Shorter Mechanical Ventilation Research Articles

The effect of minimizing central line days for very low birth weight infants through quality improvement

Blood culture proven sepsis is associated with increased mortality and morbidity. Given the extended hospitalization of very preterm infants, catheter-related blood stream infections (CRBSIs) play a substantial role in sepsis. The reported incidence of CRBSIs in neonates varies from 3.2 to 21.8 CRBSIs per 1000 catheter line days. Moreover, discrepancies in neonatal practices and potential neglect may lead to the unwarranted prolongation of central lines. This study aims to compare two distinct periods (Pre-QI vs. Post-QI) in relation to the central line insertion rate and duration, as well as blood culture proven sepsis, duration of total parenteral nutrition (TPN), and the progression of feeding. These factors are known to be associated with prolonged hospitalization and increased morbidities. A total of 210 very low birth weight infants (VLBWIs), defined as either less than 32 weeks of gestational age (GA) or weighing less than 1500 g, were admitted to the Neonatal Intensive Care Unit (NICU) at Seoul St. Mary’s Hospital, The Catholic University of Korea, between January 2020 and June 2023. Fourteen infants were excluded from the study as they did not survive beyond 1 month of life, and one was excluded due to a congenital anomaly. Consequently, the analysis included 195 VLBWIs. The Quality Improvement (QI) initiative began in January 2022, marking the division into two distinct epochs: the Pre-QI period, encompassing the years 2020 to 2021, and the Post-QI period, spanning from 2022 to 2023. The primary outcome measures included PICC insertion rates, duration, and feeding advancement or feeding-related complications. The hospital outcome measures were also compared between the two periods. A total of 195 VLBWI were included in the analysis. The birth weight was significantly lower in the pre-QI period, with an average of 1023 g compared to 1218 g (P < 0.001). Severe BPD ≥ moderate was significantly lower in the post-QI period (36.2% vs. 53.9%) (P < 0.001) along with shorter mechanical ventilation days (12 ± 29 vs. 22 ± 27) (P = 0.046). The PICC insertion rate was significantly decreased from 95.6% in pre-QI period compared to 55.2% in post-QI period (P < 0.001) along with a notable reduction in blood culture-proven sepsis (25.6% vs. 10.5%, P = 0.008). CRBSI rate was reduced from 1.3 to 1.1 per 1000 catheter days in the post-QI period. Moreover, the time required to achieve full enteral feeding of 100 mL/kg/day was significantly shorter in the post-QI (24 ± 23 vs. 33 ± 25) (P = 0.006). Multivariable logistic regression analysis for sepsis revealed that both birth weight and pre/post QI consistently demonstrated an association with lower sepsis rates in the Post-QI period. QI has the potential to reduce the burden of unnecessary interventions and blood culture proven sepsis rate along with CRBSI rate, thereby, optimizing the better care of very preterm babies.

Abstract 431: Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest and Prolonged Mechanical Ventilation Period: Insight From the National Inpatient Sample Database 2019

Introduction: The TTM2 trial showed that targeted temperature management (TTM) did not improve the functional status of survivors of out-of-hospital cardiac arrest (OHCA). However, the TTM2 trial OHCA survivors cohort had short mechanical ventilation (MV) duration (3.8 days in the hypothermic group and 2.9 days in the normothermic group). Aims: We aimed to investigate the functional status of OHCA survivors who required a prolonged MV duration. Methods: We utilized the National Inpatient Sample Database 2019. Participants were included if they were primarily admitted for cardiac arrest regardless of initial rhythm. Prolonged MV was defined as &gt; 4 days. Patients who have ICD-10 codes for both short and prolonged MV durations were excluded as they potentially had multiple intubations. The primary outcome was discharge from the hospital to home, as a surrogate for good functional status on discharge. Results: A total of 28,890 patients were admitted for cardiac arrest in 2019 in the United States. Of them, 67.5% (n=19,515) had MV. Of the mechanically ventilated patients, 74.3% (n=14,490) were ventilated for ≤ 4 days, 24.8% (n=4,835) had prolonged MV, and 190 admissions were excluded for possible multiple MV episodes. TTM utilization was comparable between survivors with prolonged MV (8.7%, n=200) and short MV (7.6%, n=380)(p=0.083). Discharge to home was higher in the short MV group [33.8% (n=1,690) vs 15% (n=345), p&lt;0.001]. After adjusting for age, sex, race, insurance, Elixhauser comorbidity index, renal replacement therapy, and coronary angiography, TTM was not independently associated with discharge to home in the short MV group (aOR 0.951, 95% CI 1.008-0.795, p=0.992). However, TTM was associated with significantly higher odds of discharge to home in the prolonged MV group (aOR 2.441, 95% CI 1.591-3.744, p&lt;0.001). Conclusions: One-fourth of the OHCA survivors, mechanically ventilated, cohort required prolonged MV. These patients have poorer functional status (discharge to home rate) that the short MV cohort. TTM seems to correlate with improved adjusted functional status on discharge from the hospital in the prolonged MV group. Future clinical trials should investigate the TTM impact on this subgroup of OHCA survivors.

Sex Differences in Outcome of Trauma Patients Presented with Severe Traumatic Brain Injury: A Multicenter Cohort Study.

The objective of this study was to determine whether there is an association between sex and outcome in trauma patients presented with severe traumatic brain injury (TBI). A retrospective multicenter study was performed in trauma patients aged ≥ 16 years who presented with severe TBI (Head Abbreviated Injury Scale (AIS) ≥ 4) over a 4-year-period. Subgroup analyses were performed for ages 16-44 and ≥45 years. Also, patients with isolated severe TBI (other AIS ≤ 2) were assessed, likewise, with subgroup analysis for age. Sex differences in mortality, Glasgow Outcome Score (GOS), ICU admission/length of stay (LOS), hospital LOS, and mechanical ventilation (MV) were examined. A total of 1566 severe TBI patients were included (831 patients with isolated TBI). Crude analysis shows an association between female sex and lower ICU admission rates, shorter ICU/hospital LOS, and less frequent and shorter MV in severe TBI patients ≥ 45 years. After adjusting, female sex appears to be associated with shorter ICU/hospital LOS. Sex differences in mortality and GOS were not found. In conclusion, this study found sex differences in patient outcomes following severe TBI, potentially favoring (older) females, which appear to indicate shorter ICU/hospital LOS (adjusted analysis). Large prospective studies are warranted to help unravel sex differences in outcomes after severe TBI.

P46 TRANSAXILLARY MITRAL VALVE SURGERY IS ASSOCIATED WITH EARLY RECOVERY AND SHORTER ICU AND HOSPITAL STAY

Abstract Background and Aim Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection and valve exposure in minimally invasive mitral valve surgery (MIMVS). Aim of this study is to compare the early outcomes of patients operated through a right trans–axillary (TAxA) approach with those achieved in conventional full sternotomy (FS) operations. Methods Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at two academic centres were reviewed. Among them, 454 patients underwent MIMVS through TAxA access and 667 patients through FS (associated aortic and CABG procedures, infective endocarditis and urgent operations were excluded). A propensity match analysis was performed using seventeen preoperative and intraoperative variables. Results There was no difference in preoperative characteristics in matched populations. The rate of mitral valve repair was similar in both groups. Patients in TAxA group had a higher rate of repair using artificial chordae. Operative times were shorter in FS group but in patients operated in minimally invasive approach there was a trend towards decreasing CPB and cross–clamp time over the study period. Hospital mortality in TAxA group was 0.25%, postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (p&amp;lt;0.001) and ICU stay (p&amp;lt;0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home vs. 5% in the FS group (p&amp;lt;0.001). Conclusions TAxA approach is safe and effective. Compared to FS, it allows shorter mechanical ventilation, ICU and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation.

Comparing the Outcomes of Deceased-Donor and Living-Donor Liver Re-Transplantation In Adult Patients

Patients with liver graft failures have an extremely low chance of finding a cadaveric graft in countries with a scarcity of deceased donors. We compared the outcomes of liver re-transplantation with living-donor liver grafts (re-LDLT) and deceased-donor liver grafts (re-DDLT) in adult patients (>18 years). The medical records of 1513 (1417 [93.6%] LDLT and 96 [6.3%] DDLT) patients who underwent liver transplantation at Memorial Hospital between January 2011 and October 2022 were reviewed. Forty patients (24 adults and 16 pediatric) were re-transplanted (2.84%); 24 adult patients (2.72%: 25 re-LDLT, 1 patient with second re-LDLT) were divided into 2 groups: re-DDLT (n=6) and re-LDLT (n=18). The groups were compared in demographics, pre-, peri-, postoperative characteristics, and outcomes. The overall survival rates were 91.7%, 79.2%, 75.0%, and 75% for <30 days, 31 to 90 days, 1, and 3 years, respectively. The LDLT group was significantly younger (P=.022), had smaller graft weight (P=.03), shorter mechanical ventilation (P=.036) but longer operation time (P=.019), and hospitalization period (P=.003). The groups were otherwise comparable. There was no statistically significant difference in survival rates between the groups (P=.058), although the re-LDLT group had an evidently higher survival rate (88.9% and 83.3 % vs 50.0%). Re-LDLT has shown comparable outcomes to re-DDLT, if not better (even not far from significance P=.058). These results may encourage performing re-LDLTs in patients with indications for re-LT without worrying about low chances of survival, especially in countries with limited sources of deceased donors.

Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis

To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models. A retrospective observational study. Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients. An ET versus late tracheostomy (LT). Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups. The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.

Extracorporeal Membrane Oxygenation Support for Interstitial Lung Disease in Idiopathic Inflammatory Myopathies: An ELSO Registry Analysis.

Extracorporeal Membrane Oxygenation Support for Interstitial Lung Disease in Idiopathic Inflammatory Myopathies: An ELSO Registry Analysis.

Success of Right Thoracotomy versus Exploratory Laparotomy in Right sided Congenital Diaphragmatic Hernia in neonates

Objective: Aim of current study is to determine the success of right thoracotomy versus exploratory laparotomy in right sided congenital diaphragmatic hernia in neonates. Study Design: Retrospective study Place and duration: The Children’s Hospital PIMS Islamabad. Jan 2021 to Dec 2021 Methods: Total 74 neonates had right sided congenital diaphragmatic hernia were included. All the neonates were admitted to hospital for surgery. Neonates were equally divided in two groups. Thirty seven patients in group I received thoracotomy and 37 patients in group II underwent for exploratory laparotomy. Post-surgery success rate among both groups were compared. Results: There were majority 41 (55.4%) males and 33 (44.6%) females. Mean age of the neonates was 13.7±4.19 days. Pre-operative tracheal intubation and cardiac malformation was found in 67 (90.4%) and 14 (18.9%) cases. Compared to thoracotomies, exploratory laparotomies were associated with shorter hospital stays, shorter durations of postoperative mechanical ventilation, and shorter times to optimum feeding. We found that recurrence rate in thoracotomy group was higher as compared to laparotomy group with p value &lt;0.004. There were no any significant differences in postoperative complications between the two groups. In both groups, 3 (8.1%) and 1 (2.7%) patients were died. Conclusion: We concluded in this study that the exploratory laparotomy among patients of right sided congenital diaphragmatic hernia was effective and useful in terms of shorter hospital stay, short mechanical ventilation and less time to optimum feeding as compared to right thoracotomy. No any significant difference was found in terms of post-surgery complication among both groups. Keywords: Congenital Diaphragmatic Hernia (CDH), Exploratory laparotomy, Thoracotomy

Efficacy of Oxymatrine Plus Antiviral in the Treatment of Sepsis and Its Effect on the Levels of Endotoxin and Inflammatory Factors.

Objective To assess the clinical efficacy of oxymatrine plus antiviral therapy in the treatment of sepsis and its effects on the levels of endotoxin and inflammatory factors. Methodology. 90 patients with sepsis were selected for retrospective analysis and were assigned to receive either conventional treatment (control group) or oxymatrine plus antiviral treatment (study group). The clinical endpoint was treatment efficacy. Results There were no significant differences in baseline patient profile between the two groups (P > 0.05). The study group showed a higher efficiency versus the control group (P < 0.05). Patients in the study group had a significantly shorter mechanical ventilation duration and ICU stay versus those in the control group (P < 0.05). Both groups had reduced Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Marshall score, levels of endotoxin, tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-8, C-reactive protein (CRP), and procalcitonin (PCT) after treatment, with lower results in the study group versus the control group (P < 0.05). Conclusion Oxymatrine plus antiviral therapy effectively improves clinical efficacy, reduces the levels of endotoxin and inflammatory factors, protects organ function, and boosts recovery. Further clinical trials are, however, required prior to general application in clinical practice.

Clinical Efficacy of Budesonide/Glycopyrronium Bromide/Formoterol in the Treatment of Patients with Acute Respiratory Distress Syndrome and Its Effect on Inflammatory Factors.

Objective To examine the clinical efficacy of budesonide/glycopyrronium bromide/formoterol (Breztri Aerosphere) as an adjunct to acute respiratory distress syndrome (ARDS). Methods A prospective study enrolled 120 patients with pulmonary endogenous ARDS admitted to the Department of Critical Care Medicine at the Fourth Hospital of Baotou from January 2017 to January 2020, and all enrollments were assigned (1 : 1) to receive conventional treatment (control group) or Breztri Aerosphere (study group). Results Breztri Aerosphere was associated with a significantly higher total efficacy versus conventional treatment. Breztri Aerosphere resulted in significantly lower acute physiology and chronic health evaluation scoring system (APACHE II) scores and Murray lung injury scores versus conventional treatment. Both groups saw an increase in the partial pressure of carbon dioxide (PCO2), partial pressure of oxygen (PO2), and oxygen saturation (SaO2) after treatment, with higher levels seen in patients given Breztri Aerosphere. After treatment, systemic vascular resistance (SVR) in both groups rose markedly, with greater elevation witnessed in the study group. The patients given Breztri Aerosphere showed significantly lower levels of pulmonary vascular resistance (PVR), mean pulmonary arterial pressure (MAPA), pulmonary artery wedge pressure (PAWP), interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-α), and procalcitonin (PCT) versus those receiving conventional treatment. The patients experienced shorter mechanical ventilation time and intensive care unit (ICU) time after treatment of Breztri Aerosphere versus conventional treatment. Conclusion Adjuvant therapy with Breztri Aerosphere in ARDS can significantly lower APACHE II scores and Murray lung injury scores, improve blood gas indexes and pulmonary circulation function indexes, and shorten mechanical ventilation time and ICU time, which may be attributed to its improvement of organism inflammation status and reduction of inflammatory factors.

Modified Zipper Method, a Promising Treatment Option in Severe Pediatric Immune-Mediated Neurologic Disorders.

ObjectiveTo introduce and evaluate a modified version of the “zipper method”—a treatment strategy alternating intravenous immunoglobulin (IVIG) and plasma exchange (PLEX) first reported for 9 pediatric cases of Guillain-Barré syndrome in 2018—for treatment of severe immune-mediated neurologic disorders in children.MethodsThe modified zipper method comprised longer intervals between PLEX-IVIG cycles (48 hours instead of 24 hours), more cycles (7-10 instead of 5), a consistent plasma volume exchange (instead of the original multistep approach), and variable infusion times for IVIGs (4-8 hours). The modified zipper method was applied as an individual treatment approach once standard therapy failed. The follow-up ranged from 6 months to 2 years. Cases were analyzed retrospectively. Disease severity was mainly quantified by the Guillain-Barré syndrome disability score.ResultsFour children (9-15 years) with (1) Miller-Fisher syndrome, (2) Bickerstaff brainstem encephalitis, (3) common Guillain-Barré syndrome, and (4) severe acute disseminated encephalomyelitis were treated by the modified zipper method. Results for duration of mechanical ventilation (median of 12 days, interquartile range [IQR] 8-16), hospital stay (median of 23 days, IQR 22-24), and time to unaided walking (median of 22 days, IQR 21-37) outperformed previous studies with IVIG/PLEX alone or IVIG + PLEX combinations unlike the zipper method.ConclusionThe modified zipper method is associated with a low mortality, a short mechanical ventilation time, a short hospital stay, and an excellent outcome in children with severe Guillain-Barré syndrome or acute disseminated encephalomyelitis. Our regimen is streamlined for applicability. Results emphasize its robust effectiveness as an option for therapy escalation in severe neuroimmunologic diseases. Now, multicenter trials are needed to evaluate this novel treatment strategy.

The Role of the Respiratory Therapy Team in the Treatment of Patients With Acquired Immunodeficiency Syndrome Complicated With Pneumocystis Pneumonia Undergoing Mechanical Ventilation.

ObjectiveTo explore the role of the respiratory therapy team in the treatment of patients with acquired immunodeficiency syndrome (AIDS) complicated with pneumocystis pneumonia (PCP) undergoing mechanical ventilation.MethodsA retrospective cross-sectional study was conducted, including 60 patients with AIDS complicated with PCP undergoing mechanical ventilation in our hospital from June 2019 to July 2020. In the process of patient respiratory monitoring, hospital transport, ventilator withdrawal, airway management, various aerosol treatments and controlled oxygen therapy, patients were divided into the control group and the case group according to whether the respiratory therapy team was involved or not (30 in the control group, 25 males and five females; 30 in the case group, 24 males and six females). The baseline data, mechanical ventilation time, hospitalization time and hospitalization expenses of the two groups were compared.ResultsThere was no statistically significant difference in baseline data between the case and control groups (P > 0.05). Compared with the control group, the case group had significantly shorter mechanical ventilation times and average hospitalization lengths and the average expenses decreased, and the difference was statistically significant (P < 0.05).ConclusionThe participation of the respiratory therapy team in the mechanical ventilation treatment of patients with AIDS and PCP helps to shorten the mechanical ventilation time and the average length of hospitalization and reduce the hospitalization expenses of patients. It is expected to increase the cure rate of such patients and improve their prognosis.

Antenatal Betamethasone Every 12 Hours in Imminent Preterm Labour.

Background: Benefits of antenatal corticosteroids have been established for preterm infants who have received the full course. In imminent preterm labours there is no time to administer the second dose 24 h later. Objective: To determine whether the administration of two doses of betamethasone in a 12 h interval is equivalent to the effects of a full maturation. Methods: We performed a retrospective cohort study including preterm infants ≤34 weeks gestational age at birth and ≤1500 g, admitted to an NICU IIIC level in a tertiary hospital from 2015 to 2020. The population was divided into two cohorts: complete maturation (CM) (two doses of betamethasone 24 h apart), or advanced maturation (AM) (two doses of betamethasone 12 h apart). The primary outcomes were mortality or survival with severe morbidities. The presence of respiratory distress syndrome and other morbidities of prematurity were determined. These variables were analysed in the neonates under 28 weeks gestational age cohort. Neurodevelopment at 2 years was evaluated with the validated Ages and Stages Questionnaires®, Third Edition (ASQ®-3). Multiple regression analyses were performed and adjusted for confounding factors. Results: A total of 275 preterm neonates were included. Serious outcomes did not show differences between cohorts, no increased incidence of morbidity was found in AM. A lower percentage of hypotension during the first week (p = 0.04), a tendency towards lower maximum FiO2 (p = 0.14) and to a shorter mechanical ventilation time (p = 0.14) were observed for the AM cohort. Similar results were found in the subgroup of neonates under 28 weeks gestational age. There were no differences in cerebral palsy or sensory deficits at 24 months of corrected age, although the AM cohort showed a trend towards better scores on the ASQ3 scale. Conclusions: Administration of betamethasone every 12 h showed similar results to the traditional pattern with respect to mortality and severe morbidities. No deleterious neurodevelopmental effects were found at 24 months of corrected age. Earlier administration of betamethasone at 12 h after the first dose would be an alternative in imminent preterm delivery. Further studies are needed to confirm these results.

Role of Intensified Lung Physiotherapy Bundle on the Occurrence of Pneumonia After Cardiac Surgery.

ObjectiveThe role of intensified lung physiotherapy bundle after cardiac surgery was investigated.MethodsA before- and after-surgery comparison was conducted between the study from January 1, 2018 to December 31, 2019 (control group), when traditional lung physiotherapy bundle was used, and from January 1, 2020 to May 1, 2021 (study group), when the intensified bundle was used. The baseline data, clinical features, incidence of postoperative pneumonia, and prognoses of all the enrolled cardiac surgery patients were analyzed.ResultsIn accordance with the study criteria, 358 patients were enrolled. The incidence rate of postoperative pneumonia was significantly lower in the study group than in the control group (14.2 vs. 22.7%, P = 0.037), as was in-hospital mortality (1.5 vs. 5.2%, P = 0.043). Patients receiving the intensified lung physiotherapy bundle had much shorter mechanical ventilation time (92 vs. 144 h, P < 0.0001), much shorter intensive care unit (ICU) stay (5 vs. 7 days, P < 0.001), and much shorter hospital stay (17 vs. 18.5 days, P = 0.022). The intensified lung physiotherapy bundle was an independent protective factor enabling the reduced occurrence of pneumonia (P = 0.007). On univariate analysis, this bundle significantly improved in-hospital mortality (P = 0.043).ConclusionsOur intensified lung physiotherapy bundle potentially reduces the rate of postoperative pneumonia after cardiac surgery. This bundle might also be adopted as a suitable reference guide for the prevention of other postoperative pulmonary complications.

Mechanical ventilation during cardiopulmonary bypass in neonates improves postoperative outcome.

Cardiopulmonary bypass generates a systemic inflammatory response. This inflammatory response is reduced if patients are ventilated during bypass, as evidenced by lower levels of postoperative circulating inflammatory mediators. However, this does not appear to make much clinical difference in adults, at least not consistently, but, to our knowledge, has never been assessed in paediatric cardiac surgery, which is the objective of this study. This is a prospective clinical study of 12 consecutive neonates operated for the correction of either transposition of the great arteries ± ventricular septal defect or aortic arch hypoplasia ± ventricular septal defect, who were ventilated during cardiopulmonary bypass. These were compared to 11 neonates with the same malformations, who had undergone the same operations but without being ventilated during bypass (historical control group). One patient from the control group died on the 15th postoperative day due to sepsis and multi-organ failure. Bypass times and cross-clamp times were similar in the 2 groups. Ventilation on bypass was associated with significantly lower postoperative serum concentrations of C-reactive protein, shorter mechanical ventilation and lower vasoactive-inotropic score. Duration of stay on intensive care unit (ICU) showed a tendency to be shorter in patients who were ventilated on bypass, but this did not reach statistical significance. There were no differences between the 2 groups with respect to postoperative mixed venous oxygen saturations and serum concentrations of lactate and troponin I. Mechanical ventilation during cardiopulmonary bypass in neonates improves postoperative outcome.

Lung recruitment improves the efficacy of intubation-surfactant-extubation treatment for respiratory distress syndrome in preterm neonates, a randomized controlled trial

BackgroundLung recruitment is a maneuver used to decrease the length of intubation in preterm neonates. This study aimed to compare the therapeutic efficacy of lung recruitment plus intubation-surfactant-extubation (INSURE) procedure and INSURE alone for the preterm neonates with respiratory distress syndrome.MethodsFrom 2017 to 2019, 184 preterm neonates (gestational age 24–32 weeks) with respiratory distress syndrome were enrolled and randomized into the lung recruitment group receiving lung recruitment (25 cm H2O, 15 s) plus INSURE and the control group receiving INSURE only. The primary outcome was the need for mechanical ventilation (MV) within 72 h after extubation. The secondary outcomes included duration of MV, noninvasive ventilation, total oxygen therapy, hospitalization time, and complications.ResultsCompared to the control group, the lung recruitment group had a significantly lower proportion of preterm neonates requiring MV within 72 h after extubation (23% vs. 38%, P = 0.025) and pulmonary surfactant administration, as well as a shorter MV duration. There was no significant difference in the incidences of complications (all P > 0.05) and in-hospital mortality (2% vs. 4%, P = 0.4) between the lung recruitment group and control group. Multivariate logistic regression analysis demonstrated that the control group had a 2.17-time higher risk of requiring MV than the lung recruitment group (AOR: 2.17, 95% CI: 1.13–4.18; P = 0.021). Compared with infants with a normotensive mother, infants with a hypertensive mother have a 2.41-time higher risk of requiring MV (AOR: 2.41, 95% CI: 1.15–5.05; P = 0.020).ConclusionLung recruitment plus INSURE can reduce the need for MV within 72 h after extubation and did not increase the incidence of complications and mortality.Trial registrationChinese Clinical Trial Registry ChiCTR1800020125, retrospectively registered on December 15, 2018.

Requirement of Postoperative Ventilation and analgesics during Off-Pump Coronary Artery Bypass (OPCAB) surgery – A Comparison between Combined High Thoracic Epidural Anaesthesia (HTEA) with GA and GA Alone

Beckground: This is often difficult to achieve optimal pain relief after coronary artery bypass surgery and also great challenge to choice appropriate analgesics with minimize the duration of mechanical ventilation. In the postoperative period inadequate analgesia may increase morbidity by causing adverse haemodynamic, metabolic, immunologic and haemostatic attentions and prolong mechanical ventilation with more ICU stay. High Thoracic Epidural Anaesthesia (HTEA) as an adjunct to general anaesthesia has been shown to be potentially beneficial in postoperative pain relief and the requirement of mechanical ventilationin patients with off-pump coronary artery bypass surgery (OPCAB). HTEA provides good protection from stress response, ensures hemodynamic stability, improves distribution of coronary blood flow with reducing demand of oxygen, less requirement of postoperative analgesia , mechanical ventilation and ICU stay. Objective: This study has been undertaken with a view to compare requirement of postoperative mechanical ventilation and analgesics in OPCAB surgery between HTEA with GA and GA alone. Methods: This prospective, randomized case control comparative study was carried out in sixty patients without having left main coronary artery disease, left ventricular ejection fraction &lt;30% or contraindication of regional anaesthesia scheduled for OPCAB. They were divided into two groups, thirty in each group. Group A received GA alone and group B received high thoracic epidural anaesthesia with GA. Requirement of postoperative analgesics, pain score, consciousness score, sedation score, satisfection level and duration of ventilation with length of stay in intensive care unit were recorded in the post-operative period. Results: Rescue analgesics received and found 16(53.3%) and 6(20.0%) needed analgesia in group A and group B respectively and the difference was statistically significant (p&lt;0.05). Regarding the pain score (VAS) during maintenance with ventilator with awareness at first fourth hour significant (p&lt;0.05) change between two groups. After extubation at rest in different time interval and found significant (p&lt;0.05) change between two groups in all follow-up times. Post-operative pain score (VAS) after extubation at movement in different time interval and found significant (p&lt;0.05) change between two groups. Post-operative pain score (VAS) after extubation at during coughing in different time interval and found significant (p&lt;0.05) change between two groups. Post-operative sedation score at first six hour (hourly) and found significant (p&lt;0.05) change between two groups except 1st hour, which was not significant (p&gt;0.05). The mean extubation hours were 7.4±1.09 hours in group A and 5.3±0.81 hours in group B. The mean ICU stay was 72.9±9.2 hours in group A and 57.1±12.0 hours in group B and the difference was statistically significant (p&lt;0.05) in unpaired t-test. No postoperative complication was observed in both groups. Conclusion: HTEA with GA appeared to be most reliable postoperative pain relief, shorter mechanical ventilation, ICU stay in OPCAB surgery Bangladesh Heart Journal 2021; 36(2): 74-81

Mitral Repair for Mitral Prolapse: Comparison of Thoracoscopic Minimally-Invasive and Conventional Approaches Using Propensity Score

Objective: Surgical repair remains the standard treatment for severe mitral regurgitation (MR) due to mitral prolapse. Minimally-invasive mitral valve surgery (MIMVS) has been increasingly performed but still is the minority, with lack of solid evidence on its superiority over conventional surgery. Our objectives were to compare the results of MIMVS and conventional surgery. Methods: Retrospective review of all patients treated in our center with degenerative severe MR (November 2011 – May 2020). Patients with previous mitral surgery and those requiring concomitant procedures other than atrial fibrillation ablation were excluded. Two groups were compared: MIMVS (minimally invasive surgery) and Open (full median sternotomy), in a cohort of matched (1:1; nearest neighbor) pairs using propensity score (PS) methods. Results: 286 consecutive patients met the inclusion criteria (MIMVS:183, Open:103). There were no significant differences preoperatively, except for lower age, NYHA III-IV and EuroSCOREII in the MIMVS group. In both groups, around 40% of patients presented with anterior or bileaflet prolapse, with no differences in repair techniques used. After PS matching, a cohort of 93 matched pairs was selected and all basal differences were balanced. Comparisons showed that despite bypass and cross-clamp times were higher (+32 and +21m; p<0.001), MIMVS presented shorter mechanical ventilation (0 vs. 6h; p<0.01), ICU stay (1.8 vs. 2.5d; p=0.02), higher hemoglobin (11 vs. 10mg/dL; p<0.02) and less renal failure (1 vs. 8%; p:0.03). There were no differences in mortality, repair rate or MR grade at discharge. During follow-up (median 2.8 years), there were no significant differences in the degree of recurrent MR and reoperation. Conclusions: Surgical repair of mitral prolapse is possible in most cases with low perioperative morbimortality and excellent mid-term results. MIMVS can be performed without compromising perioperative outcomes, repair rate and durability, while providing shorter ICU and mechanical ventilation duration, less blood loss and renal failure.

Tracheostomy in Postoperative Pediatric Cardiac Surgical Patients—The Earlier, the Better

AbstractObjectives This study was aimed to assess the benefits of early tracheostomy (ET) compared with late tracheostomy (LT) on postoperative outcomes in pediatric cardiac surgical patients.Design Present one is a prospective, observational study.Setting The study was conducted at a cardiac surgical intensive care unit (ICU) of a tertiary care hospital.Participants All pediatric patients below 10 years of age, who underwent tracheostomy after cardiac surgery from January2019 to december2019, were subdivided into two groups according to the timing of tracheostomy: “early” if done before 7 days or “late” if done after 7 days postcardiac surgery.Interventions ET versus LT was measured in the study.Results Out of all 1,084 pediatric patients who underwent cardiac surgery over the study period, 41 (3.7%) received tracheostomy. Sixteen (39%) patients underwent ET and 25 (61%) underwent LT. ET had advantages by having reduced risk associations with the following variables: preoperative hospital stay (p = 0.0016), sepsis (p = 0.03), high risk surgery (p = 0.04), postoperative sepsis (p = 0.001), C-reactive protein (p = 0.04), ventilator-associated pneumonia (VAP; p = 0.006), antibiotic escalation (p = 0.006), and antifungal therapy (p = 0.01) requirement. Furthermore, ET was associated with lesser duration of mechanical ventilation (p = 0.0027), length of ICU stay (LOICUS; p = 0.01), length of hospital stay (LOHS; p = 0.001), lesser days of feed interruption (p = 0.0017), and tracheostomy tube change (p = 0.02). ET group of children, who had higher total ventilation-free days (p = 0.02), were decannulated earlier (p = 0.03) and discharged earlier (p = 0.0089).Conclusion ET had significant benefits in reduction of postoperative morbidities with overall shorter mechanical ventilation, LOICUS, and LOHS, better nutrition supplementation, lesser infection, etc. These benefits may promote faster patient convalescence and rehabilitation with reduced hospital costs.

Congenital diaphragmatic hernia in neonates: Open versus thoracoscopic repair.

Background:There are no standard criteria to select patients for thoracoscopic repair of congenital diaphragmatic hernia (CDH). The objective of this study was to compare open laparotomy versus thoracoscopic repair of CDH in neonates.Patients and Methods:This retrospective study included 41 patients who had repair of CDH from 2011 to 2019. Patients were divided into two groups according to the surgical approach; open laparotomy (n = 30) and thoracoscopic repair (n = 11). Study endpoints were duration of post-operative mechanical ventilation, hospital stay and the return to full enteral feeding.Results:Patients who had thoracoscopic repair were significantly younger (3 [25th- 75th percentiles: 3-3] vs. 4 [3–5] days; P = 0.004). Other pre-operative variables were comparable between both groups. The duration of surgery was significantly longer in the thoracoscopic repair (174 [153–186] vs. 91 (84–99) min; P < 0.001). The use of pre-operative nitrous oxide inhalation was associated with prolonged ventilation (P = 0.004), while the thoracoscopic repair was associated with shorter mechanical ventilation (P = 0.006). Hospital stay is lower in the thoracoscopic approach but did not reach a significant value (P = 0.059). The use of pre-operative nitrous oxide was associated with a prolonged hospital stay (P = 0.002). Younger age (HR: 1.33, P = 0.014) and open approach (HR: 3.56, P = 0.004) were significantly associated with delayed feeding.Conclusions:The thoracoscopic approach is safe and effective for repairing the CDH. It is associated with shorter mechanical ventilation and rapid return to enteral feeding. Proper patient selection is essential to achieve good outcomes.