A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial.

Aims and background: The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery. Materials and methods: This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to -1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay. Results: 108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups. Conclusion: This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate. How to cite this article: Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, et al. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024;28(5):467-474.

Gallstone Pancreatitis and Choledocholithiasis: Using Imaging and Laboratory Trends to Predict the Likelihood of Persistent Stones at Cholangiography.

BACKGROUND: Patients with gallstone pancreatitis (GP) or choledocholithiasis (CDL) may have common bile duct (CBD) stones that persist until cholangiography. The aim of this study is to evaluate pre-cholangiogram factors that predict persistent CBD stones. METHODS: Multiple logistic regression analyses were performed to identify demographic, laboratory, and radiologic predictors of persistent CBD stones and non-therapeutic cholangiography among adults with GP or CDL. RESULTS: In 152 patients from 2010 to 2015, preoperative diagnosis, presence of a CBD stone on US, and age ≥ 60 years were associated with persistent CBD stones. Two risk factors alone had a PPV of 88% and the absence of all risk factors had a NPV of 94%. Age < 60 years and the absence of a CBD stone on US were most predictive of non-therapeutic cholangiography. CONCLUSION: Age, LFTs, and US help predict persistent CBD stones in patients initially presenting with GP or CDL and help minimize non-therapeutic preoperative cholangiography.

Outcome of patients receiving CPR in the ED of an urban academic hospital.

BACKGROUND: The success of Closed Chest Cardiopulmonary Resuscitation (CC-CPR) degrades with prolonged times. Open Chest CPR (OC-CPR) is an alternative that may lead to superior coronary and cerebral perfusion. It is critical to determine when continued CC-CPR is unlikely to be successful to justify initiating OC-CPR as rescue therapy. The purpose of this study is to review CC-CPR outcomes to define a time threshold for attempting OC-CPR. METHODS: We identified all adult non-trauma patients diagnosed with cardiac arrest, ventricular fibrillation, ventricular tachycardia and asystole from 1/1/10-12/31/14. We collected demographics, cardiac rhythm, resuscitation duration, survival to hospital discharge and neurological outcome. Using time to ROSC after ED arrival and good neurological outcome, we explored various times as triggers for attempting OC-CPR. RESULTS: Among 242 cases of CPR, 205 cases were out-of-hospital cardiac arrest (OHCA). Mean age was 63.7 (±16.9),woman comprised 29.8% (72/242), and median prehospital CPR time was 30 min (20-44). Patients suffering ED arrest had improved ROSC (54.1% vs. 12.7%, p<0.001) and survival to hospital discharge rates (37.8% vs. 2.9%, p<0.001) compared to OHCA. Patients achieving ROSC had median total CPR duration of 18 minutes (10 minutes of pre-hospital CPR) compared with patients without ROSC who had 45 minutes (30 pre-hospital) respectively. No patient receiving > 10 minutes of CPR in the ED survived to hospital discharge. CONCLUSION: In patients suffering OHCA and requiring CC-CPR in the ED, overall survival rate to good neurologic function is low. OC-CPR could potentially be attempted after 10 minutes of CC-CPR in the ED.

Lactate Non-Clearance versus Lactate Clearance: A Comparison of Hospital Mortality in High-Risk Surgical Patients.

Objective: The optimal endpoints of resuscitation in high-risk surgical patients remain controversial. Specifically, it is difficult to establish the effective predictive markers as the endpoints of resuscitation in this patient group. Therefore, the study was conducted to assess the predictive value of early lactate non-clearance condition on hospital mortality in high-risk surgical patients. Material and Method: The study is a prospective analytic study. The data were collected in one university-based surgical intensive care unit (SICU) over a 5-month period. All consecutive adult high-risk surgical patients admitted to SICU in postoperative period were recruited to the study. Blood lactate levels were measured on SICU admission (0-hour), 12 hours later, and then calculated for 12-hour blood lactate clearance. The authors categorized the patients into two groups: lactate clearance (LC) and lactate non-clearance (LNC). After that, the patients were monitored until hospital discharge or inhospital death. Results: There were 122 high-risk surgical patients recruited to the study. As concerns the factors of interest, higher incidences of suspected or confirmed infection and mechanical ventilation were found among the LNC group. Regarding the main outcomes, hospital mortality was 5.3% among the LNC group and 3.9% among the LC group (p = 0.578), with no statistical significant differences in hospital mortality, hospital length of stay and SICU length of stay. The independent risk factors associated with LNC condition were considered. The factor of interest was suspected or confirmed infection by multiple logistic regression analysis after adjustment for age and sex revealed that the adjusted odds ratio was 2.70 with a 95% confidence interval of 0.85-8.55, p = 0.092. Conclusion: In high-risk surgical patients, 12-hour LNC cannot demonstrate the prognostic value for hospital morbidity and mortality. However, there is a trend for the suspected or confirmed infection group to associate with the LNC condition, but with no statistical significance.

Incidence and Predictive Factors Associated With Delayed Extubation After Pediatric Neurosurgery.

INTRODUCTION: Decisions on appropriate time of extubation after pediatric neurosurgery are often challenging for anesthesiologists. The primary goal was to investigate the incidence of delayed extubation after pediatric neurosurgery. The secondary goal was to identify the factors affecting delayed extubation in these patients. METHODS: This retrospective study was done in pediatric patients who underwent neurosurgery at a university hospital in a 5-year period from April 2015 to March 2020. Delayed extubation was that the patients who were not extubated at the end of procedure before leaving the operating room. Demographic data, preoperative and intraoperative factors associated with delayed extubation were collected and analyzed. RESULTS: A total of 539 pediatric patients were included in our study. There were 56 children in delayed extubation group with the incidence of 10.4%. In the multivariate analysis, the factors associated with delayed extubation were including neonates (adjusted odds ratio [aOR], 3.743; 95% confidence interval [CI], 1.076-13.028), American Society of Anesthesiologists physical status III-IV (aOR, 3.010; 95% CI, 1.057-8.573), preoperative oxygen supplement (aOR, 6.033; 95% CI, 1.713-21.243), intracranial surgery (aOR, 4.494; 95% CI, 1.458-13.847), estimated blood loss (EBL) ≥ 40% of total blood volume (TBV) (aOR, 5.465; 95% CI, 1.640-18.210), and finishing operation after official hours (aOR, 3.810; 95% CI, 1.633-8.889). CONCLUSIONS: There were the preoperative and intraoperative factors associated with delayed extubation such as preoperative oxygen supplement, intracranial surgery, or EBL ≥ 40% of TBV. These might be useful for anesthesiologists in making decisions about the planning of extubation after neurosurgery in children.

Nutrition Risk in Critically Ill Versus the Nutritional Risk Screening 2002: Are They Comparable for Assessing Risk of Malnutrition in Critically Ill Patients?

BACKGROUND: Malnutrition influences clinical outcomes. Although various screening tools are available to assess nutrition status, their use in the intensive care unit (ICU) has not been rigorously studied. Our goal was to compare the Nutrition Risk in Critically Ill (NUTRIC) to the Nutritional Risk Screening (NRS) 2002 in terms of their associations with macronutrient deficit in ICU patients. METHODS: We performed a retrospective analysis to investigate the relationship between NUTRIC vs NRS 2002 and macronutrient deficit (protein and calories) in critically ill patients. We performed linear regression analyses, controlling for age, sex, race, body mass index, and ICU length of stay. We then dichotomized our primary exposures and outcomes to perform logistic regression analyses, controlling for the same covariates. RESULTS: The analytic cohort included 312 adults. Mean NUTRIC and NRS 2002 scores were 4 ± 2 and 4 ± 1, respectively. Linear regression demonstrated that each increment in NUTRIC score was associated with a 49 g higher protein deficit (ß = 48.70: 95% confidence interval [CI] 29.23-68.17) and a 752 kcal higher caloric deficit (ß = 751.95; 95% CI 447.80-1056.09). Logistic regression demonstrated that NUTRIC scores >4 had over twice the odds of protein deficits ≥300 g (odds ratio [OR] 2.35; 95% CI 1.43-3.85) and caloric deficits ≥6000 kcal (OR 2.73; 95% CI 1.66-4.50) compared with NUTRIC scores ≤4. We did not observe an association of NRS 2002 scores with macronutrient deficit. CONCLUSION: Our data suggest that NUTRIC is superior to NRS 2002 for assessing malnutrition risk in ICU patients. Randomized, controlled studies are needed to determine whether nutrition interventions, stratified by NUTRIC score, can improve patient outcomes.

Early nutritional inadequacy is associated with psoas muscle deterioration and worse clinical outcomes in critically ill surgical patients.

PURPOSE: To explore whether psoas cross sectional area (CSA) and density (Hounsfield Units, HU) are associated with nutritional adequacy and clinical outcomes in surgical intensive care unit patients. MATERIALS AND METHODS: Subjects with at least one CT scan within 72h of ICU admission were included. Demographic, nutritional, radiographic, and outcomes data were collected. Psoas muscle CSA and HU were assessed at the L4-L5 intervertebral disk level. Change (Δ) in CSA and HU overall and per day were calculated. RESULTS: 140 patients were included. There was no significant correlation between baseline CSA and HU and clinical outcomes. Patients with at least two CT scans (n=65), had a median decrease in CSA of -15% [IQR: -20%, -8%] and decrease in HU of -2% [IQR: -30%, +24%]. Patients with the greatest daily %HU decline received significantly fewer calories/kg and proteins/kg and accumulated greater protein deficits at day 7 and overall. Patients with daily %HU increase had the shortest ICU and hospital LOS and more ventilator-free days in univariate and multivariable analyses. CONCLUSIONS: In this exploratory study, early nutritional deficits were correlated with muscle quality deterioration. Inpatient gain in psoas density, compared to maintenance or loss, is associated with shorter hospital stay.

Total and ionized magnesium testing in the surgical intensive care unit - Opportunities for improved laboratory and pharmacy utilization.

PURPOSE: Ionized fraction (iMg) is the physiologically active form of magnesium (Mg); total Mg may not accurately reflect iMg status. Erroneously "low" Mg levels may result in unnecessary repetitive testing. MATERIALS AND METHODS: From 11/2015 to 01/2016, patients ordered for Mg from a pilot ICU also had iMg tested. Weighted kappa statistic was used to assess agreement between Mg categories (low, normal, high). Predictors of unnecessary repeated Mg testing and repletion using data were explored through logistic regression models using GEE techniques to account for repeated measurements in both bivariate and multivariable analyses. RESULTS: There were 470Mg/iMg paired measurements from 173 patients. The weighted kappa statistic was 0.35 (95%CI 0.27-0.43) indicating poor agreement in assessment of magnesium status. Of the 34Mg samples reported as "low", only 6 (18%) were considered "low" using concurrent iMg testing. In the multivariable models, history of atrial fibrillation (aOR=1.61, 95%CI 1.16-2.21, p=0.004) and concomitant metoclopramide (aOR=1.71, 95%CI 1.03-2.81, p=0.036) were significant predictors of unnecessary repeat Mg testing. CONCLUSIONS: In the surgical ICU, categorical agreement (low, normal, high) was poor between Mg and iMg. Over 80% of "low" total Mg values are erroneous and may result in unnecessary additional measurements and repletion.

Elevated admission N-terminal pro-brain natriuretic peptide level predicts the development of atrial fibrillation in general surgical intensive care unit patients.

BACKGROUND: New onset atrial fibrillation (AF) in critically ill surgical patients is associated with significant morbidity and increased mortality. N-terminal pro-B type natriuretic peptide (NT-proBNP) is released by cardiomyocytes in response to stress and may predict AF development after surgery. We hypothesized that elevated NT-proBNP level at surgical intensive care unit (ICU) admission predicts AF development in a general surgical and trauma population. METHODS: From July to October 2015, NT-proBNP concentrations were measured at ICU admission. Abnormal NT-proBNP concentrations were defined by age-adjusted cut-offs. We examined the relationship between the development of AF and demographics, clinical variables, and NT-proBNP level using univariate analysis and a multivariable logistic regression model. RESULTS: Three hundred eighty-seven subjects were included in the cohort, none of whom were in AF at ICU admission. The median age was 63 years (52-73 years), and 40.3% were women. The risk of developing AF was higher for abnormal versus normal NT-proBNP (22% vs. 4%; p < 0.0001). Using optimal derived cutoffs (regardless of age), the risk of developing AF was 2% for NT-proBNP less than 600 ng/L, 15% for NT-proBNP of 600 ng/L to 1,999 ng/L, and 27% for NT-proBNP of 2,000 ng/L or greater. Multiple logistic regression analysis identified three independent predictors for new-onset AF: age, older than 70 years (odds ratio [OR], 3.7, 95% confidence interval [CI], 1.5-9.3), history of AF (OR, 25.3; 95% CI, 9.6-67.0), and NT-proBNP of 600 or greater (OR, 4.3; 95% CI, 1.3-14.2). When none or only one predictor was present, AF incidence was less than 1%. When all three predictors were present, AF incidence was 66%. For subjects 70 years or older but no history of AF, AF incidence was 12.8% when NT-proBNP was 600 or greater compared with 0% when NT-proBNP was less than 600. For subjects younger than 70 years with a history of AF, AF incidence was 44.4% when NT-proBNP was 600 or higher compared to 0% when NT-proBNP was less than 600. CONCLUSION: Elevated NT-proBNP at ICU admission in general surgical and trauma patients is predictive of AF development in the first 3 ICU days. Addition of NT-proBNP measurement to known risk factors can improve predictive power and identify patients who might potentially benefit from evidence-based prophylactic treatment for AF.