Use Of Inotropes Research Articles

The Effect of Anesthesia Type Applied in Transcatheter Aortic Valve Implantation.

Different results have been obtained in studies on the effect of anesthesia type applied during transcatheter aortic valve implantation on in-hospital outcomes. In this study, we aimed to investigate the association of the type of anesthesia with the lenght of stay in the intensive care unit and the need for inotropes in patients undergoing transcatheter aortic valve implantation. A total of 140 patients who underwent transcatheter aortic valve implantation between January 2016 and January 2022 were retrospectively analyzed. The patients were divided into 2 groups as deep sedation and general anesthesia according to the type of anesthesia. The mean age of all patients was 78.5 ± 8.6 years, and 69 of the patients (49.3%) were female. Length of stay in intensive care unit, midazolam dosage, use of inotropic agents, and procedural hypotension were significantly lower in the deep sedation group than in the general anesthesia group [(1[1-2] vs. 1[1-2.5] days, P = 0.03), (2.1 ± 0.4 mg/kg vs. 2.3 ± 05, P = 0.02), (39 (37.9%) vs. 22 (59.5%), P = 0.02), (41 (39.8%) vs. 25 (67.6%), P = 0.004)]. General anesthesia was associated with increased use of inotropic agents during transcatheter aortic valve implantation compared to deep sedation (odds ratio = 2.93 95% CI = 1.18-7.30, P = 0.02). The use of inotropes is less in transcatheter aortic valve implantation procedures performed under deep sedation and length of stay in intensive care unit is shorter.

Mortality Predictors in Elderly Intensive Care Unit Patients with Acute Kidney Injury Requiring Hemodialysis

Introduction: The incidence of acute kidney injury is increasing in the elderly. This condition is especially serious during the course of critical illness, and the rate of mortality rises with the condition’s increasing severity. We aimed to identify the risk factors for in-hospital, 28-day, and 90-day mortality among elderly patients admitted to the intensive care unit with acute kidney injury requiring dialysis. Materials and Method: We conducted a retrospective study between January 2011 and December 2019 of patients 65 years of age and older who were hospitalized with acute kidney injury requiring dialysis in the intensive care unit of an internal medicine department. Results: A total of 144 patients were evaluated, 63 male (43.75%) and 81 female (56.25%). The in-hospital, 28-day, and 90-day mortality rates were 40.9%, 47.2%, and 56.2%, respectively. Sepsis etiology was associated with poor prognosis. In univariate Cox regression analysis, we identified use of inotropes, final C-reactive protein, neutrophil to lymphocyte ratio as mortality predictors at all three time points. Use of inotropes, final C-reactive protein continued to be predictors of mortality in multivariate analysis. Age was not found to be a factor affecting mortality. Conclusions: Data are limited on the outcomes of elderly patients with acute kidney injury requiring dialysis, but routinely evaluated laboratory parameters in intensive care practice may be predictive of mortality. Our results provide deeper understanding of how these variables interact and contribute to the risk of mortality. Chronological age alone should not be a consideration for hemodialysis. Keywords: Aged; Critical Care; Hemodialysis; Acute Kidney Injury; Mortality.

Diphtheria Remains a Threat to the Health System Even in the Era of Vaccination: A Cross-sectional Observational Study from Karnataka, India

Introduction: Diphtheria is an infectious disease caused by a gram-positive facultatively anaerobic bacilli, Corynebacterium (C.) diphtheriae. The present health statistics and data from the few studies that have been carried out suggest that our war with this disease is still going on and is far from being over in spite of the vaccine that’s freely available. Aim: To study clinical profile, complications, and outcome of diphtheria in karnataka population and to correlate with immunisation status. Materials and Methods: This was a hospital-based prospective cross-sectional observational study done in the Department of Paediatrics, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India, from January 2018 to November 2018. Patients admitted with history suggestive of diphtheria were enrolled and categorised into probable and confirmed cases. The age, sex, area of residence, religion, immunisation status, mean time of presentation to hospital from onset of illness, use of inotropes and mechanical ventilation were recorded in a predesigned proforma. Throat swab smear for C.diphtheria and culture, complete blood count, Renal Function Tests (RFT) with serum electrolytes, chest radiograph, Electrocardiogram (ECG) and 2-Dimensional (2D) Echocardiogram (ECHO) were also recorded. Results: Out of total 28 cases, 18 fulfilled the inclusion criteria. Male to female ratio was 2:1 and the mean age of presentation was 9.7 years. Highest incidence (n=14, 77.8%) was seen in the age group of 09-11 years. Most common clinical presentation was fever and sore-throat present in all 18 (100%), neck swelling in 13 (72.2%), dysphagia in 05 (27.7%). Examination revealed tonsillar hypertrophy and pseudomembrane in 17 (94.4%) patients, whereas one patient had laryngeal diphtheria, which was diagnosed when swab was sent while intubating in view of membranous laryngitis. Mean time of presentation to hospital after the onset of symptoms was 5.65 days. All children received appropriate antibiotics and Antidiphtheritic Serum (ADS). Total of seven patients were ventilated, of which 5 (27.7%) succumbed, and two were extubated. Four (22.2%) patients developed myocarditis in the second week, and all succumbed to resistant arrhythmias. One patient developed sepsis with ventilator dependency, and succumbed to inotrope resistant septic shock. On follow-up, 5 (27.7%) developed palatal palsy among which three had associated polyneuropathy; all these children recovered with only supportive care. Conclusion: Diphtheria is down but not out, the present study unmasks the fact that the disease is equally prevalent in immunised and older children with the changing epidemiology of diphtheria in the era of vaccines.

Assessment of Antenatal and Postnatal Prognostic Indicators in the Outcome of Neonatal Congenital Diaphragmatic Hernia: A Prospective Observational Study.

Despite advances in neonatal intensive care, surgical methods, and anesthesia, congenital diaphragmatic hernia (CDH) is still associated with significant mortality. Predicting which babies will have poorer outcomes is essential to identify the high-risk babies and to give targeted care and accurate prognosis to the parents, especially in a resource crunch set-up. The aim of this study is to evaluate the antenatal and postnatal prognostic factors in neonatal CDH that can be used to predict the outcome. This was a prospective observational study in a tertiary care center. Neonates presented with CDH within 28 days of life were included in the study. Bilateral disease, recurrent diseases, and babies operated outside were excluded from the study. The data were collected prospectively, and babies were followed until discharge or death. Data were expressed in mean with standard deviation or median with range based on normality. All the data were analyzed using the SPSS software version 25. Thirty babies with neonatal CDH were studied. There were three right-sided cases. The male-to-female ratio was 2.3:1, and 93% of babies were antenatally diagnosed. Seventeen out of the 30 babies underwent surgery. Nine (52.9%) underwent laparotomy, and 8 (47%) underwent thoracoscopic repair. Overall mortality was 53.3%, and operative mortality was 17.6%. Demographic characteristics were comparable between expired versus survived babies. The significant predictors of outcome identified were - Persistent pulmonary hypertension (PPHN), mesh repair, high-frequency oscillatory ventilation (HFOV), use of inotropes, 5-min APGAR, ventilator index (VI), and HCO3 levels. We conclude that the prognostic indicators associated with poor prognosis are low 5-min APGAR, high VI, low HCO3 levels in venous blood gas analysis, mesh repair, HFOV, inotropes usage, and PPHN. None of the antenatal factors studied showed any statistical significance. Further prospective studies with a larger sample size are recommended to confirm the findings.

The role of human milk feeds on inotrope use in newborn infants with sepsis.

Regarding neonatal hypotension, there is no certainty as to whether inotrope properties are beneficial or whether they may be harmful. However, given that the antioxidant content of human milk plays a compensatory role in neonatal sepsis and that human milk feeding has direct effects in modulating the cardiovascular function of sick neonates, this research hypothesized that human milk feeds might predict lower requirements of vasopressors in the management of neonatal septic shock. Between January 2002 and December 2017, all late preterm and full-term infants attending a neonatal intensive care unit, with clinical and laboratory findings of bacterial or viral sepsis, were identified in a retrospective study. During their first month of life, data on feeding type and early clinical characteristics were collected. A multivariable logistic regression model was constructed to determine the impact of human milk on the use of vasoactive drugs in septic newborns. 322 newborn infants were eligible to participate in this analysis. Exclusively formula-fed infants were more likely to be delivered via C-section, to have a lower birth weight and a lower 1-minute Apgar score than their counterparts. Human milk-fed newborns had 77% (adjusted OR = 0.231; 95% CI: 0.07-0.75) lower odds of receiving vasopressors than exclusively formula-fed newborns. We report that any human milk feeding is associated with a decrease in the need for vasoactive medications in sepsis-affected newborns. This observation encourages us to undertake further research to determine whether human milk feeds mitigate the use of vasopressors in neonates with sepsis.

Prognosis of Patients with Acute Kidney Injury due to Type 1 Cardiorenal Syndrome Receiving Continuous Renal Replacement Therapy

Introduction: The prognosis of patients with acute kidney injury (AKI) caused by type 1 cardiorenal syndrome (CRS) requiring continuous renal replacement therapy (CRRT) is unclear. We investigated the in-hospital mortality and prognostic factors in these patients. Methods: We retrospectively identified 154 consecutive adult patients who received CRRT for AKI caused by type 1 CRS between January 1, 2013, and December 31, 2019. We excluded patients who underwent cardiovascular surgery and those with stage 5 chronic kidney disease. The primary outcome was in-hospital mortality. Cox proportional hazards analysis was performed to analyze independent predictors of in-hospital mortality. Results: The median age of patients at admission was 74.0 years (interquartile range: 63.0–80.0); 70.8% were male. The in-hospital mortality rate was 68.2%. Age ≥80 years (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.21–2.87; p = 0.004), previous hospitalization for acute heart failure (HR, 1.67; 95% CI, 1.13–2.46; p = 0.01), vasopressor or inotrope use (HR, 5.88; 95% CI, 1.43–24.1; p = 0.014), and mechanical ventilation at CRRT initiation (HR, 2.24; 95% CI, 1.46–3.45; p < 0.001) were associated with in-hospital mortality. Conclusion: In our single-center study, the use of CRRT for AKI due to type 1 CRS was associated with high in-hospital mortality.

Symmetrical peripheral gangrene in a chronic kidney disease patient on hemodialysis

Symmetrical peripheral gangrene (SPG) is a rare but well-described condition characterized by ischemic changes in the distal limbs with preserved flow in the major vessels. It results from thrombosis of the microcirculation resulting from a complex interplay of infectious and non-infectious factors. Often described as a complication of disseminated intravascular coagulation (DIC), it has got multiple aggravating factors. Timely recognition and management is important as significant residual disability is noted in surviving patients. Here, we describe a patient with chronic kidney disease on maintenance hemodialysis presenting with SPG associated with spontaneous bacterial peritonitis and DIC. She had multiple aggravating factors such as hypotension, use of inotropes, and renal failure. As there were no evidence-based guidelines and since the general condition of the patient was poor, she was managed with supportive care.

Non-occlusive mesenteric ischemia in critically ill patients.

Non-occlusive mesenteric ischemia (NOMI) is a life-threatening acute condition that has an overall in-hospital mortality rate of up to 75%. Critically ill patients are often admitted to intensive care units (ICUs) due to shock, and these patients are frequently at risk of developing NOMI. The objective of this study was to determine the clinical features of critically ill patients with NOMI and evaluate the risk factors for in-hospital mortality among these patients. We reviewed the electronic medical records of 7,346 patients who underwent abdominal contrast-enhanced computed tomography during their ICU stay at Samsung Medical Center (Seoul, Korea) between January 1, 2010 and December 31, 2019. After reviewing each patient's computed tomography (CT) scans, 60 patients were diagnosed with NOMI and included in this analysis. The patients were divided into survivor (n = 23) and non-survivor (n = 37) groups according to the in-hospital mortality. The overall sequential organ failure assessment (SOFA) score for the included patients upon admission to the ICU was 8.6 ± 3.1, and medical ICU admissions were most common (66.7%) among the patients. The SOFA score upon admission to the ICU was higher for the non-survivors than for the survivors (9.4 vs. 7.4; p = 0.017). Non-survivors were more often observed in the medical ICU admissions (39.1% vs. 83.8%) than in the surgical ICU admissions (47.8% vs. 10.8%) or the cardiac ICU admissions (13.0% vs. 5.4%). Laboratory test results, abdominal CT findings, and the use of vasopressors and inotropes did not differ between the two groups. In a multivariable analysis, SOFA scores >8 upon admission to the ICU (odds ratio [OR] 4.51; 95% 1.12-18.13; p = 0.034), patients admitted to the ICU with medical problems (OR 7.99; 95% 1.73-36.94; p = 0.008), and abdominal pain (OR 4.26; 95% 1.05-17.35; p = 0.043) were significant prognostic predictors for in-hospital mortality. The SOFA score >8 upon admission to the ICU, admission to the ICU for medical problems, and abdominal pain at diagnosis are associated with increased mortality among patients with NOMI.

365: THE USE OF TOCILIZUMAB IN CRITICALLY ILL CHILDREN: A SINGLE PEDIATRIC CENTER EXPERIENCE

Introduction: Tocilizumab has been demonstrated to prevent systemic inflammatory responses by inhibiting the inflammatory cytokine interleukin-6 (IL-6). Our objective was to review a single-center experience of the use of tocilizumab in critically ill children and describe its effect on inflammatory markers and platelet counts. Methods: After IRB approval, a retrospective analysis of all inpatients who received tocilizumab from July 2017 to June 2022 was performed, collecting demographic, clinical, and outcome variables. Twenty doses of tocilizumab were given to 14 patients. Chi-square or Fisher’s exact test and Wilcoxon signed-rank test were used to analyze the data. Results: The cohort was mostly male (85.7%), white (78.6%), and Hispanic (78.6%). The mean age was 124±95 months. COVID-19 pneumonia (50%) and cytokine release syndrome (CRS; 28.6%) were two common indications. The mean (range) PRISM3 risk of mortality was 7.1% (0.8-30.3%). The mean LOS and mortality rate in PICU were 50.6 days and 42.9%, respectively. The mortality rate was 0% in COVID-19, 75% in CRS, and 100% in others (p< 0.01). Multiple organ failure (MOF = >2 organ failures) was present in 50%. Individual organ failure included respiratory failure (85.7%), cardiovascular failure (42.9%), liver dysfunction (57.1%), thrombocytopenia, (50%), coagulopathy (21.4%), and acute kidney injury (21.4%). 5 of the 6 patients (83%) with inotropic use died (p=0.026). MOF was present in 71% of patients who died compared to 14% of those who survived (p=0.13). The median (IQR) values of LDH, IL6, CRP, and ferritin before tocilizumab were 1817 (1190-3100), 22.8 (10.9-400), 7.4 (2.3-34.6), and 1175 (615-4095), respectively. The median platelet count increased from 92 (24-178) to 158 (63-278) and CRP decreased from 7.4 (2.3-34.6) to 1.7 (0.5-4.6) within 3 days after tocilizumab (p< 0.001). The median vasoactive infusion score decreased from 46 (2.5-87) to 9 (2.5-46) after tocilizumab (p=0.5). Conclusions: The use of tocilizumab increased with COVID-19 pandemic. The mortality associated with the use of tocilizumab varied with underlying diagnoses and was lowest with COVID-19. Platelet count increased and CRP decreased after administration of tocilizumab. The role of tocilizumab in critically ill children with hypercytokinemia needs further evaluation.

OGC P18 Feeding jejunostomy complications after oesophagectomy: a quality improvement project at a tertiary referral centre

Abstract Background A feeding jejunostomy is one method to provide adequate nutrition after oesophagectomy. This bypasses the anastomosis allowing healing before oral feeding resumes. However, routinely using feeding jejunostomies may not be appropriate for patients within an Enhanced Recovery After Surgery protocol due to complications. Feeding jejunostomies have 3–61% morbidity, with mechanical (i.e tube dislodgement) and non-mechanical (i.e. site infection) complications plus associated increased length of stay. The local standard after oesophagectomy is routine feeding jejunostomy placement. However, selective, rather than routine feeding jejunostomy placement may therefore be warranted. Aim Conduct a quality improvement project addressing the local feeding jejunostomy complication rate after oesophagectomy. Methods Cycle 1: A review of oesophagectomies between 2018–2021 assessing complications using the Clavien-Dindo classification. An existing database of oesophagectomies was screened for patients undergoing concurrent feeding jejunostomy insertion. Patients ≥18 were included, whilst any indication for oesophagectomy was included. Patients lacking information on type and bore of jejunostomy tube inserted were excluded. Demographics, jejunstomy tube type and bore, complication and Clavien-Dindo grade of complication were recorded. The Charlson comorbidity score of each patient was determined to help find a population at risk. Intervention: Findings to be presented at a departmental audit meeting, with patient risk stratification to identify a cohort at risk. Cycle 2: re-audit (July 2022 - July 2023) as per cycle 1 after presentation. Improvement = fewer jejunostomy-specific complications. Results 110 patients were included, with a median age of 65.5 (IQR 61.0–72.0). 81.8% patients (n=90) sustained a complication, mostly Clavien-Dindo grade II. Jejunostomy-specific complications occurred in 21.8% patients (n=24), with the commonest jejunostomy-specific complication being a leak (44.8%). 4 ‘major’ (Clavien-Dindo ≥III) jejunostomy-specific complications were reported. No ischaemic small bowel necrosis was reported, significantly less than a prior audit (0.0% vs. 3.74%, p=0.029). Demographics/ Charlson comorbidity score, jejunostomy type inserted (JJ tube, 15F or 9F) and jejunostomy insertion method (open/ laparoscopic) did not impact overall or major feeding jejunostomy-specific complication rate. Conclusions This first cycle agrees with the reported complication rate in the literature. Though a population at risk could not be determined, reviewing local non-specialist centres may aid this, to reduce future complications. The literature would support a more selective approach to feeding jejunostomy insertion and as such this should be taken to reduce post-insertion complications. Continued prominent advice regarding inotropes may prevent ischaemic bowel. We aim to introduce clear warnings to the local ERAS protocol over the concurrent use of jejunostomy feed and inotropes, whilst electronic warnings flagging concurrent jejunostomy feed and inotrope prescribing are being worked upon. Moreover, poor hospital coding of jejunostomies may have limited the cohort, preventing determining a cohort at risk of feeding jejunostomy insertion.

Physicians' Knowledge of Abdominal Compartment Syndrome and Intra-Abdominal Hypertension in Saudi Arabia: An Online Cross-Sectional Survey Study.

To determine physicians' knowledge of abdominal compartment syndrome and intra-abdominal hypertension in Saudi Arabia. A cross-sectional online survey study was conducted on physicians in Saudi Arabia between March and August 2022. A previously developed questionnaire was adapted and used in this study. The survey instrument investigated the knowledge and management of intra-abdominal hypertension and abdominal compartment syndrome among physicians. Logistic regression was used to identify predictors of being knowledgeable about abdominal compartment syndrome and intra-abdominal hypertension. A total of 266 physicians participated in this study. Around one-fifth (21.8%) the study participants were ICU physicians and 25.0% reported that they practice internal medicine. Intra-abdominal hypertension (IAH) and the impact of increased intra-abdominal pressure (IAP) on organ function were terms that the majority of research participants (70.3%) reportedthey were familiar with. A similar percentage (73.7%) reported that they are familiar with abdominal compartment syndrome (ACS). Around 43.0% of the study participants reported that they do not know how to measure IAP. The most frequently reported (13.5%) intervention in the treatment of IAH and ACS was the use of inotropes or vasopressors. The study participants showed a weak level of knowledge of ACS and IAH with a median score of 3.00 (IQR: 5.00-2.00), which represents 27.3% of the maximum attainable score. Physicians working at hospitals with 20-50 ICU beds were 41.0% (odds ratio: 0.59 (CI: 0.37-0.96)) less likely to be knowledgeable about intra-abdominal hypertension and abdominal compartment syndrome (p≤0.05). Physicians demonstrated a low level of IAP and ACS knowledge. To increase the safety of medical practices and enhance clinical outcomes for patients, awareness should be raised about the proper diagnosis and managementof IAP and ACS. Future research should focus on developing effective educational strategies to improve physicians' understanding of IAP and ACS.

Worse survival in patients with right ventricular dysfunction and COVID-19–associated acute respiratory distress requiring extracorporeal membrane oxygenation: A multicenter study from the ORACLE Group

ObjectiveWe sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring veno-venous extracorporeal membrane oxygenation. MethodsSix academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared. ResultsThe cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1% of patients who received extracorporeal membrane oxygenation and 27.4% of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5% of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non–extracorporeal membrane oxygenation cohorts stratified by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7% vs 24.4%, P < .001), bleeding complications (77.1% vs 53.8%, P = .015), and worse survival independent of left ventricular dysfunction (39.6% vs 64.1%, P = .012). There was no significant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically significant differences in in-hospital outcomes. ConclusionsThe presence of right ventricular dysfunction in patients with COVID-19–related acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation was associated with increased in-hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality.

New insight: particle flow rate from the airways as an indicator of cardiac failure in the intensive care unit.

Exhaled breath particles have been explored for diagnosing different lung diseases. We recently showed in an experimental model that different cardiac output results in different particle flow rate (PFR) from the airways. Given the well-known close relationship between impaired cardiac function and respiratory failure, we hypothesized that PFR in exhaled air can be used to detect cardiac failure. PFR was analysed using a customized PExA device. Particles in the range of 0.41-4.55μm were measured. The included patients (n=20) underwent cardiac surgery and received mechanical ventilation as a part of routine post-operative care. Ten patients with clinical signs of pronounced post-operative haemodynamic instability and need for inotrope or mechanical support had been selected to the cardiac failure group. The control group consisted of 10 patients without signs of cardiac failure. The patients in cardiac failure group required inotropic support in the form of dobutamine (9/10), epinephrine (2/10), or levosimendan (4/10) or use of an intra-aortic balloon pump (4/10). There was no use of inotropes or mechanical support devices among the controls. All patients in the cardiac failure group had pre-operative left ventricular ejection fraction ≤40% compared with the control group, whose pre-operative ejection fraction was ≥50%, P<0.001. Patients with cardiac failure had significantly longer median total time in mechanical ventilation compared with the patients in the control group: 53.5h (IQR 6.8-116101.0h) and 4.5h (IQR 4.0-5.5h), respectively, P<0.001, and the median length of stay in the ICU, 165h (IQR 28-192h) and 22h (IQR 20-23.5h), respectively, P=0.007. Median PFR in patients with cardiac failure was higher than PFR in those with normal cardiac function: 80.9 particles/min (interquartile range (IQR) 25.8-336.6 particles/min), vs. 15.3 particles/min (IQR 8.1-17.7 particles/min), respectively, P<0.001. Median particle mass was 8.95ng (IQR 1.68-41.73ng) in the cardiac failure group and 0.75ng (IQR 0.18-1.45ng) in the control group, P=0.002. Patients with post-operative cardiac failure following cardiac surgery exhibited an increase in exhaled particle mass and PFR compared with the control group, indicating a significant difference between those two groups. The increase in particle mass and PFR in the absence of respiratory pathologies may indicate cardiac failure. In comparison with controls, impaired cardiac function was also associated with different composition of the particles regarding their size distribution.

Invasive versus Conservative Treatment Approach among Older Adult Patients Admitted with Acute ST-Segment Elevation Myocardial Infarction.

Primary percutaneous coronary intervention (PCI) is the preferred treatment strategy for patients with ST-elevation myocardial infarction (STEMI); however, its efficacy remains unclear in very older adult patients with STEMI. This retrospective single-center observational study included 530 patients aged &gt;75 years admitted to Tel Aviv Sourasky Medical Center with a diagnosis of acute STEMI. Primary PCI was performed for patients with symptoms ≤12 hours in duration, while the other patients were conservatively treated. We evaluated 30-day mortality and complications occurring during hospitalization based on data from patient records. Among the study patients, only 28/530 (5%) were conservatively treated. In-hospital complications, including the use of inotropes or intra-aortic balloon counterpulsation and the need for mechanical ventilation, did not differ significantly between the groups. The only parameter that showed a trend toward significance was the incidence of heart failure during hospitalization (p=0.042). The risk for 30-day mortality was substantially higher in the conservative treatment group than in the invasive treatment group (27% vs. 10%; p = 0.02). Our data suggested that despite concerns regarding the safety of the primary PCI strategy in the older adult STEMI population, this treatment strategy was associated with a survival benefit.

Retinopathy of Prematurity: Incidence, Risk Factors &amp; Outcome in North Indian Rural and Semi-urban population

Introduction: ROP is a challenge due to better premature survival. It has an increasing trend and is a preventable cause of vision loss. Its occurrence, severity and outcome in rural population is poorly studied. Methods: Ahospital based prospective observational longitudinal study was conducted on babies born at a tertiary care centre. Babies with gestation &lt;32 weeks or birth weight &lt; 1500 g were screened for ROP. Preterm babies of &gt;32 weeks gestation with oxygen requirement, RDS, surfactant use, PDA, neonatal hyperbilirubinemia requiring phototherapy, septicemia, red cell transfusion due to anemia, need for inotropes were also included. Babies with ROP were assessed for severity as also need for intervention and were followed for12 months. Results: Of the 211 neonates screened, 51 had ROP. Frequency was inversely related to both birth weight and gestational age with no gender difference. Oxygen therapy (p 0.001), RDS (p 0.005), mechanical ventilation (p0.003) and septicemia (p 0.005) were main risk factors. Neonatal hyperbilirubinemia requiring phototherapy was found to be protective (p 0.0005). 15.68% cases required laser photocoagulation. During follow up, ROP regressed in all patients. Conclusions: Risk factors for ROP included oxygen usage, RDS, mechanical ventilation and septicemia. Blood products or inotropes use was not an independent factor. Neonatal hyperbilirubinemia was protective. When diagnosed early, outcome is good in ROP.

In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study

Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation. EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing. Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms. Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required. None.

Clinical spectrum and short-term outcome of post-COVID multisystem inflammatory syndrome in children after the 2019 pandemic: a longitudinal cohort study

Background As a post-COVID complication in children, multisystem inflammatory syndrome in children (MIS-C) is important because of its varied and life-threatening manifestations. With this background, this study attempts to focus on MIS-C cases in an underprivileged rural setting in north-eastern India, with most patients being treated with methylprednisolone rather than intravenous immunoglobulin due to financial constraints. Methods In this prospective longitudinal cohort study at MGM Medical College, 27 MIS-C cases diagnosed following WHO criteria were included. Laboratory and radiological investigations, including echocardiography, were performed as required for diagnosis and to assess prognosis. Most patients were treated with methylprednisolone. A follow-up assessment was done six weeks after discharge for any residual impairment. Results The most frequently affected age group was 5–10 years (59.28%), while respiratory (48.14%) and cardiac (40.74%) were the most commonly involved systems. Logistic regression studies established a significant association between serum ferritin level and prolonged hospital stay (coefficient 0.0674, p=0.0041), possibly due to greater complications in cases with high ferritin levels. Organ impairment was found to increase the need for inotrope use (coefficient 3.8797, p=0.00584). Most cases were treated with methylprednisolone alone (85.18%) with a favourable response and no death occurred. Conclusion The favourable response in cases treated with methylprednisolone only affirms the effectiveness of the drug as a cheaper alternative in a resource-poor setting. The study highlights that higher ferritin levels in complicated cases leads to prolonged hospitalisation and the increased need for inotropes in cases with organ impairment.

Abstract 13525: The Mitraclip System Improves Cardiovascular Outcomes Compared to Medical Management in the Setting of Cardiogenic Shock

Introduction: Cardiogenic shock (CS) is associated with high mortality and morbidity. Severe mitral regurgitation (MR) in the setting of CS is associated with poor outcomes. Transcatheter Edge-to-Edge Repair (TEER) with the Mitraclip system is commonly used to treat MR, though its use in CS is less defined. Hypothesis: TEER with Mitraclip in patients with moderate to severe MR and CS improves cardiovascular outcomes compared to medical management alone. Methods: A single-center, retrospective study included adult patients with moderate to severe MR and CS between 2012 and 2021. Moderate to severe MR was defined by grades 3+ and 4+ MR. CS was defined as a sustained systolic blood pressure &lt;90mmHg for at least 1 hour, use of inotropes, vasopressors, or mechanical circulatory support, and clinical and laboratory findings of end-organ damage. The primary outcome was major adverse cardiovascular events (MACE) defined as cardiovascular death, heart failure admission, stroke, and myocardial infarction at 30 days and 6 months. The secondary outcome was change in New York Heart Association (NYHA) classification. Results: There were 28 patients included in the medical management and 33 in the Mitraclip groups. Table 1 includes this study’s outcomes. There were no significant differences in patients with a MACE at 30 days (13 vs. 8, p=0.069), though there were significant differences at 6 months (12 vs. 7, p=0.002). There were no differences in cardiovascular death. Patients in the Mitraclip group had fewer heart failure admissions at 6 months (p=&lt;0.001), though not at 30 days. At 30 days, more patients in the Mitraclip group improved to NYHA classes I/II compared to medical management alone (10 [35.7%] vs. 16 [50%], p=0.043). There were no differences in NYHA classes I/II at 6 months (7 [43.7%] vs. 13 [54.2%], p=0.63). Conclusions: TEER using the Mitraclip system improves mid-term cardiovascular outcomes in patients with CS compared to medical management alone.

Abstract 13672: Quality of Life Impact of Transcatheter Edge to Edge Repair of Mitral Valve With the Mitraclip System in Patients With Mitral Regurgitation and Cardiogenic Shock

Introduction: Transcatheter Edge to Edge Repair (TEER) of the mitral valve is a viable option for patients with moderate to severe mitral regurgitation (MR) who are at high surgical risk. TEER has been shown to improve quality of life (QOL) in patients with MR. Data is limited regarding QOL in patients with MR and cardiogenic shock (CS) who undergo TEER. Methods: A single-center, retrospective cohort study including adult patients with moderate to severe MR and CS who underwent TEER between January 2012 and December 2021. CS was defined as a sustained systolic blood pressure &lt;90mmHg for at least 1 hour, use of inotropes, vasopressors, or mechanical circulatory support, and clinical and lab findings of end-organ damage. The primary outcome was change in disease-specific health status (Kansas City Cardiomyopathy Questionnaire-Overall Summary score [KCCQ-OS] at 30 days. Statistical analysis was done using Wilcoxon signed-rank test and t-test. Results: Thirty-three patients with mod-severe MR and CS had undergone TEER (See table 1 for baseline characteristics) . KCCQ data were available on 30% survivors at 30 days. KCCQ increased from 17.19 (11.88) before TEER to 53.85 (30.89) in 30 days (mean change 36.67; 95% CI 14.24-59.09; P&lt;0.05, see table2). There was an improvement in 2 out of 4 KCCQ domains; symptoms frequency (mean change 49.17; 95% CI 18.17-80.16; P&lt;0.05) and social limitation (mean change 49.54; 95% CI 22.25-76.83); P&lt;0.05). Conclusion: TEER of the mitral valve improves QOL at 30 days in patients with moderate to severe MR and CS.

Anaesthesia for non-cardiac surgery in children and young adults with Fontan physiology.

Patients with Fontan physiology require non-cardiac surgery. Our objectives were to characterise perioperative outcomes of patients with Fontan physiology undergoing non-cardiac surgery and to identify characteristics which predict discharge on the same day. Children and young adults with Fontan physiology who underwent a non-cardiac surgery or an imaging study under anaesthesia between 2013 and 2019 at a single-centre academic children's hospital were reviewed in a retrospective observational study. Continuous variables were compared using the Wilcoxon rank sum test, and categorical variables were analysed using the Chi-square test or Fisher's exact test. Multivariable logistic regression analysis results are presented by adjusted odds ratios with 95% confidence intervals and p values. 182 patients underwent 344 non-cardiac procedures with anaesthesia. The median age was 11 years (IQR 5.2-18), 56.4% were male. General anaesthesia was administered in 289 (84%). 125 patients (36.3%) were discharged on the same day. On multivariable analysis, independent predictors that reduced the odds of same-day discharge included the chronic condition index (OR 0.91 per additional chronic condition, 95% CI 0.76-0.98, p = 0.022), undergoing a major surgical procedure (OR 0.17, 95% CI 0.05-0.64, p = 0.009), the use of intraoperative inotropes (OR 0.48, 95% CI 0.25-0.94, p = 0.031), and preoperative admission (OR = 0.24, 95% CI: 0.1-0.57, p = 0.001). In a contemporary cohort of paediatric and young adults with Fontan physiology, 36.3% were able to be discharged on the same day of their non-cardiac procedure. Well selected patients with Fontan physiology can undergo anaesthesia without complications and be discharged same day.