Evaluating mortality and recovery of extreme hyperbilirubinemia in critically ill patients by phasing the peak bilirubin level: A retrospective cohort study.

BACKGROUND: Hyperbilirubinemia is a devastating complication in patients admitted to an intensive care unit (ICU). The sequential organ failure assessment (SOFA) score classifies hyperbilirubinemia without further detailed analyses for bilirubin increase above 12 mg/dL. We evaluated whether the level of bilirubin increase in patients with extreme hyperbilirubinemia (total bilirubin ≥ 12 mg/dL) affects and also helps estimate mortality or recovery. METHODS: A retrospective cohort analysis comprising 427 patients with extreme hyperbilirubinemia admitted to the ICU of Samsung Medical Center, Seoul, Korea between 2011 and 2015 was conducted. Extreme hyperbilirubinemia was classified into four grades: grade 1 (12-14.9 mg/dL), grade 2 (15-19.9 mg/dL), grade 3 (20-29.9 mg/dL), and grade 4 (≥ 30 mg/dL). These grades were then assessed for their association with hospital mortality and recovery from hyperbilirubinemia to SOFA grade (point) 2 or below (total bilirubin < 6 mg/dL). The influences of various factors, some of which caused extreme hyperbilirubinemia, while others induced bilirubin recovery, were assessed. RESULTS: A total of 427 patients (mean age: 59.8 years, male: 67.0%) were evaluated, and the hospital mortality for these patients was very high (76.1%). Extreme hyperbilirubinemia was observed in 111 (grade 1, 26.0%), 99 (grade 2, 23.2%), 131 (grade3, 30.7%), and 86 (grade 4, 20.1%) patients with mortality rates of 62.2%, 71.7%, 81.7%, and 90.7%, respectively (p < 0.001). The peak bilirubin value correlated with the mortality (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04-1.15, p < 0.001). Compared to those with grade 1 extreme hyperbilirubinemia, the mortality rate gradually increased as the grade increased (OR [95% CI]: 1.92 [0.70-5.28], 3.55 [1.33-9.48], and 12.47 [3.07-50.59] for grades 2, 3 and 4, respectively). The main causes of extreme hyperbilirubinemia were infection including sepsis and hypoxic hepatitis. The recovery from hyperbilirubinemia was observed in 110 (25.8%) patients. Mortality was lower for those who recovered from hyperbilirubinemia than for those who did not (29.1% vs. 92.4%, p < 0.001). The favorable factors of bilirubin recovery were albumin and ursodeoxycholic acid (UDCA). CONCLUSIONS: This study determined that the level of extreme hyperbilirubinemia is an important prognostic factor in critically ill patients. We expect the results of this study to help predict the clinical course of and determine the optimal treatment for extreme hyperbilirubinemia.

Application of Thromboelastographic Markers to Predict the Survival in Acute Trauma Patients.

BACKGROUND: The aim of the study is to investigate the coagulation status in trauma patients using thromboelastography and their association with survival and blood transfusion. METHODS: We included 452 trauma patients who visited the trauma center of Uijeongbu St. Mary's Hospital. The thromboelastography (TEG) clotting variables and routine coagulation tests were evaluated. Also, we investigated the transfusion requirement and mortality during hospitalization period. RESULTS: The mean age was 52.3 years and the mortality rate was 39/452 (8.6%). Lower GCS, longer TEG K-time, and lower TEG MA were independent factors associated with mortality. The lower MA group demonstrated the highest probability of survival (odds ratio 0.207), followed by prolonged R-time (odds ratio 0.220). The patient numbers in fibrinolysis shutdown (SD), physiologic fibrinolysis, and hyperfibrinolysis groups were 219 (52.3%), 131 (31.4%), and 68 (16.3%), respectively. The mortality rates of fibrinolysis SD group (11.9%) and hyperfibrinolysis (8.8%) were higher than the physiologic fibrinolysis groups (3.8%). The cutoff obtained from ROC analysis was found to be suitable for predicting survival. The transfusion requirements were significantly higher in the fibrinolysis SD group than in the other two groups. CONCLUSIONS: TEG based markers were shown to be more useful to make a diagnosis of coagulopathies including dysfibrinolysis and predict the survival than routine coagulation tests. Dysfunctional fibrinolysis showed higher mortality than physiologic group. If multiple integrations of each TEG markers are used, it would be helpful for prompt diagnosis and management of coagulopathies and to decrease preventable deaths in trauma.

Applicability of the masseter muscle as a nutritional biomarker.

Nutritional assessment is feasible with computed tomography anthropometry. The abdominal muscle at the L3 vertebra is a well-known nutritional biomarker for predicting the prognosis of various diseases, especially sarcopenia. However, studies on nutritional assessment of the brain using computed tomography are still scarce. This study aimed to investigate the applicability of the masseter muscle as a nutritional biomarker.Patients who underwent simultaneous brain and abdominopelvic computed tomography in the emergency department was retrospectively analyzed. We assessed their masseter muscle 2 cm below the zygomatic arch and abdominal muscle at L3 via computed tomography anthropometry. The skeletal muscle index, prognostic nutritional index, and other nutritional biomarkers were assessed for sarcopenia using the receiver operating characteristic curve analysis.A total of 314 patients (240 men and 72 women) were analyzed (mean age, 50.24 years; mean areas of the masseter and abdominal muscles, 1039.6 and 13478.3 mm, respectively). Masseter muscle areas significantly differed in sarcopenic, obese, and geriatric patients (P < .001). The areas under the curve of the masseter muscle in sarcopenic, geriatric, and obese patients were 0.663, 0.686, and 0.602, respectively. Multivariable linear regression analysis showed a correlation with the abdominal muscle area, weight, and age.The masseter muscle, analyzed via computed tomography anthropometry, showed a statistically significant association with systemic nutritional biomarkers, and its use as a nutritional biomarker would be feasible.

Clinical impact of massive transfusion protocol implementation in non-traumatic patients.

BACKGROUND: Massive transfusion protocol (MTP) has been used to provide plasma and packed red blood cells (pRBCs) rapidly. MTP also has been adapted for non-traumatic patients. The effects of hospital-wide MTP implementation on clinical outcomes were reviewed. METHODS: This was a retrospective study of patients who received massive transfusion before and after MTP implementation, between August 2010 and May 2018. Massive transfusion was defined as 10 or more units of pRBCs within 24 h. Recipients of massive transfusion were divided into periods before and after MTP implementation. The 24 -h death rate, thirty-day death rate and several laboratory findings were investigated. RESULTS: Eighty patients whose massive transfusion occurred before MTP implementation and 63 patients whose massive transfusion occurred after MTP implementation were compared. No statistically significant difference was found in 24 -h death rate (15.0% vs. 23.8%, p = 0.181), or 30-day death rate (43.8% vs. 36.5%, p = 0.381). Use of an anti-fibrinolytic agent was more frequent in patients after the MTP implementation (31.3% vs. 55.6%, p = 0.003). A statistically significant difference was found in the lowest body temperature of the two groups during the 24 -h period (34.7 °C vs. 35.6 °C, p < 0.001). Transfusion ratio of plasma to pRBC was numerically improved after the MTP implementation (1:1.91 vs. 1:1.58, p = 0.173). Earlier initiation of pRBC transfusion was achieved after implementation (51 min vs. 40 min, p = 0.042). CONCLUSIONS: MTP implementation showed improved coagulation profiles, but did not show a statistically significant death-rate reduction in non-traumatic patients.

Correction: Readmission and hospital mortality after ICU discharge of critically ill cancer patients.

[This corrects the article DOI: 10.1371/journal.pone.0211240.].

Readmission and hospital mortality after ICU discharge of critically ill cancer patients.

BACKGROUND: Intensive care unit (ICU) readmission is generally associated with increased hospital stays and increased mortality. However, there are limited data on ICU readmission in critically ill cancer patients. METHOD: We conducted a retrospective cohort study based on the prospective registry of all critically ill cancer patients admitted to the oncology medical ICU between January 2012 and December 2013. After excluding patients who were discharged to another hospital or decided to end-of-life care, we divided the enrolled patients into four groups according to the time period from ICU discharge to unexpected events (ICU readmission or ward death) as follows: no (without ICU readmission or death, n = 456), early (within 2 days, n = 42), intermediate (between 2 and 7 days, n = 64), and late event groups (after 7 days of index ICU discharge, n = 129). The independent risk factors associated with ICU readmission or unexpected death after ICU discharge were also analyzed using multinomial logistic regression model. RESULTS: There were no differences in the reasons for ICU readmission across the groups. ICU mortality did not differ among the groups, but hospital mortality was significantly higher in the late event group than in the early event group. Mechanical ventilation during ICU stay, tachycardia, decreased mental status, and thrombocytopenia on the day of index ICU discharge increased the risk of early ICU readmission or unexpected ward death, while admission through the emergency room and sepsis and respiratory failure as the reasons for index ICU admission were associated with increased risk of late readmission or unexpected ward death. Interestingly, recent chemotherapy within 4 weeks before index ICU admission was inversely associated with the risk of late readmission or unexpected ward death. CONCLUSION: In critically ill cancer patients, patient characteristics predicting ICU readmission or unexpected ward death were different according to the time period between index ICU discharge and the events.

Antibiotic use in patients with abdominal injuries: guideline by the Korean Society of Acute Care Surgery.

PURPOSE: A task force appointed by the Korean Society of Acute Care Surgery reviewed previously published guidelines on antibiotic use in patients with abdominal injuries and adapted guidelines for Korea. METHODS: Four guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. Five topics were considered: indication for antibiotics, time until first antibiotic use, antibiotic therapy duration, appropriate antibiotics, and antibiotic use in abdominal trauma patients with hemorrhagic shock. RESULTS: Patients requiring surgery need preoperative prophylactic antibiotics. Patients who do not require surgery do not need antibiotics. Antibiotics should be administered as soon as possible after injury. In the absence of hollow viscus injury, no additional antibiotic doses are needed. If hollow viscus injury is repaired within 12 hours, antibiotics should be continued for ≤ 24 hours. If hollow viscus injury is repaired after 12 hours, antibiotics should be limited to 7 days. Antibiotics can be administered for ≥7 days if hollow viscus injury is incompletely repaired or clinical signs persist. Broad-spectrum aerobic and anaerobic coverage antibiotics are preferred as the initial antibiotics. Second-generation cephalosporins are the recommended initial antibiotics. Third-generation cephalosporins are alternative choices. For hemorrhagic shock, the antibiotic dose may be increased twofold or threefold and repeated after transfusion of every 10 units of blood until there is no further blood loss. CONCLUSION: Although this guideline was drafted through adaptation of other guidelines, it may be meaningful in that it provides a consensus on the use of antibiotics in abdominal trauma patients in Korea.

Risk factor of benign paroxysmal positional vertigo in trauma patients: A retrospective analysis using Korean trauma database.

Benign paroxysmal positional vertigo (BPPV) is a comorbid condition prevalent in patients recovering from trauma. Due to the paucity of studies investigating the etiology of this condition, the present study sought to analyze the high-risk group of BPPV patients following trauma.Trauma patients visiting the emergency department from January to December 2016 were enrolled. The study excluded patients with minor superficial injuries, those who were dead, and those discharged within 2 days after their visit. The medical records were reviewed, and every abbreviated injury score, injury severity score, and other clinical characteristics, such as age and sex, were gathered. A diagnosis of BPPV was reached only after a provocation test was administered by an otolaryngologist. The correlation was statistically analyzed.A total of 2219 trauma patients were analyzed. The mean age of the patients was 52.6 years, and the mean injury severity score (ISS) was 7.9. About 70% of the patients were men. Additional BPPV patients were identified among patients with injuries to head and neck, chest, and abdomen, and those with external injuries. However, patients with head and neck (odds ratio [OR] (95% confidence interval [CI]) = 10.556 (1.029-108.262), and abdominal injury (OR [95% CI] = 78.576 [1.263-4888.523]) showed statistically significant correlation with BPPV in the logistic regression analysis. Patients-not only those with head and neck injuries but those with abdominal injuries-who complain of dizziness need to be evaluated for BPPV using provocation tests. Further studies investigating traumatic BPPV are needed.

Preoperative statins are associated with a reduced risk of postoperative delirium following vascular surgery.

Delirium is a common complication of vascular surgery. The protective effect of preoperative statins on delirium after vascular surgery is controversial. The authors hypothesized that preoperative statin administration would decrease the incidence of delirium after vascular surgery. From May 2010 to May 2015, 1,132 patients underwent vascular surgery. Postoperative delirium was diagnosed from patients' medical records. The incidence of delirium was 11.5%. The preoperative statin exposure was not associated with reduced delirium in the univariate analysis. After adjusting for covariates, preoperative statin exposure was associated with reduced delirium (OR, 0.54; 95% CI, 0.33-0.87; p = 0.011). This favor effect of statin for delirium was observed after propensity matching (OR, 0.59; 95% CI, 0.34-1.02; p = 0.060). However, the median hospital lengths of stay and in-hospital mortality were not statistically different between the two groups. CRP(C-reactive protein) levels in the unmatched population were lower in the preoperative statin group compared with the other group (p<0.001), however, there was only numerically different without statistical difference after matching (p = 0.083). Preoperative statin use was associated with a decreased incidence of postoperative delirium in patients who underwent vascular surgery. However, preoperative statin did not reduce mortality rate and hospital stay.

Classification and regression tree model for predicting tracheostomy in patients with traumatic cervical spinal cord injury.

PURPOSE: In patients with cervical spinal cord injury (CSCI), respiratory compromise and the need for tracheostomy are common. The purpose of this study was to identify common risk factors for tracheostomy following traumatic CSCI and develop a decision tree for tracheostomy in traumatic CSCI patients without pulmonary function test. METHODS: Data of 105 trauma patients with CSCI admitted in our institution from April, 2008 to February, 2014 were retrospectively analyzed. Patients who underwent tracheostomy were compared to those who did not. Stepwise logistic regression analysis and classification and regression tree model were used to predict the risk factors for tracheostomy. RESULTS: Tracheostomy was performed in 20% of patients with traumatic CSCI on median hospital day 4. Patients who underwent tracheostomy tended to be more severely injured (higher Injury Severity Score, lower Glasgow Coma Score, and lower systolic blood pressure on admission) which required more frequent intubation in the emergency room (ER) with a higher rate of complete CSCI compared to those who did not. Upon multiple logistic analysis, Age ≥ 55 years (OR: 6.86, p = 0.037), Car accident (OR: 5.8, p = 0.049), injury above C5 (OR: 28.95, p = 0.009), ISS ≥ 16 (OR: 12.6, p = 0.004), intubation in the ER (OR: 23.87, p = 0.001), and complete CSCI (OR: 62.14, p < 0.001) were significant predictors for the need of tracheostomy after CSCI. These factors can predict whether a new patient needs future tracheostomy with 91.4% accuracy. CONCLUSIONS: Age ≥ 55 years, injury above C5, ISS ≥ 16, Car accident, intubation in the ER, and complete CSCI were independently associated with tracheostomy after CSCI. CART analysis may provide an intuitive decision tree for tracheostomy.

Association of body mass index with clinical outcomes for in-hospital cardiac arrest adult patients following extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Obesity might be associated with disturbance of cannulation in situation of extracorporeal cardiopulmonary resuscitation (ECPR). However, limited data are available on obesity in the setting of ECPR. Therefore, we investigated the association between body mass index (BMI) and clinical outcome in patients underwent ECPR. METHODS: From January 2004 to December 2013, in-hospital cardiac arrest patients who had ECPR were enrolled from a single-center registry. We divided patients into four group according to BMI defined with the WHO classification (underweight, BMI < 18.5, n = 14; normal weight, BMI = 18.5-24.9, n = 118; overweight, BMI = 25.0-29.9, n = 53; obese, BMI ≥ 30, n = 15). The primary outcome was survival to hospital discharge. RESULTS: Analysis was carried out for a total of 200 adult patients (39.5% females). Their median BMI was 23.20 (interquartile range, 20.93-25.80). The rate of survival to hospital discharge was 31.0%. There was no significant difference in survival to hospital discharge among the four groups (underweight, 35.7%; normal, 31.4%; overweight, 30.2%; obese, 26.7%, p = 0.958). Neurologic outcomes (p = 0.85) and procedural complications (p = 0.40) were not significantly different among the four groups either. SOFA score, initial arrest rhythm, and CPR to extracorporeal membrane oxygenation (ECMO) pump on time were significant predictors for survival to discharge, but not BMI. CONCLUSION: BMI was not associated with in-hospital mortality who underwent ECPR. Neurologic outcomes at discharge or procedural complications following ECPR were not related with BMI either.

The impact of implementation of an enteral feeding protocol on the improvement of enteral nutrition in critically ill adults.

BACKGROUND AND OBJECTIVES: The optimal delivery of enteral nutrition (EN) may improve clinical outcomes in critically ill patients; thus, optimal EN protocols should be developed. The purpose of this study was to evaluate the impact of implementing an EN protocol on the improvement of EN practices and on the clinical outcomes of critically ill patients. METHODS AND STUDY DESIGN: This was a retrospective study with prospectively collected data. Multidisciplinary working group developed an evidence-based EN protocol based on an extensive review of literature and existing guidelines. Subjects included patients consecutively admitted to the ICU who received EN for more than 24 hours. EN practices and clinical outcomes were compared before and after implementation of the protocol. RESULTS: A total of 270 patients were included, 134 patients before implementation and 136 after implementation of the protocol. EN was initiated earlier (35.8 vs 87.1 hours, p=0.001) and more patients received EN within 24 hours (59.6% vs 41.0%, p=0.002) after implementation of the protocol. The interval between starting EN and reaching the caloric goal was not different, but more patients reached the caloric goal after implementation (52.2% vs 38.3%, p=0.037). The post-implementation group was given more prokinetics and less parenteral nutrition. The incidences of diarrhea and gastrointestinal bleeding significantly decreased following implementation of the protocol. There was no difference in clinical outcomes including in-hospital mortality and length of hospital and ICU stay. CONCLUSION: The implementation of the EN protocol significantly improved the practices of EN and decreased complications in critically ill patients. Clinical outcomes were not different before and after implementation.

Clinical usefulness of capnographic monitoring when inserting a feeding tube in critically ill patients: retrospective cohort study.

BACKGROUND: It is not rare for a small-bore feeding tube to be inserted incorrectly into the respiratory system in critically ill patients. Thus, monitoring is necessary to prevent respiratory malplacement of the tube. We investigated the utility of capnographic monitoring to prevent respiratory complications due to feeding tube mispositioning in critically ill patients. METHODS: This study was a pre and post-interventional study, including 445 feeding tube placements events studied retrospectively in the medical and surgical intensive care units of the Samsung Medical Center. We compared outcomes between time periods before and after capnographic monitoring and documented any respiratory complications. RESULTS: Feeding tubes were inserted in 275 cases without capnographic monitoring. Capnographic monitoring was performed in 170 cases. Sixteen patients (4%) had respiratory complications of all tube placements. Feeding tube was inserted into the trachea in 11 (2%) patients and for a pneumothorax in five (1%) patients. Fourteen cases of respiratory complications were detected in the control group (14/275, 5%, 10 tracheal insertions and four pneumothoraxes). Two respiratory complications were detected in the capnographic monitoring group (2/170, 1%, one tracheal insertion and one pneumothorax). Respiratory complications were detected less frequently in the capnographic monitoring group than that in the control group (P = 0.035). CONCLUSIONS: Capnographic monitoring is simple, easy to learn, and may be useful to prevent respiratory complications when placing a feeding tube in a critically ill patient.

Survival After Extracorporeal Cardiopulmonary Resuscitation on Weekends in Comparison With Weekdays.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) requires urgent decision-making and high-quality skills, which may not be uniformly available throughout the week. Few data exist on the outcomes of patients with cardiac arrest who receive in-hospital ECPR on the weekday versus weekend. Therefore, we investigated whether the outcome differed when patients with in-hospital cardiac arrest received ECPR during the weekend compared with a weekday. METHODS: Two hundred patients underwent extracorporeal membrane oxygenation after in-hospital cardiac arrest between January 2004 and December 2013. Patients treated between 0800 on Monday to 1759 on Friday were considered to receive weekday care and patients treated between 1800 on Friday through 0759 on Monday were considered to receive weekend care. RESULTS: A total of 135 cases of ECPR for in-hospital cardiac arrest occurred during the weekday (64 during daytime hours and 71 during nighttime hours), and 65 cases occurred during the weekend (39 during daytime/evening hours and 26 during nighttime hours). Rates of survival to discharge were higher with weekday care than with weekend care (35.8% versus 21.5%, p = 0.041). Cannulation failure was more frequent in the weekend group (1.5% versus 7.7%, p = 0.038). Complication rates were higher on the weekend than on the weekday, including cannulation site bleeding (3.0% versus 10.8%, p = 0.041), limb ischemia (5.9% versus 15.6%, p = 0.026), and procedure-related infections (0.7% versus 9.2%, p = 0.005). CONCLUSIONS: ECPR on the weekend was associated with a lower survival rate and lower resuscitation quality, including higher cannulation failure and higher complication rate.

Surgical Outcomes of a Modified Infarct Exclusion Technique for Post-Infarction Ventricular Septal Defects.

BACKGROUND: Postinfarction ventricular septal defects (pVSDs) are a serious complication of acute myocardial infarctions. The aim of this study was to analyze the clinical outcomes of the surgical treatment of pVSDs. METHODS: The medical records of 23 patients who underwent operations (infarct exclusion in 21 patients and patch closure in two patients) to treat acute pVSDs from 2001 to 2011 were analyzed. Intra-aortic balloon counter-pulsation was performed in 19 patients (82.6%), one of whom required extracorporeal membrane support due to cardiogenic shock. The mean follow-up duration was 26.2±18.6 months. RESULTS: The in-hospital mortality rate was 4.3% (1/23). Residual shunts were found in seven patients and three patients required reoperation. One patient needed reoperation due to the transformation of an intracardiac hematoma into an abscess. No patients required reoperation due to recurrence of a ventricular septal defect during the follow-up period. The cumulative survival rate was 95.5% at one year, 82.0% at five years, and 65.6% at seven years. CONCLUSION: The use of a multiple-patch technique with sealants appears to be a reliable method of reducing early mortality and the risk of significant residual shunting in patients with pVSDs.

Effect of Early Intervention on Long-Term Outcomes of Critically Ill Cancer Patients Admitted to ICUs.

OBJECTIVES: The objective of this observational study was to evaluate whether early intervention was associated with improved long-term outcomes in critically ill patients with cancer. DESIGN: Retrospective analysis with prospectively collected data. SETTING: A university-affiliated, tertiary referral hospital. PATIENTS: Consecutive critically ill cancer patients who were managed by a medical emergency team before ICU admission between January 2010 and December 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the study period, 525 critically ill cancer patients were admitted to the ICU with respiratory failure (41.7%) and severe sepsis or septic shock (40.6%) following medical intervention by a medical emergency team. Of 356 ICU survivors, 161 (45.2%) received additional treatment for cancer after ICU discharge. Mortality was 66.1% at 6 months and 72.8% at 1 year. Median time from physiological derangement to intervention before ICU admission was significantly shorter in 1-year survivors (1.3 hr; interquartile range, 0.5-4.8 hr) than it was in nonsurvivors (2.9 hr; interquartile range, 0.8-9.6 hr) (p< 0.001). Additionally, the early intervention (≤ 1.5 hr) group had a lower 30-day mortality rate than the late intervention (> 1.5 hr) group (29.0% vs 55.3%; p < 0.001) and a similar difference in mortality rate was observed up to 1 year. Other factors associated with 1-year mortality were illness severity, performance status, malignancy status, presence of more than three abnormal physiological variables, time from derangement to ICU admission, and the need for mechanical ventilation. Even after adjusting for potential confounding factors, early intervention was significantly associated with 1-year mortality (adjusted hazard ratio, 0.456; 95% CI, 0.348-0.597; p < 0.001). CONCLUSION: Early intervention for clinical derangement on general wards was significantly associated with long-term outcomes in critically ill cancer patients.

Risk factors for acquisition of multidrug-resistant bacteria in patients with anastomotic leakage after colorectal cancer surgery.

PURPOSE: The risk factors for acquiring an infection with multidrug-resistant (MDR) bacteria in patients with anastomotic leakage after colorectal cancer surgery are poorly understood. We evaluated the risk factors associated with the initial acquisition of MDR pathogens in patients with anastomotic leakage after colorectal cancer surgery. METHODS: This study was a retrospective review of prospectively collected data at a university affiliated-tertiary referral hospital in South Korea. From January 2009 to April 2013, a total of 6767 consecutive patients with colorectal cancer who underwent surgery were registered. Of these patients, 190 (2.8%) were diagnosed with anastomotic leakage. Finally, 143 (2.1%) patients with culture test results were included in this study. RESULTS: Of the 143 enrolled patients, 46 (32.2%) were classified in the MDR group. The use of antibiotics for more than 5 days before diagnosis of anastomosis site leakage (p = 0.016) and diabetes mellitus (p = 0.028) was identified as independent risk factors for MDR acquisition by multivariate analysis. The rate of adequate initial empirical antibiotic therapy in the MDR group was lower than in the non-MDR group (35 vs. 75%, p < 0.001). Furthermore, the duration of antibiotic administration after the leak was longer in the MDR group (p = 0.013). Patients in the MDR group also had a longer hospital stay (p = 0.012). CONCLUSIONS: The length of antibiotic administration before the diagnosis of anastomotic leakage and diabetes mellitus were risk factors associated with the acquisition of MDR bacteria in patients with anastomotic leakage after colorectal cancer surgery.

Predictors of neurological outcomes after successful extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) refers to use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary arrest. Although ECPR can increase survival rates after cardiac arrest, it can also result in poor post-resuscitation neurological status. Thus, we investigated predictors of good neurological outcomes after successful ECPR. METHODS: A total of 227 patients underwent ECPR from May 2004 to June 2013 at Samsung Medical Center. Successful ECPR was defined as survival more than 24 hours after ECPR. Neurological outcomes were assessed at discharge using the Glasgow-Pittsburgh Cerebral Performance Categories scale (CPC). CPC 1 and 2 were classified as good and CPC 3 to 5 were classified as poor neurological outcomes. Excluded were 22 patients who did not survive more than 24 hours after ECPR and 90 patients who died from unknown causes or causes other than brain death or whose neurological status could not be assessed at discharge. Multiple logistic regression analysis was used to identify independent predictors of neurological outcomes. RESULTS: Included were 115 patients with a mean age of 58 (range 45-66) years and 80 men (70%). Cardiopulmonary resuscitation (CPR) was performed at non-hospital sites for 19 (17%) patients and bystander CPR was performed in 9 of 19 cases (47%). Cardiac etiology was verified in 74 (64%) patients and therapeutic hypothermia was performed in 9 patients (8%); 68 (59%) had good neurological outcomes and 47 (41%) did not and 24 patients died from brain death. Neurological outcomes were affected by hemoglobin levels before ECMO (P = 0.02), serum lactic acid (P < 0.001) before ECMO insertion, and interval from cardiac arrest to ECMO (P = 0.04). CONCLUSIONS: Low hemoglobin or high serum lactic acid levels before ECMO, and prolonged interval from cardiac arrest to ECMO predicted poor neurological outcomes after successful ECPR. Early institution of ECMO and a low threshold for blood transfusion might improve neurological outcomes for patients who survive ECPR.

Impact of a surgical intensivist on the clinical outcomes of patients admitted to a surgical intensive care unit.

PURPOSE: An intensivist is a key factor in the mortality of patients admitted to the intensive care unit (ICU). The aim of this study was to evaluate the effect of an intensivist on clinical outcomes of patients admitted to a surgical ICU. METHODS: During the study period, the surgical ICU was converted from an open ICU to an intensivist-directed ICU managed by an intensivist who was board certified in both general surgery and critical care medicine. We compared consecutive patients admitted to the surgical ICU before and after implementing the intensivist-directed care. The primary outcome was ICU mortality, and secondary outcomes were hospital mortality, 90-day mortality, length of hospital stay, ICU-free days, ventilator-free days, and ICU readmission rate. RESULTS: A total of 441 patients were included in this study: 188 before implementation of the intensivist and 253 after implementation. Clinical characteristics were not different between the two groups. ICU mortality decreased from 11.7% to 6.3% (P = 0.047) after implementation, and 90-day mortality also decreased significantly (P = 0.008). The adjusted hazard ratio of the intensivist for ICU mortality was 0.43 (95% confidence interval, 0.22-0.87; P = 0.020). ICU-free days (P = 0.013) and the hospital length of stay (P = 0.032) were significantly improved after implementing the intensivist-directed care. Before implementation period, 16.0% of patients were readmitted, compared with only 9.9% after implementation (P = 0.05). CONCLUSION: Implementing intensivist-directed care in the surgical ICU was associated with significant improvements in ICU mortality and significant clinical outcomes.