Temporal trends in ICU outcomes by BMI: A retrospective propensity-score matched study.

Pediatric Penetrating Trauma Volume and Patient Outcome: A National Trauma Data Bank Study.

Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction that may occur after rapid weight loss or anatomical changes. Patients with Duchenne muscular dystrophy (DMD) are particularly vulnerable due to progressive muscle wasting and scoliosis correction. We report a unique case of recurrent SMA syndrome in a patient with end-stage DMD who required prolonged noninvasive ventilation. After initial nutritional interventions, the patient experienced two recurrences within 15 months. Laparoscopic gastrojejunostomy was safely performed after the second recurrence, despite severely compromised respiratory and cardiac function. This case underscores the importance of early recognition and timely surgical consideration in refractory SMA syndrome, even in patients with advanced neuromuscular disease.

ObjectiveThis study aimed to analyze the correlation between serum levels of Procalcitonin (PCT) and C-reactive protein (CRP) and the occurrence and severity of Bronchopulmonary Dysplasia (BPD) in Extremely Low Birth Weight (ELBW) and Very Low Birth Weight (VLBW) neonates, and to identify associated risk factors.MethodsA retrospective analysis was conducted on 213 ELBW/VLBW neonates admitted between January 2021 and January 2024. According to BPD diagnosis, they were categorized into a control group (n=62, without BPD) and an observation group (n=151, with BPD). The observation group was further stratified by severity into mild (n=71), moderate (n=46), and severe (n=34) BPD. Serum PCT and CRP levels were compared across groups. The correlation between these biomarkers and BPD severity was analyzed, and risk factors for BPD were investigated.ResultsPCT and CRP levels were significantly higher in the observation group than in the control group (P<0.05). A significant increasing trend in both PCT and CRP levels was observed with worsening BPD severity (P<0.05). Spearman analysis confirmed positive correlations between BPD severity and PCT (r=0.354) and CRP (r=0.472) levels (P<0.05). Multivariate logistic regression identified intrauterine infection, gestational age <28 weeks, assisted ventilation >2 weeks, infectious pneumonia, and FiO2 >40% as independent risk factors for BPD (P<0.05).ConclusionIn this retrospective study, elevated serum PCT and CRP levels were positively associated with the severity of BPD in ELBW/VLBW neonates. The identified risk factors, including intrauterine infection, gestational age <28 weeks, prolonged assisted ventilation, infectious pneumonia, and high FiO2, are independently associated with BPD. These findings suggest that monitoring these biomarkers and risk factors may warrant intensified clinical attention.

Introduction: Tracheostomy is common in the ICU and may affect mobility and functional performance, often leading to poor outcomes. Objective: to evaluate the clinical characteristics, and the mobility and functionality of tracheostomized patients from the ICU admission until hospital discharge; to describe the main outcomes, and the tracheostomy decannulation process. Methods: This prospective study involved four general ICUs, collecting data on demographics, SAPS III, Charlson comorbidity index, reasons for ICU admission and intubation, use of neuromuscular blockers, sedation, mechanical ventilation duration, reintubation, tracheostomy indication and duration, mobility scales, and functional independence. Results: Thirty-one patients underwent tracheostomy; 22 died before decannulation, and nine were decannulated. The sample consisted mostly of elderly, male, neurological, and respiratory patients, with a median SAPS III of 74. About 25% required prolonged ventilation. Decannulated patients had a median age of 67, median SAPS III of 73.5, and were sedated for a median of 15 days. The median tracheostomy duration was 36 days. Indications included extubation failure and prolonged ventilation. Decannulation characteristics included a median occlusion time of 144 hours, with all patients passing the airway patency and blue dye tests. Eight decannulated patients were discharged, and one died. The median ICU and hospital stays were 38 and 55 days, respectively. Mobility and functionality improved over time, with surviving decannulated patients achieving modified dependence to complete independence. Conclusion: The study population had high comorbidities and poor prognosis, explaining the low decannulation rate. However, decannulated survivors showed mobility and functionality improvements despite the long hospital stay.

Fast-track extubation has emerged as a vital component of Enhanced Recovery After Surgery pathways, designed to optimize recovery and resource utilization after cardiac surgery, contrasting with traditional prolonged ventilation. This review explores the evidence supporting fast-track extubation, detailing patient selection criteria based on preoperative risk factors and functional status and outlining perioperative management strategies. It synthesizes findings from various studies, including randomized controlled trials, retrospective studies, and meta-analyses, focusing on intraoperative techniques such as low-dose opioids, neuromuscular blockade reversal, controlled cardiopulmonary bypass duration, judicious inotrope use, and minimal transfusion, alongside structured postoperative protocols emphasizing early sedative weaning and spontaneous breathing trials. Results demonstrate that fast-track extubation decreases intensive care unit stay, reduces costs and ventilator-associated complications, with a safety comparable to conventional care. Prolonged cardiopulmonary bypass time, dependency on inotropes, and intraoperative blood transfusions are identified as critical predictors of fast-track extubation failure. In conclusion, the successful implementation of fast-track extubation protocols requires a collaborative, multidisciplinary approach, proving essential for improving patient outcomes, minimizing complications such as postoperative delirium, and enhancing hospital efficiency in cardiac surgery. Further research should aim to refine patient selection and standardize protocols across healthcare systems.

Prolonged mechanical ventilation after cardiac surgery occurs in 15% of patients and significantly increases morbidity and mortality. We investigated the potential benefits of diaphragm pacing following cardiac surgeries to decrease ventilator burden. A randomized controlled pilot study was conducted at 2 centres using diaphragm pacing in patients undergoing open cardiac surgery by median sternotomy. Enrolled patients had at least one pre-identified high-risk criterion for requiring prolonged ventilation. Diaphragm pacing was initiated postoperatively. Sixty-six patients were randomized into Standard of Care (34) and Treatment (32) groups. This study provides evidence that diaphragm pacing may reduce mechanical ventilation time and improve weaning success prior to 24 hours post-operatively. Treated patients had a total of 246 hours of mechanical ventilation compared to 670 hours for the standard of care group. Treatment group patients were more likely to be successfully weaned at 12 hours post-operatively, 83% compared to 65%, which represented an 18% absolute and 52% relative risk reduction. For the subset of 14 Treatment and 19 Standard of Care patients that required ventilation beyond 6 hours, those receiving diaphragm pacing had a reduced median time on ventilation: 8.3 hours (95% CI 7.1-12.5) compared to 16.8 hours (95% CI 8.1-23.4). Diaphragm pacing may reduce the time on mechanical ventilation following cardiac surgery in patients at risk of prolonged ventilation. These results will inform the design of a prospective, pivotal, randomized controlled trial to assess the ability of diaphragm pacing to reduce ventilator burden in high-risk cardiac surgery patients. Clinicaltrials.gov: NCT04899856, NCT05404477.

Acute hypoxemic respiratory failure (RF) occurs frequently in critically ill patients and is associated with substantial morbidity, mortality and resource use. We developed a comprehensive machine-learning–based monitoring system to support ICU physicians in managing RF through early detection, continuous monitoring, assessment of extubation readiness, and prediction of extubation failure (EF). In study patients, the model predicted 80% of RF events with 45% precision, identifying 65% of events more than 10 hours before, significantly outperforming standard clinical monitoring based on oxygenation index. The model was successfully validated in an external ICU cohort. We also demonstrated how predicted EF risk could help prevent extubation failure and unnecessarily prolonged ventilation. Lastly, we illustrated how prediction of RF risk, along with ventilator need and extubation readiness, helped ICU resource planning for mechanical ventilation. Our model predicted ICU-level ventilator demand 8–16 hours ahead, with a mean absolute error of 0.4 ventilators per 10 patients.

ObjectiveThis retrospective cohort study aimed to systematically evaluate the impact of different mechanical ventilation strategies on postoperative pulmonary complications (PPCs) in thoracic surgery and to establish a risk prediction model that facilitates high-risk patient identification and perioperative management.MethodsA total of 300 patients undergoing thoracic surgery at a tertiary hospital were enrolled. Demographic data, perioperative indicators, and mechanical ventilation parameters were collected. Potential risk factors were initially identified by univariate analyses and then entered into multivariable logistic regression and machine learning models (random forest and XGBoost) for model training and evaluation. The primary outcome was the incidence and types of PPCs, and the predictive performances of different models were compared.ResultsPPCs occurred in 38.7% of the 300 patients included in the final analysis. Both univariate and multivariate analyses indicated that higher tidal volume, lower positive end-expiratory pressure (PEEP), higher plateau pressure, and prolonged ventilation duration were positively associated with an increased risk of PPCs. Conversely, pulmonary protective ventilation strategies and recruitment maneuvers had a significant protective effect. The logistic regression model demonstrated an AUC of 0.60, with key variables including tidal volume (OR = 2.119, 95%CI 1.362–3.294), PEEP level (OR = 1.570, 95%CI 1.180–2.088), and plateau pressure (OR = 1.984, 95%CI 1.202–3.276) as significant predictors. Compared with traditional logistic regression and random forest models, the XGBoost model showed moderate performance with potential clinical utility, with a sensitivity and specificity of approximately 0.70 and 0.48, respectively, and an AUC of 0.56. Feature importance analyses revealed that ventilation-related variables (e.g., tidal volume, PEEP, plateau pressure, and total ventilation time) carried substantial weight in predicting PPCs.ConclusionAdopting pulmonary protective ventilation strategies––such as low tidal volume, appropriate PEEP, and recruitment maneuvers––significantly reduces the risk of PPCs in patients undergoing thoracic surgery. Machine learning algorithms like XGBoost may assist in identifying high-risk patients and tailoring individualized ventilation management. Further applications of multicenter big data and real-time monitoring technologies may help optimize mechanical ventilation strategies and improve patient outcomes.

ABSTRACTObjectivesProlonged cardiopulmonary bypass (CPB) time during coronary artery bypass grafting (CABG) is associated with poor outcomes, however, the association of other operating room (OR) times is less understood. We studied the impact of OR times on outcomes and resource utilization after CABG.MethodsPatients undergoing isolated primary CABG from a large multicentre regional collaborative were analysed. The impact of risk-adjusted total OR, surgery, non-surgery, CPB, and off-CPB times on morbidity, extubation time, ICU and hospital length of stay (LOS), cost, and mortality, was studied. Multivariable regressions were performed adjusting for STS predicted risk of morbidity or mortality, intraoperative blood transfusion, CPB time, cross-clamp time, presence of a cardiothoracic surgery fellowship program, and year of surgery. Our adjustment accounted for patient and intraoperative factors that contribute to complexity and intraoperative course of surgery. All models incorporated centre as a random effect to account for hospital-level variations.ResultsAmong 29 206 patients (mean age 64.8 years, 76% male), median OR, surgery, non-surgery, and CPB times were 308, 235, 72, and 141 minutes, respectively. Longer surgery times were significantly associated with complications, prolonged ventilation, longer ICU and hospital LOS, and mortality. Similarly, increasing non-surgery OR time was significantly associated with worse outcomes, including longer LOS and complications. Each additional 15 minutes in the OR was associated with increased odds of complications, mortality, and cost.ConclusionsLonger non-surgical OR times are associated with adverse outcomes and increased cost. Improving OR efficiency may contribute to better patient outcomes.

Separation from venovenous extracorporeal membrane oxygenation (VV-ECMO) is a pivotal transition for patients with acute respiratory distress syndrome (ARDS). Impaired alveolar ventilation more so than oxygenation may be implicated in weaning failure. The ventilatory ratio (VR), a simple marker of patient ventilatory efficiency, correlates with physiological dead space and ARDS outcomes. We hypothesised that elevated VR measured during sweep gas off trials (SGOT) predicts unsafe liberation from VV-ECMO. In this monocentric retrospective study, adult patients undergoing VV-ECMO for ARDS between July 2019 and August 2023 were recruited. Patients who died on ECMO or were palliatively separated were excluded. Physiological, ventilatory and ECMO data were extracted from the electronic medical record. VR was calculated as VE [minute ventilation] × PaCO₂/(predicted body weight × 100 × 37.5). Safe wean was defined as ECMO free survival without predefined "unsafe criteria" (hypoxia, hypercapnia with acidosis, escalations in mechanical ventilation, or haemodynamic deterioration) occurring during SGOT (sweep gas off trial) or within 48h of ECMO separation. Thirty-nine patients (median age 47 years; 76.9% male) were included. Twenty-four patients separated safely from ECMO following a single SGOT, the remaining 15 patients underwent 36 unsafe trials before decannulation, 69.4% of which failed due to hypercapnia. Safe wean trials were longer (19 [5.7-25.0]hr vs. 5 [0.3-13.3]hr; p = 0.01) and preceded by lower fractional delivered oxygen (FdO2) (65 [40-85]% vs. 100 [60-100]%; p = 0.03). During unsafe SGOT, VR was higher at both early (1.7 vs. 1.4; p = 0.02), and late time points (2.6 vs. 1.7; p = 0.01) in unsafe trials. Hypercapnia following separation was associated with prolonged post-ECMO ventilation (β = 1.4 [0.21-2.59]; p = 0.02). No deaths or re-initiations occurred within 48h of ECMO removal. Elevated ventilatory ratio during SGOT was associated with unsafe weaning from VV-ECMO in this retrospective cohort of patients with ARDS. Prospective validation is warranted to inform future weaning practice.

Introduction . Acute aortic dissection is a current and urgent problem in modern cardiac surgery. In the early stages of the dissection, the surgeon is faced with the dilemma of choosing the volume of intervention from the ascending part reconstruction only or radically ascending and aortic arch replacement. Hybrid systems for one-stage reconstruction of the thoracic aorta are currently being actively developed. The Frozen Elephant Trunk (FET) technique allow us to replacement ascending and arch of the aortae combined with antegrade stent grafting into the descending aorta from the classical sternotomy access. This type of operation doesn’t increase the time of the intervention, there isn’t stage-by-stage reconstruction of the aorta, adequate blood flow in the descending aorta and aortic vessels is restored, and the risks of an adverse outcome are reduced. Objective . To analyze the results of surgical treatment of acute aortic dissection type A, performed using the FET technique in a multidisciplinary surgical hospital – N.V. Sklifosovsky Research Institute for Emergency Medicine. Material and methods . The research included 18 patients which were operated from 2022 to 2024 in acute stage of aortic dissection. All patients were operated using a hybrid technique FET. Results . Multisystem organ failure developed in 5 patients (27.8%). Four patients (22.2%) required renal replacement therapy due to acute renal failure. In 38.9% of the subjects, prolonged artificial ventilation was complicated by pneumonia. Cerebral complications were observed in 6 patients (33.3%). Sepsis accompanied the course of the disease in 16.7% of cases. The 30-day mortality was 22.2%, in the study group. Conclusion . Using the hybrid prosthesis allowed us to obtain relatively satisfactory results of reconstruction thoracic aortae in case of the acute dissection in the early postoperative period.

Mechanical power in mechanical ventilation and its association with ventilator-induced lung injury: A systematic review.

Incremental cost of complications after TAVR and SAVR in contemporary clinical practice.

Risk factors for moderate/severe bronchopulmonary dysplasia: A retrospective cohort study including results of an accurate assessment of intra-uterine microbes.

BackgroundMitral annular calcification (MAC) is a chronic and degenerative process, affecting the mitral valve annulus. MAC complicates the decision over the appropriate surgical approach to mitral valve disease. Distorted valvular anatomy increases surgical risk and therefore requires careful patient selection. Here, we report our single-center experience performing mitral valve surgery in the setting of MAC over a 10-year period.MethodsThis is a 10-year retrospective analysis of 172 patients with MAC. Sixty-seven patients underwent MAC severity scoring using a 10-point system based on computed tomography (CT). The primary outcome was 30-day mortality, readmission, reoperation, stroke, prolonged ventilation, renal failure and deep sternal infection. Secondary analyses stratified MAC by underlying mitral disease type as well as evaluated outcomes by CT severity score. Patients without MAC undergoing mitral valve replacement surgery during the same time period served as controls.ResultsThe 30-day mortality was significantly higher in MAC patients compared with non-MAC (9.9% vs. 4.2%, P<0.001), as were rates of stroke (4.7% vs. 1.6%, P=0.036), prolonged ventilation (33.1% vs. 21.1%, P<0.001), and renal failure (8.7% vs. 4.3%, P=0.008). Resource utilization was also greater, with longer intensive care unit (ICU) hours {118 [interquartile range (IQR), 58.2–254] vs. 72.3 (IQR, 41.0–141.5) hours, P<0.001}, postoperative length of stay [10 (IQR, 7–22) vs. 8 (IQR, 6–13) days, P<0.001], and total hospitalization [12 (IQR, 8–28) vs. 10 (IQR, 6–17) days, P=0.001].ConclusionsMAC complicates mitral valve surgery, with significant differences seen in survival stroke, renal failure, prolonged ventilatory support, and ICU and hospital length of stay. Careful evaluation of surgical risk and patient selection is warranted in patients with MAC.

Mechanical ventilation (MV) is a cornerstone of supportive care in intensive care units (ICUs), but prolonged ventilation is associated with adverse outcomes. Several pharmacologic agents with respiratory stimulants have been investigated to facilitate weaning and improve clinical outcomes; yet no comprehensive comparison across available agents exists. This network meta-analysis (NMA) aimed to compare and rank available interventions in adult patients receiving MV. A systematic search of PubMed, Web of Science, and Scopus (up to November 10, 2023) identified 15 randomized controlled trials (1,528 participants) evaluating ten respiratory stimulants in mechanically ventilated critically ill adults: Almitrine Bismesylate (AB), Doxofylline (DX), Progesterone (PRG), Acetazolamide (ACZT), Growth Hormone (GH), Oxandrolone (OXA), Nandrolone (NA), Caffeine (CAF), Donepezil (DPZ), and a multi-agent adjuvant therapeutic (AT) regimen containing anisodamine. Data were analyzed using a frequentist network meta-analysis with treatment rankings based on SUCRA values. Risk of bias was assessed using the modified Cochrane RoB 2 tool. No pharmacologic intervention significantly reduced hospital or ICU mortality, duration of mechanical ventilation, or time to successful weaning compared with placebo. According to SUCRA rankings, NA, OXA, and PRG had the highest probabilities of reducing hospital mortality, with NA also associated with shorter ICU and hospital stays. DPZ and PRG significantly shortened weaning duration, while GH showed the greatest reduction in mechanical ventilation duration. GH, PRG, and DPZ had the highest likelihood of successful weaning. Heterogeneity and inconsistency were generally low, except for the duration of mechanical ventilation (I² = 86.2%, p < 0.001). No pharmacologic intervention significantly reduced hospital mortality. However, agents such as NA, GH, and DPZ may help shorten ICU stay, reduce duration of mechanical ventilation, or improve weaning efficiency. These findings underscore the potential value of multi-agent adjuvant approaches and highlight the need for larger, high-quality trials to confirm their clinical benefits.Trial registration: CRD42023454122 (18/10/2023).

BackgroundPressure recording analytical method (PRAM) parameters, derived from arterial pressure waveform analysis, provide continuous and minimally invasive assessment of cardiovascular function. This study examines the changes in PRAM parameters during the spontaneous breathing trial (SBT) in patients undergoing prolonged mechanical ventilation (PMV, defined as >24 hours) after cardiac surgery and explores their potential to predict the outcomes of SBT.MethodsIn this prospective observational study, 58 adult patients requiring PMV (>24 h) after cardiac surgery underwent a single 60-min SBT. PRAM variables and systemic hemodynamics were recorded immediately before and throughout the trial.ResultsFifteen patients (25.9%) failed weaning. Generalised estimating equations revealed a significant group × time interaction for cardiac cycle efficiency (CCE) (P<0.001). In the success group, CCE changes over time were not significant, whereas in the failure group, CCE decreased significantly from pressure support ventilation (PSV) to SBT-last minute (−0.011±0.170 to −0.118±0.226, P=0.007 with Bonferroni correction). A significant interaction was also found for the maximal slope of systolic upstroke (dp/dt) (P=0.02), with dp/dt significantly decreasing at SBT-last minute in the failure group. Receiver-operating-characteristic analysis indicated moderate discrimination for CCEPSV [the area under the curve (AUC) =0.6752, 95% confidence interval (CI): 0.5345–0.8159; P=0.045]. Patients in the low-CCE quartile experienced a 40% failure rate and longer intensive care unit (ICU) stay {6 [3–7] vs. 4 [3–5] days; P=0.02} compared with the high-CCE quartile, in which no failures occurred.ConclusionsThis study indicates that CCE and dp/dt exhibit different trends during successful and failed SBTs in prolonged ventilated patients after cardiac surgery. CCE measured during SBT and its dynamic decline show promise as indicators of weaning outcome, but these findings are preliminary. Consequently, future well-powered prospective studies incorporating multivariate adjustment are warranted to determine whether real-time CCE monitoring can serve as a reliable tool for guiding weaning and extubation decisions.

Critically-ill patients are at increased risk for cytomegalovirus (CMV) reactivation, associated with adverse clinical outcomes. Given the surge in intensive care unit (ICU) admissions during the COVID-19 pandemic and the continued burden of critical illness associated with the ongoing circulation of SARS-CoV-2, we sought to resolve risk factors for CMV reactivation and disease within the broader ICU patient population including those with and without COVID-19, to identify common and potentially distinct contributors to CMV reactivation and disease in this vulnerable setting. This prospective study included 208 adult ICU (85 COVID-19, and 123 concomitant non-COVID-19) patients, monitored weekly for CMV DNAemia. CMV reactivation was categorized as any detectable DNAemia or as clinically-significant reactivation characterized by high-level DNAemia (≥ 1000 IU/mL) and/or CMV disease. Overall, 29.8% of ICU patients experienced CMV reactivation, with 10.6% exhibiting clinically-significant reactivation. COVID-19 ICU patients had significantly higher rates of any CMV reactivation (40% vs. 23%, p = 0.009), high-level DNAemia (18% vs. 2%, p = 0.001), and CMV disease (12% vs. 1%, p = 0.001) compared to concomitant non-COVID-19 patients. Risk factors associated with clinically-significant CMV reactivation in ICU patients included septic shock, lower absolute lymphocyte count, high-dose steroid use, multiple blood transfusions, and COVID-19. CMV reactivation correlated with prolonged ventilation, hospitalization, and ICU stay, and increased in-hospital mortality. The high rates of clinically-significant CMV reactivation in both COVID-19 and non-COVID-19 ICU patients and the identified risk factors, along with the worse clinical outcomes linked to CMV reactivation, highlight the need for vigilant monitoring of CMV reactivation and for consideration of early antiviral treatment in ICU patients at risk, and support future interventional trials.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has led to a rise in tracheal stenosis (TS) due to prolonged invasive ventilation. Limited data are available on outcomes following tracheal resection and anastomosis (TRA) in this specific population. This study aimed to evaluate early restenosis, postoperative complications, and reintervention rates after TRA in a real-world, multicenter setting.MethodsThis prospective, observational study included patients who developed TS after invasive mechanical ventilation for COVID-19 and underwent tracheal or laryngotracheal resection across five high-volume thoracic surgery centers in Italy (June 2020 to December 2023). The primary endpoint was restenosis incidence; secondary endpoints included complication rates and in-hospital mortality.ResultsNinety patients (mean age: 58.4±11.5 years; 62% male) were included. Most patients (81%) developed stenosis post-tracheostomy; 35% had failed prior endoscopic treatments, while 65% underwent upfront surgery. Major and overall complication rates were 7.8% and 30%, respectively. Early restenosis (defined as restenosis occurring within 90 days from surgery) occurred in 8 patients (8.8%) at a mean of 34.2±26.0 days. Interventions included endoscopic dilatation (n=4), stenting (n=1), and tracheostomy (n=3). Multivariate analysis identified preoperative endoscopic treatment [hazard ratio (HR) 12.25, 95% confidence interval (CI): 1.45–103.2, P=0.02] and diabetes (HR 8.64, 95% CI: 1.12–66.3, P=0.03) as independent predictors of early restenosis.ConclusionsTRA in post-COVID-19 patients, when performed in high-volume centers, is safe and effective, with low restenosis and complication rates. However, early restenosis may occur, particularly in patients with comorbidities or prior endoscopic procedures. Close bronchoscopic follow-up is warranted within the first months postoperatively to enable timely detection and management.