Prolonged Postoperative Intensive Care Research Articles

Risk factors associated with prolonged intensive care unit stay following surgery for total anomalous pulmonary venous connection: a retrospective study

BackgroundProlonged intensive care unit (ICU) stays consume medical resources and increase medical costs. This study identified risk factors associated with prolonged postoperative intensive care unit (ICU) stay in children with total anomalous pulmonary venous connection (TAPVC).MethodsThe medical records of 85 patients who underwent surgical repair of TAPVC were retrospectively analyzed. The patients were divided into prolonged-stay and standard-stay groups. The prolonged stay group included all patients who exceeded the 75th percentile of the ICU stay duration, and the standard stay group included all remaining patients. The effects of patient variables on ICU stay duration were investigated using univariate and logistic regression analyses.ResultsPatient median age was 41 (18–103) days, and median weight was 3.80 (3.30–5.35) kg.Postoperative duration of ICU stay was 11–68 days in the prolonged stay group (n = 23) and 2–10 days in the standard stay group (n = 62). Lower preoperative pulse oximetry saturation (SpO2), higher intraoperative plasma lactate levels, and prolonged postoperative mechanical ventilation were independent risk factors for prolonged ICU stay. Preoperative SpO2 < 88.5%, highest plasma lactate value > 4.15 mmol/L, and postoperative mechanical ventilation duration was longer than 53.5 h, were associated with increased risk of prolonged ICU stay. Young age, low body weight, subcardiac type, need for vasoactive drug support, emergency surgery, long anesthesia time, low SpO2 after anesthesia induction, long cardiopulmonary bypass (CPB) and aortic clamp times, high lactate level, low temperature, large volume of ultrafiltration during CPB, large amounts of chest drainage, large red blood cells (RBCs) and plasma transfusion, and postoperative cardiac dysfunction may be associated with prolonged ICU stay.ConclusionsLower preoperative SpO2, higher intraoperative plasma lactate levels, and prolonged postoperative mechanical ventilation were independent risk factors for prolonged ICU stay in children with TAPVC. When SpO2 was lower than 88.5%, the highest plasma lactate value was more than 4.15 mmol/L, and the postoperative mechanical ventilator duration was longer than 53.5 h, the risk of prolonged ICU stay increased. Improved clinical management, including early diagnosis and timely surgical intervention to reduce hypoxia time and protect intraoperative cardiac function, may reduce ICU stay time.

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.

Using Revolution™ CT Angiography to Assess Complex Coarctation of the Aorta in Infants and Its Association with a Prolonged Postoperative Cardiac ICU Stay.

To investigate the accuracy of aortic dimensions measured by Revolution™ computed tomography (CT) in infants with complex coarctation of the aorta (CoA) and to further analyze the utility of the degree of CoA in predicting the risk of prolonged postoperative cardiac intensive care unit stay. A total of 30 infants with complex CoA who underwent surgical correction from January 2020 to July 2022 were retrospectively enrolled. General demographic data, preoperative imaging, and perioperative outcomes were collected. Univariate and multivariate analyses were performed to investigate predictors of prolonged postoperative cardiac intensive care unit stay, and the reliability of the CT measurements was assessed by the intraclass correlation coefficient. All infants were divided into a mild or severe CoA group. The duration of mechanical ventilation and cardiac intensive care unit stay in the mild CoA group were significantly lower than those in the severe CoA group. After multivariate analysis, we found that the degree of CoA and age at surgery were significant predictors of prolonged postoperative cardiac intensive care unit stay. The intraclass correlation coefficient between CT measurements and intraoperative measurements was between 0.937 and 0.975, and the measurement results had good reliability. CT angiography can provide a comprehensive and accurate preoperative evaluation of aortic dimensions measured in infants with complex CoA. The degree of CoA is an independent risk factor for prolonged postoperative cardiac intensive care unit stay in infants with complex CoA.

Postoperative prolonged mechanical ventilation correlates to poor survival in patients with surgically treated spinal metastasis.

Patients with spinal metastasis (SM) are at advanced stages of systemic cancer disease. Surgical therapy for SM is a common treatment modality enabling histopathological diagnosis and the prevention of severe neurological deficits. However, surgery for SM in this vulnerable patient cohort may require prolonged postoperative intensive care treatment, which could adversely affect the anticipated benefit of the surgery. We therefore assessed postoperative prolonged mechanical ventilation (PMV) as an indicator for intensive care treatment with regard to potential correlations with early postoperative mortality and overall survival (OS). Between 2015 and 2019, 198 patients were surgically treated for SM at the author´s neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 hours. A multivariate analysis was performed to identify pre- and perioperative collectable predictors for 30 days mortality. Twenty out of 198 patients (10%) with SM suffered from postoperative PMV. Patients with PMV exhibited a median OS rate of 1 month compared to 12 months for patients without PMV (p < 0.0001). The 30 days mortality was 70% and after one year 100%. The multivariate analysis identified "PMV > 24 hrs" (p < 0.001, OR 0.3, 95% CI 0.02-0.4) as the only significant and independent predictor for 30 days mortality (Nagelkerke's R2 0.38). Our data indicate postoperative PMV to significantly correlate to high early postoperative mortality rates as well as to poor OS in patients with surgically treated SM. These findings might encourage the initiation of further multicenter studies to comprehensively investigate PMV as a so far underestimated negative prognostic factor in the course of surgical treatment for SM.

Risk Factors for Candidemia After Open Heart Surgery: Results From a Multicenter Case-Control Study.

Background Candida species are among the most frequent causative agents of health care–associated bloodstream infections, with mortality >40% in critically ill patients. Specific populations of critically ill patients may present peculiar risk factors related to their reason for intensive care unit admission. The primary objective of the present study was to assess the predictors of candidemia after open heart surgery.MethodsThis retrospective, matched case–control study was conducted in 8 Italian hospitals from 2009 to 2016. The primary study objective was to assess factors associated with the development of candidemia after open heart surgery.ResultsOverall, 222 patients (74 cases and 148 controls) were included in the study. Candidemia developed at a median time (interquartile range) of 23 (14–36) days after surgery. In multivariable analysis, independent predictors of candidemia were New York Heart Association class III or IV (odds ratio [OR], 23.81; 95% CI, 5.73–98.95; P < .001), previous therapy with carbapenems (OR, 8.87; 95% CI, 2.57–30.67; P = .001), and previous therapy with fluoroquinolones (OR, 5.73; 95% CI, 1.61–20.41; P = .007). Crude 30-day mortality of candidemia was 53% (39/74). Septic shock was independently associated with mortality in the multivariable model (OR, 5.64; 95% CI, 1.91–16.63; P = .002). No association between prolonged cardiopulmonary bypass time and candidemia was observed in this study.ConclusionsPrevious broad-spectrum antibiotic therapy and high NYHA class were independent predictors of candidemia in cardiac surgery patients with prolonged postoperative intensive care unit stay.

Long-term mortality in patients with a prolonged postoperative intensive care unit (PICU) stay

Non-cardiac surgical patients undergoing major surgery are progressively older and with multiple associated comorbidity. A worse baseline status and complicated postoperative course is usually assumed in patients who die in the postoperative intensive care unit (PICU). This study evaluates mortality in patients with prolonged ICU stay and try to identify differences in subjects characteristics and to determine risk factors for mortality among those dying in ICU.

Deep sternal wound infection after coronary artery bypass: How to manage?

Mediastinitis is a devastating sternal wound complication. The aim of this study was to identify the incidence, risk factors, mortality, and different treatment modalities of mediastinitis after isolated coronary artery bypass grafting. From January 2007 to May 2010, 1424 patients who underwent isolated coronary artery bypass grafting were studied retrospectively; 1398 (group 1) had no mediastinitis, and 26 (group 2) developed mediastinitis. The diagnosis and classification of mediastinitis were based on the criteria of the Center for Disease Control and Prevention and the Emory classification, respectively. Multivariate analysis showed only 4 risk factors: diabetes mellitus, obesity, prolonged postoperative intensive care unit stay, and prolonged intubation time. On univariate analysis, female sex, renal failure, and reexploration for bleeding were also significant risk factors. The incidence of mediastinitis (1.83%) and the subsequent mortality rate (7.69%) were comparable to those of previous reports. Early detection and aggressive management of mediastinitis play major roles in decreasing the related mortality and morbidity. The Emory classification with some modification is very helpful in choosing the proper treatment modality.

Survival, Functional Capacity, and Quality of Life after Cardiac Surgery Followed by Long-Term Intensive Care Stay

The rising prevalence of multimorbid patients undergoing cardiac surgery often leads to prolonged postoperative intensive care unit (ICU) treatment. The fate of these patients after discharge is poorly investigated. This study is aimed to assess survival, functional outcome, and quality of life (QOL) in patients after an ICU stay of at least 5 days. Between August 2009 and July 2010, 1,092 patients underwent various cardiac procedures. Of these patients, 119 required ICU treatment of at least 5 days. Preoperative characteristics as well as postoperative course were analyzed and the discharged patients were contacted after 1 year to gain information about survival, functional capacity, and QOL. European system for cardiac operative risk evaluation I of the patients was 22.3 ± 16.7. Mean ICU stay was 19 ± 20 days. Forty three patients (36.1%) died in the hospital, 1-year overall survival was 46.2%, and 1-year survival of the discharged patients was 72.4%. Barthel mobility index was 85, showing a satisfactory mobilization. QOL, assessed with short form 12 questionnaire, was comparable with the reference group. Long-term ICU treatment after cardiac surgery is related to a high in-hospital and follow-up mortality. The physical and psychological recovery of the survivors is encouraging, justifying the extensive engagement of hospital resources.

Right ventricular stroke work index as a negative predictor of mortality and initial hospital stay after lung transplantation

Studies have shown that patients with poor pre-lung transplant (LTx) right ventricular (RV) function have prolonged post-operative ventilation time and intensive care stay as well as a higher risk of in-hospital death. RV stroke work index (RVSWI) calculates RV workload and contractility. We hypothesized that patients with higher RV workload capacity, indicated by higher RVSWI, would have better outcomes after LTx. A retrospective record review was performed on all LTx patients between 2005 and 2011 who had right heart catheterizations (RHC) 1-year before LTx. In addition, results for echocardiograms and cardiopulmonary exercise testing within 1-year of RHCs were gathered. Mean RVSWI was 9.36 ± 3.59 for 115 patients. There was a significant relation between mean pulmonary artery pressure (mPAP), RVSWI, RV end-diastolic diameter (RVEDd), left atrial dimension (LAD), peak and resting pressure of end-tidal carbon dioxide, minute ventilation /volume of carbon dioxide production, and 1-year mortality after LTx. Contrary to our hypothesis, those who survived had lower RVSWI than those who died within 1 year (8.99 ± 3.38 vs 11.6 ± 4.1, p = 0.026). Hospital length of stay significantly correlated with mPAP, RVSWI, left ventricular ejection fraction, percentage of fractional shortening, RVEDd, RV fractional area change, LAD, and RV wall thickness in diastole. Intensive care length of stay also significantly correlated with these variables and with body mass index. RVSWI was significantly different between groups of different RV function, indicating that increased RVSWI is associated with impairment of RV structure and function in patients undergoing LTx evaluation. This study demonstrates an association between 1-year mortality, initial hospital and intensive care length of stay, and pre-LTx RVSWI. Increased mPAP is a known risk for outcomes in LTx patients. Our findings support this fact and also show increased mortality with elevation of RVSWI, demonstrating the value of RV function in the assessment of risk for pre-LTx patients.

Functional status and survival after prolonged intensive care unit stay following cardiac surgery†

The clinical outcomes of patients discharged after prolonged postoperative intensive care unit (ICU) stay following cardiac surgery are unclear. The aim of this study was to assess survival and functional status in patients whose ICU stay exceeded 5 or 10 days in a tertiary cardiac surgical unit. Patients undergoing adult cardiac surgery between October 2008 and October 2010 who stayed in an ICU for 5-10 days (Group A) or >10 days (Group B) were studied. Demographics, operative details and postoperative data were prospectively collected. The follow-up of all patients was performed by telephone questionnaire. Functional status was assessed using the Karnofsky performance score by only one investigator for uniformity of scoring. For those patients who could not be contacted, the electronic patient records and data from the UK Office for National Statistics were reviewed to determine mortality. Between 2008 and 2010, 2250 patients underwent adult cardiac surgery. Of these, 108 (4.7%) patients stayed >5 days (Group A, n = 53 and Group B, n = 55) in the ICU, having undergone various adult cardiac surgical procedures. The mean logistic EuroSCORE was 13 (range 1.5-86) for Group A and 16 (range 1-78) for Group B (P = 0.11). The mean ICU stay was 7 (range 6-8 days) for Group A and 21 (range 10-78 days) for Group B. Death in ICU occurred in 7 (13%) Group A patients and 11 (20%) Group B patients (P = 0.34). The median follow-up of patients who survived to the hospital discharge was 30 (range 13-38 months). Of the 90 survivors discharged from the hospital, there were 13 (25%) late deaths in Group A and 26 (47%) in Group B (P = 0.02). All survivors were contacted for the assessment of their functional status. The mean Karnofsky scores for Group A and Group B were 87 (range 70-100%) and 77.3% (range 40-100%), respectively, indicating satisfactory functional status. Patients who have a prolonged ICU stay following cardiac surgery have high early and late mortalities. However, the functional status of the survivors is satisfactory after 1 year and beyond.

‘FREEDOM’ trial: Have the interventional cardiologists lost their freedom?

‘FREEDOM’ trial: Have the interventional cardiologists lost their freedom?

Preoperative Intraaortic Balloon Pump for Off-Pump Coronary Arterial Revascularization

Prophylactic intraaortic balloon pump (IABP) support showed better outcomes in critical patients undergoing coronary revascularization compared with intraoperative or postoperative insertion. We conducted a prospective, randomized study to determine the optimal timing for preoperative IABP insertion in high-risk patients undergoing off-pump coronary artery revascularization. The study enrolled 230 consecutive high-risk patients (having a logistic European System for Cardiac Operative Risk Evaluation score of ≥10) undergoing off-pump coronary artery revascularization. They were randomized for preoperative IABP starting at 2 hours (2T, n=115) or 12 hours (12T, n=115). Clinical, biochemical, and hemodynamic results, and the need for inotropic drug support, were markers of outcome and compared between groups. Hospital mortality in group 12T was reduced by 60%, but the difference between groups was not statistically significant (hazard ratio, 0.4; 95% confidence interval, 0.1 to 1.5; p=0.1). Twelve hours of preoperative IABP therapy reduced postoperative low output syndrome (hazard ratio, 0.4; 95% confidence interval, 0.1 to 0.9; p=0.03) and biomarker leakage upper normal limit (hazard ratio, 0.3; 95% confidence interval, 0.1 to 0.7; p=0.001). Postoperative left ventricular function was similar between the groups. Group 2T patients required higher inotropic support for a longer average duration and prolonged postoperative intensive care unit and hospital length of stay. Twelve hours preoperative IABP therapy improved treatment efficacy. Postoperative morbidity was reduced, but hospital mortality rate was not affected. The IABP-related complication rate was low and not related to the length of treatment.

Invited Commentary

Invited Commentary

Survival and Quality of Life in Cardiac Surgery Patients With Prolonged Intensive Care

The clinical outcome in discharged cardiac surgery patients after prolonged postoperative intensive care needs further investigation. The aim was to study survival, functional status, and quality of life in cardiac surgery patients with more than 10 days postoperative intensive care unit stay. We performed a population-based study including 4,086 cardiac surgery patients and identified 141 patients who had a postoperative intensive care unit stay of more than 10 days. Data regarding patients and outcome were collected, and all discharged patients alive in May 2008, or a family member, were contacted to assemble information regarding functional status and quality of life using the Karnofsky performance scale and the Short Form-36 questionnaire. Early mortality was 33%. Risk factors for early mortality were advanced age and postoperative dialysis. Survival at 1, 3, and 5 years was 62%, 56%, and 52%, respectively. Ninety-five patients were discharged from the hospital, and during a mean follow-up of 1.9 years, 62% were readmitted at least once. In discharged patients, 65% had a Karnofsky score of 80 or more. We found significantly lower physical (39.7 versus 43.6; p = 0.03), and mental (44.1 versus 50.8; p = 0.001) scores in the study group compared with a reference group. Early mortality was high, especially in patients who required dialysis. However, long-term survival and functional status were encouraging. Quality of life was worse compared with the general population in both physical and mental aspects, but the difference was moderate. Extensive efforts in this patient group seem reasonable despite high resource utilization.

Long-term survival and quality of life of patients with prolonged postoperative intensive care unit stay: Unmasking an apparent success

Our objective was to evaluate the long-term survival and quality of life of patients who faced a prolonged (>10 days) postoperative stay in the intensive care unit and were discharged from the hospital. Among 3125 consecutive patients who underwent cardiac operations in a 5-year period, we prospectively identified 57 who faced a prolonged postoperative intensive care unit stay and were discharged alive from the hospital. Patients were enrolled in a prospective follow-up protocol and evaluated every 6 to 12 months both clinically and instrumentally. Mean intensive care unit stay was 34 +/- 9 days (range 11-141 days). Follow-up was complete and mean follow-up time was 71 months. Overall survival was 12 (21%) of 57, and the majority of follow-up deaths were cardiac related. Of the surviving patients, only a small minority (4/12) regained full autonomy and returned to their previous lifestyle. Risk factors for prolonged intensive care unit stay were age, New York Heart Association/Canadian Cardiovascular Society class, hypertension, diabetes, low ejection fraction, aortic surgery, preoperative renal failure, nonelective surgery, prolonged cardiopulmonary bypass time, and perioperative use of aortic counterpulsator. Patients who face a prolonged postoperative intensive care unit stay and who were discharged from the hospital have a very poor long-term outcome and even worse quality of life. These data lead to a consideration of the wisdom of using heroic treatment in patients who face a prolonged postoperative intensive care unit stay in view of the dismal clinical results and enormous use of hospital and human resources.

Successful percutaneous pulse spray thrombolysis of extensive acute portocaval hemitransposition thrombosis

We report a case of extensive acute thrombosis of portal vein and cava in a portocaval hemitransposition liver graft that was treated successfully with percutaneous pulse spray thrombolysis through a femoral vein access. The patient subsequently developed descending and sigmoid colon ischemic necrosis because of the venous thrombosis necessitating emergency colon resection. The patient had prolonged postoperative intensive care stay, but was eventually discharged in a good condition with normal liver function. Three month follow up demonstrated persistent normalization of hepatic function and normal duplex ultrasound.

Effects of prolonged intensive care unit stay on quality of life and long-term survival after transthoracic esophageal resection

There are few prospective data on the effects of prolonged intensive care unit stay on the quality of life and long-term survival of a homogeneous patient population. Therefore, the aims of this prospective study were a) to describe the quality of life in patients after having a transthoracic esophageal resection; and b) to analyze the influences of a prolonged intensive care unit stay on quality of life and survival in patients after esophageal cancer resection who survived to hospital discharge. Prospective study. Medical center. The study population consisted of 109 patients undergoing a transthoracic resection for adenocarcinoma of the middistal esophagus or gastric cardia between April 1994 and February 2000. None. A comparison was made between patients staying <or=5 days vs. >or=6 days in the intensive care unit and also <or=2 days vs. >or=14 days. Quality of life was assessed in all patients by mailed self-report questionnaires at baseline (preoperatively), at 5 wks, and at 3, 6, 9, 12, 18, 24, 30, and 36 months after surgery. Daily physical, emotional, and social functioning was assessed with the generic Medical Outcome Studies Short Form-20. Disease-specific quality of life was measured by an adapted Rotterdam Symptom Check List. Quality of life data were gathered between July 1994 and March 2003. Five of the 109 patients died in the hospital and were excluded from the analysis. All five of them were in the intensive care unit >or=6 days. Of the remaining 104 patients, 92 provided baseline scores. The data of the 92 patients were used for the quality of life analyses. For the clinicopathologic and survival analysis, the data of 104 hospital survivors were used. Patients spent a median of 5.5 days (range 0-71) in the intensive care unit. The Medical Outcome Studies Short Form-20 and the Rotterdam Symptom Check List measurements showed no clear differences in long-term quality of life between patients after a short vs. a prolonged postoperative intensive care unit period. The median overall survival in all patients was 2.0 yrs (range 0.1-8.0). Median overall survival in patients staying in the intensive care unit <or=5 days was 1.9 yrs (range 0.3-7.4 yrs) vs. 2.7 yrs (range 0.9-7.2 yrs) in patients staying >or=6 days (p = .9, log-rank test). Median overall survival in patients staying in the intensive care unit <or=2 days was 1.7 yrs (range 1.2-2.6 yrs) vs. 2.0 yrs (range 0.2-3.8 yrs) in patients staying >or=14 days (p = .74, log-rank test). For patients who survived to hospital discharge after transthoracic esophagectomy, there was no difference in long-term quality of life or survival between those submitted to the intensive care unit for a short period vs. a long period.

EuroSCORE Predicts Intensive Care Unit Stay and Costs of Open Heart Surgery

Background This study aimed to determine whether the preoperative risk stratification model EuroSCORE predicts the different components of resource utilization in open heart surgery. Methods Data for all adult patients undergoing heart surgery at the University Hospital of Lund, Sweden, between 1999 and 2002 were prospectively collected. Costs were calculated for the surgery and intensive care and ward stay for each patient (excluding transplant cases and patients who died intraoperatively). Regression analysis was applied to evaluate the correlation between EuroSCORE and costs. The predictive accuracy for prolonged postoperative intensive care unit (ICU) stay was assessed by the Hosmer-Lemeshow goodness-of-fit test. The discriminatory power was evaluated by calculating the areas under receiver operating characteristics curves. Results The study included 3,404 patients. The mean cost for the surgery was $7,300, in the ICU $3,746, and in the ward $3,500. Total cost was significantly correlated with EuroSCORE, with a correlation coefficient of 0.47 ( p < 0.0001); the correlation coefficient was 0.31 for the surgery cost, 0.46 for the ICU cost, and 0.11 for the ward cost. The Hosmer-Lemeshow p value for EuroSCORE prediction of more than 2 days' stay in the ICU was 0.40, indicating good accuracy. The area under the receiver operating characteristics curve was 0.78. The probability of an ICU stay exceeding 2 days was more than 50% at a EuroSCORE of 14 or more. Conclusions In this single-institution study, the additive EuroSCORE algorithm could be used to predict ICU cost and also an ICU stay of more than 2 days after open heart surgery.

Determinants of the need for intensive care and prolonged mechanical ventilation in patients undergoing bariatric surgery.

Bariatric surgery at the upper extremes of weight can be associated with serious postoperative complications. In many cases, these complications will require the availability of critical care resources. The purpose of this study is to examine factors that increase the likelihood for prolonged postoperative intensive care unit (ICU) and extended mechanical ventilation (MV) >24 hours. A retrospective chart review was conducted of all patients undergoing bariatric surgery over a 7-year period at a tertiary care academic institution. There were 250 total patients undergoing either vertical banded gastroplasty (n=15) or Roux-en-Y gastric bypass (n=235). Age, Gender, BMI, pulmonary co-morbidity, revisional surgery (previous bariatric operations), and need for reoperation for suspected intra-abdominal complications were examined by univariate and multivariate analyses. Mean age was 43.6+/-10.6 years and mean BMI 56+/-10.6 kg/m2. Pulmonary co-morbidity was present in 123/250 patients (49%), 42/250 (17%) had revisional surgery, and 21/250 (8%) required reoperation. ICU care was required in 60 patients (24%). By univariate analysis, age >50 yrs (P=0.047), male gender (P=0.038), and need for reoperation (P <0.001) were associated with need for ICU. By multivariate analysis, BMI >60 kg/m2, odds ratio (OR) 2.25, 95% confidence Interval (CI) 1.11-4.60, P=0.04, and need for reoperation, OR 39.8, 95% CI 10.41-264.7, P <0.0001, were associated with need for ICU. MV >24 hrs was required in 44 patients (18%). By univariate analysis, BMI >60 kg/m2 (P=0.013), pulmonary co-morbidity (P=0.014), male gender (P =0.029), and reoperation (P <0.0001) were associated with need for MV. By multivariate analysis, BMI >60 kg/m2, OR 3.1, 95% CI 1.44-7.13, P=0.005, and need for reoperation, OR 22.3, 95% CI 7.4-79.2, P <0.0001, were associated with need for MV. Patients who are male, older (>50 yrs), heavier (BMI >60 kg/m2), and who have complications requiring reoperation will likely need intensive care. Additionally, males, heavier patients (BMI >60 kg/m2), pulmonary co-morbidity, and need for reoperation may warrant need for extended MV. Surgeons and hospitals should consider this when planning resources for bariatric surgery programs.

Risk factor analysis of Swedish Left Ventricular Assist Device (LVAD) patients

Background The use of left ventricular assist devices (LVADs) is established as a bridge to heart transplantation. Methods All Swedish patients on the waiting list for heart transplantation, treated with LVAD since 1993 were retrospectively collected into a database and analyzed in regards to risk factors for mortality and morbidity. Results Fifty-nine patients (46 men) with a median age of 49 years (range, 14 to 69 years), Higgins score median of 9 (range, 3 to 15), EuroScore median of 10 (range, 5 to 17) were investigated. Dominating diagnoses were dilated cardiomyopathy in 61% (n = 36) and ischemic cardiomyopathy in 18.6% (n = 11). The patients were supported with LVAD for a median time of 99.5 days (range, 1 to 873 days). Forty-five (76%) patients received transplants, and 3 (5.1%) patients were weaned from the device. Eleven patients (18.6%) died during LVAD treatment. Risk factor analysis for mortality before heart transplantation showed significance for a high total amount of autologous blood transfusions ( p < 0.001), days on mechanical ventilation postoperatively ( p < 0.001), prolonged postoperative intensive care unit stay ( p = 0.007), and high central venous pressure 24 hours postoperatively and at the final measurement ( p = 0.03 and 0.01, respectively). Mortality with LVAD treatment was 18.6% (n = 11). High C-reactive protein ( p = 0.001), low mean arterial pressure ( p = 0.03), and high cardiac index ( p = 0.03) preoperatively were risk factors for development of right ventricular failure during LVAD treatment. Conclusions The Swedish experience with LVAD as a bridge to heart transplantation was retrospectively collected into a database. This included data from transplant and nontransplant centers. Figures of mortality and morbidity in the database were comparable to international experience. Specific risk factors were difficult to define retrospectively as a result of different protocols for follow-up among participating centers.