Surgical Intensive Care Unit Research Articles

Targeted Sanger Sequencing of a Cluster of COVID-19 Cases in the Surgical ICU of a Non-COVID Hospital: Lessons Learned.

Small clusters of infection due to SARS-CoV-2 in a non-COVID-19 healthcare facility can disrupt services. Here, we investigated a cluster of SARS-CoV-2 cases by targeted Sanger sequencing and clinical epidemiological methods in a non-COVID-19 super-specialty hospital. Epidemiological data were collected in a blinded manner using a proforma to find the risk factors associated with infection. Targeted Sanger sequencing of the spike protein receptor binding domain (RBD) coding region was performed on all the available real-time reverse transcription polymerase chain reaction (RT-PCR)-positive samples that included a patient, his mother, and 11 healthcare workers (HCWs) to determine any genomic variations in the samples from the cluster. All positive cases were due to the Delta variant. However, it detected a unique mutation, N501I, in the RBD region of the SARS-CoV-2 strains. The viral genome extracted from the mother's sample lacked the mutation, thus excluding her from the cluster and pointing out that the outbreak was nosocomial, leading to a focus on infection control measures. Though whole genome sequencing is more universally accepted, in this study, targeted sanger sequencing provided a rapid and cost-effective solution to correctly delineate between the actual cases that form the cluster and other community cases in a pandemic situation.

Current status of nutritional provision and effects of nutritional support on the clinical outcomes of acute kidney injury requiring continuous renal replacement therapy in the surgical intensive care unit.

Patients with acute kidney injury requiring continuous renal replacement therapy are at high risk of malnutrition. Nutritional support is an important part of treatment for patients with critical illness admitted to the intensive care unit. We aimed to investigate the status of nutritional provision and the effects of nutritional support on clinical outcomes. Our institution's medical records (from January 1, 2020, to December 31, 2021) were analyzed in this retrospective cohort study. We included 43 patients aged >18 years who received continuous renal replacement therapy for acute kidney injury in the surgical intensive care unit. The demographic characteristics were similar between the survivor and non-survivor groups. The protein supply per body weight (0.88 ± 0.37 g/kg vs. 0.47 ± 0.53 g/kg, p = 0.029) and the proportion of patients who met the target protein level (58.9 ± 24.9% vs. 30.8 ± 34.9%, p = 0.022) were significantly higher in the survivor group. Approximately 79.1% of the patients had a high malnutrition risk with a modified Nutrition Risk in the Critically Ill score of ≥5. The lengths of hospital and intensive care unit stays were longer in the high nutritional risk group compared with that in the low nutritional risk group, but the result was not significant. The nutritional amount provided in patients with critical illness is significantly lesser than the recommended amount. Ensuring proper nutritional support can improve the clinical outcomes.

Examining the Role of Race in End-of-Life Care in the Intensive Care Unit: A Single-Center Observational Study.

Prior studies have shown variation in the intensity of end-of-life care in intensive care units (ICUs) among patients of different races. We sought to identify variation in the levels of care at the end of life in the ICU and to assess for any association with race and ethnicity. An observational, retrospective cohort study. A tertiary care center in Boston, MA. All critically ill patients admitted to medical and surgical ICUs between June 2019 and December 2020. Self-identified race and ethnicity. The primary outcome was death. Secondary outcomes included "code status," markers of intensity of care, consultation by the Palliative care service, and consultation by the Ethics service. A total of 9083 ICU patient encounters were analyzed. One thousand two hundred fifty-nine patients (14%) died in the ICU; the mean age of patients was 64 years (standard deviation 16.8), and 44% of patients were women. A large number of decedents (22.7%) did not have their race identified. These patients had a high rate of interventions at death. Code status varied by race, with more White patients designated as "Comfort Measures Only" (CMO) (74%) whereas more Black patients were designated as "Do Not Resuscitate/Do Not Intubate (DNR/DNI) and DNR/ok to intubate" (12.1% and 15.7%) at the end of life; after adjustment for age and severity of illness, there were no statistical differences by race for the use of the CMO code status. Use of dialysis at the end of life varied by self-identified race. Specifically, Black and Unknown patients were more likely to receive renal replacement therapy, even after adjustment for age and severity of illness (24% and 20%, p = 0.003). Our data describe a gap in identification of race and ethnicity, as well as differences at the end of life in the ICU, especially with respect to code status and certain markers of intensity.

Patient Characteristics and Clinical and Economic Outcomes Associated with Unplanned Medical and Surgical Intensive Care Unit Admissions: A Retrospective Analysis.

To characterize medical and surgical patient characteristics, as well as clinical and economic outcomes, associated with unplanned intensive care unit (ICU) admissions. This was a retrospective matched cohort analysis that utilized the PINC AITM Healthcare Database, which collects deidentified data from 25% of United States (US) hospital admissions. Discharge records were assessed for medical and surgical admissions in 2021. An unplanned ICU admission was defined as direct transfer from a medical, surgical, or telemetry unit to the ICU. Patients with and without an unplanned ICU admission were 1:1 propensity score matched. Differences between patients with and without unplanned ICU admissions were assessed using two-sample t-tests for continuous measures and Chi-square tests for categorical measures. A total of 3,807,124 qualifying admissions were identified. Medical admissions with unplanned ICU transfers were more likely to be urgent/emergent (odds ratio [OR] 2.9, 95% confidence interval [CI 2.7-3.0], p<0.0001), with patient characteristics including male sex (1.4, [1.4-1.4], p<0.0001), obesity (1.7, [1.6-1.7], p<0.0001), and increased Charlson Comorbidity Index (CCI=1: 1.8, [1.8-1.9], p<0.0001; CCI≥5: 3.2, [3.1-3.3], p<0.0001). Surgical admissions with unplanned ICU transfers were more likely to be urgent/emergent (3.1, [2.9-3.2], p<0.0001) and with patients of higher CCI (2.5, [2.3-2.6], p<0.0001 to a CCI of≥5 (7.9, [7.4-8.4], p<0.0001). Between matched medical patients, mean differences in length of stay, cost, and mortality were 4.1 days (p<0.0001), $13,424 (p<0.0001), and 21% (p<0.0001), respectively. Between matched surgical patients, mean differences in these outcomes were 6.4 days (p<0.0001), $21,448 (p<0.0001), and 14% (p<0.0001), respectively. Emergency care in patients with a higher co-morbid burden is more likely to lead to unplanned ICU admission, putting patients at a significantly increased chance of mortality, longer length of stay, and increased costs. Improving care and monitoring of patients outside the ICU may help detect early changes in pathophysiology and enable early intervention.

Preoperative Anxiety and Its Postoperative Associated Factors in Patients Receiving Post Anesthetic Recovery Care at Surgical Intensive Care Unit

Objectives: This study determined the postoperative associated factors with preoperative anxiety in patients receiving post anesthetic recovery care at surgical intensive care unit. Methods: In this cross-sectional correlational study, 84 postoperative patients were admitted to a surgical intensive care unit for post anesthetic recovery care. Participants completed questionnaires on anxiety, pain, stress, and sleep disturbance on the preoperative day and on the morning of postoperative day 1. Data were analyzed with χ 2 -test, unpaired t-test, Pearson correlation analysis and logistic regression. Results: Forty patients (47.6%) had a high preoperative anxiety score of ≥ 18. Higher preoperative anxiety was associated with greater postoperative anxiety (r = 0.24, &lt;i&gt;p&lt;/i&gt; = 0.026), higher postoperative stress (r = 0.24, &lt;i&gt;p&lt;/i&gt; = 0.026), and poorer postoperative sleep (r = 0.39, &lt;i&gt;p&lt;/i&gt; &lt; 0.001). High preoperative anxiety was associated with postoperative physical restraint (B = 1.72, OR: 5.59, 95% CI: 1.19-21.32). High preoperative anxiety was associated with postoperative sleep disturbance (B = 0.29, OR: 1.34, 95% CI: 1.08-1.65). Conclusions: High preoperative anxiety is associated with poorer sleep during the first postoperative night among surgical intensive care unit patients.

Effectiveness of Sublingual Buprenorphine for Pain Control in the ICU.

The objective of this study was to compare pain control and opioid consumption in critically ill patients who were treated with buprenorphine sublingual or oxycodone oral/enteral during ICU admission. This was a retrospective, parallel, cohort study. General medical or surgical ICUs of a quaternary, urban hospital in Sydney, NSW, Australia. Data were obtained for all patients admitted to two general medical or surgical ICU from January 2019 to January 2023. Patients were grouped as those who received buprenorphine sublingual versus oxycodone oral/enteral. None. Pain control was compared between a propensity score matched cohort of patients who received buprenorphine versus oxycodone. The primary outcome was the probability of significant pain. A significant pain score was defined as greater than or equal to 4 on the 0-10 Numeric Rating Scale or greater than or equal to 6 on the Behavioral Pain Scale. The study cohort included 1,070 patients (288 buprenorphine and 782 oxycodone). After propensity score matching, there were 288 patients in each group. The mean age of the matched cohort was 64 ± 16 years, 295 (51%) were male, and 359 (62%) had a surgical admission. The median probability of significant pain was 0.16 with buprenorphine and 0.17 with oxycodone (median difference, 0.01; 95% CI, -0.02 to 0.04; p = 0.50). Median opioid consumption in oral morphine milligram equivalents (MMEs) was 65 with buprenorphine and 70 with oxycodone (median difference, -1 mg; 95% CI, -10 to 10 mg; p = 0.73). Median MME per ICU day was 22 with buprenorphine and 22 with oxycodone (median difference, 1 mg; 95% CI, -2 to 5 mg; p = 0.38). Buprenorphine sublingual is as effective as oxycodone oral/enteral with regard to pain control and opioid consumption in the ICU. Buprenorphine sublingual is an appropriate option for patients in the ICU who are unable to take oral/enteral medications.

Difficult Airway Management in Surgical Intensive Care Unit

Difficult Airway Management in Surgical Intensive Care Unit

The Predictive Value of Urinary Trypsinogen-2 Dipstick for Early Diagnosis of Acute Pancreatitis in Intensive Care

Abstract Background Acute pancreatitis is a sudden inflammation in the pancreas, with potential and variable involvement of adjacent organs or other organ systems. Aim of the Work to evaluate the rule of urinary trypsinogen-2 using dipstick test in the diagnosis of acute pancreatitis. Patients and Methods This cross-sectional study was carried out in surgical intensive care unit, Ain Shams University hospitals, during a period of 6 months. Forty five patients were included in our study, thirty patients were diagnosed as acute pancreatitis and fifteen patients weren’t diagnosed as acute pancreatitis through cross sectional study. All patients were subjected to full history taking, full clinical examination, laboratory investigations including serum levels of renal function tests, CBC, total and direct bilirubin, liver enzymes, alkaline phosphatase, INR, amylase and lipase. Urinary trypsinogen-2 dipstick test was done. Also, radiological examinations were done using ultrasonography of abdomen and pelvis, computed tomography of the abdomen. Results The most common cause of acute pancreatitis was gall stone obstructive pancreatitis (70%) and we found that serum amylase and lipase were elevated in (83.3% and 86.7% respectively) in acute pancreatitis patients. While the sensitivity of urinary trypsinogen-2 dipstick test was 93.3% in acute pancreatitis patients. The specificity of serum amylase, serum lipase was 73.3% for both of them, while the specificity of urinary trypsinogen-2 was 100% in diagnosis of acute pancreatitis. Conclusion In-conclusion urinary trypsinogen-2 dipstick test is a promising low cost, bed side and easy test to be done in the diagnosis of acute pancreatitis.

Postoperative complications following Schwab-grade-I versus Schwab-grade-II PCO in treating severe rigid kyphoscoliosis patients: comparative matched-group outcomes with minimum 2-year follow-up

BACKGROUND CONTEXTStandard partial facetectomies, (Smith-Petersen Osteotomy, (SPO), (Schwab-grade-I) and complete facet resection also known as Ponte osteotomy, (PO), (Schwab-grade-II) are narrowly akin and collectively appreciated as posterior column shortening osteotomies (PCOs). The former is considered a gentler osteotomy grade than the latter. The spine literature provides very little information on their comparison regarding perioperative complications and major curve correction rate outcomes. PURPOSETo determine whether Schwab-grade-I PCO (SPO) and Schwab-grade-II PCO (PO) are comparably safe in the surgical management of severe rigid scoliosis or kyphoscoliosis patients. STUDY DESIGN/SETTINGRetrospective single-center comparative clinical study. PATIENT SAMPLEA total of 38 patients with severe rigid scoliosis or kyphoscoliosis were propensity score matched in this study, (SPO-treated); n=21 (55.30%) and (PO-treated); n=17 (44.70%), who underwent primary spinal deformity corrective surgery, respectively. OUTCOME MEASURESOutcomes included demographics, baseline pulmonary functional outcomes, perioperative complications incidence, hospital costs, Oswestry disability index (ODI), and the Scoliosis Research Society-22 (SRS-22) questionnaire scores. METHODSFollowing approval by the Institutional Review Board (IRB) of Beijing Chaoyang Hospital-Affiliated Capital Medical University in Beijing, out of a total of 82 consecutive surgical patients with complete data demonstrating severe and/or rigid spinal deformity, a pool of 38 of the 82 (46.3%) propensity-matched adult (≥18 years) patients with severe rigid scoliosis or kyphoscoliosis defined with a preoperative major curve magnitude of ≥80° on anteroposterior plain radiographs, and flexibility of <25% on bending plain radiographs who underwent primary spinal deformity corrective surgery were retrospectively evaluated. The patients were dichotomized into two osteotomy groups: standard (partial) facetectomy (SPO-treated), n=21 with an average age of 24.67 years, (Schwab-grade-I PCO) and complete facet excision, (PO-treated), (ie, Schwab-grade-II PCO), n=17 with an average age of 23.12 years. The minimum follow-up period was 2 years. Primary outcomes included baseline demographics and clinical features. Secondary outcomes included perioperative [intraoperative, immediate, and 2-year postoperative] complication rates. Tertiary outcomes included perioperative ODI and SRS-22 scores. Statistical analyses were carried out by Student t-test and Pearson's Chi-square test (Fisher's Exact Test), through Python statistical software package. Statistical significance was set at (p<.05). RESULTSOf the 38 matched severe rigid scoliosis or kyphoscoliosis patients, 55.30% (n=21) were SPO-treated and 44.70% (n=17) were PO-treated patients, respectively. The overall average age of patients was 23.97 years, with a female incidence of 76.32%. Major curve correction rates were 49.19% and 57.40% in SPO-treated and PO-treated patients, respectively, (p>.05). Immediately following surgery, comparable overall complication rates of 28.57% (n=6/21) versus 29.41% (n=5/17) were observed in the SPO-treated and PO-treated patients, respectively, (p=.726). We observed incidences of 9.52%, (n=2/21) versus 5.88%, (n=1/17) for surgical intensive care unit (SICU) admission, and incidences of 4.76%, (n=1/21) versus 5.88%, (n=1/17) for cardiopulmonary events in SPO-treated versus PO-treated patients following corrective surgery, respectively, (p>.05). The incidences of neurological deficits in the SPO-treated and PO-treated patients were respectively, 14.29%, (n=3/21) versus 17.65%, (n=3/17) immediately following surgery, (p>.05), and 0.00%, (n=0/21) in SPO-treated versus 14.28%, (n=3/21) in PO-treated patients at ≥2 years postoperative, (p<.05). Among the three patients that reported neurological deficits in the PO-treated group at ≥2 years postoperative, two patients had pre-existing baseline neurological deficits. The ODI score in the PO-treated group was significantly inferior at a minimum 2-year follow-up, (p<.05). CONCLUSIONSIn the current study, both SPO-treated and PO-treated patients demonstrated statistically comparable surgical complications immediately following corrective surgery. Severe rigid kyphoscoliosis patients with preexisting baseline neurological deficits were more inclined to sustain neurological morbidity following corrective surgery. PCO corrective techniques are warranted as safe options for treating patients with severe rigid spine deformity phenotypes.

Variables associated to intensive care unit (ICU)-mortality among patients admitted to surgical intensive care unit in Ethiopia: a retrospective observational study

BackgroundThe present study aimed to assess variables associated to ICU-mortality among patients admitted to surgical intensive care unit in Ethiopia.MethodsA Hospital-based retrospective follow-up study was conducted on all patients who were admitted to the surgical intensive care unit. Data were extracted from patients’ charts with a pretested data extraction tool, entered into Epi-data 4.6.0, and analyzed with STATA- 14. Bivariate and multivariate Cox proportional hazards regression models were fitted.ResultsOf the total study participants (388), 148 (38.1%) patients admitted to the surgical intensive care unit died during the follow-up period with a median survival time of 11 days. Potassium level < 3.5 mmol/L (adjusted hazard ratio ( AHR): 3.46, 95% CI (1.83 6.55), potassium level > 5.0 mmol/L (AHR:2.41, 95% CI (1.29–4.51), hypoxia (AHR:1.66, 95% CI (1.10–2.48), Glasgow Coma Scale (GCS) score < 9 (AHR: 4.06, 95% CI (1.51–10.89), mechanical ventilation (AHR:12, 95%CI (3–45), absence of thromboprophylaxis (AHR:10.8,95% CI (6.04–19.29), absence of enteral feeding (AHR:3.56, 95% CI (2.20–5.78) were variables associated with ICU-mortality among patients admitted to surgical intensive care unit.ConclusionsThe overall ICU-mortality of patients admitted to our surgical intensive care unit was higher compared to patients admitted to similar intensive care unit in developed countries. The variables associated to ICU-mortality among patients admitted to surgical intensive care unit were abnormal serum potassium level, lower GCS score, mechanical support, hypoxia, absence of thromboprophylaxis, and enteral feeding.

Regional anesthesia for geriatric population.

Advancements in modern health care over 20 years have substantially increased the average lifespan in developed countries, and the fastest growing population is the elderly population. The proportion of people in Saudi Arabia aged 60 or more is predicted to be 25 percent of the total population of 40 million by the end of 2050. Moreover, the number of people aged 80 or more is expected to reach 1.6 million or 4 percent of the total population in the same period. Improvements in surgical techniques, anesthesia, and intensive care units make surgical interventions in older and sicker patients possible. It is estimated that over half of the population older than 65 years will require surgical intervention at least once during the remainder of their lives. Therefore, elderly patients are becoming an even larger part of anesthetic practice. Regional anesthesia (RA) is frequently used in elderly patients, especially during orthopedic surgery, genitourologic and gynecologic procedures, and hernia repair. Although age can no longer be considered a contraindication to anesthesia and surgery, anesthesia-related morbidity and mortality remain higher among elderly than among young adult surgical patients. Undoubtedly, peripheral nerve (PN) blocks improve analgesia and reduce opioid consumption and their associated side effects. This is beneficial in the perioperative care of elderly patients who may have less physiologic reserve to withstand the side effects of general anesthesia (GA).

Posterior Reversible Encephalopathy Syndrome in a Patient with Septic Shock: A Case Report.

Posterior reversible encephalopathy syndrome (PRES) is a reversible condition with nonspecific neurologic and characteristic radiologic findings. Clinical presentation may include headache, nausea, vomiting, altered mental status, seizures, and vision changes. Diagnosis is confirmed through T2-weighted brain magnetic resonance imaging (MRI) showing bilateral hyperintensities in the white matter of posterior circulatory regions. We report a case of PRES in a patient suffering from complicated diverticulitis. Following medical management in the emergency department, the patient deteriorated, becoming hypotensive and altered. Bowel resection under general anesthesia was performed. Postoperative brain MRI demonstrated bilateral and symmetric T2 signal hyperintensities suggestive of PRES. Following supportive treatment, the patient was discharged from the surgical intensive care unit on postoperative day 21 with no residual deficits. It is important to recognize the nonspecific neurologic symptoms associated with PRES. Emergency physicians should suspect acute PRES when managing patients with prolonged or unexplained encephalopathy, while recognizing that hypertension need not be present.

Experience of nurses in the prevention of Ventilator-Associated Pneumonia among critically ill patients at Muhimbili National Hospital in Dar Es Salaam

Background: Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections that occur more than 48 hours after intubation and initiation of mechanical ventilation. It is associated with morbidity and mortality, increased health costs, and prolonged hospital stays. The estimated incidence of VAP globally is about 5-40% whereby in low and middle-income countries is about 47.9 per 1000 ventilator days. However, there is limited literature about VAP prevention in hospitals in Tanzania. Therefore this study aimed to explore nurses’ experience in the prevention of VAP. Methods: An exploratory descriptive study design was conducted with 15 nurses who were purposefully recruited from medical and surgical ICUs. A semi-structured interview guide consisting of main questions and probes was used to collect data. All interviews were audio-recorded and transcribed verbatim. Data were analyzed using an inductive thematic analytical approach. Results: Four main themes emerged; nurses’ roles in the prevention of VAP, nurses’ challenges toward care provision, nurses’ competency in implementing VAP prevention strategies, and enablers toward the implementation of VAP. The revealed prevention strategies were suctioning, early weaning, head of bed elevation of 30-45°, oral care, administration of medication, and implementation of IPC measures. The study has also revealed important barriers such are inadequate equipment, lack of VAP prevention protocols, shortage of staff, and inadequate knowledge. However, the major facilitators were responsible leadership, a quality control team, the availability of IPC guidelines, and individual motivation. Conclusion: This study provides insights into the experience of nurses in the prevention of VAP. Nurses face several challenges including a shortage of staff, shortage of equipment and supplies, lack of training, lack of VAP prevention protocols, and inadequate knowledge of VAP prevention. Despite these challenges nurses in their capacity are involved in VAP preventive measures. Keywords: Ventilator-associated pneumonia, strategies, experience, nurses, critically ill patients.

Association between anion gap and all-cause mortality of critically ill surgical patients: a retrospective cohort study

BackgroundThere are few widely accepted and operationally feasible models for predicting the mortality risk of patients in surgical intensive care unit (SICU). Although serum anion gap (AG) is known to be correlated with severe metabolic acidosis, no investigations have been reported about the association between AG level and the outcome during hospitalization in SICU. This study aimed to explore the predictive power of AG for 90-day all-cause mortality in SICU.MethodsData of the eligible patients in SICU from 2008 to 2019 was obtained from the Medical Information Mart for Intensive Care IV version 2.0 (MIMIC-IV v2.0) database. Baseline clinical data of the selected patients was compared in different groups stratified by the outcome during their admission via univariate analysis. Restricted cubic spline (RCS) was drawn to confirm the relationship of AG and the short-term mortality. Kaplan-Meier survival curve was plotted in different AG level groups. Univariate and multivariate Cox analyses were performed, and Cox proportional-hazards models were built to investigate an independent role of AG to predict 90-day all-cause mortality risk in SICU. Receiver operating characteristics (ROC) curves analysis was performed to evaluate the predictive value of AG on the 90-day prognosis of patients.ResultsA total of 6,395 patients were enrolled in this study and the 90-day all-cause mortality rate was 18.17%. Univariate analysis showed that elevated serum AG was associated with higher mortality (P < 0.001). RCS analysis indicated a positively linear relationship between serum AG and the risk of 90-day all-cause mortality in SICU (χ2 = 4.730, P = 0.193). Kaplan-Meier survival analysis demonstrated that low-AG group (with a cutoff value of 14.10 mmol/L) had a significantly higher cumulative survival rate than the counterpart of high-AG group (χ2 = 96.370, P < 0.001). Cox proportional-hazards models were constructed and confirmed the independent predictive role of AG in 90-day all-cause mortality risk in SICU after adjusting for 23 confounding factors gradually (HR 1.423, 1.246–1.625, P < 0.001). In the further subgroup analyses, a significant interaction was confirmed between AG and sepsis as well as surgery on the risk for the 90-day mortality. The ROC curve showed that the optimal cut-off value of AG for predicting 90-day mortality was 14.89 with sensitivity of 60.7% and specificity of 54.8%. The area under curve (AUC) was 0.602. When combined with SOFA score, the AUC of AG for predicting 90-day prognosis was 0.710, with a sensitivity and specificity of 70% and 62.5% respectively.ConclusionsElevated AG (≥ 14.10 mmol/L) is an independent risk factor for predicting severe conditions and poor prognosis of critical ill surgical patients.

The persistent inflammation, immunosuppression, and catabolism syndrome 10 years later.

With the implementation of new intensive care unit (ICU) therapies in the 1970s, multiple organ failure (MOF) emerged as a fulminant inflammatory phenotype leading to early ICU death. Over the ensuing decades, with fundamental advances in care, this syndrome has evolved into a lingering phenotype of chronic critical illness (CCI) leading to indolent late post-hospital discharge death. In 2012, the University of Florida (UF) Sepsis Critical Illness Research Center (SCIRC) coined the term Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) to provide a mechanistic framework to study CCI in surgical patients. This was followed by a decade of research into PICS-CCI in surgical ICU patients in order to define the epidemiology, dysregulated immunity, and long-term outcomes after sepsis. Other focused studies were performed in trauma ICU patients and emergency department sepsis patients. Early deaths were surprisingly low (4%); 63% experienced rapid recovery. Unfortunately, 33% progressed to CCI, of which 79% had a poor post-discharge disposition and 41% were dead within one year. These patients had biomarker evidence of PICS, and these biomarkers enhanced clinical prediction models for dismal one-year outcomes. Emergency myelopoiesis appears to play a central role in the observed persistent immune dysregulation that characterizes PICS-CCI. Older patients were especially vulnerable. Disturbingly, over half of the older CCI patients were dead within one year and older CCI survivors remained severely disabled. Although CCI is less frequent (20%) after major trauma, PICS appears to be a valid concept. This review will specifically detail the epidemiology of CCI, PICS biomarkers, effect of site of infection, acute kidney injury, effect on older patients, dysfunctional high-density lipoproteins, sarcopenia/cachexia, emergency myelopoiesis, dysregulated erythropoiesis, and potential therapeutic interventions.

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report.

During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula. The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged. Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel. An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Improved clinical outcomes following introduction of an attending intensivist for patients admitted to the cardiac surgical intensive care unit after valvular heart surgery: a single-center experience.

Although numerous studies have documented the improved clinical outcomes of patients undergoing cardiac surgery following introduction of attending intensivist, most of these studies included heterogeneous patient populations. We aimed to investigate the impact of an attending intensivist on the clinical outcomes of patients admitted to the cardiac surgical intensive care unit (CSICU) following valvular heart surgery. Patients who underwent valvular heart surgery between January 2007 and December 2012 (control group, n=337) were propensity matched (1:1) between January 2013 and June 2017 (intensivist group, n=407). During the propensity score matching analysis, 285 patients were extracted from each group. Patients in the intensivist group underwent mechanical ventilation for a significantly shorter time than those in the control group (21.8±69.8 vs. 39.2±115.3 hours, P=0.021). More patients were extubated within 6 hours in the intensivist group than in the control group (53.7% vs. 42.8%, P=0.015). The incidence of ventilator-associated pneumonia (1.4% vs. 4.9%, P=0.031), cardiac arrest due to cardiac tamponade associated with post-cardiotomy bleeding (0.4% vs. 3.9%, P=0.002), and acute kidney injury (2.8% vs. 7.7%, P=0.011) in the intensivist group was significantly lower than that in the control group. The 30-day mortality rate of the intensivist group was significantly lower than that of the control group (2.1% vs. 6.7%, P=0.015). Critical care provided in the CSICU staffed by an attending intensivist is associated with a lower 30-day mortality rate and reduced incidence of postoperative complications.

Patient- and Team-Level Characteristics Associated with Handoff Protocol Fidelity in a Hybrid Implementation Study: Results from a Qualitative Comparative Analysis.

Standardization is an evidence-based approach to improve handoffs. The factors underpinning fidelity (that is, adherence) to standardized handoff protocols are not well specified, which hampers implementation and sustainability efforts. The Handoffs and Transitions in Critical Care (HATRICC) study (2014-2017) involved the creation and implementation of a standardized protocol for operating room (OR)-to-ICU handoffs in two mixed surgical ICUs. The present study used fuzzy-set qualitative comparative analysis (fsQCA) to characterize combinations of conditions associated with fidelity to the HATRICC protocol. Conditions were derived from postintervention handoff observations yielding quantitative and qualitative data. Sixty handoffs had complete fidelity data. Four conditions from the SEIPS 2.0 model were used to explain fidelity: (1) whether the patient was newly admitted to the ICU; (2) presence of an ICU provider; (3) observer ratings of attention-paying by the handoff team; and (4) whether the handoff took place in a quiet environment. None of the conditions were singly necessary or sufficient for high fidelity. Three combinations of conditions were sufficient for fidelity: (1) presence of the ICU provider and high attention ratings; (2) a newly admitted patient, presence of the ICU provider, and quiet environment; and (3) a newly admitted patient, high attention ratings, and quiet environment. These three combinations explained 93.5% of the cases demonstrating high fidelity. In a study of OR-to-ICU handoff standardization, multiple combinations of contextual factors were associated with handoff protocol fidelity. Handoff implementation efforts should consider multiple fidelity-promoting strategies that support these combinations of conditions.

Comparative Analysis of Oxygen Saturation by Pulse Oximetry and Arterial Blood Gas in Hypoxemic Patients in a Tertiary Care Hospital.

Oxygen saturation is essential for medical care and is closely regulated within the body. Arterial blood gas (ABG) analysis is used to evaluate critically ill individuals' ventilation, oxygenation, acid-base status, and metabolic condition. Pulse oximetry is an easy and non-invasive way to measure the status of oxygen saturation non-invasively in clinical settings and provides a quick and precise assessment of oxygenation and reduces medical errors. SpO2 may not always be a reliable predictor of arterial oxygen saturation (SaO2), and hypoxemic, hemodynamically compromised, and critically ill patients may have lower SpO2 accuracy. A study is needed to assess and compare various oxygen saturation methods. The study aimed to compare the oxygen saturation levels measured by pulse oximetry and ABG analysis in hypoxemic patients. The objectives were tocompare the values between SaO2, PaO2, and SpO2 values obtained from the patients, and correlate the study parameters among both techniques. The study was conducted from February 2021 to June 2022 among the 102 hypoxemic patients who were admitted to the emergency and surgical intensive care unit (ICU) of Sree Balaji Medical College and Hospital in Chennai. Primary data on ABGanalysis and pulse oximetry readings were collected from the study subjects. The patient and their past medical records, physical exam, chest x-ray findings, pulse oximetry, and ABG results were all reviewed. Each patient had their ABG, and pulse oximetry measured simultaneously. A comparison was made between SpO2 and partial pressure of oxygen (PaO2) and arterial oxygen saturation (SaO2) parameters using a paired t-test. The correlation was done against the SpO2 and ABG parameters and assessed for association using the correlation coefficient value; gender was also considered while correlating. An observational study was done among 102 study samples to comparatively analyze the oxygen saturation by two methods, namely pulse oximetry and ABG, in hypoxemic patients. While comparing the mean values of SaO2 and SpO2, they were 84.41 ± 4.24 and 80.58 ± 5.77, respectively, and this difference was statistically very significant (p< 0.001). While comparing the mean values of PaO2 and SaO2, they were 61.02 ± 5.01 and 84.41 ± 4.24, respectively, and this difference was statistically significant (p = 0.043). While comparing the mean values of PaO2 and SpO2, they were 61.02 ± 5.01 and 80.58 ± 5.77, respectively, and this difference was statistically significant (p = 0.054). Among the study population, with regard to the correlation factor, there is notably a very high and strong positive correlation between SaO2 and SpO2 and between SpO2 and PaO2. There was a negative correlation between SpO2 and finger abnormalities and between SpO2 and blood pressure. The ABGmethod is considered the gold standard. When SpO2 levels fall below 90%, pulse oximetry may not be accurate enough to reliably assess oxygenation. In such cases, where alveolar hypoventilation is suspected, it is recommended to complement pulse oximetry with ABG studies. This is because ABG analysis provides a more comprehensive assessment of oxygenation and acid-base status, which can aid in the diagnosis and management of respiratory conditions.

The Impact of Obesity on Mortality and Complications in Posterior Retroperitoneoscopic Adrenalectomy.

Background Obesity is a global epidemic. It influences surgical technique, ergonomics, safety, and outcomes. However, there is a paucity of evidence of obesity-related impact in posterior retroperitoneoscopic adrenalectomy (PRA). This study compared perioperative outcomes of obese and non-obese participants undergoing PRA. Methodology This is a multi-center retrospective cohort study of elective PRA from March 2014 to December 2022. Patient demographics, surgical techniques, clinicopathological parameters, and outcomes, including overall complication rate, were analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results Seventy-five patients underwent a PRA, of which 97.3% were completed retroperitoneoscopically. The overall complication rate was (9.3%), and on subgroup analysis, the obese cohort had a lower percentage complication profile at 6.5%. Male participants comprised 52%, with a median age of 55 (IQR=19). The median BMI was 29.0 (IQR=8), of which 41% were obese, and 40% were overweight. Univariate analysis showed that being obese was not significantly associated with a higher complication rate (p=0.471). In addition, there was no significant increase in conversion (p=0.508), bleeding/transfusion (p=0.508), surgical site infection (SSI; p=1.000), incisional hernia (p=1.000), ICU or high dependency unit admission (p=0.292) and any-cause mortality (p=1.000). No sentinel deaths directly related to PRA were recorded. Procedure duration was longer in obese (117 mins) vs. non-obese participants (88.9 mins, p=0.022). However, there was no significant difference in the length-of-hospital stay (p=0.592). The cohort conversion rate was (2.7%), and tumor size was associated with a higher conversion rate (35.4 vs. 62.5mm, p=0.040). Conclusion Posterior retroperitoneoscopic adrenalectomy can be a safe procedure in obese populations, and obesity does not increase perioperative morbidity or mortality.