The impact of acute kidney injury stages on the outcomes of veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: Although acute kidney injury (AKI) has been established as an independent risk factor for in-hospital mortality for patients on veno-arterial (V-A) extracorporeal membranous oxygenation (ECMO), the impact of Kidney Disease Improving Global Outcomes (KDIGO) stages of AKI has yet to be elucidated as a risk factor. METHODS: We conducted a retrospective analysis of patient outcomes based on KDIGO stages of AKI at a single institution. The analysis was a cohort of 179 patients; 66 without AKI, 19 with stage 1 AKI, 18 with stage 2 AKI, and 76 with stage 3 AKI. RESULTS: Every 1-year increase in age was associated with 4% increased odds of mortality at 30 days (95% confidence interval [CI] 1.01, 1.07; p = 0.004). The presence of AKI at any stage was associated with 59% increased odds of 30-day mortality (95% CI 0.81, 3.10; p = 0.176). The presence of stage 1 AKI was associated with a 5% decreased odds of 30-day mortality (95% CI 0.32, 2.89). The presence of stage 2 AKI (odds ratio [OR] 2.29, 95% CI 0.69, 7.55; p = 0.173) and stage 3 AKI (OR 1.68, 95% CI 0.81, 3.46; p = 0.164) was associated with increased odds of 30-day mortality. CONCLUSION: Based on our single-center study, higher KDIGO stages of AKI likely have increased odds of mortality at 30 days. Larger studies are needed to confirm these findings.

A Comparison of Intubation and Airway Complications Between COVID-19 and Non-COVID-19 Critically Ill Subjects.

Introduction The number of subjects infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout the western hemisphere increased exponentially in the later months of 2020. With this increase in infection, the number of subjects requiring advanced ventilatory support increased concomitantly. We decided to compare the survival rates between coronavirus disease 2019 (COVID-19) subjects versus non-COVID-19 subjects undergoing intubation in the intensive care unit (ICU). We hypothesized that COVID-19 subjects would have lower rates of survival post-intubation. Methods We screened all subjects admitted to the adult critical care unit between January 2020 and June 2020 to determine if they met the inclusion criteria. These subjects were required to be spontaneously ventilating upon admission and eventually required intubation. Subjects were selected from our electronic health record (EHR) system EPIC© (Epic Systems, Verona, WI) through a retrospective ICU admission analysis. We identified and included 267 non-COVID-19 subjects and 56 COVID-19 subjects. Our primary outcome of interest was intubation-related mortality. We defined intubation mortality as unexpected death (within 48 hours of intubation). Our secondary outcomes were the length of stay in the ICU, length of time requiring ventilator support, and proportion of subjects requiring tracheostomy placement. Results Compared to non-coronavirus disease (COVID) subjects, COVID subjects were more likely to be intubated for acute respiratory distress. COVID subjects had longer stays in the ICU and longer ventilator duration than non-COVID subjects. COVID-positive subjects had a decreased hazard ratio for mortality (HR = 0.42, 95% CI: 0.20-0.87, P < 0.05) and increased chances of survival compared to non-COVID subjects. Conclusions We showed the rates of intubation survival were no different between the COVID and non-COVID groups. We attribute this finding to intubation preparation, a multidisciplinary team approach, and having the most experienced provider lead the intubation process.

Use of the Change in Weaning Parameters as a Predictor of Successful Re-Extubation.

OBJECTIVE: Weaning parameters are well studied in patients undergoing first time extubation. Fewer data exists to guide re-extubation of patients who failed their first extubation attempt. It is reasonable to postulate that improved weaning parameters between the first and second extubation attempt would lead to improved rates of re-extubation success. To investigate, we studied a cohort of patients who failed their first extubation attempt and underwent a second attempt at extubation. We hypothesized that improvement in weaning parameters between the first and the second extubation attempt is associated with successful reextubation. INTERVENTIONS: Rapid shallow breathing index (RSBI), maximum inspiratory pressure (MIP), vital capacity (VC), and the blood partial pressure of CO2 (PaCO2) were measured and recorded in the medical record prior to extubation along with demographic information. We examined the relationship between the change in extubation and re-extubation weaning parameters and re-extubation success. MEASUREMENTS AND MAIN RESULTS: A total of 1283 adult patients were included. All weaning parameters obtained prior to re-extubation differed between those who were successful and those who required a second reintubation. Those with reextubation success had slightly lower PaCO2 values (39.5 ± 7.4 mmHg vs. 41.6 ± 9.1 mmHg, p = 0.0045) and about 13% higher vital capacity volumes (1021 ± 410 mL vs. 907 ± 396 mL, p = 0.0093). Lower values for RSBI (53 ± 32 breaths/min/L vs. 69 ± 42 breaths/min/L, p < 0.001) and MIP (-41 ± 12 cmH2O vs. -38 ± 13 cm H2O), p = 0.0225) were seen in those with re-extubation success. Multivariable logistical regression demonstrates lack of independent associated between the change in parameters between the 2 attempts and re-extubation success. CONCLUSIONS: The relationship between the changes in extubation parameters through successive attempts is driven primarily by the value obtained immediately prior to re-extubation. These findings do not support waiting for an improvement in extubation parameters to extubate patients who failed a first attempt at extubation if extubation parameters are compatible with success.

The Association of Preoperative Hematocrit With Adverse Events Following Exploratory Laparotomy in Septic Patients: A Retrospective Analysis.

BACKGROUND: Sepsis continues to be the leading cause of death in intensive care units and surgical patients comprise almost one third of all sepsis patients. Anemia is a modifiable risk factor for worse postoperative outcomes in sepsis patients. Here we aim to evaluate the association of preoperative anemia and postoperative mortality in sepsis patients undergoing exploratory laparotomy. METHODS: The National Surgical Quality Improvement Program registry was used to query for preoperative sepsis patients undergoing exploratory laparotomy between 2014 and 2016. Preoperative hematocrit was stratified into 4 categories: ≥30% to polycythemia, <21%, 21 and less than 30%, and polycythemia. The primary outcome was 30-day mortality. Multivariable logistic regression was used to evaluate the association of preoperative hematocrit with primary and secondary endpoints. The multivariable analysis included preoperative hematocrit, gender, age, BMI, smoking status, functional status, hypertension, steroid use, bleeding disorder, and sepsis. The odds ratio (OR) with associated 95% confidence interval (CI) is reported for all outcomes. A p-value of less than <0.05 was considered statistically significant. RESULTS: The unadjusted 30-day death rate was the highest for patients with preoperative hematocrit <21% (p < 0.001) compared to the other hematocrit cohorts. The odds of 30-day death was significantly increased for patients with preoperative hematocrit <21% (OR 2.39 95% CI: 1.28-4.49, p = 0.006) and 21-30% (OR 1.35, 95% CI: 1.05 -1.72, p = 0.017) compared to patients with preoperative hematocrit of ≥30% and less than polycythemic ranges (reference cohort). CONCLUSION: Preoperative anemia in sepsis patients undergoing surgery can lead to increased mortality, postoperative complications, and length of hospital stay. Diagnosing sepsis early in the hospital course can allow physicians more time to titrate anticoagulation medications and treat preoperative anemia.

The Influence of Hospital Urbanicity on Mortality in Patients With Acute Respiratory Failure: A National Cohort Retrospective Analysis.

BACKGROUND: The primary objective of this study was to employ a national database to evaluate the association of hospital urbanicity, urban versus rural, on mortality and length of hospital stay in patients hospitalized with acute respiratory failure. METHODS: We used the 2014 National Inpatient Sample database to evaluate the association of hospital urbanicity with (1) mortality and (2) prolonged hospital stay, defined as ≥ 75th percentile of the study population. We conducted a mixed-effects logistic regression analysis adjusting for sociodemographic variables and medical comorbidities. The random effect was hospital identification number (a unique value assigned in the NIS database for a specific institution). The odds ratio (OR), 95% CI, and P values were reported for each independent variable. RESULTS: The odds of inpatient mortality were significantly higher among urban teaching (OR 1.39, 95% CI 1.39-1.66, P < .001) and urban nonteaching hospitals (OR = 1.39, 95% CI 1.26-1.52, P < .001) compared to rural hospitals. The odds of prolonged hospital stay were significantly higher among urban teaching (OR = 1.82, 95% CI 1.66-2.0, P < .001) and urban nonteaching compared to rural hospitals (OR = 1.50, 95% CI 1.36-1.65, P < .001). CONCLUSIONS: This study supports the current body of literature that there are significant differences in patient populations among hospital type. Differences in health outcomes among different types of hospitals should be considered when designing policies to address health equity as these are unique populations with specific needs.

A Point-Based Risk Calculator Predicting Mortality in Patients That Developed Postoperative Sepsis.

BACKGROUND: Predicting the mortality from post-operative sepsis remains a continuing problem. We built a statistical model using national data to predict mortality in patients who developed post-operative sepsis. METHODS: This is a retrospective study using the American College of Surgeons National Quality Surgical Improvement Program database, in which we gathered data from adult patients between 2011 and 2016 who experienced postoperative sepsis. We designed a predictive model using multivariable logistic regression on a training set and validated the model on a separate test set. RESULTS: There were 128,325 patients included in the final dataset, in which 18,499 (14.4%) died within 30-days of surgery. The model consisted of 10 covariates: American Society of Anesthesiologists Physical Status classification score, preoperative sepsis, age, chronic obstructive pulmonary disease, postoperative myocardial infarction, postoperative stroke, postoperative acute renal failure, transfusion requirement, and infection type. A point-based risk calculator was developed, which had an area under the receiver operating characteristics curve of 0.819 (95% confidence interval 0.814-0.823). CONCLUSION: Although further work is needed to confirm and validate our model on external datasets, our scoring system provides a novel way to measure mortality in septic post-operative patients.

Shoulder instability in the setting of bipolar (glenoid and humeral head) bone loss: the glenoid track concept.

BACKGROUND: An assortment of variables has been used in predicting anterior shoulder instability resulting from pathologic engagement of Hill-Sachs lesions on the glenoid. The glenoid track is a unique biomechanical model that relates both Hill-Sachs and bony Bankart lesions to predict shoulder engagement. We examined the glenoid track concept to determine if it provides a model that unifies glenoid rim and humeral head bone loss in predicting engagement. QUESTIONS/PURPOSES: In this review we addressed two questions: (1) How are humeral head and glenoid rim bony defects and their interactions quantified? (2) Why is the concept of the glenoid track important? METHODS: We performed a systematic review of the literature using PubMed (MEDLINE) and OVID for biomechanical studies and peer-reviewed articles published until March 2013. Twenty-four studies fit the inclusion criteria. These were subdivided into four anatomic studies, four studies quantifying glenohumeral bone loss, nine studies biomechanically defining shoulder engagement, six studies analyzing current treatment models, and one clinical study to be included in the final review. RESULTS: Data demonstrate pathologic engagement is dependent on the medial margin of the Hill-Sachs lesion traveling outside the glenoid track. The width of the glenoid track decreases accordingly if there is a glenoid defect, making engagement more likely. Most treatment models focus on widening the glenoid track before addressing Hill-Sachs lesions. CONCLUSIONS: The glenoid track uses both glenoid and humeral head bone loss to predict subsequent risk of humeral head engagement and possible dislocation. The glenoid track shows us that restoring the track to its natural width should be among the surgeon's first priority in restoring shoulder stability. Humeral head lesions, also known as Hill-Sachs lesions, are surgically addressed when they cause clinical symptoms. Symptoms arise when the medial margin of the defect engages the glenoid track.