Shorter Ventilation Time Research Articles

Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia.

Background Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR). Materials and Method s In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol ( n = 188) and nonmannitol ( n = 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at p < 0.05. Results Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%; p = 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours; p = 0.021), higher reintubation rate (11.3 vs. 2.7%; p = 0.009), ICU readmission (12.7 vs. 4.8%; p = 0.026), prolonged ICU (112 vs. 70 hours; p = 0.040), and hospital stay (17.8 vs. 12.6 days; p < 0.001), leading to higher expenses (19,349 € vs. 16,606 €, p < 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7; p < 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89; p = 0.02). Conclusion Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.

Comparison of intraoperative tranexamic acid and epsilon-aminocaproic acid in cardiopulmonary bypass patients.

ObjectiveTo compare tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) in patients undergoing cardiac surgery with cardiopulmonary bypass.MethodsOver a consecutive 2-year period, 824 adult cardiac surgery patients who received TXA during an EACA shortage were compared with 778 patients who received EACA postshortage. Patient characteristics and process and outcome variables were collected through chart review and database queries. This retrospective analysis used inverse probability of treatment weighting to control for confounding by indication, and propensity scores were calculated using a logistic regression model.ResultsIn adjusted models, overall transfusion rates for the TXA cohort (odds ratio [OR], 0.94; 95% confidence interval [95% CI], 0.81-1.10) and administration of platelets (OR, 1.04; 95% CI, 0.85-1.27), red blood cells (OR, 0.93; 95% CI, 0.80-1.09), fresh frozen plasma (OR, 1.00; 95% CI, 0.79-1.25), and cryoprecipitate (OR, 1.08; 95% CI, 0.71-1.64) were equivalent to the EACA cohort. In addition, there was no statistical difference with respect to stroke, seizure, mortality, reoperation for bleeding, chest tube drainage, and acute kidney injury. Patients who received TXA had shorter ventilator times (difference in medians −1.33 hours [95% CI, −1.86 to −0.80]) and lower postsurgical charges (difference of medians −$2913 [95% CI, −5147 to −679]).ConclusionsSubstituting TXA for EACA during cardiac surgery with cardiopulmonary bypass did not change transfusion rate or amount, nor was there a significant difference in chest tube drainage. Patients who received TXA had a statistically significant but not clinically significant lower postoperative ventilator times and charges without an increase in mortality, stroke, reoperation for bleeding, acute kidney injury, or seizures.

Surgery of ascending aorta with complex procedures for aortic dissection through upper mini-sternotomy versus conventional sternotomy

BackgroundUse of minimally invasive approaches for isolated aortic valve or ascending aorta surgery is increasing. However, total arch replacement or aortic root repair through a minimally invasive incision is rare. This study was performed to report our initial experience with surgery of the ascending aorta with complex procedures through an upper mini-sternotomy approach.MethodsWe retrospectively analyzed 80 patients who underwent ascending aorta replacement combined with complex procedures including hemi-arch, total arch, and aortic root surgeries from September 2010 to May 2018. Using standard propensity score-matching analysis, 36 patients were matched and divided into 2 groups: the upper mini-sternotomy group (n = 18) and the median sternotomy group (n = 18). The preoperative assessment revealed no statistically significant differences between the two groups.ResultsHospital mortality occurred in one patient (2.8%). The mini-sternotomy group showed a longer cross-clamping time (160 ± 38 vs. 135 ± 36 min, p = 0.048) due to higher rate of valve-sparing aortic root replacement and total arch repair. The cardiopulmonary bypass time in mini-sternotomy group was shorter than that of full sternotomy group (209 ± 47 min vs 218 ± 62 min, p = 0.595) but fell short of significance. There was no significant difference in lower body hypothermia circulatory arrest time between the two groups (40 ± 10 min vs 48 ± 20 min, p = 0.139). The upper mini-sternotomy group displayed a shorter ventilation time (22 vs. 45 h, p = 0.014), intensive care unit stay (4.6 ± 2.7 vs. 7.9 ± 3.7 days, p = 0.005), and hospital stay (8.2 ± 3.8 vs. 21.4 ± 11.9 days, p = 0.001). The upper mini-sternotomy group showed a lower postoperative red blood cell transfusion volume (4.6 ± 3.3 vs. 6.7 ± 5.7 units, p = 0.042) and postoperative drainage volume (764 ± 549 vs. 1255 ± 745 ml, p = 0.034). The rates of dialysis for newly occurring renal failure, neurological complications, and re-exploration were similar between the two groups (p = 1.000).ConclusionThe upper mini-sternotomy approach is safe and beneficial in ascending aorta surgery with complex procedures for aortic dissection, including total arch replacement and aortic root repair.

Ventilation time and prognosis after stroke thrombectomy: the shorter, the better!

Background and purposeThe aim was to investigate the clinical impact of the duration of artificial ventilation in stroke patients receiving mechanical thrombectomy (MT) under general anaesthesia.MethodsAll consecutive ischaemic stroke patients who had been treated at our centre with MT for anterior circulation large vessel occlusion under general anaesthesia were identified over an 8‐year period. Ventilation time was analysed as a continuous variable and patients were grouped into extubation within 6 h (‘early’), 6–24 h (‘delayed’) and >24 h (‘late’). Favourable outcome was defined as modified Rankin Scale scores of 0–2 at 3 months post‐stroke. Pneumonia rate and reasons for prolonged ventilation were also assessed.ResultsAmongst 447 MT patients (mean age 69.1 ± 13.3 years, 50.1% female), the median ventilation time was 3 h. 188 (42.6%) patients had a favourable 3‐month outcome, which correlated with shorter ventilation time (Spearman’s rho 0.39, P < 0.001). In patients extubated within 24 h, early compared to delayed extubation was associated with improved outcome (odds ratio 2.40, 95% confidence interval 1.53–3.76, P < 0.001). This was confirmed in multivariable analysis (P = 0.01). A longer ventilation time was associated with a higher rate of pneumonia during neurointensive care unit/stroke unit stay (early/delayed/late extubation: 9.6%/20.6%/27.7%, P < 0.01). Whilst stroke‐associated complications represented the most common reasons for late extubation (>24 h), delayed extubation (6–24 h) was associated with admission outside of core working hours (P < 0.001).ConclusionsProlonged ventilation time after stroke thrombectomy independently predicts unfavourable outcome at 3 months and is associated with increased pneumonia rates. Therefore, extubation should be performed as early as safely possible.

Minimally invasive aortic valve replacement with central cannulation: A cost-benefit analysis in a developing country

BackgroundMinimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding. However, few centers have started using these approaches with standard equipment because of the limited resources. We sought to report intra- and postoperative clinical outcomes and address health resource utilization after MIAVR.ResultsA total of 102 eligible patients who had aortic valve replacement were enrolled in a prospective, multicenter cohort study conducted from June 2015 to December 2017. Fifty patients underwent aortic valve surgery via upper inverted T-shaped hemi-sternotomy (MS), and 52 patients were operated using full sternotomy (FS) in two centers in a developing country. Central cannulation was performed in all cases. Major adverse cardiac events, pain, and wound complications were compared. A cost analysis was performed, and exposure and feasibility for cannulation were assessed. The mean length of MS skin incision was 5.82 ± 0.67 cm. Cumulative cross-clamp time was insignificant between both groups (91.87 ± 34.41 versus 94.91 ± 33.96 min; p = 0.66). MS exhibited shorter ventilation time (6.18 ± 1.86 versus 10.68 ± 12.78 h; p = 0.029) and intensive care stays (33.27 ± 19.75 versus 49.42 ± 47.1 h; p = 0.037). Major adverse cardiac events (MACEs) were compared, and MS group exhibited fewer transfusions (1.18 ± 0.89 versus 1.7 ± 0.97 units; p = 0.002), fewer pulmonary complications (1 (2%) versus 2 (3.8%); p < 0.001), and less sternotomy wound infection (1 (2%) versus 5 (9.6%); p = 0.048). Total operative mortality of 4.46% was recorded (n = 5). Significant cost reduction was recorded favoring MS; central cannulation saved $907.16 and carried a total cost reduction of $580 (9.3%) when compared with the FS approach (p < 0.0001).ConclusionsWith a lack of logistics in developing countries, MIAVR not only has a cosmetic advantage but carries a significant reduction in blood use, respiratory complications, pain, and cost. MIAVR can be feasible, with a rapid learning curve in developing centers.

Clinical study of fluid management in children with septic shock guided by ultrasound

Objective To investigate the effects of critical care chest ultrasonic examination (CCUE) by intensive care physician on fluid management among septic shock patients in pediatric intensive care unit (PICU). Methods Forty children from PICU who were diagnosed as septic shock in Shenzhen Bao′an Maternal and Child Health Hospital were included in this study.Twenty-two of them who were hospitalized in PICU during January 2017 to December 2018, under the care of 4 PICU physicians who had certificates of the Chinese Critical Ultrasound Study Group(CCUSG) were defined as CCUE group.Eighteen PICU patients from January 2014 to December 2015 having no access to CCUE were recruited as control group.Both groups were treated according to the septic shock management guidelines with routine anti-shock and anti-infection therapy, as well as mechanical ventilation.Fluid management following conventional protocol was performed in the control group.While in the CCUE group, CCUE was applied to monitor the hemodynamic status for adjustment in fluid management. Results Compared with the control group, the CCUE group had shorter mechanical ventilation time as well as less fluid intake and output within 48 hours after admission[(4.68±2.06)d vs.(7.33±0.49)d, (6.34±1.85)ml/(kg·h) vs.(8.55±0.39) ml/(kg·h), (2.47±1.22)ml/(kg·h) vs.(6.18±1.72)ml/(kg·h)] (P 0.05). Conclusion Application of CCUE helps to optimize fluid management and shorten the ventilation time among children with septic shock in PICU. Key words: Septic shock; Fluid management; Critical care chest ultrasonic examination in emergency consultation

Admission to the surgical intensive care unit during intensivist coverage is associated with lower incidence of postoperative acute kidney injury and shorter ventilator time.

This study aimed to assess the impact of intensivist coverage on the incidence of acute kidney injury (AKI) and ventilator time among patients postoperatively admitted to the intensive care unit (ICU). Adult patients postoperatively admitted to the ICU between January 2012 and December 2017 were retrospectively enrolled. The incidence of AKI within 72h of surgery and the postoperative ventilator time were compared between the groups covered by intensivists and non-intensivists. After propensity score (PS) matching, 5650 patients were included in the final analysis (2825 patients in each group). The incidence rate of AKI was significantly higher in the non-intensivist coverage group than in the intensivist coverage group (22.7% vs. 20.2%; P = 0.023). Moreover, logistic regression analysis in the PS-matched cohort showed that the incidence of postoperative AKI in the non-intensivist coverage group increased by 16% compared to that in the intensivist coverage group (odds ratio 1.16, 95% confidence interval 1.02-1.32; P = 0.023). Additionally, the median time of ventilator use in the non-intensivist coverage group was significantly longer than that in the intensivist coverage group [7.8 (interquartile range, IQR 2.6-13.8)h vs. 5.3 (1.8-8.3) h; P < 0.001]. High-intensity intensivist coverage is associated with a lower risk of postoperative AKI and shorter postoperative ventilator times. These findings suggested that in addition to medical trainees, initial management of surgical ICU patients by intensivists may lower the risk of AKI and facilitate early weaning from mechanical ventilation.

Effect of Personalized Music Intervention in Mechanically Ventilated Children in the PICU: A Pilot Study.

To determine the feasibility of a personalized music intervention with mechanically ventilated patients in the PICU. Pilot study with a quasi-experimental design. Tertiary children's hospital in China with a 40-bed PICU. Children, 1 month to 7 years, with mechanical ventilation were recruited and assigned to music group (n = 25) and control group (n = 25). Children in the music group received their own favorite music and listened for 60 minutes three times a day. The control group receive routine care without music. Primary outcome measure was comfort measured with the COMFORT Behavior scale 5 minutes before and after the music. Secondary outcome measures were physiologic variables; heart rate, respiration, blood pressure, oxygen saturation. Mechanical ventilation time, length of stay, and sedation medication were also collected. Qualitative analysis revealed that nurses had a positive attitude in delivering the interventions and identified improvements for the main trial. Children in the music group had lower COMFORT Behavior scores (15.7 vs 17.6; p = 0.011). Children in the music group had better physiologic outcomes; heart rate (140 vs 144; p = 0.039), respiration rate (40 vs 43; p = 0.036), systolic blood pressure (93 vs 95 mm Hg; p = 0.031), oxygen saturation (96% vs 95%; p < 0.001), diastolic blood pressure was not significantly (52 vs 53 mm Hg; p = 0.11). Children in the music group had a shorter ventilation time (148.7 vs 187.6; p = 0.044) and a shorter length of stay, but not significant (11.2 vs 13.8; p = 0.071). Children in the control group had higher total amount of on-demand midazolam (29 vs 33 mg; p = 0.040). Our pilot study indicates that personalized music intervention is feasible and might improve the comfort of children with mechanical ventilation. Further studies are needed to provide conclusive evidence in confirming the effectiveness of music interventions comforting critically ill children in PICUs.

Mitral valve replacement via minimally invasive totally thoracoscopic surgery versus traditional median sternotomy: a propensity score matched comparative study.

To compare surgical outcomes after mitral valve replacement via either minimally invasive thoracoscopic (MIs) or traditional median sternotomy (MS) surgery and determine the short- and mid-term clinical outcomes of the MI approach. All patients who received either MIs (n=405) or MS (n=691) mitral valve replacement surgery at the Guangdong Cardiovascular Institute between January 2012 and July 2015 were analyzed for outcome differences due to surgical approach using propensity score matching. The best 202 matches from the MI group and the MS group were analyzed. The clinical data of the two groups were collected, including preoperative cardiac function, operative data, postoperative complications, and follow-up. A final total of 404 patients were included in this study after propensity score matching; the MIs group and the MS group each contained 202 patients. The two groups were similar in age, weight, pathological changes, and surgical approach. Compared with the MS group, the MIs group had a longer cardiopulmonary bypass time (P<0.001), aortic cross-clamping time (P<0.001), and total procedure time (P<0.001). There were no significant differences between the groups regarding in-hospital mortality, stroke, pneumonia, acute renal failure, arrhythmia, and chylothorax. The MS group had significantly more patients with poor wound healing than the MIs group (P=0.004). The MI group had a lower rate of transfusion (P=0.037), shorter ventilation time (P=0.041), shorter ICU stay (P=0.033), reduced chest tube drainage and length of chest tube stay (P<0.001), and shorter hospital stay (P<0.001). There was no significant difference between the groups in hospital re-admission for bleeding, but the total hospitalization cost was higher in the MIs group (P=0.002). The mean follow-up was 26.59±12.33 months, the 1-year postoperative survival rate was 98.86%, and the overall survival rate was 97.44%. Compared with the MS group, the MIs group recovered earlier (P<0.05), and returned to work or study earlier (P<0.05). More patients in the MIs group were satisfied with the wound (P<0.001). The MS group had a higher incidence of postoperative osteomyelitis than the MIs group (P=0.028). There were no significant differences between groups in rates of mortality, stroke, pacemaker, reoperation, or 36-item Short Form Health Survey score. Compared with the MS approach, the MIs method of mitral valve replacement has longer cardiopulmonary bypass time and aortic cross-clamp time; however, it does not increase the risk of mortality and complications. Furthermore, MIs causes less trauma, fewer transfusions, less wound infection, faster recovery, faster return to work or study, and greater satisfaction with the incision in the mid-term. MI cardiac surgery is safe, effective, and feasible.

Minimal volume ventilation during robotically assisted mitral valve surgery.

A minimal volume ventilation method for robotically assisted mitral valve surgery is described in this study. In an attempt to reduce postoperative pulmonary dysfunction, 40 of 174 patients undergoing robotically assisted mitral valve surgery were ventilated with a small tidal volume during cardiopulmonary bypass. After propensity score matching, 31 patients with minimal volume ventilation were compared with 54 patients with no ventilation. Total ventilation time, PaO2/FiO2 ratio, arterial lactate concentration, and the rate of unilateral pulmonary edema in the matched minimal ventilation and standard treatment groups were evaluated. Patients in the minimal ventilation group had shorter ventilation times, 12.0 (interquartile range: 9.9-15.0) versus 14.0 (interquartile range: 12.0-16.3) hours (p = 0.036), and lower postoperative arterial lactate levels, 0.99 (interquartile range: 0.81-1.39) versus 1.28 (interquartile range: 0.99-1.86) mmol/L (p = 0.01), in comparison to patients in the standard treatment group. There was no difference in postoperative PaO2/FiO2 ratio levels or in the rate of unilateral pulmonary edema between the groups. Minimal ventilation appeared beneficial in terms of total ventilation time and blood lactatemia, while there was no improvement in arterial blood gas measurements or in the rate of unilateral pulmonary edema. The lower postoperative arterial lactate levels may suggest improved lung perfusion among patients in the minimal volume ventilation group. The differences in the ventilation times were in fact small, and further studies are required to confirm the possible advantages of the minimal volume ventilation method in robotically assisted cardiac surgery.

Outcome of pump assisted beating mitral valve replacement in patients with chronic severe mitral regurgitation and left ventricular dysfunction. A clinical randomized trial

BackgroundAs a natural extension of warm heart surgery, beating heart valve surgery was born. The fundamental question was posed: why arrest the heart if technically adequate valve procedures could be accomplished with continuous warm perfusion? So this study was carried out to evaluate the results of mitral valve replacement on beating heart in patients with chronic severe mitral regurgitation and left ventricular dysfunction. MethodsSixty patients underwent surgical correction of mitral insufficiency were prospectively randomized to 30 patients (group 1) mitral valve replacement using warm blood cardioplegia, and 30 patients (group II) mitral valve replacement using beating heart technique. ResultsPreoperatively, there was no significant difference between the two examined groups in age, sex, NYHA and echocardiographic data. The mitral surgical time (from beginning of opening of the left atrium till finishing left atrial closure) was significantly longer in the beating (group II) compared to the control (group I). However, the total bypass time was not significantly longer in the beating (group II) compared to the control (group I). The beating (group II) patients had shorter ventilation time and ICU stays time than in the control (group I). P value (0.003 and 0.049 respectively). Also (group II) patients had less incidence of low cardiac output status after surgery than the control (group I) (p value 0.007). The postoperative echocardiographic results showed a significant difference on LV myocardial function in favor of the beating technique (group II) over the cardioplegic technique (group I). ConclusionsBeating heart mitral valve replacement has proven in our study to be associated with better LV function early postoperatively than mitral valve replacement using warm bloody cardioplegic arrest. This together with the absence of related perioperative mortality and the major complications suggests that it is safe and beneficial to LV function.

Single Versus Bilateral Lung Transplantation for Idiopathic Pulmonary Fibrosis in the Lung Allocation Score Era

BackgroundIdiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease. Lung transplantation is the only therapy associated with prolonged survival. The ideal transplant procedure for IPF is unclear. Outcomes after single transplantation (SLTx) versus bilateral lung transplantation (BLTx) in IPF patients after introduction of the Lung Allocation Score were examined. MethodsRecords of patients undergoing lung transplantation for IPF at our institution between May 2005 and March 2017 were reviewed to examine the effect of transplant laterality. Primary outcomes were overall, rejection-free, and bronchiolitis obliterans (BOS)-free survival at 1 and 5 years post-transplant. ResultsLung transplantation was performed in 151 IPF patients post-Lung Allocation Score. Most recipients were male with average age 59 ± 8 years. SLTx was performed in 94 patients (62%). In the overall cohort, comparative survival between SLTx and BLTx was similar at 1 and 5 years before and after adjusting for age and pulmonary hypertension (PH). SLTx was associated with shorter ventilator time and intensive care unit stay and trended toward improved survival over BLTx in patients without PH. ConclusionsThe use of SLTx versus BLTx in IPF did not correspond to significantly different survival adjusting for age and PH. BLTx was associated with prolonged postoperative ventilation and length of stay compared with SLTx. Patients without PH, all older patients, and patients with PH and advanced disease should be considered for SLTx for IPF.

Successful Use of Sternal-Sparing Minimally Invasive Surgery for Proximal Ascending Aortic Pathology

A sternal-sparing approach to surgery of the proximal aorta could decrease postoperative morbidity. To determine the potential benefits of using a minimally invasive right thoracotomy approach for the treatment of ascending aortic pathology, we retrospectively reviewed our experience in patients who required circulatory arrest for the treatment of ascending aortic pathology (with or without aortic valve involvement) between January 2009 and November 2014 (N= 177). We compared baseline characteristics, intraoperative characteristics, and postoperative clinical outcomes between those who underwent a sternotomy (n= 103) and those who underwent a minimally invasive right thoracotomy approach (n= 74). All surgical procedures were performed by a single surgeon. Propensity score matching was performed to account for baseline differences between groups. More patients in the minimally invasive group had bicuspid aortic valve, degenerative aortic valve, or aortic insufficiency than in the sternotomy group, but other baseline characteristics were similar between groups. No strokes occurred. In the unmatched cohort, 30-day mortality was 2.7% for the minimally invasive group compared with 1.9% for the sternotomy group (p= 1.00). In the propensity score-matched cohort, 30-day mortality was 3.2% for both groups; circulatory arrest times were longer in the minimally invasive group than in the sternotomy group (p < 0.0001), but the minimally invasive group had fewer red blood cell transfusions, shorter ventilation times, and shorter intensive care unit and hospital length ofstay. A sternal-sparing approach to surgery of the proximal aorta is safe when performed by an experienced surgeon and conserves hospital resources.

Minimally invasive mitral valve surgery is associated with excellent resource utilization, cost, and outcomes

ObjectivesMinimally invasive mitral valve surgery (mini-MVR) has numerous associated benefits. However, many studies fail to include greater-risk patients. We hypothesized that a minimally invasive approach in a representative cohort provides excellent outcomes with reduced resource utilization. MethodsMitral valve surgical records from 2011 to 2016 were paired with institutional financial records. Patients were stratified by approach and propensity-score matched to balance preoperative difference. The primary outcomes of interest were resource utilization including cost, discharge to a facility, and readmission. ResultsA total of 478 patients underwent mitral surgery (21% mini-MVR) and were balanced after matching (n = 74 per group), with 18% of patients having nondegenerative mitral disease. Outcomes were excellent with similar rates of major morbidity (9.5% mini-MVR vs 10.8% conventional, P = .78). Mini-MVR cases had lower rates of transfusion (11% vs 27%, P = .01) and shorter ventilator times (3.7 vs 6.0 hours, P < .0001). Mean total hospital cost was equivalent ($49,703 vs $54,970, P = .235) with mini-MVR having lower ancillary ($1645 vs $2652, P = .001) and blood costs ($383 vs $1058, P = .001). These savings were offset by longer surgical times (291 vs 234 minutes, P < .0001) with greater surgical ($7645 vs $7293, P = .0001) and implant costs ($1148 vs $748, P = .03). Rates of discharge to a facility (9.6% vs 16.2%) and readmission (9.6% vs 4.1%) were not statistically different. ConclusionsIn a real-world cohort, mini-MVR continues to demonstrate excellent results with a favorable resource utilization profile. Greater surgical and implant costs with mini-MVR are offset by decreased transfusions and ancillary needs leading to equivalent overall hospital cost.

Sedation and analgesia effects of dexmedetomidine on multiple trauma patients with mechanical ventilation

Objective To explore the sedation and analgesia effect of dexmedetomidine (DEX) in patients with multiple trauma during mechanical ventilation. Methods Eighty cases of multiple trauma patients under mechanical ventilation treated from September 2016 to March 2017 were analyzed by retrospective case-control study. There were 58 males and 22 females with an age range of 18-60 years (mean, 41.87 years). The injury severity score (ISS) was (18.45±4.53)points. The patients were treated with sedation and analgesia, and they were divided into two groups according to the sedative drugs. DEX composite tartaric acid butorphanol were used in 40 patients as DEX group. Midazolam composite tartaric acid butorphanol were used in 40 patients as Midazolam group. The degree of sedation score (Ramsay score) were compared between groups. The time from initial drug use to effective sedation achievement, daily wake-up time, mechanical ventilation duration, emergency intensive care unit (EICU) time, dosage of tartaric acid butorphanol, heart rate, blood pressure changes, and incidence of delirium were compared. Results (1) Two groups could both reach the target of sedation. DEX group had shorter daily wake-up time, shorter mechanical ventilation time and shorter length of EICU stay compared with Midazolam group (P 0.05). Conclusions For multiple trauma patients with mechanical ventilation, DEX can attain sedation and analgesia and shorten daily wake-up time, mechanical ventilation time, and length of hospital stay. DEX can reduce the dosage of analgesic (butorphanol) and the incidence of delirium. Blood pressure and heart rate are associated with small variations before and after sedation. Key words: Multiple trauma; Analgesia; Dexmedetomidine

Selection of piperacillin/tazobactam infusion mode guided by SOFA score in cancer patients with hospital-acquired pneumonia: a randomized controlled study.

BackgroundThis study aimed to select piperacillin/tazobactam (TZP) infusion mode guided by Sequential Organ Failure Assessment (SOFA) score in cancer patients with hospital-acquired pneumonia (HAP) postoperation.Patients and methodsA total of 120 cancer patients with postoperative HAP were divided into two groups: improved administration group (L group) and conventional treatment group (Con group). The Con group received traditional infusion of TZP and the L group received it as prolonged infusion. Blood drug concentration was detected at different time points. Based on the SOFA cut-off value of 9, the patients were regrouped into M (mild) and S (severe) groups.ResultsPercent time that the free drug concentrations remain above the minimum inhibitory concentration (%fT>MIC) was longer than 5 h in L group, but <4 h in Con group. Administration method (p=0.033, OX value 2.796, B value 1.028, 95% CI: 0.855–8.934) and SOFA score (p=0.038, OX value 0.080, B value −2.522, 95% CI: 0.007–0.874) were independent predictors of patient survival. In the S group, compared to conventional treatment, prolonged infusion mode resulted in shorter days of antibiotic use and shorter ventilator time, and achieved longer survival, better clinical efficacy, and lower 28-day mortality rate.ConclusionFor cancer patients with SOFA score ≥9, prolonged infusion of TZP could benefit the patients and obtain better clinical efficacy.

Predictors of in-hospital mortality in adult postcardiotomy cardiacgenic shock patients successfully weaned from venoarterial extracorporeal membrane oxygenation

Objective: To assess the factors associated with outcome of patients undergoing extracorporeal membrane oxygenation (ECMO) in a large ECMO center. Methods: Patients aged >18 years who received ECMO support for postcardiotomy cardiogenic shock were identified between January 2011 and December 2015. One hundred and seventy-seven patients (64.8%) successfully weaned from ECMO. These patients were divided into two groups depending on whether they could survive to hospital discharge: the survival group (group S, n=119) and death group (group D, n=58). Multivariate logistic regression was performed to identify risk factors independently associated with in-hospital mortality. Results: Compared to those from group D, patients in group S exhibited a younger age[(53.4±11.7) vs (58.9±11.5) years], a lower inotrope score at the beginning of ECMO [25(15, 60) vs 35.0(23, 60)], a lower average platelets transfusion [4.0(2.0, 5.2) vs 5.0(3.0, 7.2)U] (all P<0.05). There were shorter duration of ECMO support [95.0(73.0, 131.0) vs 120.0(95.8, 160.2) h], shorter ventilation time [137.0(70.0, 236.8) vs 215.0(164.0, 305.0) h], shorter stay in ICU [182.0(140.0, 236.0) vs 259.0(207.0, 382.0) h] and longer hospital stay after weaned from ECMO [14(11, 24) vs 8(4, 16) d] in group S patients compared to those in group D (all P<0.05). Age>65 years (P=0.046), neurologic complications (P<0.001) and lower extremity ischemia (P<0.001) during ECMO support, left ventricular ejection fraction<35% (P=0.011) and central venous pressure (CVP)>12 cmH(2)O(P=0.018) when weaned from ECMO, and the multi-organ function failure (P<0.001) after weaned from ECMO were independently associated with in-hospital mortality. Conclusions: Neurologic complications and lower extremity ischemia that occurred during ECMO, multi-organ function failure after weaned from ECMO had a significant impact on in-hospital mortality. Further studies are needed to prevent neurologic complications and lower extremity ischemia in these patients. Interventions that could reduce these complications may improve outcome.

Advantages of Minimal Access versus Conventional Aortic Valve Replacement in Elderly or Severely Obese Patients

Objective: the aim of the study to evaluate the benefits of minimal access versus conventional surgery in elderly obese patients undergoing aortic valve replacement (AVR). Materials and Methods: this is a retrospective, observational, cohort study of prospectively collected data on 45 elderly and obese patients undergoing isolated primary AVR between July 2012 and March 2014 in our Cardiac Surgery Unit. Of these, 31 were performed with conventional surgery and 14 were performed with an upper ministernotomy. With propensity score matching, 14 patients (minimally invasive group) were compared with 14 patients in conventional sternotomy (control group). Results: After propensity matching score the two groups were comparable in terms of preoperative characteristics. Median age was 76±7 years in minimally invasive group and 76.7± 10 years in control group, the BMI was respectively 32.2 ± 6.8 and 30.5± 5.6. Cardiopulmonary bypass time was longer in minimally invasive group than in control group (107.7± 22.9 vs 92.4± 19.1 min, p= 0.065) , no significant difference in aortic cross clamp time (76.9± 19.4 vs 72± 16.5 min, p= 0.48) but shorter ventilation time (13±8 vs 23± 13 hours, p=0.029), intensive care unit stay (1±1 vs 2±2 days, p=0.026) and hospital stay (8.5± 4 vs 13.5± 7 days, p=0.037). No difference in the incidence of major and minor postoperative complications and related morbidity was observed. Conclusions: Our limited experience shows that mini-access isolated AVR is a reproducible, safe and effective surgical option in elderly obese patients. Because shorter ventilation time and faster recovery we therefore advocate minimal approach as the procedure of choice for primary isolated AVR in these cohort of patients.

Tube Thoracostomy at the Time of Congenital Diaphragmatic Hernia Repair: Reassessing the Risks and Benefits.

Postoperative pneumothorax and effusion remain a concern following congenital diaphragmatic hernia (CDH) repair. Despite a recent trend away from intraoperative thoracostomy, few studies have actually compared outcomes with and without a chest tube. Rationale commonly cited for the more minimalistic approach include the presumed low likelihood of postoperative complications, potential risk of patch infection, and prolonged intubation. We evaluate these theories, as well as the implications of intraoperative chest tube (IOCT) placement. We performed a retrospective chart review of 174 patients who underwent CDH repair at our academic children's hospital from 2004 to 2015. We compared incidence of clinically significant pleural events between patients who received an IOCT (n = 49) and those who did not (NIOCT, n = 124). We also evaluated time to extubation and rate of patch infections. Clinically significant pneumothorax or effusion occurred in 28% of NIOCT patients versus 10% of IOCT patients (P = .01). After thoracoscopic repair, time to extubation averaged 5.2 days in IOCT patients, 5.4 days in NIOCT patients with no postoperative complications, and 6.4 days in NIOCT patients requiring postoperative intervention. After open repair, time to extubation averaged 13.8, 13.6, and 22.5 days, respectively. There were no documented patch infections. Chest tube placement during CDH repair is associated with significantly lower incidence of clinically significant pleural complications, does not delay extubation, and results in shorter ventilator times than cases that require postoperative intervention. Patch infections are extremely rare. There is no evidence that chest tube placement increases this risk.

Role of minimally invasive surgery in cardiac valve disease

Introduction: Over the past decade minimally invasive cardiac surgery has gained significant popularity, more cases of valve, bypass and congenital surgery are being done by smaller incisions as experience increases. Materials & Methods: Between January 2013 and December 2015 a total of 50 cases were performed using ministernotomy or right thoracotomy. The patients were between 17-58 years of age and included 29 males, 21 females. Results: In Minimally invasive surgery average pump time was 20-60 minutes, cross clamp time 30-50 minutes, ventilation <8 hours, ICU stay < 1day, 2 or less units of blood required in majority of patients. Conclusion: Minimally invasive cardiac surgery results in smaller incisions, shorter ventilator time, ICU and hospital stay, faster recovery, less pain, lower incidence of infection and bleeding and better cosmesis.