidisciplinary team based intraoperative and postoperative management of these patients. Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA), aiming to replace the whole length of the diseased distal aorta while protecting the spinal cord and visceral organs to limit ischemia-related complications. This surgery carries significant risks, including death, paraplegia, renal failure requiring permanent dialysis and respiratory complications leading to prolonged ICU stay, but these still outweigh the natural history of TAAA with conservative treatment. We describe in detail our current approach to open extent II TAAA repair by a step-by-step illustration of the technique and the surgical adjuncts. We routinely use left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor-evoked potentials (MEPs), cerebral, paraspinal and lower limbs oxygen saturations by near-infrared spectrometry as well as selective visceral perfusion via the coeliac, superior mesenteric and renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft and when possible and we selectively reattach one or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in absence of a significant reduction on the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft. Favorable early outcomes and a durable repair can be achieved at experienced high-volume centers, with standardized pre-operative selection and multidisciplinary team based intraoperative and postoperative management of these patients.

Triage and monitoring of COVID-19 patients in intensive care using unsupervised machine learning

BackgroundWe designed an algorithm to assess COVID-19 patients severity and dynamic intubation needs and predict their length of stay using the breathing frequency (BF) and oxygen saturation (SpO2) signals. MethodsWe recorded the BF and SpO2 signals for confirmed COVID-19 patients admitted to the ICU of a teaching hospital during both the first and subsequent outbreaks of the pandemic in France. An unsupervised machine-learning algorithm (the Gaussian mixture model) was applied to the patients' data for clustering. The algorithm's robustness was ensured by comparing its results against actual intubation rates. We predicted intubation rates using the algorithm every hour, thus conducting a severity evaluation. We designed a S24 severity score that represented the patient's severity over the previous 24 h; the validity of MS24, the maximum S24 score, was checked against rates of intubation risk and prolonged ICU stay. ResultsOur sample included 279 patients. . The unsupervised clustering had an accuracy rate of 87.8% for intubation recognition (AUC = 0.94, True Positive Rate 86.5%, true Negative Rate 90.9%). The S24 score of intubated patients was significantly higher than that of non-intubated patients at 48 h before intubation. The MS24 score allowed for the distinguishing between three severity levels with an increased risk of intubation: green (3.4%), orange (37%), and red (77%). A MS24 score over 40 was highly predictive of an ICU stay greater than 5 days at an accuracy rate of 81.0% (AUC = 0.87). ConclusionsOur algorithm uses simple signals and seems to efficiently visualize the patients' respiratory situations, meaning that it has the potential to assist staffs' in decision-making. Additionally, real-time computation is easy to implement.

Clinical presentation and management of leuconostoc bacteremia in patient with prolonged ICU stay: Case report

A 54 years old female came to emergency with the complaints of pain in abdomen, recurrent vomiting, abdominal distention and not able to pass flatus since two days. Patient was managed in intensive care unit and was empirically put on Meropenem and Targocid. She developed multiple episodes of loose motion, and stool culture was sent which was positive for Clostridium defficle. Therefore, patient was put on Vancomycin and Metrogyl. The blood cultures reported growth of Leuconostoc pseudomesenteroides. Infection with Leuconostoc may cause fever, intravenous catheter-related sepsis, bacteremia, abdominal pain, gastroenteritis, colitis or meningitis. To summarize this rare organism which is most commonly seen in immunocompromised patients, was isolated in a previously healthy individual, post Vancomycin therapy with prolonged ICU stays.

Combating a Case of COVID Pneumonia with ARDS – a Physiotherapist’s Standpoint

Introduction: Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus, affecting multiple organ systems. The disease usually presents as mild to moderate respiratory illness but in many cases has progressed to development of pneumonia and ARDS ultimately requiring ventilatory support and prolonged ICU stay. Prolonged immobilization itself is a harbinger of various complications drastically altering a patient’s functional status. Physiotherapy plays a vital role in the management of COVID-19 symptoms as well as in the prevention of complications. &#x0D; Case Study: This case report describes the progress of a 44-year old female patient diagnosed with COVID-19 presenting with subsequent pneumonia and ARDS. The patient was started with medical management and supplemental oxygen therapy. In combination to the above-mentioned protocols, physiotherapy treatment was also initiated. After 2 weeks of rehabilitation and drug therapy, the patient displayed improved respiratory function at room air and was able to independently ambulate with minimal breathing difficulty.&#x0D; Discussion: This case report aims to highlight the importance of early intervention of physiotherapy in COVID-19 patients. The scope of physiotherapy treatment in patients with COVID-19 pneumonia is vast. The treatment protocol adapted for this patient are in tune with the various research articles analysed to ensure evidence-based care. This will enable the healthcare professionals to ensure timely referral and early initiation of Physiotherapy treatment.&#x0D; Conclusion: As per the findings and results of this case report, it is evident that the patient benefited from the timely advent of physiotherapy intervention. The key factor was the correct identification of the problematic areas and accurate prioritization based on the clinical presentation and investigation findings

The Prevalence of Malnutrition and its Impact on Children with Congenital Heart Disease in Post Cardiac Surgery

Background: Children with congenital heart disease (CHD) require adequate nutrition for growth and development. Children with CHD are often malnourished and with dyspnea, leading to failure to thrive. Children with CHD have a high basal metabolic rate leading to high caloric requirement. Objective: To evaluate the prevalence ofmalnutrition and its impact on children with congenital heart disease in post cardiac surgery. Method: This cross-sectional study was carried out at Bangladesh Shishu Hospital and Institute, Bangladesh. Data were collected from January 2019 to January 2020. A total of 40 pediatric patients with CHD admitted for cardiac surgery were included in the study. Sample were collected through purposive sampling as per inclusion criteria. Results: During the study, most of the children belonged to 1 year to 5 years of age group and 60% were male. The nutritional status of the patients before surgery was defined as normal 55%, malnutrition 45%. In malnutrition group heart defect cases was higher than that of normal group. Mean z score for A/W(SEM) was -1.05 in normal group and -3.06 in malnutrition group. Malnourished patients clearly showed a tendency (P=0.005) to have a longer length of intubation, i.e., mean 35.67 hours when compared with those with a normal nutritional status who have mean intubation time of 27.51 hours. The other morbidity factor measured was the length of ICU stay, which also showed a significant result. Conclusion: In Bangladesh, malnutrition is frequent among children with congenital cardiac defects which increases risk of morbidity related with prolonged mechanical ventilation and ICU stays. To minimize potentially harmful effects, the health care system should be able to screen and identify these individuals early on.

Correlation of Serum Albumin Level to Lung Ultrasound Score and Its Role as Predictors of Outcome in Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study.

Background There is ambiguity in the literature regarding hypoalbuminemia as a cause of extravascular lung water and acute respiratory distress syndrome (ARDS) outcomes. The aim of the study was to determine if low serum albumin on admission leads to lung deaeration and higher lung ultrasound score (LUSS) in ARDS patients. Patients and Methods. It was a prospective observational study in which 110 ARDS patients aged between 18 and 70 years were recruited. Serum albumin level and lung ultrasound score were assessed on the day of ICU admission. Length of ICU stay and hospital mortality were recorded. Results The mean and standard deviation of serum albumin level in mild, moderate, and severe ARDS was 2.92 ± 0.65 g/dL, 2.91 ± 0.77 g/dL, and 3.21 ± 0.85 g/dL, respectively. Albumin level was not correlated to the global LUSS (Pearson correlation r −0.006, p=0.949) and basal LUSS (r −0.066, p=0.513). The cut-off value of albumin for predicting a prolonged length of ICU stay (≥10 days) in ARDS patients was <3.25 g/dL with AUC 0.623, p < 0.05, sensitivity of 86.67%, specificity of 45.45%, and 95% confidence interval (CI) [0.513–0.732], and on multivariate analysis it increased the odds of prolonged ICU stay by 8.9 times (Hosmer and Lemeshow p value 0.810, 95% CI [2.760–28.72]). Serum albumin at admission was not a predictor of mortality. LUSS on the day of admission was not useful to predict either a prolonged length of ICU stay or mortality. Basal LUSS contributed about 56% of the global LUSS in mild and moderate ARDS, and 53% in severe ARDS. Conclusion Serum albumin level was unrelated to LUSS on admission in ARDS patients. Albumin level <3.25 g/dL increased the chances of a prolonged length of ICU stay (≥10 days) but was not associated with an increase in mortality. LUSS on the day of admission could not predict either a prolonged length of ICU stay or mortality. This trial is registered with CTRI/2019/11/021857.

291. Epidemiology of Candidemia Rates during COVID-19 and Comparison of Outcomes in Candidemia Between COVID-19 and Non-COVID-19 Patients

BackgroundFungemia is associated with high rates of morbidity, mortality and increase in length of hospital stay. Several studies have recognized increased rates of candidemia since the COVID-19 pandemic. MethodsA retrospective cohort study was conducted at a tertiary healthcare system in Detroit, Michigan to evaluate the impact of the COVID-19 pandemic on incidence of candidemia. The “pre COVID-19” timeframe was defined as January – May 2019 while the “during COVID-19” timeframe was January – May 2020. To compare incidence and patient characteristics between cohorts, t-tests and chi-square analysis was used. Additional sub-analysis was performed in candidemia patients during COVID-19 timeframe comparing outcomes of patients based on COVID-19 status. A Fisher Exact and Satterthwaite Test were used for analysis of categorical and continuous variables, respectively. ResultsOverall, 46 cases of candidemia were identified in both the pre COVID-19 and during COVID-19 periods. Pre COVID-19, the average number of cases was 3.0 ± 1.2 per month. The incidence more than doubled during COVID-19 to 6.2 ± 4.2 cases per month (p = 0.14) (Figure 1). No significant differences in patient demographics were detected between cohorts, however, patients in the COVID-19 cohort had higher rates of corticosteroid use, mechanical ventilation and vasopressors (Table 1). In the 2020 period, 31 patients developed candidemia and 12 (38.7%) patients tested SARS-CoV-2 positive. On average, COVID-19 patients developed candidemia 12.1 days from admission, compared to 17.8 days in the COVID-19 negative cohort (p = 0.340). Additionally, COVID-19 patients with candidemia coinfection were significantly more likely to expire; 83.3% (n=10) COVID-19 patients expired compared to 36.8 (n=7) in the COVID-19 negative cohort (p = 0.025) (Table 2). Figure 1. Incidence of Candidemia in the Pre-COVID-19 (January 2019 – May 2019) and During COVID-19 (January 2020-May 2020) periods Table 1. Characteristics of Candidemia patients in the pre-COVID (January 2019-May 2019) and during-COVID periods (January 2020-May 2020) Table 2. Characteristics of Candidemia patients in the SARS-COV-2 negative and SARS-COV-2 positive cohorts from January 2020-May 2020 ConclusionThe prevalence of fungemia markedly increased during the COVID-19 surge. Increased use of corticosteroids and broad spectrum antimicrobials, prolonged use of central venous catheters and prolonged ICU length of stay likely contributed to this increase. Patients who developed candidemia co-infection with COVID-19 were found to have poorer outcomes as compared to those who were SARS-CoV-2 negative or untested. Disclosures All Authors: No reported disclosures

Incidence and mortality of necrotizing fasciitis in The Netherlands: the impact of group A Streptococcus

BackgroundLittle is known about the exact incidence of necrotizing soft tissue infections. The few incidences reported in international literature are not directly relatable to the Netherlands, or other European countries, due to geographic heterogeneity in causative micro-organisms involved. This resulted in the aim of this study to map the incidence, mortality rate and hospital course of necrotizing fasciitis infections in the Netherlands to gain insight in the incidence of necrotizing fasciitis in the Netherlands and the associated mortality and health care burden.MethodsThis nationwide retrospective database study used three distinct data sources to map the incidence of necrotizing fasciitis in the Netherlands between 2014 and 2019, being data from the Dutch Hospital Data (DHD) foundation, data from Osiris-AIZ, which is a database of notifiable diseases managed by regional Public Health Services (GGD) and the National Institute for Public Health and the Environment (RIVM), and previously published studies on necrotizing fasciitis conducted in the Netherlands.ResultsThe incidence of necrotizing fasciitis in the Netherlands is estimated to be approximately 1.1 to 1.4 cases per 100,000 person years, which corresponds to 193–238 patients per year. Of all necrotizing fasciitis infections, 34 to 42% are caused by the group A Streptococcus. Annually, 56 patients die as a result of a necrotizing fasciitis infection (mortality of 23–29%) and 26 patients undergo an amputation for source control (11–14%). Patients stay a mean of 6 to 7 days at the intensive care unit and have a mean hospital length of stay of 24 to 30 days.ConclusionThe combination of nationwide databases provides reliable insight in the epidemiology of low-incidence and heterogenic diseases. In the Netherlands, necrotizing fasciitis is a rare disease with group A Streptococcus being the most common causative micro-organism of necrotizing fasciitis. The prior Dutch cohort studies on necrotizing fasciitis report slightly higher sample mortality rates, compared to the population mortality. However, necrotizing fasciitis remain associated with substantial morbidity and mortality, risk at amputation and health care burden characterized by prolonged ICU and hospital stay.

Pulmonary Hypertension as a Predictor of Early Outcomes of Mitral Valve Replacement: A Study in Rheumatic Heart Disease Patients.

AimMitral valve pathology in rheumatic heart disease patients is a common cause of secondary pulmonary hypertension (PH). Our aim was to evaluate pulmonary hypertension severity as a predictor of in-hospital mortality and early complications following mitral valve replacement.MethodsA retrospective review of rheumatic heart disease patients who underwent mitral valve replacement between January 2017 and August 2020 was performed. Systolic pulmonary artery pressure (sPAP) was used to classify patients as no PH (<35 mmHg), mild PH (35-44 mmHg), moderate PH (45-59 mmHg) or severe PH (>60 mmHg). Patients subjected to additional cardiac procedures (such as aortic valve replacement and coronary artery bypass grafting) were excluded from the study sample.ResultsThe study group was composed of 159 patients (mean age: 40; 73 male, 86 female) categorized as no PH (n = 32; 20.1%), mild PH (n = 14; 8.8%), moderate PH (n = 65, 40.9%) and severe PH (n = 48, 30.2%) groups. Patient demographic data and preoperative comorbidities were comparable among the four groups. Use of intraoperative and postoperative blood products was similar in all the groups. Severe PH patients had similar in-hospital mortality (4.2%; p = 0.74) as in groups with lesser degrees of pulmonary hypertension. Likewise, increasing severity of pulmonary hypertension did not confer any significant increase in early postoperative complications, namely prolonged ICU stay (10.4%; p = 0.41), prolonged ventilation (2.1%; p = 0.70), reintubation (4.2%; p = 0.90), reopening for bleeding tamponade (6.3%; p = 0.39), new-onset renal failure (6.3%; p = 0.91), postoperative stroke (4.2%; p = 0.52) or prolonged length of stay (mean: 5.6 + 2.8 days; p = 0.49).ConclusionsIncreasing severity of pulmonary hypertension does not appear to have a significant impact on in-hospital mortality or early postoperative outcomes of patients undergoing mitral valve replacement.

The effects of supplementary nutrition support (sns) on the physical and functional recovery of covid-19 patients

Rationale: Nutritional insufficiency and decreased muscle mass of patients with COVID-19 leads to prolonged respiratory support, ICU & hospital stay, as well as reduced muscle strength and quality of life after COVID-19. Aim of study was to evaluate effects of SNS on the physical health recovery of COVID-19 patients.

Safety of delivering bronchial thermoplasty in two treatment sessions

BackgroundBronchial thermoplasty (BT) is a novel endoscopic therapy for severe asthma. Traditionally it is performed in three separate treatment sessions, targeting different portions of the lung, and each requires an anaesthetic and hospital admission. Compression of treatment into 2 sessions would present a more convenient alternative for patients. In this prospective observational study, the safety of compressing BT into two treatment sessions was compared with the traditional 3 treatment approach.MethodsSixteen patients meeting ERS/ATS criteria for severe asthma consented to participate in an accelerated treatment schedule (ABT), which treated the whole left lung followed by the right lung four weeks later. The short-term outcomes of these patients were compared with 37 patients treated with conventional BT scheduling (CBT). The outcome measures used to assess safety were (1) the requirement to remain in hospital beyond the electively planned 24-h admission and (2) the need for re-admission for any cause within of 30 days of treatment.ResultsThe total number of radiofrequency activations delivered in the ABT group was similar to CBT (187 ± 21 vs 176 ± 40, p = 0.326). With ABT, 11 in 31 admissions (37.9%) required prolonged admission due to wheezing, compared to 5.4% with CBT (p = 0.0025). The mean hospital length of stay with ABT was 1.8 ± 1.3 days, compared to 1.1 ± 0.4 days (p < 0.001). ICU monitoring was required on 5 occasions with ABT (16.1%), compared to 0.9% with CBT (p = 0.002). Subgroup analysis demonstrated that females were more likely to require prolonged admission (OR 11.6, p = 0.0025). The 30-day hospital readmission rate was similar for both groups (6.4% vs 5.4%, p = 0.67). All patients made a complete recovery after treatment with similar outcomes at the 6-month follow-up reassessment.ConclusionThis study demonstrates that ABT results in greater short-term deterioration in lung function associated with a greater risk of prolonged hospital and ICU stay, predominantly affecting females. Therefore, in females, these risks need to be balanced against the convenience of fewer treatment sessions. In males, it may be an advantage to compress treatment.

The In-hospital Outcome of Ventricular Septal Defect Closure and Predictor of Morbidity and Mortality at Tertiary Level Cardiac Center

Background and Aims: Factors responsible for complications and outcomes of surgical closure of ventricular septal defect differ between different cardiac centers globally. In this study, we tried to evaluate outcomes and predictors of morbidity and mortality of surgical closure of VSD in a single center. Methods: The retrospective cohort study was conducted in Shahid Gangalal National Heart Centre from 14th April 2018 to 13th April 2020. It included consecutive series of patients undergoing ventricular septal defect closure as a primary surgery Results: Out of a total 166 patients, males were 100 (60%). Adverse complications occurred on 36 (21%) with mortality of 6 (3.6%). The age ranged from 4 months to 35 years. The weight &lt;10 kgs at the time of operation had significant post-operative prolong ventilation duration (more than 6 hours) with a p value of 0.012; significant prolong ICU stays (&gt;2 days) with a p value of &lt;0.001; significant prolong hospital stay (&gt; 7 days) with a p value of &lt;0.001. The longer CPB time was associated with significantly prolonged ventilation duration (p value 0.001); significant longer ICU stay (p value 0.02). The age &lt;1 year at the time of operation had significant prolonged ICU stay; significantly prolonged hospital stays (p value of 0.033). Severe pulmonary artery hypertension (PAH) and weight up to 10 kgs at the time of operation demonstrated a trend towards association with mortality. Conclusion: Surgical VSD closure can be done with acceptable level of mortality and morbidity in our context.

COVID-19 associated infections in the ICU setting: A retrospective analysis in a tertiary-care hospital

IntroductionOur work describes the frequency of superinfections in COVID-19 ICU patients and identifies risk factors for its appearance. Second, we evaluated ICU length of stay, in-hospital mortality and analyzed a subgroup of multidrug-resistant microorganisms (MDROs) infections. MethodsRetrospective study conducted between March and June 2020. Superinfections were defined as appeared ≥48h. Bacterial and fungal infections were included, and sources were ventilator-associated lower respiratory tract infection (VA-LRTI), primary bloodstream infection (BSI), secondary BSI, and urinary tract infection (UTI). We performed a univariate analysis and a multivariate analysis of the risk factors. ResultsTwo-hundred thirteen patients were included. We documented 174 episodes in 95 (44.6%) patients: 78 VA-LRTI, 66 primary BSI, 9 secondary BSI and 21 UTI. MDROs caused 29.3% of the episodes. The median time from admission to the first episode was 18 days and was longer in MDROs than in non-MDROs (28 vs. 16 days, p<0.01). In multivariate analysis use of corticosteroids (OR 4.9, 95% CI 1.4–16.9, p 0.01), tocilizumab (OR 2.4, 95% CI 1.1–5.9, p 0.03) and broad-spectrum antibiotics within first 7 days of admission (OR 2.5, 95% CI 1.2–5.1, p<0.01) were associated with superinfections. Patients with superinfections presented respect to controls prolonged ICU stay (35 vs. 12 days, p<0.01) but not higher in-hospital mortality (45.3% vs. 39.7%, p 0.13). ConclusionsSuperinfections in ICU patients are frequent in late course of admission. Corticosteroids, tocilizumab, and previous broad-spectrum antibiotics are identified as risk factors for its development.

Abstract 10428: Bad Fall, Good Catch: Diagnosing a Rare Condition Presenting as Acute Coronary Syndrome

A 72 year-old mountain bicyclist suffered a biking accident. The following week, he presented to the emergency room with abdominal pain, where he was treated for superior mesenteric artery thrombosis and new-onset atrial fibrillation. Two months later, he presented with intermittent left scapular pain that radiated to the chest. Pharmacologic stress testing revealed a large reversible perfusion defect in the anterior wall with an ejection fraction of 41%. Left heart catheterization showed narrowing of the distal left main coronary artery and the proximal left anterior descending (LAD) and circumflex arteries, by what appeared to be external compression. Follow-up CT angiogram demonstrated two sinus of Valsalva aneurysms (SOVA) originating from the left and right coronary cusps. A transesophageal echocardiogram confirmed these findings and showed tremendous thrombus within the larger aneurysm. The patient was admitted to cardiothoracic surgery. Troponin was elevated to 0.16 μg/L, with EKG showing 1 mm ST-segment depressions in V4-6, prompting treatment for a non-ST segment myocardial infarction. He underwent complex surgery involving thrombus extraction and closure of the SOVA with pericardial patch repair, and coronary artery bypass grafting of the LAD and obtuse marginal arteries. After a prolonged ICU course in which the patient was managed for cardiogenic shock, he was discharged to a hospital equipped with a rehabilitation facility. Unfortunately, he developed profound lactic acidosis from ischemic bowel and passed away. SOVA are rare lesions that arise from congenital or acquired etiologies, such as this patient’s biking accident. Multi-modality imaging is important for quantifying size and anatomy. Unruptured SOVA can present as embolic phenomenon from thrombus, valvular regurgitation, or chest pain from compression of the coronary arteries. Rupture is a highly morbid condition, and so urgent referral to cardiothoracic surgery is recommended.

Abstract 12405: Treatment With Impella and Veno-Arterial Extracorporeal Membrane Oxygenation During Extracorporeal Cardiopulmonary Resuscitation Improves Survival - A Multicenter Cohort Study

Introduction: Left ventricular (LV) unloading with Impella has been shown to improve survival in patients with cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). This study aimed to investigate whether treatment with VA-ECMO and Impella (so called “ECMELLA”) during extracorporeal cardiopulmonary resuscitation (i.e., cardiac arrest due to myocardial infarction and no return of spontaneous circulation at device implantation) was associated with improved outcomes. Hypothesis: ECMELLA treatment is associated with improved survival (primary outcome) as well as prolonged hospital and ICU length of stay (secondary outcomes) compared to VA-ECMO treatment. Methods: Cox proportional-hazard and Poisson regression models were used to analyze the association between treatment groups (ECMELLA vs. VA-ECMO) and outcomes. Analyses were adjusted for age, sex, body mass index, type of ECG rhythm (shockable vs. non-shockable), location of cardiac arrest (out of hospital vs. in-hospital) as well as first lactate and pH levels after device implantation. Results: 93 adult patients from three tertiary care centers were included, out of whom 52 (56%) received ECMELLA and 41 (44%) received VA-ECMO treatment. ECMELLA treatment was associated with decreased in-hospital mortality (HR 0.41 [95% CI 0.22-0.79], P=0.007), prolonged hospital (IRR 1.70 [95% CI 1.46-1.98], P&lt;0.001) and ICU length of stay (IRR 1.67 [95% CI 1.42-1.96], P&lt;0.001). Kaplan-Meier analysis confirmed survival benefits in the ECMELLA group (P=0.004, Figure 1). With an exploratory intent, we showed that LV ejection fraction was severely impaired at ICU admission immediately after device implantation (19% ECMELLA vs. 21% ECMO) but improved strongly in ECMELLA group at ICU discharge (38% ECMELLA vs. 31% ECMO). Conclusion: LV unloading in patients treated with VA-ECMO was associated with lower mortality rates during extracorporeal cardiopulmonary resuscitation.