Prolonged Ventilatory Support Research Articles

The Characterization of Postoperative Mechanical Respiratory Requirement in Neonates and Infants Undergoing Cardiac Surgery on Cardiopulmonary Bypass in a Single Tertiary Institution

Although neonates and infants undergoing cardiac surgery on cardiopulmonary bypass (CPB) are at high risk of developing perioperative morbidity and mortality, including lung injury, the intraoperative profile of lung injury in this cohort is not well-described. Given that the postoperative course of patients in the pediatric cardiac surgical arena has become increasingly expedited, the objective of this study was to characterize the profiles of postoperative mechanical ventilatory support in neonates and infants undergoing cardiac surgery on CPB and to examine the characteristics of lung mechanics and lung injury in this patient population who are potentially amendable to early postoperative recovery in a single tertiary pediatric institution. A retrospective data analysis of neonates and infants who underwent cardiac surgery on cardiopulmonary bypass. A single-center, university teaching hospital. The study included 328 neonates and infants who underwent cardiac surgery on cardiopulmonary bypass. A subset of 128 patients were studied: 58 patients undergoing ventricular septal defect (VSD) repair, 36 patients undergoing complete atrioventricular canal (CAVC) repair, and 34 patients undergoing bidirectional Glenn (BDG) shunt surgery. Of the entire cohort, 3.7% experienced in-hospital mortality. Among all surgical procedures, VSD repair (17.7%) was the most common, followed by CAVC repair (11.0%) and BDG shunt surgery (10.4%). Of patients who underwent VSD repair, CAVC repair, and BDG shunt surgery, 65.5%, 41.7%, and 67.6% were off mechanical ventilatory support within 24 hours postoperatively, respectively. In all three of the surgical repairs, lung compliance decreased after CPB compared to pre-CPB phase. Sixty point three percent of patients with VSD repair and 77.8% of patients with CAVC repair showed a PaO2/FIO2 (P/F) ratio of <300 after CPB. Post- CPB P/F ratios of 120 for VSD patients and 100 for CAVC patients were considered as optimal cutoff values to highly predict prolonged (>24 hours) postoperative mechanical ventilatory support. A higher volume of transfused platelets also was associated with postoperative ventilatory support ≥24 hours in patients undergoing VSD repair, CAVC repair, and BDG shunt surgery. There was a high incidence of lung injury after CPB in neonates and infants, even in surgeries amendable for early recovery. Given that CPB-related factors (CPB duration, crossclamp time) and volume of transfused platelet were significantly associated with prolonged postoperative ventilatory support, the underlying cause of cardiac surgery-related lung injury can be multi-factorial.

Utilisation of RAM cannula for non-invasive respiratory support for infants in the cardiac ICU.

Children with CHD carry an additional burden of pulmonary insufficiency, often necessitating prolonged ventilatory support, especially in the peri-operative phase. There has been an increase in the utilisation of non-invasive ventilatory support for these children. The objective of this study was to evaluate the utilisation, safety, and outcomes of RAM cannula as a tool for escalation and de-escalation of respiratory support in paediatric cardiac patients less than one year of age. A single-centre retrospective cohort study of patients supported with RAM cannula. A total of 275 instances of RAM use were included in the study, 81.1% being post-operative. Patients were stratified into escalation and de-escalation cohorts based on the indication of non-invasive ventilation. The success rate of using RAM cannula was 69.5% overall, 66.1% in the escalation group, and 72.8% in the de-escalation group. At baseline, age at cardiac ICU admission >30 days, FiO2 ≤ 40%, PaCO2 ≤ 50 mmHg; and after 12 hours of non-invasive ventilation support respiratory rate ≤ 60/min, PaO2 ≥ 50 mmHg, PaCO2 ≤ 50 mmHg; and absence of worsening on follow-up chest X-ray predicted the success with a sensitivity of 95% in the logistic regression model. Successful support was associated with a significantly shorter unit stay. RAM cannula can be safely used to provide non-invasive support to infants in the cardiac ICU for escalation and de-escalation of respiratory support. Factors associated with success can be used to make decisions about candidacy and appropriate timing of non-invasive ventilation use to maximise effectiveness.

Complications and Neurological Outcome following Intraoperative Aneurysm Rupture in Adult Patients Undergoing Intracranial Aneurysmal Clipping: A Retrospective Study.

Background Intraoperative aneurysmal rupture (IAR) is a catastrophic complication; however, its impact on neurological outcome is debatable. We studied the effects of IAR on intraoperative and postoperative complications and neurological outcome. Methods In this retrospective study, adult patients who underwent aneurysmal clipping over a period of 2 years were divided as follows: group R (with IAR) and group N (without IAR). Various perioperative parameters, intraoperative and postoperative complications were noted. Glasgow outcome scale (GOS) was noted at discharge from hospital and categorized as favorable (GOS IV and V) and unfavorable (GOS I, II and III). Collected data was statistically analyzed. Univariate and multiple logistic regression analyses were performed to identify predictors of IAR. A p value < 0.05 was considered significant. Results Thirty-two out of 195 (16.41%) patients suffered IAR, with majority involving anterior communicating artery aneurysm (46.88%). Duration of temporary clipping ( p < 0.001), volume of blood loss, and fluid and blood transfusion were significantly more in group R. Postoperatively, significantly more patients in group R developed intracranial hematoma, cerebral infarct, and required prolonged ventilatory support (≥5 days). Unfavorable neurological outcome was observed more in group R ( p = 0.013). In univariate analysis, blood loss > 500 mL, use of colloids, and duration of surgery > 5 hours were found to be associated with IAR. After multiple logistic regression analysis, only use of colloids and duration of surgery > 5 hours were the most predictive variables for IAR. Conclusions IAR is associated with serious intraoperative and postoperative complications and unfavorable neurological outcome.

Fungemia in COVID-19 ICU patients, a single medical center experience.

A known proportion of patients who are admitted for the novel coronavirus disease 2019 (COVID-19) requires intensive care unit (ICU) level of care. Prolonged ICU stay is a risk factor for the development of nosocomial candidemia. The current study aimed to investigate the incidence and risk factors associated with the development of nosocomial candidemia among patients admitted to the ICU for COVID-19. Patients who developed nosocomial candidemia were identified, and their clinical course was reported. A 1:3 case control matching was used to identify non-candidemia patients who served as controls. 89 patients were admitted to the ICU for COVID-19 during the study period. The incidence of nosocomial candidemia was 8.9% (n = 8). Case-control matching identified 24 patients with similar disease severity at the time of ICU admission. Median time to first isolation of yeast was 26 days. Candidemia patients reported longer median ICU stay than controls. (40 vs. 10 days, p = .004). In hospital death rates were comparable in both groups (38% vs. 54%, p = .548). Prolonged mechanical ventilation support was associated with the development of nosocomial candidemia.

The importance of viral load in the severity of acute bronchiolitis in hospitalized infants

OBJECTIVE:The relationship between viral load and the clinical evolution of bronchiolitis is controversial. Therefore, we aimed to analyze viral loads in infants hospitalized for bronchiolitis.METHODS:We tested for the presence of human respiratory syncytial virus (HRSV) or human rhinovirus (HRV) using quantitative molecular tests of nasopharyngeal secretions and recorded severity outcomes.RESULTS:We included 70 infants [49 (70%) HRSV, 9 (13%) HRV and 12 (17%) HRSV+HRV]. There were no differences among the groups according to the outcomes analyzed individually. Clinical scores showed greater severity in the isolated HRSV infection group. A higher isolated HRSV viral load was associated with more prolonged ventilatory support, oxygen therapy, and hospitalization days, even after adjustment for the age and period of nasopharyngeal secretion collection. In the co-infection groups, there was a longer duration of oxygen therapy when the HRSV viral load was predominant. Isolated HRV infection and co-infection with a predominance of HRV were not associated with severity.CONCLUSION:Higher HRSV viral load in isolated infections and the predominance of HRSV in co-infections, independent of viral load, were associated with greater severity. These results contribute to the development of therapeutic and prophylactic approaches and a greater understanding of the pathophysiology of bronchiolitis.

Impact of Perioperative Massive Transfusion on Long Term Outcomes of Liver Transplantation: a Retrospective Cohort Study.

Background: Liver transplantation (LT) is associated with a significant risk of intraoperative hemorrhage and massive blood transfusion. However, there are few relevant reports addressing the long-term impacts of massive transfusion (MT) on liver transplantation recipients.Aim: To assess the effects of MT on the short and long-term outcomes of adult liver transplantation recipients.Methods: We included adult patients who underwent liver transplantation at West China Hospital from January 2011 to February 2015. MT was defined as red blood cell (RBC) transfusion of ≥10 units within 48 hours since the application of LT. Preoperative, intraoperative and postoperative information were collected for data analyzing. We used one-to-one propensity-matching to create pairs. Kaplan-Meier survival analysis was used to compare long-term outcomes of LT recipients between the MT and non-MT groups. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with MT in LT.Results: Finally, a total of 227 patients were included in our study. After propensity score matching, 59 patients were categorized into the MT and 59 patients in non-MT groups. Compared with the non-MT group, the MT group had a higher 30-day mortality (15.3% vs 0, p=0.006), and a higher incidence of postoperative complications, including postoperative pulmonary infection, abdominal hemorrhage, pleural effusion and severe acute kidney injury. Furthermore, MT group had prolonged postoperative ventilation support (42 vs 25 h, p=0.007) and prolonged durations of ICU (12.9 vs 9.5 d, p<0.001) stay. Multivariate COX regression indicated that massive transfusion (OR: 2.393, 95% CI: 1.164-4.923, p=0.018) and acute rejection (OR: 7.295, 95% CI: 2.108-25.246, p=0.02) were significant risk factors affecting long-term survivals of LT patients. The 1-year and 3-year survival rates patients in MT group were 82.5% and 67.3%, respectively, while those of non-MT group were 93.9% and 90.5%, respectively. The MT group exhibited a lower long-term survival rate than the non-MT group (HR: 2.393, 95% CI: 1.164-4.923, p<0.001). Finally, the multivariate logistic regression revealed that preoperative hemoglobin <118 g/L (OR: 5.062, 95% CI: 2.292-11.181, p<0.001) and intraoperative blood loss ≥1100 ml (OR: 3.212, 95% CI: 1.586-6.506, p = 0.001) were the independent risk factor of MT in patients undergoing LT.Conclusion: Patients receiving MT in perioperative periods of LT had worse short-term and long-term outcomes than the non-MT patients. Massive transfusion and acute rejection were significant risk factors affecting long-term survivals of LT patients, and intraoperative blood loss of over 1100 ml was the independent risk factor of MT in patients undergoing LT. The results may offer valuable information on perioperative management in LT recipients who experience high risk of MT.

Rattlesnake Envenomation in a Venom-Naive Man With Significant Coagulopathy and Severe Oropharyngeal Edema Requiring Emergent Surgical Airway

The majority of snakebite envenomation events in North America are attributed to rattlesnakes with pit-vipers responsible for nearly all envenomation events. Significant morbidity is associated with rattlesnake envenomation including local tissue destruction and coagulopathy. Severe oropharyngeal edema requiring emergent securing of airway has been reported in victims with no prior exposure to pit-vipers but is exceptionally rare. We present a case report of a venom-naive male in his early twenties who received a pit-viper bite to the right thumb, resulting in an anaphylactoid reaction complicated by severe oropharyngeal edema, coagulopathy, and persistent respiratory failure requiring prolonged ventilator support. This case highlights how anaphylactic and anaphylactoid reactions are nearly identical in presentation and may be associated with significant morbidity. Regardless of whether the underlying etiology is anaphylaxis or anaphylactoid, the management should focus on providing CroFab ® early in the clinical course. J Curr Surg. 2021;11(1):15-20 doi: https://doi.org/10.14740/jcs426

Efeitos deletérios ocasionados por sonda orogástrica em recém nascido a pré-termo em uma uti neonatal: relato de caso clínico

There are countless causes that lead a baby to be born premature: placental changes (placenta previa and premature detachment), excess amniotic fluid, maternal age (mothers under 18 years of age), maternal infections, primacy, use of alcohol and drugs. The premature baby's trajectory begins with hospitalization, usually for long periods in the Neonatal Intensive Care Unit (NICU), due to pulmonary immaturity and the need for prolonged ventilatory support. Gastric probing by oral or nasal route is an essential procedure in assisting nutrition for newborns up to thirty-four weeks of gestational age, as it does not have fully developed sucking and swallowing reflexes. The literature describes several oral changes present in premature and low birth weight children, highlighting an increase in the incidence of enamel defects, such as hypoplasia and hypomineralization, an increase in the incidence of dental caries, developmental and eruption delay of the primary dentition, dental and palate malformation. The aim was to report the clinical case of a premature infant with chronic use of an orogastric tube (OT) with lesion in the middle region of the upper lip and gum pad. After 24 hours of repositioning the OT, can be observed the lesion regression. Thus, the presence of the dentist in the NICUs, assisting with protocol and diagnostic measures, can minimize deleterious effects on the oral cavity. It should be noted that the training and applicability of dental protocols in NICUs improves safety in the care of the newborn.

Whipple's pancreaticoduodenectomy for cancer of the head of the pancreas in a patient with amyotrophic lateral sclerosis: perioperative challenges.

The association of amyotrophic lateral sclerosis and pancreatic cancer is rare. Amyotrophic lateral sclerosis is a neurodegenerative disease characterised by pure motor symptoms in the form of progressive muscle weakness and wasting, and can involve the bulbar and respiratory muscles, leading to significant morbidity. Successful surgery for patients with amyotrophic lateral sclerosis for pancreatic cancer has rarely been reported. Surgery in such patients is a dual-edged sword and is decided based on risk-benefit ratio. Patients are at high risk for general anaesthesia because of muscular weakness, increased sensitivity to muscle relaxants and certain anaesthetic drugs. There is a high chance of prolonged postoperative ventilatory support, aspiration pneumonia and pulmonary complications. We report a patient with cancer of the head of the pancreas who underwent successful elective pancreaticoduodenectomy.

Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing.

PurposeThe likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high-grade liver injuries is a major concern. Thus, although early re-laparotomy tends to be recommended, we conducted this study to evaluate the feasibility of performing definite laparotomy within ≤ 48 h in this clinical population.MethodsThe subjects of this retrospective study were 65 patients (n = 24, ≤ 48-h group; n = 41, > 48-h group) who underwent DCS and perihepatic packing. The primary outcome was the rate of repacking for bleeding during re-laparotomy and the secondary outcomes were mortality and length of stay in the intensive care unit (ICU).ResultsThe ≤ 48-h group had a higher rate of angioembolization and transfusion of red blood cells (RBCs), fresh frozen plasma, and platelets, but the rates of repacking and mortality were not significantly different between the groups. However, the incidence of pneumonia and ventilation support requirement were significantly lower in the ≤ 48-h group than in the > 48-h group.ConclusionThe re-laparotomy performed within ≤ 48 h after DCS and perihepatic packing is feasible for patients with high grade liver injury, using angioembolization and aggressive transfusion, as required. Early re-laparotomy reduces the need for prolonged ventilator support and the incidence of ventilator-associated pneumonia.

EARLY OUTCOMES OF TOTAL CORRECTION IN TETRALOGY OF FALLOT IN A TERTIARY CARE HOSPITAL OF PESHAWAR, KHYBER PAKHTUNKHWA, PAKISTAN; A TWO-YEAR RETROSPECTIVE STUDY

Objective: To investigate the early outcomes of patients undergoing total-correction (TC) for Tetralogy of Fallot (TOF). Methodology: A retrospective study was carried out after acquiring Institutional ethical review committee approval. All patients diagnosed with TOF combined with pulmonary stenosis that had undergone primary repair between November 2016 and November 2018 at the Cardiothoracic Surgery Unit of Rehman Medical Institution, Peshawar were included while patients having anatomical defects alongside TOF were excluded from the study. Data was collected using a proforma. SPSS version 25 format was used for data entry and analysis. Comparisons between age related intraoperative parameters and age related early outcomes of the procedure was done by using the Student’s T-test and Chi-squared test keeping p ≤ 0.05 as significant. Results: A total of 186 patient’s data was retrieved from the hospital record. There were 109 (58.60%) males and 77 (41.40%) females. Mean cardiopulmonary bypass time (CBP) was 94.84±37.92 minutes and aortic cross clamp (ACC) time was 67.17±31.86 minutes. In the postoperative period, 11 (5.91%) patients developed Low cardiac output syndrome (LCOS). Prolonged ventilator support (&gt;24 hrs.) was required in 21(11.29%) patients and prolonged ICU stay (&gt;48 hrs.) was seen in 38(20.43%) patients. A total of 166 (89.25%) patients were discharged while 20 (10.75%) died post operatively due to complications. Conclusion: Total repair for TOF is a favorable option in most patients as early outcomes were satisfactory with acceptable mortality rate after surgery.

Characterisation and outcomes of ARDS secondary to pneumonia in patients with and without SARS-CoV-2: a single-centre experience

IntroductionAcute respiratory distress syndrome (ARDS) is the major cause of mortality in patients with SARS-CoV-2 pneumonia. It appears that development of ‘cytokine storm’ in patients with SARS-CoV-2 pneumonia precipitates progression...

English

BACKGROUND Hypomagnesaemia is associated with other electrolyte abnormalities like hypokalaemia, hyponatremia, and hypophosphatemia. We wanted to study the serum magnesium levels in critically ill patients, and correlate the serum magnesium levels with patient outcome and other parameters like duration of stay in ICU, ventilator support and APACHE-II (Acute Physiology and Chronic Health Evaluation-II) score. METHODS The study included all the cases admitted in the ICU of Narayan Medical College &amp; Hospital, with variable medical conditions within 6 months fulfilling the inclusion criteria. Demographic data (age and sex), medical history, surgical history, medications administrated and length of ICU stay were recorded for each patient. The severity scoring system used was Acute Physiology and Chronic Health Evaluation-II (APACHE-II). RESULTS Prevalence of Hypomagnesaemia in the present study was 60.2 %. Mortality and mechanical ventilator support (2.7 % and 28.4 %) in normomagnesemia subjects were significantly lesser than hypomagnesaemia subjects (33.9 % and 54.5 % respectively). CONCLUSIONS Hypomagnesaemia is a common electrolyte imbalance in critically ill patients. It is associated with higher mortality and morbidity in critically ill patients and is also associated with more frequent and more prolonged ventilatory support. KEYWORDS Critically Ill, Hypomagnesaemia, APACHE-II Score, Mortality, Ventilator Support

Serial Imaging of Virus-Associated Necrotizing Disseminated Acute Leukoencephalopathy (VANDAL) in COVID-19.

Various patterns of leukoencephalopathy have been described in coronavirus disease 2019 (COVID-19). In this article, we aimed to describe the clinical and imaging features of acute disseminated leukoencephalopathy in critically ill patients with COVID-19 and the imaging evolution during a short-term follow-up. We identified and reviewed the clinical data, laboratory results, imaging findings, and outcomes for 8 critically ill patients with COVID-19 with acute disseminated leukoencephalopathy. All patients demonstrated multiple areas of white matter changes in both cerebral hemispheres; 87.5% (7/8) of patients had a posterior predilection. Four patients (50%) had short-term follow-up imaging within a median of 17 days after the first MR imaging; they developed brain atrophy, and their white matter lesions evolved into necrotizing cystic cavitations. All (8/8) patients had inflammatory cytokine release syndrome as demonstrated by elevated interleukin-6, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, and ferritin levels. Most (7/8; 87.5%) patients were on prolonged ventilator support (median, 44.5 days; interquartile range, 20.5 days). These patients had poor functional outcomes (6/8 [75%] patients were discharged with mRS 5) and high mortality (2/8, 25%). Critically ill patients with COVID-19 can develop acute disseminated leukoencephalopathy that evolves into cystic degeneration of white matter lesions with brain atrophy during a short period, which we dubbed virus-associated necrotizing disseminated acute leukoencephalopathy. This may be the result of COVID-19-related endothelial injury, cytokine storm, or thrombotic microangiopathy.

Analysis of Pneumothorax in Noninvasive Ventilator Users With Duchenne Muscular Dystrophy

With the advancement of cardiorespiratory interventions, the survival rate among patients with Duchenne muscular dystrophy (DMD) has increased. Subsequently, pneumothorax has become a significant problem in patients with prolonged ventilatory support. What are the frequency, recurrence rate, risk factors, and prognosis of pneumothorax in patients with DMD requiring noninvasive ventilation (NIV)? Also, are there known risk factors of pneumothorax on chest CT scans? This retrospective longitudinal cohort study included 176 patients treated between 2006 and 2019. We collected information regarding location, severity, treatment methods, recurrence frequency, abnormal findings on CT scanning, and date of death. We compared the pneumothorax and nonpneumothorax groups. We calculated the estimated survival probabilities from the age at NIV application according to pneumothorax occurrence. Sixteen of the 176 patients (9.0%) experienced pneumothorax (median age at diagnosis, 24.6 years; range, 20.7-33.7 years). Among the 16 patients, 15 demonstrated pneumothorax after NIV application (median time between diagnosis and initial NIV application, 5.6 years; range, 3days-9.6 years). Sixteen patients experienced 31 episodes of pneumothoraces (range, one-five episodes); among them, seven episodes (22.6%) were asymptomatic. Known risk factors not clearly visible by radiography scans were found in chest CT scan in 11 patients (68.8%). Seven of 16 patients (43.8%) eventually sustained severe lung damage with pulmonary fibrosis. No significant between-group differences were found in body weight, BMI, and age at NIV application; however, the pneumothorax group showed a significantly higher mortality rate after NIV application. On pneumothorax occurrence in patients with DMD, recurrences and severe lung damage are common; moreover, these patients show higher mortality rates than patients without pneumothorax. Chest CT scans should be performed to identify risk factors, and treatment should be initiated accordingly. In addition, physicians should consider chest CT scanning in the case of suspected pneumothorax, even if no radiographic abnormality is found.

Intracranial hemorrhage in critically ill patients hospitalized for COVID-19

In this study, we report three cases of spontaneous intracranial hemorrhage in patients who were initially hospitalized at our tertiary care center in Washington, DC with symptoms of COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all three patients, who were critically ill, requiring intubation and ventilatory support. During their protracted hospitalizations, subsequent imaging disclosed intracranial hemorrhages, including intracerebral and subarachnoid hemorrhages, in the context of anticoagulation and coagulopathy. We believe this is related to the tropism of SARS-CoV-2 to the endothelial lining of the cerebral vasculature via their angiotensin-converting enzyme (ACE) II receptors. Given our findings, we advocate heightened vigilance for intracerebral hemorrhage events, and scanning when practicable, in COVID-19 patients which have prolonged ventilatory support and depressed neurologic examinations.

Tracheostomy for Coronavirus Disease 2019 Patients: Maintaining the Standard of Care.

Objectives:To respond to the new recommendations for delaying tracheostomy for coronavirus disease 2019 patients to day 21 post-intubation to ensure viral clearance.Design:Prospective observational cohort from April 1, 2020, to April 30, 2020, with 60 days follow-up.Setting:Academic medical center with nine adult ICUs dedicated to caring for coronavirus disease 2019 patients requiring mechanical ventilation.Patients:Mechanically ventilated patients with coronavirus disease 2019 pneumonia requiring tracheostomy for prolonged ventilatory support.Interventions:Adherence to the standard of care for timing of tracheostomy as deemed necessary by the intensivist without delay and utilizing the existing tracheostomy team in performing the needed procedures within 1 day of the request.Measurements and Main Results:One hundred eleven patients with coronavirus disease 2019 received tracheostomy in the month of April 2020. Median time to tracheostomy was 11 days. All procedures were performed percutaneously at bedside under bronchoscopic guidance. Sixty-three percent of patients who received tracheostomy either weaned or discharged alive within 60 days of the procedure. Performing tracheostomy on these patients without delay did not lead to coronavirus disease 2019 viral transmission to the tracheostomy team as evident by lack of symptoms and negative antibody testing.Conclusions:Adherence to standard of care in timing of tracheostomy is safe. Recommending delaying the procedure may lead to harmful consequences from prolonging mechanical ventilation and sedation without apparent benefit.

Major complications following surgical correction of spine deformity in 257 patients with cerebral palsy.

Study designObservational.ObjectivesTo report on the rate of major complications following spinal fusion and instrumentation to treat spinal deformity in patients with cerebral palsy (CP).Summary of background dataUnderstanding the risk of major complications following the surgical treatment of spine deformities in patients with CP is critical.MethodsA prospectively collected, multicenter database of patients with CP who had surgical correction of their spinal deformity (scoliosis or kyphosis) was reviewed for all major complications. Patients with ≥ 2 year follow-up or who died ≤ 2 years of surgery were included. A complication was defined as major if it resulted in reoperation, re-admission to the hospital, prolongation of the hospital stay, was considered life-threatening, or resulted in residual disability. Overall complication and revision rates were calculated for the perioperative (Peri-op; occurring ≤ 90 days postoperative) and delayed postoperative (Delayed; > 90 days) time periods.ResultsTwo hundred and fifty-seven patients met inclusion. Seventy-eight (30%) patients had a major complication, 18 (7%) had > 1. There were 92 (36%) major complications; 64 (24.9%) occurred Peri-op. The most common Peri-op complications were wound (n = 16, 6.2%) and pulmonary issues (n = 28, 10.9%), specifically deep infections (n = 12, 4.7%) and prolonged ventilator support (n = 21, 8.2%). Delayed complications (n = 28, 10.9%) were primarily deep infections (n = 8, 3.1%) and instrumentation-related (n = 6, 2.3%). There were 42 additional surgeries for an overall unplanned return to the operating room rate of 16% (Peri-op: 8.6%, Delayed: 7.8%). Thirty-six (14.0%) reoperations were spine related surgeries (wound or instrumentation-related). Eleven (4.3%) patients died between 3 months to 5.6 years postoperatively; 4 occurred ≤ 1 year of surgery. Two deaths were directly related to the spinal deformity surgery.ConclusionSpinal deformity surgery in CP patients with greater than 2 years of follow-up have a postoperative major complication rate of 36% with a spine-related reoperation rate of 14.0%.Level of evidenceTherapeutic-IV.

Go with the flow-clinical importance of flow curves during mechanical ventilation: A narrative review.

Most clinicians pay attention to tidal volume and airway pressures and their curves during mechanical ventilation. On the other hand, inspiratory–expiratory flow curves also provide a plethora of information, but much less attention is paid to them. Flow curves chronologically show the velocity and direction of inspiration and expiration and are influenced by the respiratory mechanics, the patient’s effort, and the mode of ventilation and its settings. When the ventilator setting does not synchronize with the patient’s respiratory pattern, the patient can easily have worsening breathing effort, patient–ventilator asynchrony, which can lead to prolonged ventilator support or lung injury. The information provided by the flow curves during mechanical ventilation, such as respiratory mechanics, the patient’s effort, and patient–ventilator interactions, are very helpful when adjusting the ventilator setting. If clinicians can monitor and assess the flow curves information appropriately, it can be a useful diagnostic and therapeutic tool at the bedside. There may be association between inspiratory effort and flow, and this may further guide us, especially in the weaning process and when patients are not synchronizing with the ventilator. In this review, we try to gather information about “flow” that is scattered around in the literature and textbooks in one place. We will summarize the different flow waveforms utilized in commonly used ventilator modes with their advantages and disadvantages, information gained by the flow curves (i.e., flow-time, flow-volume, and flow-pressure), how to detect and manage asynchronies, and some ideas for future uses. Flow waveforms shapes and patterns are very beneficial for the management of patients undergoing mechanical ventilatory support. Attention to those waveforms can potentially improve patient outcomes. Clinicians should be familiar with this information and how to act upon them.

Extracorporeal Membrane Oxygenation During the Coronavirus Disease 2019 Pandemic.

Extracorporeal Membrane Oxygenation During the Coronavirus Disease 2019 Pandemic.