Unit Length Research Articles

Perioperative Management of Pediatric Combined Heart and Liver Transplantation: A 17 year single center experience.

An increasing number of centers are undertaking combined heart and liver transplantation in adult and pediatric patients with congenital heart disease. The primary aim of this study was to describe the perioperative management of a single center cohort, identifying challenges and potential solutions. We conducted a retrospective review of all patients undergoing combined heart and liver transplantation at Stanford Children's Hospital from 2006 to 2022. Preoperative information included cardiac diagnosis, hemodynamics, and severity of liver disease. Intraoperative data included length of surgery, cardiopulmonary bypass time, and blood products transfused. Postoperative data included blood products transfused in the intensive care unit, time to extubation, length of intensive care unit stay, survival outcomes and 30-day adverse events. Eighteen patients underwent en bloc combined heart and liver transplantation at Stanford Children's Hospital from 2006 to 2022, and the majority 15 (83%) were transplanted for failing Fontan circulation with Fontan Associated Liver Disease. Median surgical procedure time was 13.4 [11.5, 14.5] h with a cardiopulmonary bypass time of 4.3 [3.9, 5.8] h. Median total blood products transfused in the operating room post cardiopulmonary bypass was 89.4 [63.9, 127.0] mLs/kg. Nine patients (50%) had vasoplegia during cardiopulmonary bypass. Activated prothrombin complex concentrates were used post cardiopulmonary bypass in 15 (83%) patients with a 30-day thromboembolism rate of 22%. Median time to extubation was 4.0 [2.8, 6.5] days, median intensive care unit length of stay 20.0 [7.8, 48.3] days and median hospital length of stay 54.0 [30.5, 68.3] days. Incidence of renal replacement therapy was 11%; however, none required renal replacement therapy by the time of hospital discharge. Neurological events within 30 days were 17% and the 30 day and 1 year survival was 89%. Perioperative challenges include major perioperative bleeding, unstable hemodynamics, and end organ injury including acute kidney injury and neurological events. Successful outcomes for en bloc combined heart and liver transplantation are possible with careful multidisciplinary planning, communication, patient selection, and integrated peri-operative management.

Bibliometric Analysis of Studies on Delirium in Critical Care

Background Delirium leads to prolongation in intensive care unit (ICU) and hospital length of stay and an increase in ICU costs and mortality. As a result of this, the number of studies on delirium in ICUs has recently increased significantly, and many articles have been published. Objectives The aim of this study was to evaluate the articles related to “delirium” in “critical care” field in the Web of Science database and the first hundred most cited articles on this subject. Methods The Web of Science database was searched for articles relevant to “delirium” in the critical care medicine field published between 1980 and 2024. Text analytics and network models used in bibliometric mapping were used for prolific authors, annual trend, citation, and countries. Results In our study, it was determined that a total of 1834 articles in the field of delirium in critical care medicine were included. It was determined that the annual citation average was 42.79 and the H-index value was 134. There is a general upward trend over the years, and it was observed that it has intensified in the last 5 to 6 years. With the Reference Spectroscopy analysis, it was determined that the most intensively cited studies on delirium were the studies of 2013 and 2010. The distribution of keywords in recent years has focused on analgosedation, acute brain injury, older patient, COVID-19, and fragility. When examined for the top 100 cited articles, it was seen that mobilization, guidelines, pain, activities of daily living, anesthesia, sedation, and haloperidol have become prominent in recent years. Conclusion In recent years, there has been a noticeable increase in the volume of research focusing on delirium studies within the field of critical care medicine. Staying current with trends, incorporating findings from frequently cited studies, and customizing interventions to suit modern difficulties can all improve the quality of care offered to critically ill patients and lead to better outcomes.

Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving with real-world data.

This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan-Do-Study-Act cycles. From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure-specific perioperative Plan-Do-Study-Act cycles, three procedure-specific postoperative prescription Plan-Do-Study-Act cycles, and four general ambulatory surgical center enhanced recovery Plan-Do-Study-Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30-day reoperation rate. A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30-day reoperation rates were unchanged. The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay.

Large-bore Mechanical Thrombectomy Versus Catheter-directed Thrombolysis in the Management of Intermediate-risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial.

There is a lack of randomized controlled trial (RCT) data comparing outcomes of different catheter-based interventions for intermediate-risk pulmonary embolism (PE). PEERLESS is a prospective, multicenter, RCT that enrolled 550 intermediate-risk PE patients with right ventricular dilatation and additional clinical risk factors randomized 1:1 to treatment with large-bore mechanical thrombectomy (LBMT) or catheter-directed thrombolysis (CDT). The primary endpoint was a hierarchal win ratio (WR) composite of the following: 1) all-cause mortality, 2) intracranial hemorrhage, 3) major bleeding, 4) clinical deterioration and/or escalation to bailout, and 5) postprocedural intensive care unit (ICU) admission and length of stay, assessed at the sooner of hospital discharge or 7 days post-procedure. Assessments at the 24-hour visit included respiratory rate, mMRC dyspnea score, NYHA classification, right ventricle (RV)/left ventricle (LV) ratio reduction, and RV function. Endpoints through 30 days included total hospital stay, all-cause readmission, and all-cause mortality. The primary endpoint occurred significantly less frequently with LBMT vs CDT (WR 5.01 [95% CI: 3.68-6.97]; P<0.001). There were significantly fewer episodes of clinical deterioration and/or bailout (1.8% vs 5.4%; P=0.04) with LBMT vs CDT and less postprocedural ICU utilization (P<0.001), including admissions (41.6% vs 98.6%) and stays >24 hours (19.3% vs 64.5%). There was no significant difference in mortality, intracranial hemorrhage, or major bleeding between strategies, nor in a secondary WR endpoint including the first 4 components (WR 1.34 [95% CI: 0.78-2.35]; P=0.30). At the 24-hour visit, respiratory rate was lower for LBMT patients (18.3±3.3 vs 20.1±5.1; P<0.001) and fewer had moderate to severe mMRC dyspnea scores (13.5% vs 26.4%; P<0.001), NYHA classifications (16.3% vs 27.4%; P=0.002), and RV dysfunction (42.1% vs 57.9%; P=0.004). RV/LV ratio reduction was similar (0.32±0.24 vs 0.30±0.26; P=0.55). LBMT patients had shorter total hospital stays (4.5±2.8 vs 5.3±3.9 overnights; P=0.002) and fewer all-cause readmissions (3.2% vs 7.9%; P=0.03), while 30-day mortality was similar (0.4% vs 0.8%; P=0.62). PEERLESS met its primary endpoint in favor of LBMT vs CDT in treatment of intermediate-risk PE. LBMT had lower rates of clinical deterioration and/or bailout and postprocedural ICU utilization compared with CDT, with no difference in mortality or bleeding.

Improving the distribution system capability by incorporating ZnO nanoparticles into high-density polyethylene cable materials

This paper introduces a novel insulated cable designed to enhance the distribution system’s capabilities. Accordingly, high-density polyethylene loaded with varying concentrations of zinc oxide (ZnO) nanoparticles (NPs) ranging from 0.0 to 5 wt% was prepared using the melt-blending technique. Zinc oxide (NPs) is synthesized by using sol–gel technique and their microstructure was examined by X-ray diffraction. The new insulated cable, HDPE nanocomposite loaded with 1 wt% of ZnO, demonstrates a 43% reduction in the relative dielectric constant and a 16.5% improvement in breakdown strength compared to pure HDPE. The observed changes in both the dielectric constant and breakdown strength offer several advantages in electrical applications. These benefits include a decrease in feeder current at the same loading level, mitigation of inrush transients during load switching, and a reduction in earth fault current values, particularly in unearthed distribution networks with ungrounded cables. A comparative study is conducted between the conventional insulating cable based on the original material (HDPE) and the new insulated cable incorporating ZnO nanomaterial at a ratio of 1.0 wt% of the total cable mass per unit length. This comparison utilizes data from two actual medium-voltage distribution feeders. Both actual feeders are simulated using the EMTP/ATP package. The obtained results prove the efficacy of the developed material cable (polymer doped with ZnO NPs) compared to the base material. The peak and duration of inrush current can be cut to 77.3% and 67% of their original values, respectively. The earth fault current can be reduced to 56.5% in ungrounded networks, while substation current under the normal operation can be cut to 84.3% with the same load currents.

Comparison of Short-Term Outcomes of DSA and ALMIS Approach for Bipolar Cemented Hemiarthroplasty in Patients with Neck of Femur Fracture

Background/Objectives: A neck of femur (NOF) fracture is one of the most common fractures, and its treatment in the geriatric population using cemented bipolar hemiarthroplasty (HA) is a standard procedure worldwide. Various surgical approaches have been described for this operation, aiming to reduce complications and improve early mobilization. The present study compares two minimally invasive approaches, the anterolateral minimally invasive approach (ALMIS) and the direct superior approach (DSA), with respect to their intraoperative and early postoperative complications in cemented bipolar HA. Methods: The medical records of all patients undergoing cemented bipolar HA for a NOF fracture between January 2017 and December 2023 were analyzed. The aim of the study was to compare the two surgical approaches. The evaluation focused on intraoperative parameters and early complications. Results: A total of 226 patients were included in the analysis, with 62 undergoing DSA and 164 ALMIS, with an average age of 83.5 years. The two approaches did not differ significantly in terms of stem implantation quality, length of hospital or intensive care unit stay, postoperative mobilization, or the need for transfusions. However, the ALMIS was associated with a significantly shorter operative time (DSA: 89.7 min vs. ALMIS: 77.2 min; p &lt; 0.01). On the other hand, the DSA had a significantly lower complication rate (DSA: 0/61 vs. ALMIS: 11/163; p = 0.04). Conclusions: In a comparison of the two minimally invasive approaches, DSA and ALMIS, for treating a NOF fracture with cemented bipolar HA, the DSA demonstrated a lower complication rate, though it had a slightly longer operating time.

Comic-based consenting on patient-reported experience and outcome measures for transfemoral aortic valve implantation

Abstract Background The impact of an improved patient informed consent (IC) before transcatheter aortic valve implantation (TAVI) on patient-reported experience and outcome measures (PREMs and PROMs) as well as on clinical outcomes remains unclear. Purpose To investigate patient satisfaction, PREMs, PROMs and clinical outcomes in patients receiving additional illustrative graphic-based IC (comic group) compared to conventional IC (control group) for TAVI at two tertiary care centers as part of a randomised controlled trial ("TAVI-COMIC study"). Methods Adult patients undergoing elective TAVI were enrolled. Patient satisfaction and PREMs were assessed after providing IC, PROMs at 90 days after TAVI and clinical safety outcomes within 7 days after TAVI (Figure). Results Only 48 (32%) of all patients read the official usual patient information sheet. Of 299 patients undergoing TAVI, comic-based IC was performed in 152 (51%) patients. Patient satisfaction was significantly higher (29 [23-32] vs 25 [22-30] of a maximum of 32 points in the validated Client Satisfaction Questionnaire [CSQ], p&amp;lt;0.001) and anxiety was lower (34 [25-51] vs 39 [29-55], p&amp;lt;0.001 in the validated Spielberger State-Trait-Anxiety Inventory [STAI]) in the comic group. 92 (61%) patients in the comic group felt "relaxed" prior to the procedure compared to only 44 (30%) patients receiving conventional IC (p&amp;lt;0.001). 91 (60%) were "very satisfied" with the delivered patient IC compared to 28 (19%) patients in the control group (p&amp;lt;0.001). PROMs at 90 days were assessed in a subgroup of 198 (66% of total cohort) patients: The comic group had similar PROMs as the control group (e.g. general health condition, walking ability and rate of dizziness, syncope, helplessness, depression, dyspnea or angina). Clinical outcomes, such as bleeding, pneumonia, stroke, delirium, or TAVI unit and hospital length of stay, were similar in both groups. Conclusion Use of an alternative IC approach, such as medical graphic narratives, might significantly improve patient satisfaction and PREMs, while facilitating similar PROMs and procedural safety as conventional treatment strategies.

Age and length characteristics of female and male Walleye broodstock collected at a spawning operation

AbstractObjectiveThe need to augment of Walleye Sander vitreus populations may increase as these populations face challenges of changing habitats and climatic conditions. Since little has been published outside of agency reports on wild broodstocks, the intent of this study was to describe sex‐specific Walleye spawning participation from a Great Plains broodstock operation. Specific objectives will assess standardization to collect target number of broodstock effort, catch per unit effort, and length and age participation of female and male broodstock.MethodsWalleye were collected at Sherman Reservoir, Nebraska, during April spawn collection operations from 2015 to 2019. Gill nets were used to collect female Walleye, and boat electrofishing was used to collect male Walleye. Catch per effort was calculated for each sex, fish were measured to nearest 1‐cm length‐group, and a dorsal spine was taken from a subset of fish per length‐group. Mean lengths and ages were calculated for each year of the study. Data were combined for all years of the project to display percent contribution by length and age.ResultThe amount of effort to capture 100 female and male Walleye varied by 4× and 2.5×, respectively, over the 5 years of sampling. Mean lengths and ages (±SE) of female (65 ± 1 cm; 10.4 ± 0.1 years) and male (43 ± 1 cm; 6.3 ± 0.1 years) Walleye collected were consistent during this study. The female Walleye collected represented 14 different ages, but ages 9–12 comprised 66% of all captured broodstock. The collected male Walleye also demonstrated age‐compressed spawning tendencies, with ages 4–7 accounting for 74% of collected individuals that represented 13 different ages.ConclusionThese results can define the anticipated variability in catch that can be expected at broodstock collection operations along with connection to specific lengths and ages of Walleye. Additionally, recognition that female and male Walleye broodstock contributions are consistently coming from four specific ages that are not the same year‐classes may allow spawning operation staff to anticipate brood availability and ultimately improve the planning efficiency of these operations.

Streamlining management in thoracic trauma: radiomics- and AI-based assessment of patient risks

BackgroundIn blunt chest trauma, patient management is challenging because clinical guidelines miss tools for risk assessment. No clinical scale reliably measures the severity of cases and the chance of complications.AimThe objective of the study was to optimize the management of patients with blunt chest trauma by creating models prognosticating the transfer to the intensive care unit and in-hospital length of stay (LOS).MethodsThe study cohort consisted of 212 cases. We retrieved information on the cases from the hospital’s trauma registry. After segmenting the lungs with Lung CT Analyzer, we performed volumetric feature extraction with data-characterization algorithms in PyRadiomics.ResultsTo predict whether the patient will require intensive care, we used the three groups of findings: ambulance, admission, and radiomics data. When trained on the ambulance data, the models exhibited a borderline performance. The metrics improved after we retrained the models on a combination of ambulance, laboratory, radiologic, and physical examination data (81.5% vs. 94.4% Sn). Radiomics data were the top-accurate predictors (96.3% Sn). Age, vital signs, anthropometrics, and first aid time were the best-performing features collected by the ambulance service. Laboratory findings, AIS scores for the lower extremity, abdomen, head, and thorax constituted the top-rank predictors received on admission to the hospital. The original first-order kurtosis had the highest predictive value among radiomics data. Top-informative radiomics features were derived from the right hemithorax because the right lung is larger. We constructed regression models that can adequately reflect the in-hospital LOS. When trained on different groups of data, the machine-learning regression models showed similar performance (MAE/ROV≈8%). Anatomic scores for the body parts other than thorax and laboratory markers of hemorrhage had the highest predictive value. Hence, the number of injured body parts correlated with the case severity.ConclusionThe study findings can be used to optimize the management of patients with a chest blunt injury as a specific case of monotrauma. The models we built may help physicians to stratify patients by risk of worsening and overcome the limitations of existing tools for risk assessment. High-quality AI models trained on radiomics data demonstrate superior performance.

Comparative Analyses of the Outcomes Between Lobectomies and Trisegmentectomies/Lingulectomies in the Surgical Management of Clinical Stage I Left Upper Lobe Non-small Cell Lung Cancer.

Lobectomies are the standard surgical intervention for lung cancer; however, recently, surgeons have considered segmentectomies for smaller tumors, with their potential for favorable survival outcomes while preserving lung function. The surgical outcomes of trisegmentectomies/lingulectomies and lobectomies for clinical stage I left upper lobe (LUL) non-small cell lung cancers (NSCLCs) remain undetermined. Thus, our study aimed to assess the differences between the short-term surgical and long-term survival outcomes in patients with clinical stage I LUL NSCLC who underwent trisegmentectomies/lingulectomies and those who underwent lobectomies. Between 2011 and 2021, we retrospectively reviewed the data of 377 patients with clinical stage I NSCLC who had undergone LUL lobectomies or trisegmentectomies/lingulectomies. Patients were categorized into two subcohorts according to tumor size, i.e. 0-2 and 2-4 cm. To ensure preoperative demographic comparability, 1:1 propensity-score matching (PSM) was performed. This study focused on the 2-4cm subcohort. Post-PSM, patients who underwent trisegmentectomies/lingulectomies had quicker operations and shorter postoperative hospital and intensive care unit lengths of stay than those who underwent lobectomies. Post-PSM, no statistically significant differences in progression-free survival (PFS) or overall survival (OS) were observed between the segmentectomy and lobectomy groups in both the0-2 and 2-4cm subcohorts. The multivariate analysis revealed that different surgical methods were not statistically significant factors for either PFS or OS. Trisegmentectomies/lingulectomies are a feasible option for clinical stage I NSCLC, with better perioperative outcomes and similar survival rates when compared with LUL lobectomies.

Revealing the pinning landscape and related vortex pattern evolution in granular superconducting films

Most superconducting electronics based on films exhibit granular structures. It has been suggested that grain boundaries form a network with relatively weak superconductivity, potentially acting as pinning centers. Yet, so far, detailed microscopic studies of the pinning landscape and its relation to vortex behavior remain scarce. Here, we imaged the vortex lattices (VL) in granular Nb films using magnetic force microscopy over large scanning areas at various magnetic fields. A non-monotonic evolution in the degree of vortex lattice ordering was observed with increasing vortex density, driven by a combination of vortex-vortex interactions and pinning effects. The spatial distribution of pinning potential within the film was directly mapped using a recently developed scanning quantum vortex microscope (SQVM). Instead of the network formed by grain boundaries, the pinning landscape presents a network-like structure, yet with domains significantly larger than the individual grains. The results of numerical simulations based on pinning landscape revealed by SQVM well reproduce our experiments. The pinning force per unit length at low magnetic fields was calculated. The critical current density, estimated from the relative positions of vortices, aligns well with the critical state model. Our work illustrates the relationship between the evolution of the vortex lattice with magnetic field and the structural features of granular Nb film, providing new insights into the design of high-performance superconducting electronic devices.

Improving Real-Scene 3D Model Quality of Unmanned Aerial Vehicle Oblique-Photogrammetry with a Ground Camera

In UAV (unmanned aerial vehicle) oblique photogrammetry, the occlusion of ground objects, particularly at their base, often results in low-quality real-scene 3D models. To address this issue, we propose a method to enhance model quality by integrating ground-based camera images. This innovative image acquisition method allows the rephotographing of areas in the 3D model that exhibit poor quality. Three critical parameters for reshooting are the reshooting distance and the front- and side-overlap ratios of reshooting images. The proposed method for improving 3D model quality focuses on point accuracy, dimensional accuracy, texture details, and the triangular mesh structure. Validated by a case study involving a complex building, this method demonstrates that integrating ground camera photos significantly improves the overall quality of the 3D model. The findings show that optimal settings for reshooting include a distance (in meter units) of 1.5–1.6 times the camera’s focal length (in millimeter units), a front overlap ratio of 30%, and a side overlap ratio of 20%. Furthermore, we conclude that an overlap rate of 20–30% in reshooting is a usable value.

Effect of glucose-insulin-potassium on lactate levels at the end of surgery in patients undergoing cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: study protocol for a randomized controlled trial

IntroductionCytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been established as an effective treatment for peritoneal cancer (PC). However, this kind of combination therapy is associated with a high lactate level. Moreover, studies have suggested that the rate of complications early after surgery directly increased with elevated lactate levels. Glucose-insulin-potassium (GIP), a potent cardioprotective intervention, has been demonstrated to adjust blood glucose (BG) levels and reduce lactate levels. However, the insulin-glucose ratio should be adjusted according to the surgery performed. Here, we aimed to evaluate the advantages of using modified GIP during CRS/HIPEC to reduce the lactate level at the end of surgery and further reduce the incidence of early postoperative complications.Methods and analysisThe modified GIP versus conventional management during surgery study is a single-center, randomized, single-blinded outcome assessment clinical trial of 80 patients with PC who are between 18 and 64 years old and undergoing CRS/HIPEC. Participants will be randomly allocated to receive modified GIP or conventional treatment (1:1). The primary outcome will be the plasma lactate level at the end of surgery. The secondary outcomes will include the highest levels and fluctuation ranges of lactate and BG during surgery, extubation time, APACHE-II score 24 h after surgery, postoperative defecation and exhaust time, postoperative lactate clearance time, postoperative liver and kidney function, incidence of complications within 7 days after surgery, length of intensive care unit stay (LIS), length of hospital stay (LHS), and total cost of hospitalization.Ethics and disseminationThe trial protocol was approved by the Scientific Research Ethics Committee of Beijing Shijitan Hospital Affiliated with Capital Medical University, approval number sjtky11-1x-2022(118). The results will be published in international peer-reviewed journals.Trial registrationChiCTR2200057258. Registered on March 5, 2022.

CO2 delivery techniques in mini-sternotomy surgery and neurological events: a multicentric study

BackgroundThe impact of air bubbles into the cerebral circulation after open heart surgery has been a topic of discussion since the introduction of the heart-lung machine. The aim of the study was to evaluate whether the use of a dedicated commercial sponge diffuser is better than a custom-made narrow section cannula or the absence of CO2 in preventing neurological events after aortic valve replacement via J mini-sternotomy.MethodsThree cohorts of J-shaped mini-sternotomy performed at three different centers were prospectively compared: CO2 supplied via sponge diffuser, CO2 supplied via cannula, and no CO2 supply. Propensity matching was used to obtain comparable groups. The primary endpoints were postoperative stroke, transitory ischemic attack, convulsions, and dizziness. Secondary endpoints were 30-day mortality, duration of mechanical ventilation, and intensive care unit length of stay.Results275 patients were enrolled in the study. After propensity matching, the sponge diffuser cohort had a significantly lower duration of mechanical ventilation (P < 0.001) and 30-day mortality (P = 0.05) when compared to the cannula cohort and the no-CO2 cohort, a lower incidence of all neurological events (P = 0.03) and dizziness (P = 0.05) when compare to the no-CO2 cohort, and a lower intensive care unit length of stay when compared to the cannula cohort (P = 0.001).ConclusionsThe sponge diffuser used to deliver the CO2 into the surgical field during aortic valve replacement via J mini-sternotomy has been demonstrated to guarantee better neurological outcomes compared to a custom-made narrow section cannula or the absence of CO2.

Determination of Lubrication Layer Thickness and Its Effect on Concrete Pumping Pressure.

The flow of six kinds of fresh concrete under different flow rates and lubrication layer thickness (TLL) values in the horizontal pipe was numerically simulated. The influence of the TLL on the pressure per unit length (PL) was analyzed. It was determined that the formation of the lubrication layer (LL) significantly reduces the PL in concrete pumping. As the TLL increased, the PL decreased. However, the degree of reduction in the PL gradually decreased as the TLL increased. Relating the simulated PL with the experimental PL, the size of the TLL was obtained, which was between 1 and 3 mm. The minimum and maximum were 1.23 and 2.58 mm, respectively, and the average value was 1.97 mm. The strength (S24, S50), the size of the aggregate (A10, A20, A25), and the flow rate of pumping all affected the TLL. The type of fresh concrete and the flow rate of pumping significantly affected the PL, which impacted the TLL. However, the TLL also impacted the PL. Finally, this made the TLL change within a certain range. When PL > 14,000 Pa/m, 2 mm < TLL< 3 mm; on the other hand, 1 mm < TLL< 2 mm. Therefore, we can use CFD to simulate the flow of all types of concrete in the actual pumping pipeline with a TLL of 2 mm to obtain their pumping pressure and guide the actual construction.

The sevoflurane concentration for light sedation in critically ill patients: A protocol for experimental study

Background: Deep-inhaled sedation is increasingly used in Thai ICUs. However, there is a lack of information regarding the level of end-tidal sevoflurane concentration during light sedation. Objectives: The study aims to determine the effective dose (ED50 and ED95) of sevoflurane concentration for light sedation (RASS score -1 to 0) in mechanically ventilated critically ill patients. Methods: This is a prospective experimental single-center study. Mechanically ventilated patients with RASS ≥ 1 who required sedation in the medical and surgical intensive care unit were enrolled. Using an up-and-down sequential allocation technique, the inhaled sevoflurane level of each patient was allocated based on the previous patient’s response. RASS score and hemodynamic parameters were monitored. The primary outcome was the ED50 and ED 95 of end-tidal sevoflurane concentration. The secondary outcomes included the length of intensive care unit stay, duration of ventilator day, the incidence of delirium, hemodynamic status, and respiratory variables changed during the study period. Hypothesis: There exist specific end-tidal sevoflurane concentrations (ED50 and ED95) that will reliably induce a target RASS score of -1 to 0 in critically ill patients who are mechanically ventilated. Conclusion: This study will provide an effective dose of inhaled sevoflurane sedation for achieving targeted light sedation levels in critically ill patients, which may have minimal effects on hemodynamics. Ethics and dissemination: This study has been approved by the Office of Human Research Ethics Committee, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand, on 22nd May 2023 (COA.MURA2023/390). Trial registration: TCTR20230825001

Optimal timing for video assisted thoracic surgery decortication for improved survival in chronic empyema

BackgroundVideo-assisted thoracic surgery decortication for phase 3 thoracic empyema is widely accepted, but its optimal timing has not been established. We aim to investigate and assess this timing, in terms of overall survival, for chronic empyema.MethodsTwo hundred four patients with pneumonia-caused phase 3 empyema were treated with video-assisted thoracic surgery decortication over 10-years at Changhua Christian Hospital. The 90-day post-operative survival status was analyzed, and we compared the survivor group versus the non-survivor group. A receiver operating characteristic curve was used to identify the optimal decortication timing.ResultsA comparison between survivors and non-survivors showed statistical differences among age (p=0.004), presence of cardiovascular disease (p=0.018), presence of end-stage renal disease (p=0.002), duration to surgery (p=0.013), length of intensive care unit stay (p=0.010), and overall length of hospital stay (p=0.015). ROC curve analysis determined the cut-off for video-assisted thoracic surgery decortication, based on optimal 90-day post-operative survival, to be 7.5 days after hospitalization; mortality increases threefold thereafter (14.2% vs 44.6%, p<0.001). Multivariate analysis revealed that age, end-stage renal disease, pleural effusion pH≦7.2 and duration to surgery >7.5 days negatively impacted 90-day post-operative survival.ConclusionsPatients receiving decortication surgery within 7.5 days of hospital admission had better overall survival.

Use of a two-bag fluid administration protocol in the treatment of paediatric diabetic ketoacidosis: A retrospective review

ABSTRACT Objectives The ‘two-bag method’ for the treatment of diabetic ketoacidosis (DKA) uses two intravenous fluid bags, only one of which contains 10% dextrose. The bags are run concurrently with rates adjusted according to a rate change table to allow the relative amount of dextrose administered to be adjusted over time, without the need for bag replacements. The Children’s Hospital at London Health Sciences Centre (CHLHSC) two-bag protocol is a simplified version of that used by other centres. The objective of this study was to ensure implementation of the CHLHSC two-bag protocol continues to provide safe and effective treatment of paediatric DKA and decreases resource utilization. Methods This retrospective chart review compared treatment pre- and post-protocol implementation. Results A total of 22 admissions were included. No significant differences in efficacy or safety outcomes were found between the protocol groups. There was no statistically significant difference between the two and one-bag protocols in time to normalization of serum bicarbonate (13.80 ± 7.68 versus 15.01 ± 7.53 h, P = 0.714), blood glucose correction (8.75 ± 4.86 versus 11.85 ± 4.92 h, P = 0.152), and critical care unit length of stay (24.26 ± 9.94 versus 32.30 ± 13.36, P = 0.399). The nursing staff appeared to appropriately implement the rate change table, but the chart documentation was poor. Conclusions The CHLHSC simplified two-bag protocol provides a safe and effective alternative to the one-bag protocol for DKA correction in paediatric patients and may also result in decreased resource utilization.

A prospective cohort study comparing monitored anesthesia care and intubated general anesthesia in cardiac surgery involving cardiopulmonary bypass

BackgroundThe aim of this study is to assess the feasibility and safety of monitored anesthesia care (MAC) versus intubated general anesthesia (IGA) for patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB).MethodsThis prospective observational study included patients scheduled for cardiac surgery involving CPB at our institution between April 2012 and February 2017. The enrolled patients were categorized into MAC and IGA groups. MAC involved local anesthesia at the sternotomy site, sedation with dexmedetomidine, analgesia with remifentanil/sufentanil, and electroacupuncture (EA). Eleven patients underwent MAC, and 13 patients received IGA. There were no instances of conversion from MAC to IGA, and both groups exhibited no major complications. The demographic characteristics, baseline parameters, and operative variables were comparable between the two groups.ResultsIntraoperative opioid consumption was significantly lower in the MAC group compared to the IGA group (P < 0.001). The time to oral intake of liquids was significantly shorter in the MAC group (2.14 ± 0.90 h) compared to the IGA group (22.31 ± 3.33 h) (P < 0.001). Furthermore, the intensive care unit length of stay (ICU-LOS) and perioperative vasoactive-inotropic score (VIS) were significantly reduced in the MAC group compared to the IGA group (P < 0.001).ConclusionsMAC emerges as a safe and viable alternative to general anesthesia for specific patient groups undergoing cardiac surgery with CPB. Furthermore, it may enhance postoperative recovery and minimize postoperative complications compared to IGA.

Association between postoperative atrial fibrillation after coronary artery bypass grafting and short-term clinical outcomes

BackgroundDespite advances in prevention and treatment, postoperative atrial fibrillation (POAF) is the most common type of complication undergoing cardiac surgery. This study aimed to identify the relationship between POAF and clinical outcomes after coronary artery bypass graft.MethodsIn this cross-sectional study, we retrospectively reviewed the medical records of 324 patients who had undergone coronary artery bypass grafting in an intensive care unit between 2010 and 2019 at a tertiary hospital in Korea. Propensity score matching was used to estimate a 1:1 match (without: with POAF) using seven covariates to overcome selection bias. Kaplan–Meier survival analysis and Cox proportional hazards modeling were performed to determine the effect on intensive care unit readmission and length of hospital stay.ResultsAfter controlling for covariates, 1:1 matching was performed for 91 patients in each group. The occurrence of postoperative atrial fibrillation was found to increase the probability of readmission to the intensive care unit, with a 23% reduced probability of readmission for every 10% increase in left ventricular ejection fraction. Multivariate analysis indicated that postoperative atrial fibrillation, chronic obstructive pulmonary disease as a comorbidity, and preoperative hemoglobin were factors affecting the length of hospitalization after surgery. The Kaplan–Meier survival analysis results indicated that the without POAF group had a higher survival rate than the with POAF group.ConclusionsHealthcare professionals should recognize negative factors such as postoperative atrial fibrillation and abnormal hematologic parameters that impact major clinical outcomes in patients and may require closer monitoring before and after coronary artery bypass grafting.