Vasopressor Use Research Articles

Abstract 4135252: Associations between Group 2 Pulmonary Hypertension and 30-Day Readmissions Following Acute Myocardial Infarction Hospitalizations.

Background: Pulmonary hypertension (PH) is a major contributor to cardiovascular disease-related morbidity and mortality. Despite this, little is known regarding the outcomes of 30-day re-admissions following Acute Myocardial Infarction (AMI) in the context of group 2 PH. Hypothesis: Group 2 PH is associated with a higher likelihood of 30-day readmissions in patients presenting with AMI. Goal: To assess the relationship between group 2 PH and adverse hospitalization outcomes in cases of AMI. Methods: We queried the 2016-2020 Nationwide Readmission Database (NRD) and identified AMI as the primary diagnosis. We compared in-hospital outcomes based on the presence versus absence of Group 2 PH. The primary outcome was 30-day readmissions. Secondary outcomes included the odds of in-patient mortality, mechanical ventilation use, vasopressor use, and mechanical circulatory support (MCS) use. Multivariable regression models were used to adjust for confounders. Results: Among 182,308 AMI hospitalizations, 364 (0.2%) had a secondary diagnosis of Group 2 PH. Group 2 PH was associated with a higher likelihood of re-admission within 30 days (adjusted OR [aOR] 1.21, 95% CI 1.07–1.36, p=0.002). Additionally among patients presenting with AMI, group 2 PH was associated with higher odds of in-patient mortality (aOR 2.64, 95% CI 1.52–4.58, p=0.001), mechanical ventilation use (aOR 2.07, 95% CI 1.19–3.6, p=0.010), vasopressor use (aOR 5.4, 95% CI 2.7-10.9, p<0.001) and MCS use (aOR 2.39, 95% CI 1.46-3.91, p<0.001) during index hospitalization compared to the patients without group 2 PH. Conclusion: Patients with Group 2 PH admitted for AMI had higher odds of 30-day readmissions and both fatal and non-fatal adverse outcomes compared to patients without PH. Further studies are needed to confirm these findings and develop strategies to improve outcomes for this high-risk population.

Abstract 4135318: Comparison of Right Ventricular Function Changes Between Volume Control and Pressure Support Ventilation Modes: A Prospective Study Using S' Prime Values

Background: This study assesses changes in right ventricular function by measuring S' values during the transition from volume control-assist control (VC-AC) to pressure support ventilation (PSV). Transitioning from VC-AC to PSV reduces the mean airway pressure (P mean) which causes a decrease in right ventricular afterload and also potentially improves venous return and right ventricular preload. PSV allows spontaneous breathing efforts, possibly increasing cardiac output. Thus, we expect a consistent increase in S' value when changing ventilator modes. Methods: This prospective observational study included ICU patients on invasive mechanical ventilation for over 24 hours. The clinical team decided when to switch from VC-AC to PSV. An average of three S' measurements was taken during VC-AC and within 10 minutes of transitioning to PSV. Sedation, vasopressor use, and Richmond Agitation-Sedation Scale scores were consistent throughout the measurements. The study was approved by the Albert Einstein College of Medicine IRB (#2023-15068) Results: Seventeen patients were included in the study, with an average age of 61.29 years (SD 11.39). Of these, 6 (35.3%) were female. The mean S' during VC-AC was 12.79 ± 4.52, and upon transitioning to PSV, it was 14.56 ± 3.89 (p-value 0.47). The intra-observer variability for S' was 5.3%. Of the seventeen patients, 5/17 (29%) showed an S' change of less than 5.3% and were deemed to have no significant variation; 7/17 (41%) experienced a significant decrease in S' (15.41% ± 7.29% SD), while the remaining 5/17 (29%) showed a significant increase (19.31 ± 13.23%). Conclusion: Our study demonstrates that transitioning from VC-AC to PSV results in variable changes in right ventricular systolic function, as indicated by S' values. Contrary to our expectations of a consistent increase, the interplay between S' values and ventilator mode changes appears to be non-linear, suggesting other factors may influence cardiopulmonary interactions in spontaneously breathing ventilated patients. These findings highlight the complexity of these interactions, underscoring the need for individualized patient management and paving the way for further research with a larger cohort.

Sex disparities in outcomes among hospitalizations for heart failure

This study investigated sex differences in clinical characteristics and in-hospital outcomes of heart failure (HF) hospitalizations using the National Inpatient Sample data, 2016–2019. HF hospitalizations ≥ 41 years of age were included and stratified by sex. Study outcomes were in-hospital mortality, prolonged length of stay, mechanical ventilation, mechanical circulatory support, vasopressor use, and disposition other than home. Propensity score matched regression analysis was done to compare outcomes between sex. A total of 4,704,684 primary HF hospitalizations were included in the analysis. Of these, 2,447,784 (52.0%) were males and 2,256,899 (48.0%) were females. Regression analysis showed that females had significantly lower odds for mortality (aOR, 0.92, 95% CI: 0.89–0.94), mechanical ventilation (aOR, 0.89, 95% CI: 0.86–0.92), mechanical circulatory support (aOR, 0.54, 95% CI: 0.51–0.58), and vasopressor use (aOR, 0.71, 95% CI: 0.66–0.74), compared to males. However, the odds for prolonged length of stay (aOR, 1.05, 95% CI: 1.04–1.06) and disposition other than home (aOR, 1.32, 95% CI: 1.31–1.34) were significantly higher among females, compared to males. There were significant differences in outcomes between males and females hospitalized for HF. Further research is required to delineate how sex affects several aspects of HF, including epidemiology, risk factors, pathogenesis, and response to medications.

Performance of Risk Models for Antimicrobial Resistance in Adult Patients With Sepsis

The results of prediction models that stratify patients with sepsis and risk of resistant gram-negative bacilli (GNB) infections inform treatment guidelines. However, these models do not extrapolate well across hospitals. To assess whether patient case mix and local prevalence rates of resistance contributed to the variable performance of a general risk stratification GNB sepsis model for community-onset and hospital-onset sepsis across hospitals. This was a retrospective cohort study conducted from January 2016 and October 2021. Adult patients with sepsis at 10 acute-care hospitals in rural and urban areas across Missouri and Illinois were included. Inclusion criteria were blood cultures indicating sepsis, having received 4 days of antibiotic treatment, and having organ dysfunction (vasopressor use, mechanical ventilation, increased creatinine or bilirubin levels, and thrombocytopenia). Analyses were completed in April 2024. The model included demographic characteristics, comorbidities, vital signs, laboratory values, procedures, and medications administered. Culture results were stratified for ceftriaxone-susceptible GNB (SS), ceftriaxone-resistant but cefepime-susceptible GNB (RS), and ceftriaxone- and cefepime-resistant GNB (RR). Negative cultures and other pathogens were labeled SS. Deep learning models were developed separately for community-onset (patient presented with sepsis) and hospital-onset (sepsis developed ≥48 hours after admission) sepsis. The models were tested across hospitals and patient subgroups. Models were assessed using area under the receiver operating characteristic curve (AUROC) and area under precision recall curve (AUPRC). A total of 39 893 patients with 85 238 sepsis episodes (43 207 [50.7%] community onset; 42 031 [48.3%] hospital onset) were included. Median (IQR) age was 65 (54-74) years, 21 241 patients (53.2%) were male, and 18 830 (47.2%) had a previous episode of sepsis. RS contributed to 3.9% (1667 episodes) and 5.7% (2389 episodes) of community-onset and hospital-onset sepsis episodes, respectively, and RR contributed to 1.8% (796 episodes) and 3.9% (1626 episodes), respectively. Previous infections and exposure to antibiotics were associated with the risk of resistant GNB. For example, in community-onset sepsis, 375 RR episodes (47.1%), 420 RS episodes (25.2%) and 3483 of 40 744 (8.5%) SS episodes were among patients with resistance to antimicrobial drugs (P < .001). The AUROC and AUPRC results varied across hospitals and patient subgroups for both community-onset and hospital-onset sepsis. AUPRC values correlated with the prevalence rates of resistant GNB (R = 0.79; P = .001). In this cohort study of 39 893 patients with sepsis, variable model performance was associated with prevalence rates of antimicrobial resistance rather than patient case mix. This variability suggests caution is needed when using generalized models for predicting resistant GNB etiologies in sepsis.

Association between delayed invasive blood pressure monitoring and all-cause mortality in intensive care unit patients with sepsis: a retrospective cohort study

PurposeHaemodynamic management is essential in sepsis management. Invasive blood pressure (IBP) monitoring is the gold standard for blood pressure (BP) assessment. Here, we identified the most advantageous time frame for IBP monitoring to mitigate adverse outcomes in patients with sepsis.MethodsWe included data on patients with sepsis from the Medical Information Mart for Intensive Care IV database. The primary endpoints comprised 28-and 90-day mortality rates, whereas secondary endpoints were acute kidney injury (AKI) rates and continuous renal replacement therapy (CRRT) requirement. To confirm our findings’ robustness, we performed multivariable Cox regression and logistic regression models, augmented by propensity score matching (PSM).ResultsOf 18,326 patients hospitalised for sepsis, 9,056 (49.42%) and 9,270 (50.58%) were included in the early and delayed IBP-monitoring groups, respectively. Our multivariable Cox regression models revealed 20 and 21% significant increases in 28-and 90-day mortality in the delayed IBP monitoring group, respectively [hazard ratios (95% confidence intervals) = 1.20 (1.11–1.31) and 1.21 (1.12–1.31), respectively; both p &amp;lt; 0.001]. Moreover, significant increases were noted in AKI, CRRT and mechanical ventilation requirement risks in the delayed IBP monitoring group [odds ratios (95% confidence intervals) = 1.44 (1.34–1.56), 1.50 (1.26–1.78) and 1.79 (1.67–1.92), respectively; both p &amp;lt; 0.001]. PSM further confirmed the validity of our findings. Delayed IBP monitoring prolonged intensive care unit (ICU) stay without extending vasopressor use duration.ConclusionProlonged delay in IBP monitoring (≥3 h) may increase mortality risks in ICU patients with sepsis. Nevertheless, early IBP monitoring may reduce AKI, CRRT and mechanical ventilation requirement risks and shorten ICU stay. However, these results warrant further validation through randomised controlled trials.

Epidemiology and outcomes of critically ill patients in the emergency department of a tertiary teaching hospital in Rwanda.

The introduction of Emergency Medicine in Rwanda in 2015 has been associated with a mortality reduction in patients presenting to Kigali University Teaching Hospital (KUTH). In the context of increasing numbers of critically ill patients presenting to Emergency Departments (ED) globally, the aim of this study was to describe the characteristics of critically ill patients, the critical care interventions performed, and the outcomes of critically ill patients presenting to the KUTH ED with the goal of informing future research into the root causes of mortality of critically ill ED patients and of identifying high yield topics for didactic and procedural training. A descriptive observational prospective cohort pilot study analyzed all patients ≥15 years who presented to KUTH between April and June 2022 with modified South African Triage Scores of Red with alarm, Red without alarm, and Orange. Of 320 patients, 66.9% were male and median age was 40 years. Patients were triaged as Orange (65.3%), Red without alarm (22.8%), and Red with alarm (11.9%). Presentations were categorized as: medical emergencies (48.0%), traumatic injury (44.5%), and surgical emergencies (7.6%). Median length of stay was 31h (IQR 28, 56) and boarding was 23h (IQR 8, 48). Overall mortality was 12.2% and highest among medical emergencies (16.5%, p = 0.048) and increased significantly with triage color: Red with alarm (47.4%), Red without alarm (16.4%), and Orange (4.3%, p < 0.0001). Cardiopulmonary resuscitation (CPR) (10.3%), endotracheal intubation (8.8%), and vasopressor administration (3.1%) were the most frequent critical interventions performed. Survival after cardiac arrest was 9.1% and 32.1% after intubation. Mortality was associated with the following interventions: CPR, intubation, and use of vasopressors (p < 0.05). This pilot study identified the most common critical care interventions performed and a high mortality among patients who required these interventions in the ED of a tertiary teaching hospital in Rwanda. These findings will inform didactics and procedural training for emergency care providers. Future research should focus on the root causes of mortality in these specific patient populations and identify areas of system strengthening to reduce mortality.

Interpretable prediction of 30-day mortality in patients with acute pancreatitis based on machine learning and SHAP.

Severe acute pancreatitis (SAP) can be fatal if left unrecognized and untreated. The purpose was to develop a machine learning (ML) model for predicting the 30-day all-cause mortality risk in SAP patients and to explain the most important predictors. This research utilized six ML methods, including logistic regression (LR), k-nearest neighbors(KNN), support vector machines (SVM), naive Bayes (NB), random forests(RF), and extreme gradient boosting(XGBoost), to construct six predictive models for SAP. An extensive evaluation was conducted to determine the most effective model and then the Shapley Additive exPlanations (SHAP) method was applied to visualize key variables. Utilizing the optimized model, stratified predictions were made for patients with SAP. Further, the study employed multivariable Cox regression analysis and Kaplan-Meier survival curves, along with subgroup analysis, to explore the relationship between the machine learning-based score and 30-day mortality. Through LASSO regression and recursive feature elimination (RFE), 25 optimal feature variables are selected. The XGBoost model performed best, with an area under the curve (AUC) of 0.881, a sensitivity of 0.5714, a specificity of 0.9651 and an F1 score of 0.64. The first six most important feature variables were the use of vasopressor, high Charlson comorbidity index, low blood oxygen saturation, history of malignant tumor, hyperglycemia and high APSIII score. Based on the optimal threshold of 0.62, patients were divided into high and low-risk groups, and the 30-day survival rate in the high-risk group decreased significantly. COX regression analysis further confirmed the positive correlation between high-risk scores and 30-day mortality. In the subgroup analysis, the model showed good risk stratification ability in patients with different gender, renal replacement therapy and with or without a history of malignant tumor, but it was not effective in predicting peripheral vascular disease. the XGBoost model effectively predicts the severity of SAP, serving as a valuable tool for clinicians to identify SAP early.

The application of interventional methods in control of blood loss during giant upper extremity tumor resection

BackgroundThe purposes of this retrospective study were to determine the efficacy of interventional methods in control of intraoperative blood losses and investigate the perioperative complications.MethodsThe cases of 44 patients in whom a giant upper extremity tumor had been operated between 2008 and 2022 were analyzed retrospectively. Of these, 29 patients were treated with interventional methods (Group A) and 15 were treated without (Group B). Group A was further divided based on the intervention methodss: Group C (combination of balloon occlusion and transarterial embolization [TAE], n = 11) and Group D (single TAE, n = 18). Within Group D, patients were categorized based on the timing of TAE relative to surgery into Group E (TAE on the same day as surgery) and Group F (TAE performed days before surgery). We compared demographic features, blood loss, ICU admission rates, and use of vasopressors during surgery.ResultsWe collected clinical records from 44 patients diagnosed with a giant upper extremity tumor who underwent surgery. Group sizes were as follows: A (29), B (15), C (11), D (18), E (7), and F (11). Tumor volumes in the interventional and non-interventional groups were similar (704.19 ± 812.77 cm³ vs. 1224.53 ± 1414.01 cm³, P = 0.127). Blood plasma transfusion was significantly higher in Group B compared to Group A (425.33 ± 476.20 ml vs. 155.90 ± 269.67 ml, P = 0.021). Although overall blood loss did not significantly differ between Group A and Group B (467.93 ± 302.08 ml vs. 1150 ± 1424.15 ml, P = 0.087), the rate of massive bleeding (defined as blood loss over 1000 ml) was lower in Group A (6.9% vs. 46.47%, P = 0.004). The proportion of minors (patients aged less than 18) in Group C was significantly higher than in Group D (27.7% vs. 0.00%, P = 0.045). The amount of RBC transfusion was also significantly higher in Group C compared to Group D (458.18 ± 292.22 ml vs. 164.44 ± 224.03 ml, P = 0.021). No significant perioperative complications were observed.ConclusionsInterventional techniques have been shown to reduce both blood loss and the necessity for blood transfusions in patients with large upper extremity tumors. Furthermore, no significant perioperative complications have been observed.

Impact of Frailty on COVID-19 Hospitalizations: Results from the California State Inpatient Database.

Frail patients are at greater risk of experiencing adverse clinical outcomes in any critical illness due to decreased physiologic reserves, greater susceptibility to the adverse effects of treatment, and greater needs for intensive care. In this study, we sought to assess the prevalence of frailty and associated adverse in-hospital outcomes among coronavirus disease 2019 (COVID-19) hospitalizations using the 2020 California State Inpatient Database (SID). For this study, we conducted a retrospective analysis of data from all COVID-19 hospital patients aged 18 years and older. We identified hospitalizations that were at high risk of frailty using the Hospital Frailty Risk Score. The primary outcome of our study was in-hospital mortality, and the secondary outcomes were prolonged length of stay, vasopressor use, mechanical ventilation, and intensive care unit admission. The prevalence of frailty was 44.3% among COVID-19 hospitalizations. Using propensity score matching analysis, we found that the odds of mortality (odds ratio [OR] 4.54, 95% confidence interval [CI] 4.28-4.82), prolonged length of stay (OR 2.81, 95% CI 2.70-2.90), vasopressor use (OR 8.65, 95% CI 7.45-10.03), mechanical ventilation (OR 6.90, 95% CI 6.47-7.35), and intensive care unit admission (OR 7.17, 95% CI 6.71-7.66) were significantly higher among the group of frail patients. Our findings show that frailty could be used for assessing and risk stratifying patients for improved hospital outcomes.

Peripheral Use of Vasopressors in Shock: Clinical Considerations and Recommendations for Use in Obstetrics.

This study aimed to evaluate the safety of peripheral administration of vasopressor agents among patients with circulatory shock. We reviewed the published literature evaluating the use of peripheral norepinephrine in patients with shock and proposed a protocol for use in labor and delivery units. Peripheral administration of norepinephrine is a safe and potentially lifesaving intervention for patients in labor and delivery with extremely low complication rates. Adoption of a protocol for peripheral administration of vasopressors in labor and delivery is safe and may prevent life threatening delays in hemodynamic resuscitation. · Administering vasopressors through a peripheral line is safe and helps avoid delays in care.. · An established protocol is essential for the safe peripheral administration of vasopressors.. · Understanding continuous blood pressure monitoring is crucial for managing critically ill patients..

Association between cardiogenic shock phenotype, vasopressor requirements and mortality

Abstract Background Greater vasopressor requirements predict higher mortality in patients with cardiogenic shock (CS).(1) The extent to which CS phenotype modifies the relationship between vasopressor dose and mortality risk is unknown. Purpose We investigated the association between in-hospital mortality and vasopressor dosing (expressed as norepinephrine equivalents [NEE]) during the first 24 hours of hospitalization across distinct CS phenotypes. Methods We included patients with CS admitted to our cardiac intensive care unit (CICU) between 2007 and 2015. Peak combined vasopressor doses during the first 24 hours of hospitalization were recorded as NEE. High dose vasopressor (HDV) use was defined as peak 24 hour NEE &amp;gt;0.3 mcg/kg/min. Unsupervised machine learning was used to assign patients to one of three phenotypes (non-congested, cardiorenal, and haemometabolic), as reported previously by our group and others.(2,3) The primary outcome was in-hospital mortality. Multivariable logistic regression was used to adjust for relevant covariates. Results A total of 1078 patients with CS (median age 69 years, 37% female, 59% with acute myocardial infarction) were admitted to our cardiac intensive care unit (CICU) between 2017 and 2015. The number of patients assigned to each CS phenotype were: haemometabolic (n=325, 30%), cardiorenal (n=314, 29%), non-congested (439, 41%). There was a strong incremental association between in-hospital mortality and NEE (Fig. 1, adjusted OR 1.104 per 0.1 mcg/kg/min, 95% CI 1.134–1.231, P&amp;lt;0.001), and patients receiving HDV (n=234, 22%) had significantly higher in-hospital mortality (57% vs 28%, p&amp;lt;0.001). Among patients who did not receive HDV, mortality was higher in haemometabolic CS (49%) compared to 24% in cardiorenal CS and 21% in non-congested CS (adjusted OR 3.58 relative to non-congested CS, 95% CI 2.46-5.23, p&amp;lt;0.001, Fig. 1). Among patients receiving HDV, hemometabolic CS was also associated with higher mortality (68%) than those with cardiorenal (46.2%) or non-congested CS (39.3%), (adjusted OR 3.26 relative to non-congested CS, 95% CI 1.75-6.18, P&amp;lt;0.001, Fig. 1). Conclusion Integration of CS phenotype with vasopressor requirements may provide incremental prognostic information in CS during the first 24 hours of admission, with haemometabolic CS portending a greater mortality risk even at lower NEE. Patients with HDV (particularly those requiring &amp;gt;=1 mcg/kg/min NEE) had high mortality irrespective of CS phenotype.Figure 1

Microaxial Flow Pump Hemodynamic and Metabolic Effects in Infarct-Related Cardiogenic Shock

Mechanical circulatory support with a microaxial flow pump (MAFP) has been shown to improve survival in ST-elevation myocardial infarction-induced cardiogenic shock (STEMI-CS). Understanding the impact on hemodynamic stability over time is crucial for optimizing patient treatment. To determine if an MAFP reduces the need for pharmacological circulatory support without compromising hemodynamics compared with standard care in STEMI-CS. This was a substudy of the Danish-German (DanGer) Shock trial, an international, multicenter, open-label randomized clinical trial. Patients from 14 heart centers across Denmark, Germany, and the UK were enrolled. Inclusion criteria for the trial were STEMI and systolic blood pressure less than 100 mm Hg or ongoing vasopressor treatment, left ventricular ejection fraction less than 45%, and arterial lactate level greater than 2.5 mmol/L. Of the enrolled patients, after exclusions from death in the catheterization laboratory or immediately on intensive care unit (ICU) admission, the remaining patients had serial recordings of hemodynamics, arterial lactate, and use of vasoactive drugs. Patients who were in comas after cardiac arrest and patients with mechanical complications or right ventricular failure were excluded. Data were analyzed from May to September 2024. MAFP and standard of care or standard of care alone. Hemodynamic status in terms of heart rate and blood pressure, metabolic status in terms of arterial lactate concentration, and vasoactive-inotropic score (VIS). The clinical events during the first 72 hours were as follows: death from all causes, escalation of mechanical circulatory support, and discharge alive from the ICU. From 355 enrolled patients, 324 (mean [IQR] age, 68 [58-75] years; 259 male [80%]) underwent ICU treatment (169 [52%] in the MAFP group, 155 [48%] in the standard-care group). Baseline characteristics were balanced. There was no difference in heart rate between groups, and mean arterial pressure was above the treatment target of 65 mm Hg in both groups but was achieved with a lower VIS in the MAFP group. No difference in arterial lactate level was found between groups at randomization, but on arrival to the ICU, the MAFP group had significantly lower arterial lactate levels compared with the standard-care group (mean difference, 1.3 mmol/L; 95% CI, 0.7-1.9 mmol/L), a difference that persisted throughout the first 24 hours of observation. The MAFP group achieved lactate normalization (<2 mmol/L) 12 hours (95% CI, 5-18 hours) before the standard-care group. Use of a MAFP reduces the use of vasopressors and inotropic medication while maintaining hemodynamic stability and achieving faster normalization of lactate level in patients with STEMI-CS. ClinicalTrials.gov Identifier: NCT01633502.

Remimazolam Reduces Vasopressor Use Post-Induction and During Maintenance of General Anesthesia in Patients Undergoing Laparoscopic Gynecology: A Propensity Score-Matched Analysis

Objectives: Laparoscopic gynecological surgeries are commonly performed under general anesthesia and can induce cardiovascular depression and hypotension, requiring vasopressor support. Remimazolam, a novel ultra-short-acting benzodiazepine, is used to treat minimal cardiovascular depression. This study compared the hemodynamic effects of remimazolam and sevoflurane anesthesia in patients undergoing laparoscopic gynecological surgery. Methods: A retrospective analysis was conducted on 474 patients who underwent laparoscopic gynecological surgery at Korea University Anam Hospital between September 2021 and December 2022. The patients were categorized into two groups based on the anesthetic agent used: remimazolam or sevoflurane. Hemodynamic parameters, vasopressor use, and intraoperative variables were compared between anesthetic agents. Propensity score matching was applied to account for potential confounders, and logistic regression was utilized to assess the relationship between anesthesia type and outcomes. Results: Remimazolam anesthesia was linked to a significantly lower incidence of vasopressor use compared to sevoflurane-based anesthesia (3.7% vs. 19.5%, p &lt; 0.0001). The odds of requiring vasopressor support were significantly lower during the post-induction and maintenance phases in the remimazolam group. Furthermore, hemodynamic stability, particularly systolic and mean arterial pressures, was better maintained with remimazolam than sevoflurane. Conclusions: Remimazolam provides superior hemodynamic stability and reduces the need for vasopressor support during laparoscopic gynecological surgery compared with sevoflurane.

Outcomes of ST-Elevation Myocardial Infarction in Patients with Adrenal Insufficiency

Abstract Background Patients with adrenal insufficiency (AI) have both increased risk of cardiovascular disease and adverse outcomes with many medical emergencies. However, limited data exist specifically regarding ST elevation myocardial infarction (STEMI) in the context of AI. Methods Admissions for STEMI were identified in the 2016-2019 National Inpatient Sample. In-hospital outcomes were compared between patients with and without AI. The primary outcome was in-hospital mortality. Secondary outcomes included percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) intervention, acute kidney injury (AKI), vasopressor use, mechanical circulatory support (MCS), mechanical ventilation, ventricular tachycardia (VT), hospital length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders. Results Among 690,430 STEMI hospitalizations, 1,382 (0.2%) had a diagnosis of AI. AI was associated with higher odds of in-hospital mortality (adjusted OR [aOR] 1.51, 95% CI 1.03-2.2), lower odds of PCI (aOR 0.73, 95% CI 0.55-0.98), higher odds of CABG (aOR 2.8, 95% CI 1.89-4.2) and, AKI (aOR 2.38, 95% CI 1.72–3.3), VT (aOR 1.55, 95% CI 1.1-2.2), need for vasopressors (aOR 2.34, 95% CI 1.33-4.1), mechanical ventilation (aOR 2.11, 95% CI 1.54-2.89) and MCS (aOR 2.18, 95% CI 1.57–3.03). Patients with AI also had a longer LOS (10 days vs. 4.2 days, p&amp;lt;0.001) and higher charges ($258,475 vs. $115,505, p&amp;lt;0.001). Conclusion Patients with AI admitted for STEMI had higher in-hospital mortality, non-fatal adverse outcomes, and resource utilization compared to patients without AI.

Association between plain ropivacaine dose and spinal hypotension for cesarean delivery: a retrospective study.

Data on the association between the plain ropivacaine dose and maternal hypotension during cesarean delivery are limited. Thus, this study aimed to explore this association. This retrospective study included patients undergoing cesarean sections under spinal or combined spinal-epidural anesthesia with plain ropivacaine at The First Hospital of Fuyang, Hangzhou, China, between 2018 and 2022. Data were obtained from the anesthesia information management system. Liner trend tests were used to distinguish the linear relationship between spinal hypotension and the plain ropivacaine dose, and receiver operating characteristic curves were used to calculate the dose threshold. Logistic regression was used to adjust for confounders. Sensitivity analyses were performed to evaluate the stability of the results. The secondary outcome was vasopressor use (metaraminol and ephedrine). In total, 1,219 women were included. The incidence of hypotension linearly correlated with the plain ropivacaine dose (adjusted P-value for trend, P<0.001). Thus, we used a dose threshold of 17.5 mg to compare the dose as a binary variable (≥17.5 mg vs. <17.5 mg). Plain ropivacaine doses of ≥17.5 mg were associated with a higher incidence of spinal hypotension (adjusted odds ratio: 2.71; 95% confidence interval [1.85-3.95]; P<0.001). The sensitivity analyses yielded similar results. The plain ropivacaine dose also correlated with metaraminol use but not ephedrine use. The incidence of spinal-induced hypotension in women undergoing cesarean section linearly correlated with the plain ropivacaine dose. The dose threshold for hypotension risk was 17.5 mg.

Practice of Fluid and Vasopressor Therapy in Critically Ill Invasively Ventilated Patients (PRoFLUID)-study protocol for an international multicenter observational cohort study.

The practice of intravenous fluid and vasopressor therapy in intensive care unit (ICU) patients, particularly in those who receive invasive ventilation, has been subject to change. Traditional approaches of 'early and liberal fluid administration' and 'late and restrictive vasopressor use' have been challenged, leading to recommendations for giving less fluids and earlier administration of vasopressors. Recommendations for fluid deresuscitation-active fluid removal-are absent. The global approach to fluid and vasopressor therapy in invasively ventilated patients is currently unclear. Our aim is to explore the practice of intravenous fluid and vasopressor therapy in invasively ventilated ICU patients in a study named 'Practice of Fluid and Vasopressor Therapy in Critically Ill Invasively Ventilated Patients' (PRoFLUID). PRoFLUID is an international, multicenter, observational cohort study in critically ill adult patients that are invasively ventilated for more than 24 hours. The outcomes include various aspects of fluid and vasopressor therapy, urine output and cumulative fluid balances. We will also collect duration of ventilation, lengths of stay and mortality in ICU and hospital. We expect to collect granular data on fluid and vasopressor therapy in a sample of at least 2,500 patients. PRoFLUID will provide useful insights into the practice of fluid and vasopressor therapy in invasively ventilated critically ill patients. PRoFLUID also allows us to determine whether geo-economic differences in management of intravenous fluid and vasopressor therapy exist, and allows for analyses of associations of aspects of fluid and vasopressor therapy with outcomes. Last but not least, its findings could feed sample size calculations of future randomized clinical trials of fluid and vasopressor therapy. In conclusion, PRoFLUID will collect data on fluid and vasopressor therapy in invasively ventilated ICU patients worldwide, providing insights that will guide future clinical decisions and randomized trial designs. ClinicalTrials.gov NCT05968066. Registered on August 1, 2023. Intensive care; invasive ventilation; fluid therapy; fluid management; vasopressor.

Perfusion index as an early predictor of hypotension during advanced oncothoracic operations (pilot study)

Introduction. Current standards of intraoperative monitoring significantly reduce the response time to a decrease in blood pressure, but do not include methods for predicting changes in hemodynamics to avoid the effects of systemic hypoperfusion.The objective was to evaluate the usefulness of determining the perfusion index for predicting the development of hypotension and its earlier correction during advanced oncothoracic operations.Materials and methods. A prospective open-label observational study was conducted, which included 100 patients who underwent elective oncothoracic surgery. Standard monitoring was established, as well as continuous monitoring of the perfusion index. The perfusion index value was recorded immediately before induction. The patients were divided into 2 groups: in the 1st group (n = 37), patients experienced a decrease in blood pressure, requiring vasopressor support; in the 2nd group (n = 63), no vasopressor support was required.Results. A moderate linear relationship was revealed with a correlation coefficient (r) equal to (–0.68), p &lt; 0.001, and a strong non-linear relationship with a coefficient (ρ) equal to (–0.95), p &lt; 0.001. To identify the relationship model, polynomial regression analysis was performed. A prognostic formula for the use of vasopressors was calculated depending on the preoperative level of perfusion index. At the next stage, a classification tree for analyzing the data array was used. The entire d data array (n = 100) is randomly divided into training (n = 70) and test samples (n = 30). It was revealed that hypotension requiring vasopressor support occurred in patients whose initial perfusion index was ≤ 2.85. ROC analysis determined an AUC of 0.952 (95% CI: 0.888–1.016).Conclusion. A low PI value before induction of anesthesia during advanced oncothoracic operations can be used to monitor the functional activity of the autonomic nervous system and predict intraoperative hypotension. Patients with a baseline PI ≤ 2.85 have a higher risk of developing hypotension during advanced oncothoracic surgery compared with those with a baseline PI ≥ 2.85. The effectiveness of the method in patients with concomitant pathologies has not been tested.

Prevalence and Association of Deep Vein Thrombosis on Clinical Outcomes Among COVID-19 Patients

Background Studies have shown that COVID-19 could lead coagulation defects, resulting in increased morbidity and mortality. In this study, we sought to estimate the prevalence of deep vein thrombosis (DVT) among COVID-19 hospitalizations and its effects on hospital outcomes using a large administrative database. Methods We conducted a retrospective analysis of the 2020 California State Inpatient Database. All hospitalizations ≥18 years and primary diagnosis of COVID-19 were included and were stratified into those with and without DVT. The main outcomes of the study were in-hospital mortality, prolonged length of stay, vasopressor use, mechanical ventilation, and intensive care unit admission. Results We included a total of 94,114 primary COVID-19 hospitalizations for the analysis. Among them, 1575 (1.7%) had DVT. After adjusting for covariates, regression analysis showed that those with DVT had significantly greater odds for mortality (adjusted odds ratio [aOR], 2.34; 95% confidence interval [CI], 2.07–2.65), prolonged length of stay (aOR, 3.51; 95% CI, 3.16–3.91), vasopressor use (aOR, 4.23; 95% CI, 3.78–4.74), mechanical ventilation (aOR, 2.90; 95% CI, 2.38–3.53), and intensive care unit admission (aOR, 4.32; 95% CI, 3.85–4.84). Conclusions In our cohort, though only a few COVID-19 hospitalizations had DVT, the risk for adverse outcome was significantly higher. Therefore, healthcare providers should promptly monitor for DVT among COVID-19 patients and manage it promptly.

Methylene blue therapy in addition to standard treatment for acute-phase septic shock: a pilot randomized controlled trial.

Methylene blue (MB) has been used to increase blood pressure in patients with septic shock by acting on guanylate cyclase and nitric oxide synthase. To determine whether the administration of MB to patients in the initial phase of septic shock leads to a reduction in the use of vasopressors compared to the Control group. This was a 1:1 randomized clinical trial of two groups (MB and Control). Forty-two patients were included in the present study; 23 patients were allocated to the Control group, and 19 were randomized to the MB group. Both groups had access to standard treatment, consisting of fluid replacement, vasopressors, and antibiotic therapy. Patients received a loading dose of MB (3 mg/kg) and maintenance (0.5 mg/kg/h) for 48 h. Vasopressor doses, laboratory test results, inflammatory and anti-inflammatory cytokine levels, and hemodynamic monitoring were recorded before the infusion of MB (T1) and after 20 min (T2), 2 h (T3), 24 h (T4), 48 h after the infusion started (T5) and 24 h after weaning (T6). MB therapy was started together with the indication of vasopressin (VAS) as a second vasopressor. The MB group showed an immediate reduction in NOR dosage, an earlier reduction in VAS dosage, and higher IL-10 levels compared to the Control group. Early administration of MB in combination with standard treatment for septic shock might be reduce vasopressors dose. Continuous infusion of MB for 48 h was considered safe and there was no adverse events. These results highlight the potential of MB as a safe adjuvant therapeutic option in the treatment of septic shock. https://clinicaltrials.gov/, identifier RBR-96584w4.

Epidural analgesia in the perioperative period and mean arterial pressure as risk factors for postoperative complications after pancreaticoduodenectomy

Objective. To study the influence of epidural analgesia and mean arterial pressure as risk factors for the development of postoperative pancreatic fistula, delayed evacuation of gastric contents and postpancreatic bleeding after pancreaticoduodenectomy. Materials and Methods. The retrospective study included 234 patients who underwent pancreaticoduodenectomy at the National Research Center of Surgery and Transplantation named after O. O. Shalimov from January 2022 to November 2023. The surgical intervention included a standard pancreaticoduodenectomy according to the modified Child's technique. The objective was to evaluate the optimal approach to anesthesia and blood pressure management to minimize the risk of postoperative complications. Data were collected on the type of anesthesia (general anesthesia or a combination of general anesthesia and epidural analgesia), mean arterial pressure, use of vasopressors, and the incidence of postoperative complications. The analysis was performed using logistic–binomial regression to assess the risk of complications depending on the level of blood pressure and the use of epidural analgesia. Results. The combined use of epidural analgesia and general anesthesia was associated with a decrease in the incidence of clinically significant postoperative pancreatic fistula, delayed evacuation of gastric contents, and other complications. Epidural analgesia, although associated with an increased risk of hemodynamic instability, contributed to better pain control and a reduction in the incidence of postoperative complications. A decrease in mean arterial pressure by each 1 mm Hg increases the risk of postoperative pancreatic fistula by 15.8%, which confirms the importance of maintaining an adequate level of pressure to ensure optimal tissue perfusion. Despite the hypothesis of a possible negative effect of vasopressors, their use did not show a statistically significant association with the incidence of postoperative pancreatic fistula. Thus, further studies are needed to clarify the optimal parameters of patient management after pancreaticoduodenectomy.