Ventilator Dependence Research Articles

23. Understanding the influence of prior positive COVID-19 infection on 90-day outcomes following elective lumbar spine surgery

BACKGROUND CONTEXTThe COVID-19 pandemic has radically impacted and transformed surgical practice over the past couple of years. While a significant proportion of research has rightfully focused on prevention and/or treatment of acutely infected COVID-19 patients, little is known about how a prior history of a positive COVID-19 infection (ie, recovered patients) influences outcomes following major elective surgeries.PURPOSEThe purpose of the current study was to study whether previous positive COVID-19 infection has an impact on 90-day medical and surgical complication rates following elective lumbar spine surgeries.STUDY DESIGN/SETTINGRetrospective cohort utilizing large all-payer database.PATIENT SAMPLEThis study included 49,639 patients undergoing elective lumbar spine surgery between 2019 and 2021.OUTCOME MEASURESNinety-day medical and surgical complication rates.METHODSThe 2019 to 2021 PearlDiver Mariner Database, an all-payer claims database, was used to identify patients undergoing elective 1- to 2-level primary posterior/anterior/combined fusions or 1- to 2-level laminectomies for degenerative lumbar spine pathologies and 1- to 2-level primary microdiscectomies for herniated discs. Patients undergoing fusion for fracture, malignancy, infection and/or those undergoing revision procedures were excluded from the study. The study group was divided into two cohorts — those who had a prior history of a COVID-19 infection within the 6 months before surgery and those who were not infected by the virus. Patients who had a positive coded COVID-19 status on the day of surgery were excluded from the analysis. Multivariate logistic regression analyses were used to assess the impact of prior COVID-19 infection on 90-day medical and surgical complication rates, while controlling for baseline demographics (age, gender, payor type/insurance) and clinical characteristics (Charlson comorbidity index, type of surgery, and prior ventilator dependence).RESULTSA total of 49,639 patients undergoing elective lumbar spine surgery between 2019 and 2021 were included in the study, out of which 150 patients (0.3%) had had a positive COVID-19 status and/or infection in the 6 months prior to the surgery. After adjusting for baseline demographics and clinical characteristics, patients with a prior history of COVID-19 infection were more likely to experience cardiac complications (3.3% vs 1.1%, OR 2.75; p=0.021), thromboembolic complications (6.0% vs 2.3%, OR 2.35; p=0.014) and sepsis (5.3% vs 2.0%, OR 2.31; p=0.024) within 90 days of the index surgery.CONCLUSIONSBased on a national retrospective review of patients undergoing elective lumbar spine surgery, it appears that having harbored a positive COVID-19 infection in the 6 months prior to surgery is associated with higher risks of experiencing thromboembolic events, sepsis and acute myocardial infarctions or acute congestive heart failure. The findings of the study support the need of careful postoperative care monitoring and/or risk-stratification of prior COVID-19 patients.FDA DEVICE/DRUG STATUSThis abstract does not discuss or include any applicable devices or drugs.

Outcomes Among Hospitalized Patients With COVID-19 and Acute Kidney Injury Requiring Renal Replacement Therapy.

IntroductionAcute kidney injury (AKI) occurs in up to 10%-30% of coronavirus disease 2019 (COVID-19) patients. AKI patients who require renal replacement therapy (RRT) often have concurrent respiratory failure and represent a high-mortality-risk population. The authors sought to describe outcomes in hospitalized COVID-19 patients with AKI requiring RRT and determine factors associated with poor outcomes. MethodsA retrospective cohort study of hospitalized COVID-19 patients with AKI requiring RRT during the period from March 14, 2020, to September 30, 2020, was performed at Kaiser Permanente Southern California. RRT was defined as conventional hemodialysis and/or continuous renal replacement therapy. The primary outcome was hospitalization mortality, and secondary outcomes were mechanical ventilation, vasopressor support, and dialysis dependence among discharged patients. Hospitalization mortality risk ratios were estimated up to 30 days from RRT initiation. ResultsA total of 167 hospitalized COVID-19 patients were identified with AKI requiring RRT. The study population had a mean age of 60.7 years and included 71.3% male patients and 60.5% Hispanic patients. Overall, 114 (68.3%) patients died during their hospitalization. Among patients with baseline estimated glomerular filtration rate (eGFR) values of ≥ 60, 30-59, and < 30 mL/min, the mortality rates were 76.8%, 78.1%, and 50.0%, respectively. Among the 53 patients who survived to hospital discharge, 29 (54.7%) continued to require RRT. Compared to patients with eGFR < 30 mL/min, the adjusted 30-day hospitalization mortality risk ratios (95% CI) were 1.38 (0.90-2.12) and 1.54 (1.06-2.25) for eGFR values of 30-59 and ≥ 60, respectively. ConclusionAmong a diverse cohort of hospitalized COVID-19 patients with AKI requiring RRT, survival to discharge was low. Greater mortality was observed among patients with higher baseline kidney function. Most of the patients discharged alive continued to be dialysis-dependent.

COVID-19 and Ventricular Shunt Revisions.

Introduction: COVID-19 patients frequently experience headaches, malaise, and fatigue. For patients with shunted hydrocephalus, these signs and symptoms can often be indicative of shunt failure. Thus, it can be challenging to determine if shunt failure has occurred in this patient population. Therefore, we explored the question of how a diagnosis of COVID-19 in shunted hydrocephalus patients influences the rate of shunt revision.Methods: We used a deidentified database network (TriNetX) to gather information on patients with shunted hydrocephalus and COVID-19 versus no COVID-19 from January 20, 2020, through September 26, 2021. Our primary outcome of interest was shunt revision at 90 days, with secondary outcomes of mortality, hospitalization, ICU admission, mechanical ventilation, tracheostomy, PEG tube placement, fall, seizure, acute kidney injury (AKI), venous thromboembolism (VTE), ischemic stroke (I.S.), myocardial infarction (MI), and sepsis. Cohorts were propensity score-matched for common comorbidities and demographics.Results: After propensity score matching, 10,600 patients with shunted hydrocephalus and COVID-19 (cohort 1) and 10,600 patients with shunted hydrocephalus and no COVID-19 (cohort 2) were identified. Average age was 38.5 years. Eight hundred and thirty-four patients (7.869%) in cohort 1 and 180 (1.698%) patients in cohort 2 underwent shunt revision (p=<0.0001, OR 4.978, 95% CI 4.198, 5.821). Mortality was 4.642% vs. 2.113% (p<0.0001, OR 2.255, 95% CI 1.921, 2.647). Hospitalization rates were 27.72% vs. 10.303% (p<0.0001), and ICU admission rates 11.567% vs. 3.463% (p<0.0001). Ventilator dependence was 3.529% vs. 0.953% (p<0.0001), tracheostomy 1.142% vs. 0.236% (p<0.0001), PEG tube insertion 2.472% vs. 0.585% (p<0.0001), falls 2.321% vs. 1.076% (p<0.0001), seizure 11.369% vs. 5.953% (p<0.0001), AKI 4.416% vs. 1.717% (p<0.0001), VTE 3.538% vs. 1.293% (p<0.0001), sepsis 3.887% vs. 1.179% (p<0.0001), IS 0.585% vs. 0.16% (p<0.0001), and MI 1.34% vs. 0.519% (p<0.0001).Conclusion: COVID-19 infection is associated with an almost five-fold increase in shunt revisions.

Outcomes following surgical repair of absent pulmonary valve syndrome: 30 years of experience from a Swedish tertiary referral centre.

Surgical approach with reduction pulmonary artery plasty and valved conduit in patients with respiratory compromise prior to repair is associated with excellent long-term survival at the cost of a higher reintervention rate. OBJECTIVESAbsent pulmonary valve syndrome is a rare congenital heart defect with pulmonary artery dilatation and secondary airway compression. Although preoperative respiratory support and early surgical repair with pulmonary arterioplasty are often required in patients with airway compromise, the need for extensive plasty in these patients and for plasty in general in those with no or mild respiratory issues remains debatable.METHODSWe performed a retrospective survey of patients with this diagnosis and repair from 1988 to 2018.RESULTSTwenty patients were identified. The median age and weight at repair were 0.8 (0.1–2.4) years and 7.0 (2.5–13.8) kg and included a valved conduit in 17 (85%) patients and a transannular patch in 3 patients. Five (29%) patients were ventilator-dependent prior to repair at the age of 0.3 (0.1–0.4) years. Pulmonary arterioplasty was performed in 7 patients (35%), including all 5 with ventilator dependency and 2 with respiratory symptoms due to recurrent infections. Two patients (10%) with preoperative ventilator dependency underwent extensive intrahilar arterioplasty. Preoperative ventilator dependency was associated with earlier repair and reinterventions (P < 0.05). There were 3 late deaths among cases with repair after 2000 (n = 14), none with preoperative ventilator dependency.CONCLUSIONSThe long-term outcomes of patients with this rare defect are good, comparable to those of other previous studies. Reduction pulmonary arterioplasty, which in this study was used only in patients with respiratory distress and ventilator dependency, is associated with excellent survival. Reinterventions are common in these patients.

Predictors of 30-Day Pulmonary Complications after Video-Assisted Thoracoscopic Surgery Lobectomy.

Pulmonary complications are the most common adverse event after lung resection, yet few large-scale studies have examined pertinent risk factors after video-assisted thoracoscopic surgery (VATS) lobectomy. Veterans, older and less healthy compared with nonveterans, represent a cohort that requires further investigation. Our objective is to determine predictors of pulmonary complications after VATS lobectomy in veterans. A retrospective review was conducted on patients who underwent VATS lobectomy from 2008 to 2018 using the Veterans Affairs Surgical Quality Improvement Program database. Patients were divided into two cohorts based on development of a pulmonary complication within 30 days. Patient characteristics were compared via multivariable analysis to determine clinical predictors associated with pulmonary complication and reported as adjusted odds ratios (aORs) with 95% confidence intervals. Patients with preoperative pneumonia, ventilator dependence, and emergent cases were excluded. In 4,216 VATS lobectomy cases, 480 (11.3%) cases had ≥1 pulmonary complication. Preoperative factors independently associated with pulmonary complication included chronic obstructive pulmonary disease (COPD) (aOR = 1.37 [1.12-1.69]; p = 0.003), hyponatremia (aOR = 1.50 [1.06-2.11]; p = 0.021), and dyspnea (aOR = 1.33 [1.06-1.66]; p = 0.013). Unhealthy alcohol consumption was associated with pulmonary complication via univariable analysis (17.1 vs. 13.0%; p = 0.016). Cases with pulmonary complication were associated with increased mortality (12.1 vs. 0.8%; p < 0.001) and longer length of stay (12.0 vs. 6.8 days; p < 0.001). This analysis revealed several preoperative factors associated with development of pulmonary complications. It is imperative to optimize pulmonary-specific comorbidities such as COPD or dyspnea prior to VATS lobectomy. However, unhealthy alcohol consumption and hyponatremia were linked with development of pulmonary complication in our analysis and should be addressed prior to VATS lobectomy. Future studies should explore long-term consequences of pulmonary complications.

Intraoperative Support for Primary Bilateral Lung Transplantation: A Propensity-Matched Analysis

BackgroundSingle-center studies support benefits of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a method of intraoperative support. Propensity-matched data from a large cohort, however, are currently lacking. Therefore, our goal was to compare outcomes of intraoperative VA-ECMO and cardiopulmonary bypass (CPB) during bilateral lung transplantation (LTx) with a propensity analysis. MethodsWe performed a retrospective analysis of 795 consecutive primary adult LTx patients (June 1, 2011-December 26, 2020) using no intraoperative support (n = 210), VA-ECMO (n = 150), or CPB (n = 197). Exclusion criteria included LTx on venovenous-ECMO, single/redo LTx, ex vivo lung perfusion, and concomitant solid-organ transplantation or cardiac procedure. Propensity analysis was performed comparing patients who underwent intraoperative CPB or VA-ECMO. ResultsThe propensity CPB group required more blood products at 72 hours (P = .02) and longer intensive care unit length of stay (P < .001) and ventilator dependence days (P < .001). There were no differences in cerebrovascular accident (P = 1), reintubation (P = .4), dialysis (P = .068), in-hospital mortality (P = .33), and 1-year (P = .67) and 3-year (P = .32) survival. The CPB group had a higher incidence of grade 3 primary graft dysfunction at 72 hours (P < .001). Neither support strategy was a predictor of 1- and 3-year mortality in our multivariable model (VA-ECMO, P = .72 and P = .57; CPB, P = .45 and P = .91, respectively). ConclusionsIntraoperative VA-ECMO during lung transplantation was associated with fewer postoperative blood transfusions, shorter length of mechanical ventilation, and lower incidence of a grade 3 primary graft dysfunction at 72 hours. Although there were some differences in the postoperative course between the VA-ECMO and CPB groups, support type was not associated with differences in survival.

Predictors of 1‐year outcome after cardiac re‐transplantation: Machine learning analysis

As cardiac re-transplantation is associated with inferior outcomes compared with primary transplantation, allocating scarce resources to appropriate re-transplant candidates is important. The aim of this study is to elucidate the factors associated with 1-year mortality in cardiac re-transplantation using the random forests algorithm for survival analysis. We retrospectively reviewed the United Network for Organ Sharing registry and identified all adult (>17 years old) recipients who underwent cardiac re-transplantation between January 2000 and March 2020. The random forest algorithm on Cox modeling was used to calculate the variable importance (VIMP) of independent variables for contributing to 1-year mortality. A total of 1294 patients underwent cardiac re-transplantation. Of these, 137 patients were re-transplanted within 1year of their first transplant, while 1157 patients were re-transplanted more than 1year after their first transplant. One-year mortality was significantly higher for patients receiving early transplantation compared with those receiving late transplantation (Early 40.6%vs. Late 13.6%, log-rank P<.001). Machine learning analysis showed that total bilirubin (>2mg/dl) (VIMP, 2.99%) was an independent predictor of 1-year mortality after early re-transplant. High BMI (>30.0kg/m2 ) (VIMP, 1.43%) and ventilator dependence (VIMP, 1.47%) were independent predictors of 1-year mortality for the late re-transplantation group. Machine learning showed that optimal 1-year survival following cardiac re-transplantation was significantly related to liver function in early re-transplantation, and to obesity and preoperative ventilator dependence in late re-transplantation.

Abstract 446: Outcome of cancer patients with COVID-19: the VCU experience

Abstract Purpose: COVID-19 has deeply impacted the care and prognosis of those with preexisting acute and chronic conditions including cancer. The purpose of this study is to identify risk factors contributing to death from COVID-19 infection in the cancer population at Virginia Commonwealth University Health System (VCUHS). Materials and Methods: 507 patients were evaluated that had a diagnosis of any solid or hematologic malignancy and admitted to the inpatient service at VCUHS while having a COVID-19 PCR positive test between February 2020 and June 2021. Patient characteristics as well as comorbidities, transplant status, ventilator dependence, intensive care admission, and malignancy type were recorded. Death was recorded as being due to COVID-19 or COVID-19 complications. Logistic regression model was used to determine odds ratio (OR) of death from COVID 19. Results were listed with respective OR both unadjusted and adjusted for age, race, sex, body mass index (BMI), and comorbidities including diabetes, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and chronic kidney disease (CKD). Results: Of the 507 patients, 37 experienced death (7.3%). Only 40 patients required ICU admission (7.9%) and 24 required ventilator support (4.7%). Increased age per 5-year increments was associated with increased risk of death in adjusted and unadjusted analysis (OR 1.30 (1.06,1.63) and 1.26 (1.10,1.46)). There was no significant risk of death in either adjusted or unadjusted analysis between Caucasian, African American, Asian or unspecified races. When not adjusted, COPD (OR 2.56, 1.28-5.11), CAD (OR 2.69, 1.36-5.32), and CKD (OR 2.14, 1.09-4.21) were all shown to have significant risk of death. However, when adjusted, there were no significant difference in odds ratio between patients with diabetes, CAD, COPD, and CKD. When adjusted, malignancies of central nervous system (CNS) (OR 70.30, 2.18-1520.3), hematologic (OR 4.79, 1.05-30.77), and head and neck (OR 11.64, 1.58-100.01) were at increased risk of death; while female associated malignancies, genitourinary (GU), lung, connective tissue, and those with multiple primary malignancies did not have significant risk. Ventilatory dependence did increase mortality risk (OR 50.54, 7.62,459.7), while transplant status and intensive care unit admission did not. Conclusions: Based on the results from this study, there is an increased risk of death from COVID-19 infections in several variables in the cancer population at VCUHS. Age, ventilator dependence, CNS, hematologic, and head and neck malignancies were all associated with increased mortality. Further evaluation will include the 13 other patients in which data was not yet available. Other variables that will be evaluated are COVID treatments, vaccination status, antibody formation, cancer treatment modality used within 30 days of COVID diagnosis, and lab values including cell counts and inflammatory markers. Citation Format: Patrick J. Willard, Temmy Olasehinde, Naji Bou Zeid, Edem Defor, Victor Yazbeck, Dipankar Bandyopadhyay. Outcome of cancer patients with COVID-19: the VCU experience [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 446.

Gender Differences in Prolonged Mechanical Ventilation Patients - A Retrospective Observational Study.

BackgroundThe gender differences in patients requiring prolonged mechanical ventilation are not understood. We investigated the effects of gender differences in terms of age, causes of respiratory failure, discharge status, successful weaning, mortality rate and long-term survival outcomes in patients receiving prolonged mechanical ventilation.MethodsWe conducted a six-year retrospective study of patients requiring prolonged mechanical ventilation. Survival curves for all patients requiring prolonged mechanical ventilation and those who were very old (aged ≥ 80 years) were compared based on gender.ResultsAmong the 574 patients enrolled. There was no statistically significant difference between male and female patients regarding successful weaning, ventilator dependence, or in-hospital mortality. We gathered long-term follow-up data on 296 patients, including 70 very old male patients and 41 very old female patients. The 6-month, 3-year, and 5-year mortality rates for the 189 male patients were 75.1%, 85.2%, and 89.9%, respectively; the corresponding rates for the 107 female patients were 66.4%, 86.0%, and 88.8%, respectively. There was no statistically significant difference between two groups regarding mortality rates. The five-year survival curve of male patients was similar to that of female patients. The 6-month, 1-year, and 5-year mortality rates for the 70 very old male patients were 90.0%, 95.7%, and 97.1%, respectively; the corresponding rates for the 41 very old female patients were 63.4%, 90.2%, and 95.1%, respectively. There was a statistically significant difference between very old male and very old female patients in the 6-month mortality rate and the five-year survival curve.ConclusionThere were no gender differences in weaning status, ventilator dependence, in-hospital mortality, or survival outcomes among patients requiring prolonged mechanical ventilation. Among very old patients requiring prolonged mechanical ventilation, the risk of death was 34% lower in very old female patients than in very old male patients for a period of five years.

Brixia Chest X-ray Severity Scoring System is in Relation with C-reactive Protein and D-dimer Values in Patients with COVID-19.

Background:The Brixia scoring system interpreted chest X-ray changes, serves as an indicator of the extent of changes in the lung parenchymaObjective:To indicate the effect of D-dimer and C-reactive protein (CRP) on Brixia score in patients with positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Methods:The research had prospective, descriptive and analytical character, and included patients (n=104) with Coronavirus disease 2019 (COVID-19) diagnosis. Chest X-ray, as well as calculation of Brixia score was done on admission, in the first week of hospitalization, on discharge, and 10 days after discharge (the patient was considered a post-COVID patient. Maximum CRP and D-dimer values were taken into account, along with data about dependence of mechanical ventilation and oxygen therapy.Results:Initial Brixia score was significantly associated with the values of CRP (r = .23, p <.05). Higher level of CRP affected the higher result on the Brixia score after the initial X-ray. High CRP and D-dimer were significantly associated with oxygen use in patients, while high D-dimer was also statistically significantly associated with comorbidity. The mean value of Brixia score (during four time points) was significantly related to the values of CRP, D-dimer, the use of mechanical ventilation and oxygen therapy, but also with the existence of comorbidities. The largest statistically significant positive correlation of Brixia scora is with the values of D-dimer (r = .45, p <.000), but also with the values of CRP (r = .36, p <.000).Conclusion:Values of CRP have an impact on Brixia score. Investigation of clinical characteristics and outcomes of severe clinical presentation of COVID-19 along with CXR scoring system will contribute to early prediction, accurate diagnosis and treatment as well as to improve the prognosis of patients with severe illness.

General Anesthesia for Patients With Chronic Obstructive Pulmonary Disease and Postoperative Respiratory Failure: A Retrospective Analysis of 120 Patients.

Background: Chronic obstructive pulmonary disease (COPD) has been considered a risk factor for postoperative respiratory failure after general anesthesia. However, the association between COPD severity and postoperative respiratory failure among COPD patients is unknown. Our aim was to compare the prevalence of postoperative respiratory failure in COPD patients according to disease severity after general anesthesia. Methods: We retrospectively reviewed COPD patients undergoing spinal surgery with general anesthesia at our clinical center between January 2016 and January 2021. These subjects were divided into four groups (group I = mild COPD, group II = moderate COPD, group III = severe COPD, and group IV = very severe COPD) according to their preoperative lung function. The primary endpoint was a respiratory failure 1 week after surgery. The diagnosis of respiratory failure was made with the presence of one or more of the following criteria: prolonged ventilator dependence, unplanned postoperative intubation, and partial pressure of arterial oxygen (PaO2) ≤ 50 mmHg while the patient was breathing ambient air in the hospital. The extubation time, perioperative PaO2 and partial pressure of arterial carbon dioxide (PaCO2), postoperative lung infection, and length of hospitalization were also compared. Results: A total of 120 patients who underwent spinal surgery with general anesthesia were included in this retrospective study. Postoperative respiratory failure occurred in 0 (0.0%) patient in group I, 1 (1.5%) patient in group II, 1 (2.5%) patient in group III, and 1 (14.5%) patient in group IV 1 week after surgery (p = 0.219). The duration of anesthesia was 243.3 ± 104.3 min in group I, 235.5 ± 78.8 min in group II, 196.0 ± 66.3 min in group III, and 173.1 ± 63.7 min in group IV (p < 0.001). Preoperative PaO2, PaCO2, intraoperative oxygenation index [a ratio of PaO2 to fraction of inspired oxygen (FiO2)], and postoperative PaO2 were significantly different among the four groups (p < 0.001, 0.001, 0.046, <0.001, respectively). No significant differences among the four groups were seen in extubation time, pulmonary infection, or hospital stay (p = 0.174, 0.843, 0.253, respectively). The univariate analysis revealed that higher preoperative PaO2 was associated with a lower rate of postoperative respiratory failure (OR 0.83; 95% CI, 0.72 to 0.95; p = 0.007). Conclusion: The severity of COPD as assessed with GOLD classification was not associated with the development of postoperative respiratory failure. However, lower preoperative PaO2 was associated with greater odds of postoperative respiratory failure in COPD patients.

Efficacy and safety of fibrinogen administration in acute post-traumatic hypofibrinogenemia in isolated severe traumatic brain injury: A randomized clinical trial

AimThis study was conducted to evaluate clinical outcomes after fibrinogen administration in hypofibrinogenemia following severe traumatic brain injury. BackgroundPost traumatic coagulopathy (PTC) is a common but devastating medical condition in patients with severe head injury. Hypofibrinogenemia is considered as an indicator for poor clinical outcomes in traumatic brain injury (TBI). MethodsIn this randomized clinical trial (RCT), primarily 137 patients with severe traumatic brain injury (Glasgow coma scale score: GCS < 9) were enrolled. Thereafter, their plasma fibrinogen level was measured. The patients with primary hypofibrinogenemia (<200 mg/dL) with no concurrent coagulopathy were randomly allocated into fibrinogen-receiving (n = 50) and control (n = 54) groups. P-value < 0.05 was considered as statistically significant. ResultsSeventy-one patients were analyzed in the final step of the study. The mean value for age in fibrinogen and control groups was 25.64 ± 10.71 and 28.91 ± 12.25 years old, respectively. Male – female patients in both groups were equally distributed. In the fibrinogen receiving group, GCS scores were significantly higher after 24, 48, and 72 h compared to the control group (p = 0.000). Hematoma expansion was better controlled in the fibrinogen receiving group (p = 0.000). Notably, the number needed to treat (NNT) for fibrinogen infusion and hematoma expansion control was 2.3. Glasgow outcome scale-extended (GOSE) was significantly better in the fibrinogen group (p = 0.25). Multiple regression tests showed intracerebral hematoma (ICH) and severe brain edema had the most detrimental effect on GOSE outcomes. The need for cranial surgery, hospital stay duration, mechanical ventilator dependency, in hospital and 90-day post discharge mortality rates were similar in both study groups. ConclusionIn severe TBI, hypofibrinogenemia correction (>200 mg/dL) could improve GOSE, GCS score progression within 3 days after primary head injury and hematoma expansion controllability.

0699 Predictors of Mortality in Obesity Hypoventilation Syndrome: A National Inpatient Sample Study

Abstract Introduction Obesity Hypoventilation Syndrome (OHS) has been linked to adverse cardiovascular outcomes and mortality in multiple observational studies. Few single-center observational studies have reported poor outcomes of inpatient admissions in OHS. Data regarding nationwide outcomes of hospital admissions in OHS is scarce. We conducted a retrospective study to identify predictors associated with mortality using the National Inpatient Sample (NIS) database. Methods We reviewed the NIS database to assess the outcomes of all weighted hospitalizations with an ICD 9 or ICD 10 code for OHS from 2007 to 2018. Patients with age &amp;lt;18, BMI &amp;lt;35, and ICD 9 and ICD 10 codes for neuromuscular disorders, chest wall disorders, or miscellaneous disorders of hypoventilation during the index hospitalization were excluded. The primary outcome was in-hospital mortality. We applied multivariable Cox regression modeling for the association of inpatient mortality with the diagnosis of OHS adjusted for age, sex, race, smoking history, BMI, GERD, OSA, renal failure, use of non-invasive and invasive MV, bronchoscopy, urban vs. rural hospital location, academic hospital status, COPD, asthma, acute PE, pulmonary hypertension, pneumonia and dependence on long-term oxygen or invasive or non-invasive mechanical ventilation. Hazard ratios (HR) with 95% confidence intervals (CI) were reported. Results A total of 1,115,927 hospitalizations were included in the final analysis. Increasing age, Native American race (compared to White), higher BMI, renal failure, a requirement of invasive and non-invasive mechanical ventilation, acute pulmonary embolism, ILD, and pulmonary hypertension were independently associated with increased risk of mortality during the hospitalization (p-value &amp;lt;0.05). Female sex, academic and urban hospital status, smoking, COPD, asthma, GERD, and OSA were independently associated with reduced risk for inpatient mortality (p-value &amp;lt;0.05). Black, Hispanic, Asian or Pacific Islander races (compared to White) were also associated with decreased risk of mortality (p-value &amp;lt;0.05). Home ventilator dependence, pneumonia, or oxygen dependence were not significantly associated with the risk of death. Conclusion Invasive mechanical ventilation (aHR 3.71, 95%CI 3.62-3.81) acute renal failure (aHR 1.93, 95%CI 1.87-2.00), and BMI &amp;gt; 70 (aHR 1.54, 95%CI 1.46-1.63) were the strongest predictors of inpatient mortality in our review of nationwide hospitalizations in OHS. Support (If Any)

Predictors of prolonged stay after laryngeal surgery for benign neoplasms in children

BackgroundPediatric benign laryngeal tumors can often be treated as same-day surgeries. This study identified factors associated with prolonged hospital stay in children undergoing laryngeal surgery for benign tumors. MethodsA retrospective analysis of records of pediatric patients who underwent laryngeal surgery with a post-op diagnosis of benign tumor was performed with the American College of Surgeons Pediatric National Surgery Quality Improvement Program (ACS-NSQIP-P) database (2014–2018). Clinical variables analyzed included comorbidities, total length of stay (LOS), readmission, and reoperation. Results1775 patients were identified with a mean age at time of surgery of 8.95 years (95% CI 8.76–9.14). 966 (54.4%) were males and 809 (45.6%) were females. Mean LOS was 0.22 days (95% CI 0.12–0.32). Only 128 (7.3%) patients had a LOS of one day or more. Children with a variety of comorbidities, including premature birth, oxygen support, tracheostomy, developmental delay, and cardiac risk factors, had a significantly prolonged LOS (P < .001). Additionally, younger children were significantly more likely to stay overnight (β = −0.041, P < .001). Twenty-three (1.3%) patients were readmitted, 2 (0.1%) were reintubated, and 13 (0.7%) underwent reoperation for related reasons. Despite the association of premature birth, ventilator dependence, oxygen support, tracheostomy, esophageal/GI disease, developmental delay, seizure, neuromuscular disorders, congenital malformations, and steroid use with LOS, only younger age and ventilator dependence were associated with readmission. ConclusionThis study suggests that laryngeal surgery for benign tumors is safe but recognizes that patients with comorbidities or young children may require a prolonged stay. Awareness of these implications may help guide management.

Management of post-operative ventilator dependency in an operated case of tetralogy of Fallot with absent pulmonary valve: a team approach involving cardiac surgeon, cardiologist, intensivist, and radiologist.

Tetralogy of Fallot with absent pulmonary valve syndrome is commonly associated with trachea-bronchial anomalies, possibly due to airway compression caused by massively dilated pulmonary arteries secondary to severe pulmonary regurgitation. This airway obstruction may persist post-operatively also. We report a case of an infant who required a series of management strategies including bronchial stenting to manage his obstructive symptoms.

Does accreditation matter? An analysis of complications of bariatric cases using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and National Quality Improvement Program databases.

Two large nationwide databases collect data on common operations in the United States. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) collects bariatric data, whereas the National Quality Improvement Program (NSQIP) gathers details on a broader range of general surgical cases. Evaluate the differences in rates of complications between both databases regarding Roux-en-Y gastric bypass and sleeve gastrectomy. National databases, United States. We evaluated the MBSAQIP and NSQIP from 2017 to 2019 using the procedure codes 43644 and 43775. Fifteen common complications were evaluated. Propensity-matched analyses (PMAs) were done to control for differences across databases. Significantly different variables after a PMA were included in multivariable models. The data were examined for differences between the 2 databases before and after the PMA, with and without adjustment for operation type. There were 483,361 cases reported in the MBSAQIP and 57,598 in the NSQIP. PMA matched 57,479 cases for each database. Seven complications were different, with higher rates reported in the NSQIP than in the MBSAQIP: myocardial infarction, sepsis, organ/space surgical site infections, deep vein thrombosis, urinary tract infections, pulmonary embolism, ventilator dependence >48 hours, and pneumonia. When adjusting for the procedure performed, sleeve gastrectomy in the NSQIP had higher rates of organ/space surgical site infections, deep vein thrombosis, sepsis, and death. Roux-en-Y gastric bypass in the NSQIP had higher rates of organ/space surgical site infections, ventilator dependence >48 hours, urinary tract infections, myocardial infarction, deep vein thrombosis, and sepsis. When compared with the MBSAQIP, the NSQIP reports higher rates of bariatric complications. Further studies are needed to confirm the reasons behind this.

Association of Phosphate-Containing versus Phosphate-Free Solutions on Ventilator Days in Patients Requiring Continuous Kidney Replacement Therapy.

Hypophosphatemia is commonly observed in patients receiving continuous KRT. Patients who develop hypophosphatemia may be at risk of respiratory and neuromuscular dysfunction and therefore subject to prolongation of ventilator support. We evaluated the association of phosphate-containing versus phosphate-free continuous KRT solutions with ventilator dependence in critically ill patients receiving continuous KRT. Our study was a single-center, retrospective, pre-post cohort study of adult patients receiving continuous KRT and mechanical ventilation during their intensive care unit stay. Zero-inflated negative binomial regression with and without propensity score matching was used to model our primary outcome: ventilator-free days at 28 days. Intensive care unit and hospital lengths of stay as well as hospital mortality were analyzed with a t test or a chi-squared test, as appropriate. We identified 992 eligible patients, of whom 649 (65%) received phosphate-containing solutions and 343 (35%) received phosphate-free solutions. In multivariable models, patients receiving phosphate-containing continuous KRT solutions had 12% (95% confidence interval, 0.17 to 0.47) more ventilator-free days at 28 days. Patients exposed to phosphate-containing versus phosphate-free solutions had 17% (95% confidence interval, -0.08 to -0.30) fewer days in the intensive care unit and 20% (95% confidence interval, - 0.12 to -0.32) fewer days in the hospital. Concordant results were observed for ventilator-free days at 28 days in the propensity score matched analysis. There was no difference in hospital mortality between the groups. The use of phosphate-containing versus phosphate-free continuous KRT solutions was independently associated with fewer ventilator days and shorter stay in the intensive care unit.

Upper Airway Dysfunction and Discoordination are Reversed by Isometric Tongue Exercise in a Novel Rodent Model of Hypoglossal Motor Neuron Loss

Motor neuron diseases (e.g., amyotrophic lateral sclerosis, pseudobulbar palsy, and Kennedy’s disease) result in life‐threatening alterations in upper airway function (i.e., swallowing and breathing) primarily due to degeneration of hypoglossal (XII) motor neurons, which leads to ventilator and/or feeding‐tube dependence. Despite its critical importance, upper airway function has seldom been studied in motor neuron diseases; thus, effective treatments remain to be discovered. Since genetic rodent models of motor neuron loss develop global symptoms (e.g., limb dysfunction, etc.), we have developed an inducible model of only XII motor neuron death in order to study targeted therapeutic interventions to enhance the functional capacity of spared XII motor neurons to improve functional outcomes. We have previously found that adult male rats intralingually injected with cholera toxin B conjugated to saporin (CTB‐SAP) have XII motor neuron loss and decreased XII motor output, degenerative changes in the XII nerve and genioglossus, and decreased tongue motility and swallowing rate. We hypothesize that deficits in upper airway function and coordination are reversed by using a translational, non‐invasive therapeutic strategy of tongue resistance exercise training in CTB‐SAP rats. To test our hypothesis, we intralingually injected adult male rats with CTB‐SAP or control (CTB unconjugated to SAP), and then studied the following parameters +/‐ isometric tongue exercise (n=3‐7/group): 1) swallowing function via videofluoroscopic swallow studies and force lickometer testing; 2) breathing function via whole‐body plethysmography; 3) XII motor output at baseline and in response to a maximal ventilatory challenge in anesthetized and ventilated rats via in vivo neurophysiology; 4) coordination of swallowing and breathing in anesthetized rats via evoked swallowing electrophysiological recordings; and 5) structural changes via magnetic resonance imaging. Thus far, our data suggests that tongue exercise in CTB‐SAP treated rats remarkably preserves tongue strength and motility and swallowing and breathing patterns/coordination, and reduces structural degeneration in the brainstem and tongue (p&lt;0.05 vs. controls). In conclusion, tongue exercise appears to preserve upper airway function and coordination in the face of XII motor neuron degeneration. Studies are now underway to understand the underlying mechanism of tongue exercise‐induced neuroplasticity in spared XII motor neurons. If successful, this work will identify behavioral (tongue exercise) and molecular strategies for future translational studies to prolong and/or improve upper airway function and coordination in patients with motor neuron diseases to significantly improve their quality and duration of life.

Prolonged Mechanical Ventilation: Outcomes and Management.

The number of patients requiring prolonged mechanical ventilation (PMV) is increasing worldwide, placing a burden on healthcare systems. Therefore, investigating the pathophysiology, risk factors, and treatment for PMV is crucial. Various underlying comorbidities have been associated with PMV. The pathophysiology of PMV includes the presence of an abnormal respiratory drive or ventilator-induced diaphragm dysfunction. Numerous studies have demonstrated that ventilator-induced diaphragm dysfunction is related to increases in in-hospital deaths, nosocomial pneumonia, oxidative stress, lung tissue hypoxia, ventilator dependence, and costs. Thus far, the pathophysiologic evidence for PMV has been derived from clinical human studies and experimental studies in animals. Moreover, recent studies have demonstrated the outcome benefits of pharmacological agents and rehabilitative programs for patients requiring PMV. However, methodological limitations affected these studies. Controlled prospective studies with an adequate number of participants are necessary to provide evidence of the mechanism, prognosis, and treatment of PMV. The great epidemiologic impact of PMV and the potential development of treatment make this a key research field.

Prediction of Stroke After the COVID-19 Infection.

Although several studies have been published about COVID-19, ischemic stroke is known yet as a complicated problem for COVID-19 patients. Scientific reports have indicated that in many cases, the incidence of stroke in patients with COVID-19 leads to death. The obtained mathematical equation in this study can help physicians' decision-making about treatment and identification of influential clinical factors for early diagnosis. In this retrospective study, data from 128 patients between March and September 2020, including their demographic information, clinical characteristics, and laboratory parameters were collected and analyzed statistically. A logistic regression model was developed to identify the significant variables in predicting stroke incidence in patients with COVID-19. Clinical characteristics and laboratory parameters for 128 patients (including 76 males and 52 females; with a mean age of 57.109±15.97 years) were considered as the inputs that included ventilator dependence, comorbidities, and laboratory tests, including WBC, neutrophil, lymphocyte, platelet count, C-reactive protein, blood urea nitrogen, alanine transaminase (ALT), aspartate transaminase (AST) and lactate dehydrogenase (LDH). Receiver operating characteristic-area under the curve (ROC-AUC), accuracy, sensitivity, and specificity were considered indices to determine the model capability. The accuracy of the model classification was also addressed by 93.8%. The area under the curve was 97.5% with a 95% CI. The findings showed that ventilator dependence, cardiac ejection fraction, and LDH are associated with the occurrence of stroke and the proposed model can predict the stroke effectively.