Clinical Outcomes and Left Ventricular Functional Remodeling after Extracorporeal Membrane Oxygenation Assisted Percutaneous Coronary Intervention in Patients with Ischemic Cardiomyopathy: A Single-Center Retrospective Observational Study of 76 Cases.

Background: Ischemic cardiomyopathy (ICM) is a common condition that leads to left ventricular (LV) functional remodeling and poor prognosis. Extracorporeal membrane oxygenation (ECMO) can provide temporary circulatory support and facilitate percutaneous coronary intervention (PCI) in patients with ICM and hemodynamic instability. However, the impact of ECMO-assisted PCI on LV functional remodeling and clinical outcomes in ICM patients is unclear. Methods: We retrospectively analyzed 76 patients with ICM who underwent ECMO-assisted PCI at our institution between January 2013 and December 2022. We assessed the changes in LV functional remodeling using echocardiography at baseline and 12 months after the procedure. We also evaluated the incidence of major adverse cardiac and cerebrovascular events (MACCEs) and ECMO-related complications during hospitalization and at one-year follow-up. Results: The mean baseline left ventricular ejection fraction (LVEF) was 29.98 ± 2.65%. The rate of complete revascularization was 58%. The median duration of ECMO support was 38.99 hours. The most common ECMO-related complications were bleeding (8%) and lower extremity ischemia (5%). The one-year mortality rate was 30%. The overall freedom from MACCEs at 12 months was 59% (95% confidence interval (CI): 49-71%). LVEF increased significantly after the procedure from baseline to 6 months, yet decreased slightly at 12 months, although it was still higher than the baseline value. Wall motion score index (WMSI), end-diastolic volume index (EDVI), and end-systolic volume index (ESVI) decreased significantly from baseline to 12 months, indicating an improvement in LV function and a reduction in LV size. Conclusions: In a high-volume tertiary center with extensive experience in advanced heart failure therapies and a dedicated ECMO team, ECMO-assisted PCI demonstrated feasibility and safety in patients with ischemic cardiomyopathy. However, the rate of complete revascularization was modest at 58%. Despite the high-risk profile of the patients, ECMO-assisted PCI was associated with a significant improvement in LV functional remodeling and a favorable 12-month survival rate. Further prospective studies are needed to confirm these findings and to identify the optimal patient and device selection criteria for ECMO-assisted PCI.

Prognostic Survey of ECPELLA in Japanese Patients With Acute Myocardial Infarction and Cardiogenic Shock　- Findings From the Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD).

BACKGROUND: The short-term mortality associated with veno-arterial extracorporeal membrane oxygenation combined with the Impella device (termed ECPELLA) for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains unclear. METHODS AND RESULTS: The Japanese Registry for Percutaneous Ventricular Assist Devices (J-PVAD) includes data on all patients treated with an Impella in Japan. We extracted data for 922 AMI-CS patients who underwent ECPELLA support and conducted an exploratory analysis focusing on 30-day mortality. The median age of patients was 69 years, and 83.8% were male. The overall 30-day mortality was 46.1%. Factors associated with mortality included age >80 years, in-hospital cardiac arrest, systolic blood pressure <90 mmHg, serum creatinine >1.5 mg/dL, and serum lactate >4.0 mmol/L. In patients aged >80 years with any of these factors, mortality was significantly higher than in those without, ranging from 57.5% to 64.9%. The J-PVAD score assigns 1 point per predictor, with a C-statistic of 0.620 (95% confidence interval 0.586-0.654). The 30-day mortality was 20.0% for a J-PVAD score of 0, increasing to 70.0% for a score of 5. CONCLUSIONS: The J-PVAD data indicate high short-term mortality in AMI-CS patients treated with ECPELLA, particularly among older patients. Further studies are needed to validate this risk stratification in this patient subset.

Extracorporeal membrane oxygenation in acute respiratory distress syndrome caused by elderly tuberculous meningitis: a case report and review of the literature.

Diagnosing and clinical management of tuberculous meningitis (TBM) are still challenging for clinicians. Analysis of cerebrospinal fluid (CSF) is an important diagnostic tool for patients with suspected central nervous system (CNS) diseases. Acute respiratory distress syndrome (ARDS), an inflammatory lung injury, can be treated by mechanical ventilation, fluid management, and even extracorporeal membrane oxygenation (ECMO). In addition, metagenomic next-generation sequencing (mNGS) can facilitate the detection of atypical, rare pathogens in clinical specimens. We report a case of a 65-year-old man with ARDS caused by TBM. He was admitted with a fever and shaking. Despite aggressive initial treatment, the patient progressed rapidly and developed ARDS. Without positive results of mNGS and culture, anti-tuberculosis (TB) treatment was started. In order to improve oxygenation levels, he was placed on veno-venous ECMO for 8 days. On day 47, the tracheotomy catheter was pulled out and sealed. The patient was conscious and could communicate with family members as normal.

Author Response: Oxygenation Indices in Adult COVID ARDS Patients.

How to cite this article: Vadi SMR, Sanwalka N, Suthar D. Author Response: Oxygenation Indices in Adult COVID ARDS Patients. Indian J Crit Care Med 2024;28(9):889.

Intravenous enoxaparin guided by anti-Xa in venovenous extracorporeal membrane oxygenation: A retrospective, single-center study.

BACKGROUND: Unfractionated heparin is used as the most common anticoagulation for venovenous extracorporeal membrane oxygenation (VV ECMO) patients. However, it is accompanied by frequent bleeding and thrombotic complications. The aim of the study was to demonstrate the feasibility of Enoxaparin anticoagulation for VV ECMO patients. METHODS: This study is a retrospective analysis of VV ECMO patients on continuous intravenous Enoxaparin anticoagulation. The primary outcome was the incidence of bleeding, thrombotic, and neurological complications during ECMO support. The secondary outcome was an analysis of secondary and primary hemostasis profiles. RESULTS: Data from 38 patients were analyzed in this study. The incidence of bleeding complications was 5.3%, for thrombotic complications it was 2.6% and for neurological (bleeding/ischemic events) complications it was 10.5%. The targeted anti-Xa activity of 0.4-0.6 IU/mL was achieved and maintained during whole ECMO period in 28 patients (73.8%), not affecting the hemocoagulation profile represented by APTT-r 1.15 ± 0.2, TT 18.67 ± 3.35 s, PT/INR 1.21 ± 0.19, fibrinogen 5.39 ± 1.49 g/L, antithrombin, and platelet count. Primary hemostasis pathology was diagnosed in all patients by PFA 200 tests Col/EPI 279 ± 38 s and Col/ADP 249 ± 66 s. The running time of ECMO was 7.8 ± 3.4 days. CONCLUSIONS: Enoxaparin anticoagulation appears to be feasible for VV ECMO patients without an increase in adverse events. Further larger-sampled and comparative studies are needed in the future to support our findings.

Association of Activated Clotting Time-Guided Anticoagulation with Complications during Extracorporeal Membrane Oxygenation Support: A Systematic Review and Meta-Analysis.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) requires systemic anticoagulation to reduce the risk of thromboembolic events. Despite its historic role, activated clotting time (ACT) remains a widely used heparin monitoring method. Systematic evidence on the association of ACT-guided monitoring with hemorrhagic or thromboembolic complications does not exist. DESIGN: Systematic literature review and meta-analysis (Scopus and PubMed, July 2023). SETTING: All cohort studies. PARTICIPANTS: Patients receiving ECMO support. INTERVENTION: Anticoagulation monitoring with ACT. MEASUREMENTS AND MAIN RESULTS: We identified 3,177 publications, with 8 studies reporting the average ACT values for patients with and without bleeding. Meta-analysis revealed no significant difference in the compared groups (SMD = 0.69; 95% CI -0.05 to 1.43, p = 0.069; I2 = 87.4%). Three studies (n = 117 patients) reported on the average ACT values for patients with thrombosis, without significant differences in ACT between patients with and without thrombosis (SMD = 0.47; 95% CI -0.50 to 1.44, p = 0.342; I2 = 81.1%). CONCLUSIONS: Even though ACT is a widely used heparin monitoring tool, the evidence on its association with hemorrhagic or thromboembolic events is still controversial and limited. Further studies are essential to elucidate the role of ACT in anticoagulation monitoring during ECMO support.

Ceftobiprole and Cefiderocol for Patients on Extracorporeal Membrane Oxygenation: The Role of Therapeutic Drug Monitoring.

INTRODUCTION: Limited data exist on therapeutic ranges for newer antimicrobials in the critically ill, with few pharmacokinetic studies including patients undergoing renal replacement therapy or extracorporeal membrane oxygenation (ECMO). CASE REPRESENTATION: These interventions can potentially alter the pharmacokinetic profile of antibiotics, resulting in therapeutic failures, antimicrobial resistance, or increased toxicity. In this report, we present two ECMO patients treated with cefiderocol and ceftobiprole, where therapeutic drug monitoring (TDM) aided in the successful treatment of severe infections. Antibiotic trough concentrations in both cases were consistent with previously reported therapeutic levels in critically ill and ECMO patients, meeting minimal inhibitory concentrations recommended by the European Committee on Antimicrobial Susceptibility Testing for the respective pathogens. CONCLUSION: Treatment might be suboptimal if doses are not adjusted based on physicochemical properties and extracorporeal support. In an era marked by highly resistant pathogens, these cases highlight the importance of timely access to real-time TDM for optimizing and individualizing antimicrobial treatment.

Comprehensive secondary analysis of thrombotic events in pediatric patients receiving extracorporeal membrane oxygenation: A prospective cohort study.

INTRODUCTION: This study aims to describe laboratory and clinical factors associated with thrombotic events during prolonged pediatric extracorporeal membrane oxygenation. METHODS: A secondary analysis of a multi-center prospective study performed between 2012 and 2014. Patients under the age of 19 years that received extracorporeal membrane oxygenation for at least 4 days of therapy were included (n = 385). Univariable analysis and binomial regression were performed to evaluate predictive factors of single and multiple thrombotic events. A posteriori scoring tool was created to categorize thrombotic event severity. RESULTS: Over 39% of children receiving prolonged ECMO experienced a thrombotic event (TE). Binomial regression demonstrated an association between higher transfused platelet volume (mL/kg) (OR 1.04, CI: 95% 1.01-1.06, p = 0.003), Anti-Xa (OR 5.38, CI: 95% 1.22-23.8, p = 0.026) and aPTT (OR 1.01, CI: 95% 1.00-1.02, p = 0.032) the day prior to TE. Patients experiencing multiple TEs were associated with higher platelet transfusion volume (mL/kg) (OR 1.08, CI: 95% 1.05-1.12, p =< 0.001), antithrombin III (OR 1.03, CI: 95% 1.01-1.04, p = 0.001) and aPTT (OR 1.02, CI: 95% 1.01-1.03, p = 0.009). Patients experiencing multiple thrombotic events had a higher risk of 28-day mortality based on a cumulative clot severity score >4 (OR 2.37 (CI: 95% 1.32-4.24). CONCLUSIONS: Current lab tests show limited sensitivity to predict these events the day prior in a vulnerable patient group, leading to potential ECMO circuit failures. Patients with multiple thrombotic events during ECMO therapy face increased mortality risks, highlighting the need for dynamic reporting tools like clot severity scores and detailed documentation of interventions to enhance understanding and improve outcomes.

Variable positive end-expiratory pressure in an experimental model of acute respiratory distress syndrome: an advanced ventilation modality.

Background: Introducing variability in tidal volume, ventilatory frequency, or both is beneficial during mechanical ventilation in acute respiratory distress syndrome (ARDS). We investigated whether applying cycle-by-cycle variability in the positive end-expiratory pressure (PEEP) exerts beneficial effect on lung function in a model of ARDS. Methods: Rabbits with lung injury were randomly allocated to receive mechanical ventilation for 6 h by applying a pressure-controlled mode with constant PEEP of 7 cm H2O (PC group: n=6) or variable PEEP (VEEP) with a coefficient of variation of 21.4%, range 4-10 cm H2O (PC-VEEP group; n=6). Lung oxygenation index (Pao2/FiO2) after 6 h of ventilation (H6) was the primary outcome and respiratory mechanics, lung volume, intrapulmonary shunt, and lung inflammatory markers were secondary outcomes. Results: After lung injury, both groups presented moderate-to-severe ARDS (Pao2/FiO2 <27 kPa). The Pao2/FiO2 was significantly higher in the PC-VEEP group than in the PC group at H6 (12.3 [sd 3.5] vs 19.2 [7.2] kPa, P=0.013) and a lower arterial partial pressure of CO2 at 1-3 h (P<0.02). The ventilation-induced increases in airway resistance and tissue elastance were prevented by PC-VEEP. There was no evidence for a difference in minute volume, driving pressure, end-tidal CO2, lung volumes, intrapulmonary shunt fraction, and cytokines between the ventilation modes. Conclusions: Prolonged mechanical ventilation with cycle-by-cycle VEEP prevents deterioration in gas exchange and respiratory mechanics in a model of ARDS, suggesting the benefit of this novel ventilation strategy to optimise gas exchange without increasing driving pressure and lung overdistension.

Case report: a co-occurring case of severe Mycoplasma pneumoniae pneumonia and Anti-IgLON5 antibody-associated encephalitis in a pediatric patient.

This case report details the clinical course of a 16-year-old female student with Mycoplasma pneumoniae infection complicated by autoimmune encephalitis, spanning from 6 February 2022, to 12 April 2022, with a one-year follow-up. The patient presented with a two-week history of cough and fever, followed by altered consciousness and neuropsychiatric symptoms, including hyperactivity and incoherent speech. Despite normal brain MRI findings, cerebrospinal fluid (CSF) analysis confirmed Mycoplasma pneumoniae with titers of, and positive IgLON5 antibodies. Initial treatment included azithromycin, ceftriaxone, and acyclovir, followed by mechanical ventilation and ECMO due to respiratory failure. The antibiotic regimen was switched to intravenous omadacycline based on genetic testing results. Autoimmune encephalitis was managed with intravenous methylprednisolone, intravenous immunoglobulin (IVIG), and plasma exchange. The patient's condition improved, and she was discharged on 12 March 2022, with normal cognitive and behavioral functions. However, she was readmitted one month later due to cognitive decline and sleep disturbances, with a Mini-Mental State Examination (MMSE) score of 20/30 and a modified Rankin Scale (mRS) score of 3. At the one-year follow-up, her MMSE score had improved to 28/30, and her mRS score was 1. This case underscores the importance of comprehensive diagnostic approaches and personalized treatment strategies in managing complex cases of mycoplasma-related infections and associated autoimmune conditions.

Traumatic cervical tracheal trunk complete rupture combined with cardiac arrest: A case report.

Traumatic main bronchus rupture is a relatively rare injury in thoracic trauma, which is extremely critical, with a mortality rate as high as 70% - 80%. The complete rupture and displacement of the traumatic cervical trachea can lead to asphyxia, hypoxia, and cardiac arrest, even death of the patient in a short time. We performed emergency surgery with the support of extracorporeal membrane oxygenation for a case of traumatic cervical tracheal trunk complete rupture and displacement combined with cardiac arrest and achieved a successful rescue. We summarized our experience and found that timely surgical reconstruction of the airway is the key to increasing the traumatic main bronchus rupture survival of patients.

Impact of sprint interval training on post-fatigue mitochondrial rate in professional boxers.

PURPOSE: Professional boxing is a sport that requires a high aerobic capacity to prevent fatigue and allow athletes to perform over 4-12 rounds. Typically, athletes will go into a heavy training period in a pre-bout camp lasting 6 to 9 weeks. This study investigates the impact of 3 weeks of repeated Wingate sprint interval training, performed on standard gym ergometer bikes, on skeletal muscle endurance and mitochondrial function. METHODS: Ten male professional boxers (age: 26 ± 4 years, height: 175 ± 5 cm, weight: 70 ± 5 kg) participated in the study. Baseline testing involved a NIRS monitor attached to the rectus femoris muscle prior to an incremental time to exhaustion test on a treadmill. After the treadmill test participants underwent a series of arterial occlusions to determine mitochondrial function post-volitional exhaustion. Participants then continued their own training for 3 weeks and then repeated baseline testing. After the second testing session, participants undertook three weekly sprint sessions consisting of 3 × 30 s maximal sprints with 60 s recovery. Testing was repeated 3 weeks later. RESULTS: The time to exhaustion increased by > 6% after 3 weeks of sprint interval training as compared to baseline and control (p < 0.05). Skeletal muscle oxygen saturation (SmO2) at exhaustion was increased by 5.5% after 3 weeks of sprint interval training as compared to baseline and control (p = 0.008). Skeletal muscle mitochondrial rate post exhaustion was increased by 160% after 3 weeks of sprint interval training as compared to baseline and control (p < 0.001). CONCLUSION: The study demonstrated that SIT led to increased incremental time to exhaustion, higher SmO2 levels at volitional exhaustion and increased mitochondrial rates in professional boxers. These findings suggest that SIT should be an integral part of a boxe's conditioning regimen to improve performance and safety within the ring.

Optimizing Congenital Diaphragmatic Hernia Repair on ECMO: Evaluating the Risk of Bleeding.

BACKGROUND: Institutions lack consensus on the management of patients with congenital diaphragmatic hernia (CDH) who are repaired on extracorporeal membrane oxygenation (ECMO). Our study aimed to evaluate risk factors associated with bleeding complications in patients with CDH repaired on ECMO. METHODS: A single-institution retrospective review evaluated all patients with CDH who underwent on-ECMO repair between January 2005 and December 2023. A significant bleeding complication post-repair was defined as bleeding necessitating re-operation. The association between preoperative factors and bleeding complications was evaluated. RESULTS: Forty-six patients were included. Bleeding complications developed in 11/46 (24%) patients. Birthweight (2.5 vs. 3.2 kg, p = 0.02), platelet count <100/mm3 (64% vs. 29%, p = 0.04), elevated blood urea nitrogen (BUN; 24.5 vs. 17.5 mg/dL, p = 0.05), and older age at repair (8 vs. 5 days, p = 0.04) were associated with bleeding. In univariate analysis, patients with platelets under 100/mm3 were more likely to develop a bleeding complication (OR = 4.4, p = 0.04). Patients who experienced a significant bleeding event experienced increased ECMO days (12 vs. 7 days, p < 0.01), ventilator days (31 vs. 18 days, p < 0.05), and lower survival to discharge (36% vs. 74%, p = 0.03). CONCLUSION: Among CDH patients undergoing repair on ECMO, those with lower birth weight, platelet counts under 100/mm3, elevated BUN, and older age at repair had an increased risk of a significant bleeding complication, resulting in more ECMO and ventilator days and higher mortality. Patients undergoing on-ECMO repair should have platelet count transfused to greater than 100/mm3. Patients at high risk for bleeding may benefit from early repair on ECMO. LEVEL OF EVIDENCE: Level III.

Repercussions of SARS-CoV-2 infection on intrapulmonary shunt in patients undergoing one-lung ventilation.

BACKGROUND: Hypoxic pulmonary vasoconstriction is the most important regulatory mechanism by which right-to-left shunts decrease during one-lung ventilation (OLV), but the effects of pulmonary microarterial thrombosis and impaired HPV after SARS-CoV-2 infection on intrapulmonary shunt during OLV remain unknown. The aim of this study was to observe the changes of intrapulmonary shunt in patients undergoing thoracoscopic partial pneumonectomy at different periods after SARS-CoV-2 infection compared with patients without SARS-CoV-2 infection history. METHODS: A total of 80 patients who underwent elective thoracoscopic partial lung resection and were classified as American Society of Anaesthesiologists (ASA) grades I-II were selected and divided into 4 groups (n = 20 in each group): patients not infected with SARS-CoV-2 (Group A), patients infected with SARS-CoV-2 for 5-8 weeks (Group B), patients infected with SARS-CoV-2 for 9-12 weeks (Group C), and patients infected with SARS-CoV-2 for 13-16 weeks (Group D). For all patients, the same anaesthesia method was adopted, and anaesthesia was maintained with propofol, remifentanil, and cisatracurium. Radial artery and mixed venous blood gases were measured at 10 min of two-lung ventilation (TLV), 15 min of one-lung ventilation (OLV15), and 30 min of OLV (OLV30) in the lateral recumbent position to calculate the intrapulmonary shunt. Multiple linear regression analysis was employed to investigate the association between intrapulmonary shunt and SARS-CoV-2 infection. RESULTS: Qs/Qt at TLV was significantly higher in Groups B and C than in Group A (P < 0.05), and PaO2 at TLV was significantly lower in Groups B and C than in Group A (P < 0.05). Qs/Qt values at OLV15 and OLV30 were significantly higher in Group B, C or D than in Group A (P < 0.05), and PaO2 values at OLV15 and OLV30 were significantly lower in Groups B, C or D than in Group A (P < 0.05). Multiple linear regression analysis revealed that SARS-CoV-2 infection (95%CI -4.245 to -0.679, P = 0.007) was an independent risk factor for increased intrapulmonary shunt during TLV, while SARS-CoV-2 infection (95%CI 0.124 to 3.661, P = 0.036), exacerbation of COVID-19 clinical classification (95%CI -5.203 to -1.139, P = 0.003), and persistent symptoms (95%CI -12.122 to -5.522, P < 0.001) were independent risk factors for increased intrapulmonary shunt during OLV after SARS-CoV-2 infection. CONCLUSION: SARS-CoV-2 infection increased intrapulmonary shunt and reduced oxygenation. Although oxygenation improved at TLV after 13-16 weeks of infection, intrapulmonary shunt and oxygenation under OLV took longer to recover. TRIAL REGISTRATION: Chinese Clinical Trial Registry, Retrospectively registered, Full date of first registration: 17/05/2023, Registration number: ChiCTR2300071539.

Cardiopulmonary bypass and VA-ECMO induced immune dysfunction: common features and differences, a narrative review.

Cardiopulmonary bypass (CPB) and veno-arterial extracorporeal membrane oxygenation are critical tools in contemporary cardiac surgery and intensive care, respectively. While these techniques share similar components, their application contexts differ, leading to distinct immune dysfunctions which could explain the higher incidence of nosocomial infections among ECMO patients compared to those undergoing CPB. This review explores the immune modifications induced by these techniques, comparing their similarities and differences, and discussing potential treatments to restore immune function and prevent infections. The immune response to CPB and ECMO involves both humoral and cellular components. The kinin system, complement system, and coagulation cascade are rapidly activated upon blood contact with the circuit surfaces, leading to the release of pro-inflammatory mediators. Ischemia-reperfusion injury and the release of damage-associated molecular patterns further exacerbate the inflammatory response. Cellular responses involve platelets, neutrophils, monocytes, dendritic cells, B and T lymphocytes, and myeloid-derived suppressor cells, all of which undergo phenotypic and functional alterations, contributing to immunoparesis. Strategies to mitigate immune dysfunctions include reducing the inflammatory response during CPB/ECMO and enhancing immune functions. Approaches such as off-pump surgery, corticosteroids, complement inhibitors, leukocyte-depleting filters, and mechanical ventilation during CPB have shown varying degrees of success in clinical trials. Immunonutrition, particularly arginine supplementation, has also been explored with mixed results. These strategies aim to balance the inflammatory response and support immune function, potentially reducing infection rates and improving outcomes. In conclusion, both CPB and ECMO trigger significant immune alterations that increase susceptibility to nosocomial infections. Addressing these immune dysfunctions through targeted interventions is essential to improving patient outcomes in cardiac surgery and critical care settings. Future research should focus on refining these strategies and developing new approaches to better manage the immune response in patients undergoing CPB and ECMO.

Effect of Delayed Surgery for Ventricular Septal Rupture on Postoperative Outcomes.

OBJECTIVES: The prognosis of ventricular septal rupture (VSR) after acute myocardial infarction remains poor; hence, surgical repair is essential. However, the appropriate timing for surgical intervention remains unclear. We aimed to compare the prognosis between early (<96 hours) and delayed (≥96 hours) surgery for VSR. METHODS: This single-center, retrospective cohort study used data from 49 patients who underwent VSR repair after acute myocardial infarction (AMI) between 2007 and 2022 at our institution. In-hospital and one-, three-, and 10-year mortality and major adverse cardiac and cerebrovascular events were compared between the early (group A) and delayed (group B) surgery after AMI. RESULTS: No significant differences were found between the patients' backgrounds of the two groups. The in-hospital mortality rates were 37.5 and 16.0% for groups A and B, respectively (P = 0.114). The overall survival rates estimated using Kaplan-Meier analysis were 66.5 ± 6.9, 58.2 ± 7.5, and 28.8 ± 10.6% after one, three, and 10 years, respectively. The mortality rates in group B at three (hazard risk ratio: 2.691; 95% confidence interval: 1.02-7.097) and 10 (hazard risk ratio: 2.575; 95% confidence interval: 1.125-5.891) years were significantly better than those in group A. Major adverse cardiac and cerebrovascular events were significantly different between the two groups at all time points. CONCLUSIONS: These results showed that patients who underwent surgery for VSR 96 hours after AMI had better long-term survival than those who underwent surgery within 96 hours.

Emergency medicine updates: Endotracheal intubation.

INTRODUCTION: Airway management including endotracheal intubation (ETI) is a key skill for emergency clinicians. Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the identification and management of patients requiring ETI. OBJECTIVE: This paper evaluates key evidence-based updates concerning ETI for the emergency clinician. DISCUSSION: ETI is commonly performed in the emergency department (ED) setting but has many nuanced components. There are several tools that have been used to predict a difficult airway which incorporate anatomic and physiologic features. While helpful, these tools should not be used in isolation. Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation, particularly with noninvasive ventilation in critically ill patients. Induction and neuromuscular blocking medications should be tailored to the clinical scenario. Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians. Recent literature suggests using a bougie during the first attempt. Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients requiring emergent intubation.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2022 Part I: Lung Transplantation.

These highlights focus on the research in lung transplantation (LTX) that was published in 2022 and includes the assessment and optimization of candidates for LTX, donor optimization, the use of organs from donation after circulatory death, and outcomes when using marginal or novel donors; recipient factors affecting LTX, including age, disease, the use of extracorporeal life support; and special situations, such as coronavirus disease2019, pediatric LTX, and retransplantation. The remainder of the article focuses on the perioperative management of LTX, including the perioperative risk factors for acute renal failure (acute kidney injury); the incidence and management of phrenic nerve injury, delirium, and pain; and the postoperative management of hyperammonemia, early postoperative infections, and the use of donor-derived cell-free DNA to detect rejection.

Profiles of muscle-specific oxygenation responses and thresholds during graded cycling incremental test.

Compared to the determination of exercise thresholds based on systemic changes in blood lactate concentrations or gas exchange data, the determination of breakpoints based on muscle oxygen saturation offers a valid alternative to provide specific information on muscle-derived thresholds. Our study explored the profiles and timing of the second muscle oxygenation threshold (MOT2) in different muscles. Twenty-six cyclists and triathletes (15 male: age = 23 ± 7 years, height = 178 ± 5 cm, body mass = 70.2 ± 5.3 kg; 11 female: age = 22 ± 4 years, height = 164 ± 4 cm, body mass = 58.3 ± 8.1 kg) performed a graded exercise test (GXT), on a cycle ergometer. Power output, blood lactate concentration, heart rate, rating of perceived exertion, skinfolds and muscle oxygen saturation were registered in five muscles (vastus lateralis, biceps femoris, gastrocnemius medialis, tibialis anterior and triceps brachii) and percentage at which MOT2 occurred for each muscle was determinated using the Exponential Dmax. The results of Statistical Parametric Mapping and ANOVA showed that, although muscle oxygenation displayed different profiles in each muscle during a GXT, MOT2 occurred at a similar percentage of the GXT in each muscle (77% biceps femoris, 75% tibalis anterior, 76% gastrocnemius medialis and 72% vastus lateralis) and it was similar that systemic threshold (73% of the GXT). In conclusion, this study showed different profiles of muscle oxygen saturation in different muscles, but without notable differences in the timing for MOT2 and concordance with systemic threshold. Finally, we suggest the analysis of the whole signal and not to simplify it to a breakpoint.