Vasopressor Requirements Research Articles

HPB SO34 - Inter-fascial/Wound Catheter with Local Anaesthetic Infusion vs Thoracic Epidural Analgesia in Hepato-biliary Surgery (HILA) – A Retrospective Cohort Study

Abstract Background Thoracic epidural analgesia (TEA) offers effective pain control after open hepato-biliary surgery, however it is associated with several limitations that delay post-operative recovery. This study compared outcomes between inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) and thoracic epidural analgesia (TEA) following open liver and biliary surgery in an enhanced recovery after surgery (ERAS) setting. Method Retrospective cohort data of all open liver and biliary surgery between August 2023 to February 2024 that used inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) or thoracic epidural analgesia (TEA). Baseline characteristics were similar in the combined IF (n=17) and WC (n=7) group vs TEA (n=39) group. Technical failure rates were 12.5% in the IF/WC group vs 20.5% in the TEA group, p=0.509. Results Vasopressor requirement immediately post-surgery decreased by 32.7% in IF/WC vs TEA group [8.3% vs 41.0%, p=0.005], whereas none in the IF/WC group required vasopressor beyond 24 hours [0 vs 25.6%, p=0.010]. Length of critical care stay reduced by 1.5 days [1.79 vs 3.28 days; 95% CI 0.28-2.70, p=0.016] while length of hospital stay reduced by 2.6 days [5.79 vs 8.41 days; 95% CI 0.72-4.52, p=0.022] in the IF/WC vs TEA group. Admission cost reduced by £3941 per patient in the IF/WC vs TEA group [£10323 vs £14265; 95% CI 661-7222, p=0.019]. Conclusion Inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) is an effective, safe and cost-saving alternative to thoracic epidural analgesia (TEA) with significant decrease in post-operative vasopressor requirements, and length of critical care and hospital stay.

VS 02 - HPB Inter-fascial Catheter with Local Anaesthetic Infusion in Hepato-biliary Surgery (HILA) – A Video Guide to Catheter Placement

Abstract Background Thoracic epidural analgesia (TEA) offers effective pain control after open hepato-biliary surgery, however it is associated with several limitations that delay post-operative recovery. Inter-fascial catheter with local anaesthetic infusion (IF) is an effective, safe and cost-saving alternative to thoracic epidural analgesia (TEA) following open liver and biliary surgery, with significant decrease in post-operative vasopressor requirements, and length of critical care and hospital stay. Method This video presentation outlines current clinical evidence with local data from Nottingham University Hospital, relevant clinical anatomy of the inter-fascial plane, intra-operative placement techniques, tips and tricks as well as troubleshooting in the event of a catheter related complication. Results The inter-fascial catheters can be placed in the transversus abdominis or posterior rectus plane based on the type of skin incision to achieve optimal post-operative pain control. It is associated with a low technical failure rate. Conclusion Inter-fascial catheter with local anaesthetic infusion is an effective, safe and cost-saving technique associated with significant decrease in post-operative vasopressor requirement, and length of critical care and hospital stay.

Abstract 4143217: Gender Disparities in Clinical Outcomes Following Transcatheter Aortic Valve Replacement: Insights from the National Inpatient Sample

Background: Transcatheter aortic valve replacement (TAVR) has revolutionized the management of aortic stenosis, offering a less invasive alternative to surgical valve replacement, particularly for high-risk patients. While TAVR has demonstrated efficacy and safety in various patient populations, there is growing recognition of gender-specific differences in clinical outcomes post-procedure.Understanding gender-related variations in TAVR outcomes is crucial for optimizing patient care and ensuring equitable access to this life-saving therapy. Methods: Using the National Inpatient Sample (2017-2020), we analyzed the characteristics and comorbidities of male and female patients undergoing TAVR. We then assessed the incidence of clinical outcomes between genders, including in-hospital mortality, mechanical ventilation, length of stay, hospital charges, vasopressor requirement, heart block, pacemaker insertion, stroke, acute kidney injury (AKI), vascular complications, and discharge disposition. Multivariate analysis was performed to evaluate mortality risk among congestive heart failure (CHF) patients. Results: Among 234,860 total admissions, females comprised 44.5% (104,365) of the population. Females were slightly older (mean age 79.4 vs. 78.5 years, p < 0.001) and had a lower mean Charlson Comorbidity Index (2.8 vs. 3.1, p < 0.001) compared to males. After adjusting for confounding factors, females had a higher odds ratio for in-hospital mortality (OR 1.48, 95% CI 1.37-1.60, p < 0.001), mechanical ventilation (OR 1.14, 95% CI 1.07-1.20, p < 0.001), stroke (OR 1.55, 95% CI 1.46-1.65, p < 0.001), and vascular complications (OR 1.24, 95% CI 1.19-1.31, p < 0.001). Length of stay (mean difference 0.37 days, 95% CI 0.32-0.42, p < 0.001) and hospital charges (mean difference $3,795, 95% CI 2,488-5,102, p < 0.001) were also significantly higher in females (p < 0.001 for both). Conclusion: The divergent clinical profile and poorer outcomes observed among females undergoing TAVR, characterized by elevated in-hospital mortality, stroke, and vascular complications compared to males, may emphasize the need for gender-specific approaches in TAVR management.

Abstract 4130368: Outcomes of Patients with Critical Limb Ischemia and Chronic Kidney Disease: A National Perspective

Background: Studies exploring the relationship between peripheral arterial disease (PAD), critical limb ischemia (CLI), and chronic kidney disease (CKD) and its effect on in-hospital outcomes are limited. Objectives: We aimed to analyze the outcomes of patients with CKD and PAD who are admitted for CLI. Methods: We utilized the National Inpatient Sample (NIS) to capture hospitalizations for CLI from 2016-2020 and then identified cases with concomitant CKD. The primary outcome was mortality, and secondary outcomes were cerebrovascular accident, major bleeding, vasopressor requirement, percutaneous coronary intervention, cardiac arrest, acute respiratory failure, transfusion, length of stay (LOS), and total hospital charges. Multivariable logistic regression was performed to adjust for covariates. Results: A total of 441,245 patients with CLI were identified, of which 122,370 (27.7%) reported concomitant CKD. Patients with CKD had a higher in-patient mortality (OR 1.68, CI, 1.17-1.68, p < 0.001), vascular complications (OR 1.31, 95% CI, 1.17-1.48, p<0.001), acute kidney injury requiring hemodialysis (OR 3.17, 95% CI, 2.64-3.80, p< 0.001) and major bleeding (OR 1.12, 95% CI 1.05-1.19, p<0.001). Patients with CKD underwent conservative (31.08% vs 36.73%, p<0.0001) and invasive procedures (14.73% vs 23.55%, p<0.0001) less often. PAD-CLI with CKD was associated with major (20.54% vs. 16.17%, OR 1.04; p<0.0001) and minor (26.87% vs. 19.53%, OR 1.2, p<0.0001) amputations more often. Conclusion: Patients admitted for PAD-CLI with concomitant CKD have significantly higher in-hospital mortality as compared to patients without CKD. Moreover, patients with CKD and PAD-CLI are less likely to receive revascularization and more likely to undergo amputation

Co-administration of dexmedetomidine with total intravenous anaesthesia in carotid endarterectomy reduces requirements for propofol and improves haemodynamic stability: A single-centre, prospective, randomised controlled trial.

Total intravenous anaesthesia guided by electroencephalography and neurophysiological monitoring may be used for carotid endarterectomy. Reduction of brain metabolic demand during cross-clamping of the internal carotid artery with propofol titrated to burst suppression requires effect-site concentrations that may delay emergence and interfere with intraoperative neurophysiological monitoring. To test the hypothesis that dexmedetomidine decreases the effect-site concentration of propofol required for burst-suppression in patients undergoing carotid endarterectomy. Randomised controlled trial. Patients undergoing carotid endarterectomy. University Hospital of Berne, Switzerland, from October 2018 to September 2024. Patients were randomised into a control (n = 23) and a dexmedetomidine groups (n = 22). Total intravenous anaesthesia was administered to both groups. Patients in the dexmedetomidine group received an intravenous bolus of dexmedetomidine (0.4 μg kg-1 over 10 min) before induction, followed by a continuous intravenous infusion (0.4 μg kg-1 h-1). The effect-site concentrations of propofol were titrated against frontal electroencephalography parameters. Burst suppression was induced with propofol during cross-clamping of the internal carotid artery. The primary outcome was the effect-site concentration of propofol required for burst-suppression. The secondary outcomes were the requirement for vasoactive substances, neurophysiological monitoring parameters, and postoperative delirium. The effect-site concentration of propofol required for burst suppression was 4.0 μg ml-1 [3.50 to 4.90] (median [interquartile range]) in the dexmedetomidine group compared with 6.0 μg ml-1 [5.5 to 7.3] in the control group (P < 0.001). Less norepinephrine was required in the dexmedetomidine group (total 454 μg [246 to 818] compared with 1000 μg [444 to 1326] (P = 0.015) in the control group). Dexmedetomidine did not affect intraoperative neurophysiological monitoring. Co-administration of dexmedetomidine to total intravenous anaesthesia for carotid endarterectomy decreased the effect-site concentrations of propofol required for burst suppression by 33%. The propofol-sparing effect and peripheral alpha-agonism of dexmedetomidine may explain the reduced requirement for vasopressors. Clinicaltrials.gov identifier: NCT04662177.

Individualised Positive End-Expiratory Pressure Settings Reduce the Incidence of Postoperative Pulmonary Complications: A Systematic Review and Meta-Analysis

Background: Progressive atelectasis regularly occurs during general anaesthesia; hence, positive end-expiratory pressure (PEEP) is often applied. Individualised PEEP titration may reduce the incidence of postoperative pulmonary complications (PPCs) and improve oxygenation as compared to fixed PEEP settings; however, evidence is lacking. Methods: This systematic review and meta-analysis was registered on PROSPERO (CRD42021282228). A systematic search in four databases (MEDLINE Via PubMed, EMBASE, CENTRAL, and Web of Science) was performed on 14 October 2021 and updated on 26 April 2024. We searched for randomised controlled trials comparing the effects of individually titrated versus fixed PEEP strategies during abdominal surgeries. The primary endpoint was the incidence of PPCs. The secondary endpoints included the PaO2/FiO2 at the end of surgery, individually set PEEP value, vasopressor requirements, and respiratory mechanics. Results: We identified 30 trials (2602 patients). The incidence of PPCs was significantly lower among patients in the individualised group (RR = 0.70, CI: 0.58–0.84). A significantly higher PaO2/FiO2 ratio was found in the individualised group as compared to controls at the end of the surgery (MD = 55.99 mmHg, 95% CI: 31.78–80.21). Individual PEEP was significantly higher as compared to conventional settings (MD = 6.27 cm H2O, CI: 4.30–8.23). Fewer patients in the control group needed vasopressor support; however, this result was non-significant. Lung-function-related outcomes showed better respiratory mechanics in the individualised group (Cstat: MD = 11.92 cm H2O 95% CI: 6.40–17.45). Conclusions: Our results show that individually titrated PEEP results in fewer PPCs and better oxygenation in patients undergoing abdominal surgery.

Patterns of Amphotericin B Use and Factors Related to Mortality in a Low-Middle Income Country: An Observational and Longitudinal Study

Background/Objectives: Amphotericin B is indicated in deep systemic fungal infections. The aim was to determine the sociodemographic, clinical and pharmacological variables of a group of Colombian patients treated with amphotericin B and factors associated with mo rtality. Methods: A longitudinal observational retrospective study on the use of amphotericin B in Colombia was conducted between January 2015 and December 2022. The multivariate analysis sought to identify variables related to mortality. Results: A total of 310 patients were identified, with a median age of 44.0 years, and 71.0% were women. Conventional amphotericin B was the most used (74.8%). The main uses were cryptococcosis (38.7%), histoplasmosis (31.9%) and candidiasis (29.4%). More than a third of patients died during hospitalization (40.3%). An increase in the Charlson Comorbidity Index score (HR: 1.13; 95% CI: 1.05–1.22) and in the qSOFA score (HR: 1.34; 95% CI: 1.04–1.73), coinfection by Mycobacterium tuberculosis (HR: 2.09; 95% CI: 1.32–3.31) and the requirement of vasopressors (HR: 4.20; 95% CI: 2.16–8.15) or invasive mechanical ventilation (HR: 2.73; 95% CI: 1.40–5.33) increased the probability of in-hospital death. In contrast, those who received systemic corticosteroids (HR: 0.43; 95% CI: 0.26–0.70) had a lower risk. Conventional amphotericin B is the most used drug mainly treating Cryptococcus neoformans infections. Conclusions: The use of amphotericin B was consistent with clinical practice guideline recommendations. In-hospital mortality was common, and factors such as increased comorbidities, higher qSOFA scores, coinfection with Mycobacterium tuberculosis and invasive procedures like mechanical ventilation were linked to increased mortality.

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

Diastolic shock index: a novel prognostic parameter unveiling insights into vasodilatory cardiogenic shock

Abstract Introduction Systemic vasodilation is an increasingly acknowledged feature in cardiogenic shock (CS), defining a subset of patients with low systemic vascular resistances and higher vasopressor requirements. While a diastolic shock index (DSI) above 2.0 predicts vasoplegia and mortality in septic shock, its cut-off and prognostic significance in CS remain unclear. Our study aimed to characterize vasoplegia in CS using the DSI and assess its impact on prognosis. Methods Single-center retrospective cohort study on Cardiac Intensive Care Unit (CICU) admissions for CS from January 2017 to October 2023. Data included patient variables, CS features, vasoactive drugs, mechanical circulatory support, and 30-day mortality. DSI (heart rate (HR) to invasive diastolic blood pressure (DBP) ratio) impact on 30-day all-cause mortality was assessed with univariate Cox regression. Optimal DSI cut-off for adverse outcomes was determined through ROC curve analysis, and survival based on this cut-off was analyzed using Kaplan-Meier curves. Results 185 patients (mean age 59 ± 12 years, 63% male) were included. Acute myocardial infarction-related CS (47%) and heart failure-related CS (29%) were predominant. According to SCAI classification, 86% were class C, 22% class D, and 4% class E, with 26% experiencing previous cardiac arrest. Median Vasoactive-Inotropic Score (VIS) was 48 (IQR 21-85), and 25% used mechanical circulatory support. At admission, median HR was 105 bpm (IQR 90-125), DBP was 60 mmHg (IQR 55-65), and DSI was 1.71 (IQR 1.31-2.18). Thirty-day all-cause mortality was 36% (n=67), with median time to death of 4 days (IQR 1-10). DSI at 30 days predicted mortality (OR 1.42, 95%CI 1.06-1.91, p=0.020). DSI showed fair discriminative power for 30-day mortality (C-Statistic 0.60, 95% CI 0.51-0.68, p=0.031) with a cut-off of 2.2. Patients with DSI &amp;gt;2.2 exhibited heightened likelihood of prior cardiac arrest (38% vs. 20%, p=0.032), and higher serum lactate (5.5 vs. 3.9 mmol/L, p=0.008), and serum creatinine (2.64 vs. 1.88 mg/dL, p=0.003) at admission. Despite higher VIS at 48 hours (120±136 vs. 65±93.9, p=0.04), MCS need did not significantly differ. This group had superior 30-day mortality risk (log-rank p=0.011). Conclusion In our cohort, the admission Diastolic Shock Index (DSI) emerged as a promising identifier for CS vasoplegic patients and was a predictor of a higher risk for mortality. A DSI above 2.2 identified a subset of patients with previous cardiac arrest and higher lactate levels, enlightening possible risk factors associated with vasoplegia. Further studies are warranted to establish the robustness of this novel prognostic parameter in CS patients and its therapeutic implications.

Clinical Characteristics, Management, and Outcomes of Bacteremia in Children with Cancer: A Retrospective Study

Abstract Background Bacteremia is a common infectious complication among pediatric oncology patients, yet management practices are not standardized. Antibiotic treatment courses as short as seven days are supported by literature and could improve patient quality of life and resource use. However, it is not known if short courses are associated with greater treatment failure in immunocompromised patients. Methods We conducted a retrospective study at St. Jude Children’s Research Hospital, including patients with a laboratory confirmed bloodstream bacterial infection between April 1, 2022, and March 31, 2023. Clinical characteristics such as age, gender, type of malignancy, phase of treatment, underlying chronic conditions, and clinical sites of infection were collected. Antibiotics used, duration of therapy, and route of administration were also gathered to examine clinical management. Clinical outcomes were measured by documenting ICU admission, oxygen, fluid and vasopressor requirements, date of hospital discharge, bacteremia recurrence, and mortality. Results 86 patients contributed 112 bacteremia episodes that met eligibility criteria. Severe neutropenia was present at onset in 68% of all episodes and 32% of patients did not have neutrophil recovery over 500 cells/ml during the episode. Gram-negative organisms accounted for 52% of isolated organisms, with the most common organisms isolated overall being Escherichia coli (19%), followed by Klebsiella pneumoniae (14%), and Viridans group streptococcus (14%). The median length of antibiotic treatment was 12 days. Treatment duration was not associated with oncologic diagnosis or Gram-negative versus Gram-positive infection. Conclusion Bacteremia occurs more frequently in patients who are neutropenic, especially those who are severely neutropenic with an absolute neutrophil count less than 500 cells/mL. Treatment duration is not associated with primary cancer diagnosis or type of bacteremia. In this single high resource setting, bloodstream infections resulted in significant morbidity, resource use, and a mortality rate of 8%, highlighting opportunities for investigation to improve clinical practices.

12586 A Case Of Ventricular Fibrillation In Thyroid Storm

Abstract Disclosure: A.A. Luzuriaga Chavez: None. N. Aamir: None. J.P. Hidalgo: None. A. Rao: None. N. Patel: None. Thyrotoxicosis is a life-threatening condition caused by an excessive level of circulating thyroid hormones. It can lead to high mortality and morbidity, even if diagnosed and treated in its early stages. Symptoms can include fever, irritability, tachycardia, diarrhea, and seizures. Levothyroxine is a medication commonly used for hypothyroidism, but cases of acute overdose have been reported worldwide. This is a case of a 55-year-old woman who was admitted after a cardiac arrest caused by a possible overdose of 8 mg of levothyroxine. Case presentation:A 55-year-old woman with a history of major depressive disorder was found unconscious by her boyfriend next to a bottle of levothyroxine (which contained a 3-month supply) and was rushed to the emergency department (ED) by EMS. According to the patient's medical chart and family, she did not have a history of hypothyroidism. In the field, she suffered a V-fib cardiac arrest but was successfully resuscitated and brought to the ED. However, she had another cardiac arrest upon arrival but was revived again after 20 minutes. During the physical examination, the patient did not exhibit any signs of thyroid enlargement, exophthalmos, or jaundice. The initial electrocardiogram showed concerning signs of ST-elevation myocardial infarction so the patient was started on heparin drip and continuing amiodarone. The patient was then transferred to the ICU for post-arrest care. Bloodwork revealed TSH &amp;lt;0.005, T3 15.74, and T4 1.57. The Burch-Wartofsky point scale indicated a score of 55, which is consistent with a high suspicion of thyroid storm. The patient's condition continued to worsen, with increasing vasopressor requirements and hyperthermia. Despite the amiodarone drip, the patient's heart rate continued to be less than 100 beats per minute, propranolol could not be started. Furthermore, the patient started bleeding from the nasogastric tube, and the medical team was unable to start any oral propylthiouracil or methimazole. Consequently, they administered hydrocortisone 300 mg, followed by 100mg every 8 hours. The patient was transitioned to comfort care measures. Discussion:Massive ingestion of levothyroxine can lead to excessive thyroid hormone levels and cause sympathetic excitation.Reports of adults ingesting levothyroxine are rare, and those who do generally experience more severe symptoms such as cardiac arrhythmias, malignant hyperthermia, and renal failure. Excessive thyroid hormone levels lead to increased beta adrenergic receptors within the myocardium, rendering it more susceptible to both vagal and sympathetic stimulation. A few isolated case reports show thyrotoxicosis was associated with ventricular fibrillation. Thyroid storm can occur a few days after an overdose of levothyroxine. However, in this case, the patient developed thyrotoxicosis within 6 to 8 hours of ingestion, making it an interesting case to study. Presentation: 6/1/2024

Metolazone Versus Chlorothiazide in Acute Heart Failure Patients With Diuretic Resistance and Renal Dysfunction: A Retrospective Cohort Study.

Guidelines recommend intravenous loop diuretics as first-line therapy for patients hospitalized with acute heart failure (AHF) and volume overload. Additional agents can be used for augmentation, but there is limited guidance on agent selection. The study objective was to determine if chlorothiazide or metolazone is associated with differences in diuretic efficacy or safety in loop diuretic-resistant patients with AHF and renal dysfunction (eGFR <45 mL/min/1.73 m²). We conducted a multicenter, retrospective cohort study of patients hospitalized with AHF and renal dysfunction who received metolazone or chlorothiazide in addition to intravenous loop diuretics. The primary end point was a comparison of 24-hour urine output (UOP) between the 24 hours before and after thiazide administration. Secondary and safety end points included weight change, requirement for vasopressors or inotropes, electrolyte abnormalities, and changes in renal function. A total of 221 patients were included. The mean daily diuretic doses were chlorothiazide 632 mg and metolazone 7 mg. The mean 24-hour UOP increased more among chlorothiazide-treated (from 1668 mL to 3826 mL) versus metolazone-treated patients (from 1672 mL to 2834 mL) ( P < 0.001) after the addition of the second diuretic. Statistically significant reductions in serum creatinine were observed in the chlorothiazide group following 72 hours of treatment ( P = 0.016). More hypomagnesemia was observed in the chlorothiazide group; no differences in other electrolytes or changes in weight were observed. Overall, chlorothiazide was associated with a greater increase in 24-hour UOP than metolazone without an excess of potassium or serum creatinine derangements. However, weight changes did not differ significantly between groups. Future prospective studies are needed to confirm potential differences in diuretic response and safety.

The relationship between uric acid albumin ratio (UAR) and prognosis in patients with atrial fibrillation hospitalized in intensive care unit

Aims: Recent studies have demonstrated an association between uric acid (UA) albumin ratio (UAR), and newly developing atrial fibrillation (AF) and also AF recurrence. We conducted a study to examine the prognostic value of UAR in critically ill patients with AF. Methods: A retrospective examination was conducted on patients diagnosed with AF based on electrocardiography, who admitted to the intensive care unit (ICU) from the emergency department during the period from January 1st to May 1st, 2024. UAR levels were calculated by dividing the amount of UA by the amount of albumin. Based on the cut-off value, UAR levels were categorized into two groups: low UAR and high UAR. A comprehensive comparison was conducted on all the data between these two groups. Results: The high UAR (UAR&gt;0.231) group exhibited significantly higher UA, vasopressor requirement, mechanical ventilation support, length of stay in ICU, and in-hospital mortality rate compared to the low UAR (UAR≤0.231) group. Conversely, albumin levels were significantly lower (p

Efficacy of methylene blue in refractory septic shock: study protocol for a multicenter, randomized, placebo-controlled trial

BackgroundSeptic shock is now the leading cause of mortality in intensive care units (ICUs). Refractory septic shock requires high doses of vasopressors. Some previous studies have revealed that methylene blue could improve hypotension status and help reduce the dosage of catecholamines. This study aims to investigate the clinical effect of methylene blue in septic shock and explore whether it can increase arterial pressure and reduce the usage of vasopressors.MethodsThis study is a multicenter, randomized, placebo-controlled trial planning to include 100 refractory septic shock patients. The protocol is to administer a bolus of 2 mg/kg methylene blue intravenously followed by a continuous infusion of 0.5 mg/kg/h for 48 h. The primary outcome is the total dose of vasopressor required in refractory septic shock in the first 48 h. Secondary outcomes include other hemodynamic parameters, oxygen metabolism indexes, tissue perfusion indexes, major organ function indexes, and certain plasma cytokines and other factors.DiscussionThis protocol aims to evaluate the safety and efficacy of methylene blue as adjuvant therapy for refractory septic shock. The main outcome measure will be vasopressor requirements and hemodynamic parameters. Additionally, bedside ultrasonography, blood gases, and cytokines will be assessed to evaluate perfusion, respiratory, and metabolic effects. The results are intended to provide evidence on the safety and efficacy of methylene blue in refractory septic shock, guiding clinical decision-making.Trial registrationThis clinical trial has been registered at ChiCTR (https://www.chictr.org.cn/) on March 16, 2023. ChiCTR registration number: ChiCTR2300069430.

Ultrasound-guided transversus abdominis plane block is an effective opioid-sparing alternative to epidural anesthesia in open abdominal aortic aneurysm repair

ObjectiveThis study evaluated the effectiveness of ultrasound-guided transversus abdominis plane (TAP) blocks compared with epidural (EPI) and general anesthesia (GA) in managing postoperative pain following open abdominal aortic aneurysm (AAA) repair. MethodsA retrospective review was conducted on 61 elective open AAA repairs performed between January 2016 and December 2021. Patients were categorized into three groups: GA, GA plus EPI, and GA plus TAP block. The primary outcome measured was opioid requirements, reported as morphine milligram equivalents (MME) at 48, 72, and 120 hours postoperatively. The additional opioid requirements between 48 and 72 hours (ΔMME₁) and between 72 and 120 hours (ΔMME₂) were also evaluated. Secondary outcomes included vasopressor requirements, extubation in the operating room, and length of stay in the intensive care unit and hospital. ResultsThe mean MMEs at 48, 72, and 120 hours were statistically significant across all groups. The mean MME at 48 hours was 51.1 ± 71.9 in the TAP group compared with 140.5 ± 121.7 in the GA group. Pairwise comparisons showed a significant difference between the GA and TAP groups at 48 hours (P = .002), whereas the difference between EPI and TAP at 48 hours was not significant (P = .098). Additional opioid requirements between 48 and 72 hours after surgery (ΔMME₁) showed a significant difference between EPI and TAP (P = .045). All groups had significantly different MMEs at 72 hours, with no significant differences observed at 120 hours. Secondary outcomes were not significantly different across the groups. ConclusionsTAP blocks provide effective postoperative pain control with decreased opioid requirements similar to EPI anesthesia during the first 48 hours postoperatively. This factor makes TAP blocks a viable alternative to EPI anesthesia in open AAA repairs. Further multicenter studies are recommended to validate these findings.

Comparison of efficacy and safety of etomidate with other anesthesia induction drugs for patients undergoing cardiac surgery: A systematic review and meta-analysis of randomized controlled trials

IntroductionEtomidate is commonly used to induce anesthesia in cardiac surgery patients due to its favorable cardiovascular profile. Sedative-hypnotic effects are mediated by gammaaminobutyric acid (GABA) receptor complexes in the central nervous system. There are numerous studies in which etomidate and other drugs are compared in terms of their clinical outcomes. The relative efficacy and safety of etomidate, however, remains inconclusive. In this study, we performed a systematic analysis of randomized controlled trials to assess the impact of etomidate, on patients undergoing cardiac surgery, with respect to patient outcome and adverse events. MethodsA systematic review was conducted of all existing clinical trials exploring the safety and efficacy of etomidate in patients undergoing cardiac surgery. Randomized controlled trials (RCTs) that compared etomidate with other drugs during induction in adult cardiac surgery assessing hemodynamic parameters and clinical outcomes were included, while studies involving non-cardiac or pediatric surgery and those lacking relevant outcome data were excluded. Primary outcomes were all-cause 30-day mortality. Secondary outcomes included duration of tracheal intubation, duration of intensive care unit (ICU) stay, duration of hospital stay, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and other hemodynamic parameters, vasopressor requirements after induction and intubation, cortisol levels, and incidence of myoclonus. ResultsSixteen randomized controlled trials involving 1162 patients were included. Etomidate did not affect the all-cause 30-day mortality of patients undergoing cardiac surgery compared to comparator drugs (RR, 0.96; 95 % CI, 0.26 to 3.49; P = 0.95). There were no significant differences in the duration of tracheal intubation (MD, −0.08 h; 95 % CI, −1.96 to 1.81; P = 0.94), the duration of ICU stay (MD, −2.07 h; 95 % CI, −8.09 to 3.96; P = 0.50) or the duration of hospital stay (MD, −0.62 d; 95 % CI, −2.25 to 1.00; P = 0.45) when etomidate was compared to comparator drugs. Patients receiving etomidate demonstrated a more stable hemodynamic profile after induction and intubation compared to those receiving comparator drugs. The requirement of a vasopressor after induction and intubation was significantly reduced with etomidate compared with those with comparator drugs (RR, 0.37; 95 % CI, 0.25 to 0.56; P < 0.00001). ConclusionsThis systematic meta-analysis found a significant heterogeneity among included studies. In addition, most studies focused only on the hemodynamic profile of etomidate. Thus, efficacy and safety of etomidate could not be answered within this context. Nevertheless, for patients undergoing cardiac surgery, etomidate seems to offer a minimal beneficial cardiovascular profile in comparison with other agents during induction and intubation. However, improved hemodynamics did not improve clinical outcomes as Etomidate did not affect mortality, duration of tracheal intubation, the length of stay in ICU and hospital. Finally, infectious side effects as one important trigger for increased mortality in ICU patients due to the use of Etomidate could not be analyzed as data were mostly missing.

Abdominal Circumference and Hypotension Incidence in Caesarean Section Under Spinal Anaesthesia.

Hypotension is a common side effect during caesarean deliveries under spinal anaesthesia, influenced by factors like obesity, physiological changes and abdominal circumference (AC). This study delves into the intricate relationship between abdominal circumference and hypotension incidence, spinal anaesthesia levels, hemodynamic shifts, and vasopressor requirements in caesarean sections. Method: A prospective observational study with 232 term pregnant women undergoing caesarean sections was categorized into two groups based on their abdominal circumference, group A (AC < 95 cm) and group B (AC > 109 cm). The studycompared hypotension incidence, achieved spinal anaesthesia levels, hemodynamic changesand ephedrine necessity and dosage between the two groups. Results: Group B with a larger abdominal circumference, exhibited a significantly higher rate of hypotension, more pronounced hemodynamic changes,higher level of spinal anaesthesia andrequired more doses of ephedrine to manage hypotension compared to group A with a smaller abdominal circumference. Conclusion: This study highlights the crucial role of abdominal circumference as a predictive factor for hypotension during caesarean sections under spinal anaesthesia. Recognizing this association enables targeted preventive measures, potentially enhancing maternal and fetal outcomes during such procedures. Awareness of this correlation emphasizes the necessity for tailored interventions to mitigate the risk of hypotension, ensuring safer caesarean deliveries under spinal anaesthesia.

Outcomes of Patients with Critical Limb Ischemia and Chronic Kidney Disease: A National Perspective

Introduction: Studies exploring the relationship between peripheral arterial disease (PAD), critical limb ischemia (CLI), and chronic kidney disease (CKD) and its effect on in-hospital outcomes are limited. We aimed to analyze the outcomes of patients with CKD and PAD who are admitted for CLI. Methods: We utilized the National Inpatient Sample (NIS) to capture hospitalizations for CLI from 2012 to 2020 and then identified cases with concomitant CKD. The primary outcome was mortality, and secondary outcomes were cerebrovascular accident, major bleeding, vasopressor requirement, percutaneous coronary intervention, cardiac arrest, acute respiratory failure, transfusion, length of stay, and total hospital charges. Multivariable logistic regression was performed to adjust for covariates. Results: A total of 441,245 patients with CLI were identified, of which 122,370 (27.7%) reported concomitant CKD. Patients with CKD had higher in-patient mortality (odds ratio [OR] 1.68, 95% confidence interval [CI], 1.17–1.68, p < 0.001), vascular complications (OR 1.31, 95% CI, 1.17–1.48, p < 0.001), acute kidney injury requiring hemodialysis (OR 3.17, 95% CI, 2.64–3.80, p < 0.001), and major bleeding (OR 1.12, 95% CI, 1.05–1.19, p < 0.001). Patients with CKD underwent minimally invasive endovascular therapy (31.08% vs. 36.73%, p < 0.0001) and invasive procedures (14.73% vs. 23.55%, p < 0.0001) less often. PAD-CLI with CKD was associated with major (20.54% vs. 16.17%, OR 1.04; p < 0.0001) and minor (26.87% vs. 19.53%, OR 1.2, p < 0.0001) amputations more often. Conclusion: Patients admitted for PAD-CLI with concomitant CKD have significantly higher in-hospital mortality as compared to patients without CKD. Moreover, patients with CKD and PAD-CLI are less likely to receive revascularization and more likely to undergo amputation.

Infusion of 20% Human Albumin Reduces the Requirement of Intraoperative Intravenous Fluids in Patients Undergoing Open Gastrointestinal Oncosurgeries – A Randomised Controlled Study

Background and Aims: The optimal strategy for intraoperative fluid management in patients undergoing major abdominal oncosurgery remains undecided. The present study was undertaken to determine the effect of 20% intravenous (IV) albumin on the requirement of IV fluids (IVFs) during open gastrointestinal (GI) cancer surgeries. Methods: This randomised, double-blinded, controlled trial was conducted in a tertiary care centre from August to October 2022 after obtaining approval from the institutional ethics committee and informed written consent from the study subjects. Forty patients were randomised to either Group A (n = 20), receiving an IV infusion of 25 mL/h of 20% albumin, or Group C (n = 20), receiving an IV infusion of 25 mL/h of plasmalyte for 4 h (total 100 mL). Fluid and vasopressor administration was guided by systemic and pulse pressure variations. The primary outcome was the intraoperative requirement for IVF in the two study groups. The secondary outcomes included intraoperative IV vasopressor requirement, serum lactate levels, incidence of post-operative complications and length of hospital stay. Results: After the exclusion of three patients due to intraoperative bleeding, 37 patients were included in the final analysis. Patients in Group A (n = 19) required less IVF (3.92 ± 0.54 mL/kg/h) as compared to Group C (n = 18) (5.03 ± 1.20 mL/kg/h) (P &lt; 0.001). Four patients (22%) in Group C required intraoperative noradrenaline IV infusion (P = 0.040). There was no significant difference between the two groups, regarding the mean intraoperative serum lactate values, incidence of post-operative complications and mean length of hospital stay (P &gt; 0.05). Conclusions: A 100 mL of 20% human albumin as an IV infusion over 4 h reduced the requirement of IV fluid and vasopressor intraoperatively in patients undergoing open GI cancer surgery.

A Comparative Study between Epidural Morphine Bolus and Ropivacaine-fentanyl Infusion in Gastrointestinal Oncosurgeries: A Randomised Clinical Trial (MORFIN Study)

Background and Aims: Epidural local anaesthetic infusion is the gold standard analgesia technique after abdominal surgery. However, hypotension associated with it often leads to the administration of large amounts of fluid, increased vasopressor requirement, reduction of epidural drug dose and thus increased intravenous opioid consumption. Epidural morphine can be an alternative technique. Methods: Eighty-six patients scheduled for open elective gastrointestinal (GI) oncosurgery were enroled in the study. In Group ROP, analgesia was provided with a 6 ml bolus of epidural ropivacaine (0.2%)-fentanyl (2 µg/ml) followed by an infusion at 3–10 ml/h during the perioperative period. In Group MOR, a bolus of epidural morphine 0.05 mg/kg in 10 ml bupivacaine 0.1% was administered every 8–24 h. In both groups, rescue analgesia was provided with intravenous fentanyl. The primary outcome of the study was to compare post-operative fentanyl consumption between the two groups. Results: Mean ± standard deviation (95% confidence interval) fentanyl consumption was significantly lower in Group MOR in the first 24 h (92 ± 191 [33, 151] vs. 255 ± 263 [173, 338] µg in Group ROP; P &lt; 0.01), 24–48 h (71 ± 203 [9, 134] in Group MOR vs. 261 ± 357 [150, 372] in Group ROP; P &lt; 0.001) and 48–72 h (51 ± 168 [0, 103] in Group MOR vs. 240 ± 319 [140, 339] in Group ROP; P &lt; 0.001) in the post-operative period. Pain scores at rest and during movement were significantly lower in group MOR in the immediate post-operative period. The post-operative fluid requirement in the first 24 h was also significantly lower. Conclusion: Intermittent boluses of epidural morphine with low-dose bupivacaine are associated with lesser post-operative fentanyl consumption compared to epidural ropivacaine-fentanyl infusion after GI oncosurgery.