Oxygen Consumption Predicts Long-Term Outcome of Patients with Left Ventricular Assist Devices.

Reduced oxygen consumption (VO2), either due to insufficient oxygen delivery (DO2), microcirculatory hypoperfusion and/or mitochondrial dysfunction, has an impact on the adverse short- and long-term survival of patients after cardiac surgery. However, it is still unclear whether VO2 remains an efficient predictive marker in a population in which cardiac output (CO) and consequently DO2 is determined by a left ventricular assist device (LVAD). We enrolled 93 consecutive patients who received an LVAD with a pulmonary artery catheter in place to monitor CO and venous oxygen saturation. VO2 and DO2 of in-hospital survivors and non-survivors were calculated over the first 4 days. Furthermore, we plotted receiver-operating curves (ROC) and performed a cox-regression analysis. VO2 predicted in-hospital, 1- and 6-year survival with the highest area under the curve of 0.77 (95%CI: 0.6-0.9; p = 0.0004). A cut-off value of 210 mL/min VO2 stratified patients regarding mortality with a sensitivity of 70% and a specificity of 81%. Reduced VO2 was an independent predictor for in-hospital, 1- and 6-year mortality with a hazard ratio of 5.1 (p = 0.006), 3.2 (p = 0.003) and 1.9 (p = 0.0021). In non-survivors, VO2 was significantly lower within the first 3 days (p = 0.010, p < 0.001, p < 0.001 and p = 0.015); DO2 was reduced on days 2 and 3 (p = 0.007 and p = 0.003). In LVAD patients, impaired VO2 impacts short- and long-term outcomes. Perioperative and intensive care medicine must, therefore, shift their focus from solely guaranteeing sufficient oxygen supply to restoring microcirculatory perfusion and mitochondrial functioning.

Stroke Volume and Arterial Pressure Fluid Responsiveness in Patients With Elevated Stroke Volume Variation Undergoing Major Vascular Surgery: A Prospective Intervention Study.

OBJECTIVES: The identification of potential hemodynamic indicators to increase the predictive power of stroke-volume variation (SVV) for mean arterial pressure (MAP) and stroke volume (SV) fluid responsiveness. DESIGN: A prospective intervention study. SETTING: At a single-center university hospital. PARTICIPANTS: Nineteen patients during major vascular surgery with 125 fluid interventions. INTERVENTIONS: When SVV ≥13% occurred for >30 seconds, 250 mL of Ringer's lactate were given within 2 minutes. MEASUREMENTS AND MAIN RESULTS: Hemodynamic variables, such as pulse-pressure variation (PPV) and dynamic arterial elastance (Edyn), were measured by pulse power-wave analysis. The outcomes were MAP and SV responsiveness, defined as an increase of at least 10% of MAP and SV within 5 minutes of the fluid intervention. Of the fluid interventions, 48% were MAP-responsive, and 66% were SV-responsive. The addition of PPV and Edyn cut-off values to the SVV cut-off decreased sensitivity from 1-to-0.66 to-0.82, and concomitantly increased specificity from 0-to- 0.65-to-0.93 for the prediction of MAP and SV responsiveness in the authors' study setting. The areas under the receiver operating characteristic curves of PPV and Edyn for the prediction of MAP responsiveness were 0.79 and 0.75, respectively. The areas under the receiver operating characteristic curves for PPV and Edyn to predict SV responsiveness were 0.85 and 0.77, respectively. CONCLUSIONS: The PPV and Edyn showed good accuracy for the prediction of MAP and SV responsiveness in patients with elevated SVV during vascular surgery. Either PPV or Edyn may be used in conjunction with SVV to better predict MAP and SV fluid responsiveness in patients undergoing vascular surgery.

Absent Metabolic Transition from the Early to the Late Period in Non-Survivors Post Cardiac Surgery.

After major surgery, longitudinal changes in resting energy expenditure (REE) as well as imbalances in oxygen delivery (DO2) and distribution and processing (VO2) may occur due to dynamic metabolic requirements, an impaired macro- and microcirculatory flow and mitochondrial dysfunction. However, the longitudinal pattern of these parameters in critically ill patients who die during hospitalization remains unknown. Therefore, we analyzed in 566 patients who received a pulmonary artery catheter (PAC) their REE, DO2, VO2 and oxygen extraction ratio (O2ER) continuously in survivors and non-survivors over the first 7 days post cardiac surgery, calculated the percent increase in the measured compared with the calculated REE and investigated the impact of a reduced REE on 30-day, 1-year and 6-year mortality in a uni- and multivariate model. Only in survivors was there a statistically significant transition from a negative to a positive energy balance from day 0 until day 1 (Day 0: −3% (−18, 14) to day 1: 5% (−9, 21); p < 0.001). Furthermore, non-survivors had significantly decreased DO2 during the first 4 days and reduced O2ER from day 2 until day 6. Additionally, a lower REE was significantly associated with a worse survival at 30 days, 1 year and 6 years (p = 0.009, p < 0.0001 and p = 0.012, respectively). Non-survivors seemed to be unable to metabolically adapt from the early (previously called the 'ebb') phase to the later 'flow' phase. DO2 reduction was more pronounced during the first three days whereas O2ER was markedly lower during the following four days, suggesting a switch from a predominantly limited oxygen supply to prolonged mitochondrial dysfunction. The association between a reduced REE and mortality further emphasizes the importance of REE monitoring.

Recent and current low food intake - prevalence and associated factors in hospital patients from different medical specialities.

BACKGROUND/OBJECTIVES: Poor food intake is a major etiological factor of malnutrition. This research aims to describe the prevalence of recent and current low food intake (LIRC) and to identify factors associated with LIRC in adult hospital patients from different medical specialities. SUBJECT/METHODS: 1865 patients participating in the nutritionDay survey 2016-2020 in Germany were included. LIRC was defined by decreased eating both on nutritionDay and in the week before hospitalisation. Multivariate binary logistic regression was used to identify factors associated with LIRC overall and in different specialities. RESULTS: LIRC was observed in 21.1% of all patients, with the highest prevalence in Gastroenterology (26.6%) and the lowest in Neurology (11.2%). Weight loss within three months before nutritionDay (OR 2.62 [95% CI 1.93-3.56]), (very) poor self-rated health (2.17 [1.62-2.91]), female sex (1.98 [1.50-2.61]), uncertain weight loss (1.90 [1.03-3.51]), digestive disease (1.90 [1.40-2.56]), inability to walk without assistance (1.55 [1.14-2.12]) and emergency admission (1.38 [1.02-1.86]) were associated with increased risk, cardiac insufficiency (0.55 [0.37-0.83]) and being in a neurological ward (0.51 [0.28-0.92]) with decreased risk in the total sample. In Gastroenterology and Oncology, estimates were higher than in the entire sample; no significant associations were found in Neurology and Geriatrics, presumably due to the low prevalence of LIRC in Neurology and limited data quality in Geriatrics. CONCLUSION: LIRC is common in German hospital patients and associated with female sex, poor health and decreased functional status. Interdisciplinary differences suggest a discipline-specific approach to dealing with malnutrition.

Characteristics of Interleukin-6 Signaling in Elective Cardiac Surgery-A Prospective Cohort Study.

Interleukin-6 (IL-6) can cause pro- and anti-inflammatory effects via different signaling pathways. This prospective study investigated the perioperative kinetics of IL-6, soluble IL-6 receptor (sIL-6R), and soluble glycoprotein 130 (sgp130) in elective patients undergoing cardiopulmonary bypass (CPB). IL-6, sIL-6R, and sgp130 were measured simultaneously and consecutively at 19 timepoints until the 10th postoperative day (POD). The proportion of pro- and anti-inflammatory pathways were determined by calculating sIL-6R/IL-6 and sIL-6R/sgp130 ratios. We analyzed 93 patients. IL-6 increased during surgery with reaching a plateau two hours after CPB and peaking on POD 1 (188.5 pg mL-1 (IQR, 126.6; 309.2)). sIL-6R decreased at the beginning of the surgical procedure, reaching a nadir level on POD 2 (26,311 pg mL-1 (IQR, 22,222; 33,606)). sgp130 dropped immediately after CPB initiation (0.13 ng mL-1 (IQR, 0.12; 0.15)), followed by a continuous recovery until POD10. The sIL-6R/IL-6 ratio decreased substantially at the beginning of the procedure, reaching a nadir on POD 1 (149.7 (IQR, 82.4; 237.4)), while the sIL-6R/sgp130 ratio increased simultaneously until 6 h post CPB (0.219 (IQR 0.18; 0.27)). In conclusion, IL-6 exhibited high inter-individual variability reflecting an inhomogeneous inflammatory response. Pro-inflammatory effects and overwhelming inflammation were rare and predominantly anti-inflammatory effects were found.

Geo-economic variations in epidemiology, ventilation management and outcome of patients receiving intraoperative ventilation during general anesthesia- posthoc analysis of an observational study in 29 countries.

BACKGROUND: The aim of this analysis is to determine geo-economic variations in epidemiology, ventilator settings and outcome in patients receiving general anesthesia for surgery. METHODS: Posthoc analysis of a worldwide study in 29 countries. Lower and upper middle-income countries (LMIC and UMIC), and high-income countries (HIC) were compared. The coprimary endpoint was the risk for and incidence of postoperative pulmonary complications (PPC); secondary endpoints were intraoperative ventilator settings, intraoperative complications, hospital stay and mortality. RESULTS: Of 9864 patients, 4% originated from LMIC, 11% from UMIC and 85% from HIC. The ARISCAT score was 17.5 [15.0-26.0] in LMIC, 16.0 [3.0-27.0] in UMIC and 15.0 [3.0-26.0] in HIC (P = .003). The incidence of PPC was 9.0% in LMIC, 3.2% in UMIC and 2.5% in HIC (P < .001). Median tidal volume in ml kg- 1 predicted bodyweight (PBW) was 8.6 [7.7-9.7] in LMIC, 8.4 [7.6-9.5] in UMIC and 8.1 [7.2-9.1] in HIC (P < .001). Median positive end-expiratory pressure in cmH2O was 3.3 [2.0-5.0]) in LMIC, 4.0 [3.0-5.0] in UMIC and 5.0 [3.0-5.0] in HIC (P < .001). Median driving pressure in cmH2O was 14.0 [11.5-18.0] in LMIC, 13.5 [11.0-16.0] in UMIC and 12.0 [10.0-15.0] in HIC (P < .001). Median fraction of inspired oxygen in % was 75 [50-80] in LMIC, 50 [50-63] in UMIC and 53 [45-70] in HIC (P < .001). Intraoperative complications occurred in 25.9% in LMIC, in 18.7% in UMIC and in 37.1% in HIC (P < .001). Hospital mortality was 0.0% in LMIC, 1.3% in UMIC and 0.6% in HIC (P = .009). CONCLUSION: The risk for and incidence of PPC is higher in LMIC than in UMIC and HIC. Ventilation management could be improved in LMIC and UMIC. TRIAL REGISTRATION: Clinicaltrials.gov , identifier: NCT01601223.

The Association of Intraoperative driving pressure with postoperative pulmonary complications in open versus closed abdominal surgery patients - a posthoc propensity score-weighted cohort analysis of the LAS VEGAS study.

BACKGROUND: It is uncertain whether the association of the intraoperative driving pressure (ΔP) with postoperative pulmonary complications (PPCs) depends on the surgical approach during abdominal surgery. Our primary objective was to determine and compare the association of time-weighted average ΔP (ΔPTW) with PPCs. We also tested the association of ΔPTW with intraoperative adverse events. METHODS: Posthoc retrospective propensity score-weighted cohort analysis of patients undergoing open or closed abdominal surgery in the 'Local ASsessment of Ventilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study, that included patients in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs. The secondary endpoint was a composite of intraoperative adverse events. RESULTS: The analysis included 1128 and 906 patients undergoing open or closed abdominal surgery, respectively. The PPC rate was 5%. ΔP was lower in open abdominal surgery patients, but ΔPTW was not different between groups. The association of ΔPTW with PPCs was significant in both groups and had a higher risk ratio in closed compared to open abdominal surgery patients (1.11 [95%CI 1.10 to 1.20], P <  0.001 versus 1.05 [95%CI 1.05 to 1.05], P <  0.001; risk difference 0.05 [95%CI 0.04 to 0.06], P <  0.001). The association of ΔPTW with intraoperative adverse events was also significant in both groups but had higher odds ratio in closed compared to open abdominal surgery patients (1.13 [95%CI 1.12- to 1.14], P <  0.001 versus 1.07 [95%CI 1.05 to 1.10], P <  0.001; risk difference 0.05 [95%CI 0.030.07], P <  0.001). CONCLUSIONS: ΔP is associated with PPC and intraoperative adverse events in abdominal surgery, both in open and closed abdominal surgery. TRIAL REGISTRATION: LAS VEGAS was registered at clinicaltrials.gov (trial identifier NCT01601223 ).

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study.

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation. RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P < 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT. CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223.

Hospital Malnutrition, Nutritional Risk Factors, and Elements of Nutritional Care in Europe: Comparison of Polish Results with All European Countries Participating in the nDay Survey.

NutritionDay (nDay) is a project established by the Medical University of Vienna and the European Society for Clinical Nutrition and Metabolism (ESPEN) to audit the nutritional status of hospitalized patients and nursing home residents. This study aimed to evaluate nDay data describing the prevalence of hospital malnutrition, nutritional risk factors, and elements of the nutritional care process implemented in hospital wards in 25 European countries and to compare the data derived from Poland with the data collected in all the European countries participating in the study. In total, 10,863 patients (European reference group: 10,863 participants including Poland: 498 participants) were involved in the study. The prevalence of malnutrition was identified on the basis of the ESPEN diagnostic criteria established in 2015, while the prevalence of nutritional risk factors was assessed by analyzing the following parameters: body mass index (BMI), score of Malnutrition Screening Tool (MST), recent weight loss, insufficient food intake, decreased appetite, increased number of drugs intake, reduced mobility, and poor self-reported health status. Malnutrition prevalence was 12.9% in patients from the European reference group and 9.4% in patients from Polish hospital wards (p < 0.05). However, the prevalence of some nutritional risk factors, i.e., recent weight loss, history of decreased food intake, and low actual food intake, were approximately four times more prevalent than diagnosed malnutrition (referring to approximately 40-50% of all participants). In comparison to the European reference group, the significant differences observed in Polish hospital wards concerned mainly dietitian's involvement in the process of treating malnutrition (16% vs. 57.2%; p < 0.001); supply of special diets (8% vs. 16.1%; p < 0.0001); provision of oral nutritional support (ONS) (3.8% vs. 12.2%; p < 0.0001); prescription of enteral/parenteral nutrition therapy to hospitalized patients (8.2% vs. 11.7%; p < 0.001); as well as recording patient weight performed at hospital admission (100% vs. 72.9%; p < 0.0001), weekly (20% vs. 41.4%; p < 0.05), and occasionally (0% vs. 9.2%). These results indicate that the prevalence of malnutrition and malnutrition risk factors in hospitalized patients in Poland was slightly lower than in the European reference group. However, some elements of the nutritional care process in Polish hospitals were found insufficient and demand more attention.

The effects of preoperative moderate to severe anaemia on length of hospital stay: A propensity score-matched analysis in non-cardiac surgery patients.

BACKGROUND: Anaemia is frequently recorded during preoperative screening and has been suggested to affect outcomes after surgery negatively. OBJECTIVES: The objectives were to assess the frequency of moderate to severe anaemia and its association with length of hospital stay. DESIGN: Post hoc analysis of the international observational prospective 'Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study. PATIENTS AND SETTING: The current analysis included adult patients requiring general anaesthesia for non-cardiac surgery. Preoperative anaemia was defined as a haemoglobin concentration of 11 g dl-1 or lower, thus including moderate and severe anaemia according to World Health Organisation criteria. MAIN OUTCOME MEASURES: The primary outcome was length of hospital stay. Secondary outcomes included hospital mortality, intra-operative adverse events and postoperative pulmonary complications (PPCs). RESULTS: Haemoglobin concentrations were available for 8264 of 9864 patients. Preoperative moderate to severe anaemia was present in 7.7% of patients. Multivariable analysis showed that preoperative moderate to severe anaemia was associated with an increased length of hospital stay with a mean difference of 1.3 ((95% CI 0.8 to 1.8) days; P < .001). In the propensity-matched analysis, this association remained present, median 4.0 [IQR 1.0 to 5.0] vs. 2.0 [IQR 0.0 to 5.0] days, P = .001. Multivariable analysis showed an increased in-hospital mortality (OR 2.9 (95% CI 1.1 to 7.5); P  = .029), and higher incidences of intra-operative hypotension (36.3 vs. 25.3%; P < .001) and PPCs (17.1 vs. 10.5%; P = .001) in moderately to severely anaemic patients. However, this was not confirmed in the propensity score-matched analysis. CONCLUSIONS: In this international cohort of non-cardiac surgical patients, preoperative moderate to severe anaemia was associated with a longer duration of hospital stay but not increased intra-operative complications, PPCs or in-hospital mortality. TRIAL REGISTRATION: The LAS VEGAS study was registered at Clinicaltrials.gov, NCT01601223.

The centenary of the Harris-Benedict equations: How to assess energy requirements best? Recommendations from the ESPEN expert group.

BACKGROUND & AIMS: The year 2019 marked the centenary of the publication of the Harris and Benedict equations for estimation of energy expenditure. In October 2019 a Scientific Symposium was organized by the European Society for Clinical Nutrition and Metabolism (ESPEN) in Vienna, Austria, to celebrate this historical landmark, looking at what is currently known about the estimation and measurement of energy expenditure. METHODS: Current evidence was discussed during the symposium, including the scientific basis and clinical knowledge, and is summarized here to assist with the estimation and measurement of energy requirements that later translate into energy prescription. RESULTS: In most clinical settings, the majority of predictive equations have low to moderate performance, with the best generally reaching an accuracy of no more than 70%, and often lead to large errors in estimating the true needs of patients. Generally speaking, the addition of body composition measurements did not add to the accuracy of predictive equations. Indirect calorimetry is the most reliable method to measure energy expenditure and guide energy prescription, but carries inherent limitations, greatly restricting its use in real life clinical practice. CONCLUSIONS: While the limitations of predictive equations are clear, their use is still the mainstay in clinical practice. It is imperative to recognize specific patient populations for whom a specific equation should be preferred. When available, the use of indirect calorimetry is advised in a variety of clinical settings, aiming to avoid under-as well as overfeeding.

Urinary neprilysin for early detection of acute kidney injury after cardiac surgery: A prospective observational study.

BACKGROUND: Acute kidney injury (AKI) predicts adverse outcomes after cardiac surgery. The accuracy of using changes in serum creatinine for diagnosis and grading of AKI is limited in the peri-operative cardiac surgical setting and AKI may be underdiagnosed due to haemodilution from cardiopulmonary bypass priming and the need for intra-operative and postoperative volume resuscitation. OBJECTIVES: To determine whether the urinary biomarker neprilysin can be used as a marker for the early detection of AKI after cardiac surgery. DESIGN: Prospective, observational cohort study. SETTING: Austrian tertiary referral centre. PATIENTS: 96 Patients undergoing elective cardiac surgery with cardiopulmonary bypass. MAIN OUTCOME MEASURES: Differences and discriminatory power of neprilysin levels early after cardiac surgery and on postoperative day 1 between patients with or without AKI, as defined by the Kidney Disease Improving Global Outcomes Group. RESULTS: AKI was found in 27% (n=26). The median neprilysin levels on postoperative day 1 were significantly higher in the AKI than in the non-AKI group, 4.0 [interquartile range (IQR): 2 to 6.25] vs. 2.0 ng ml [IQR: 1.0 to 4.5], P = 0.0246, respectively. In addition, the median neprilysin levels at the end of surgery were significantly different between both groups, 5.0 [IQR: 2.0 to 9.0] vs. 2.0 ng ml [IQR: 1.0 to 4.0], P = 0.0055, respectively. The discriminatory power of neprilysin for detecting early AKI corresponded to an area under the curve of 0.77 (95% confidence interval, 0.65 to 0.90). CONCLUSION: Urinary neprilysin has potential as a biomarker for the early detection of AKI after cardiac surgery and has comparable discriminatory power to recently studied AKI biomarkers. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov (NCT03854825, https://clinicaltrials.gov/ct2/show/NCT03854825).

Intraoperative mechanical ventilation practice in thoracic surgery patients and its association with postoperative pulmonary complications: results of a multicenter prospective observational study.

BACKGROUND: Intraoperative mechanical ventilation may influence postoperative pulmonary complications (PPCs). Current practice during thoracic surgery is not well described. METHODS: This is a post-hoc analysis of the prospective multicenter cross-sectional LAS VEGAS study focusing on patients who underwent thoracic surgery. Consecutive adult patients receiving invasive ventilation during general anesthesia were included in a one-week period in 2013. Baseline characteristics, intraoperative and postoperative data were registered. PPCs were collected as composite endpoint until the 5th postoperative day. Patients were stratified into groups based on the use of one lung ventilation (OLV) or two lung ventilation (TLV), endoscopic vs. non-endoscopic approach and ARISCAT score risk for PPCs. Differences between subgroups were compared using χ2 or Fisher exact tests or Student's t-test. Kaplan-Meier estimates of the cumulative probability of development of PPC and hospital discharge were performed. Cox-proportional hazard models without adjustment for covariates were used to assess the effect of the subgroups on outcome. RESULTS: From 10,520 patients enrolled in the LAS VEGAS study, 302 patients underwent thoracic procedures and were analyzed. There were no differences in patient characteristics between OLV vs. TLV, or endoscopic vs. open surgery. Patients received VT of 7.4 ± 1.6 mL/kg, a PEEP of 3.5 ± 2.4 cmH2O, and driving pressure of 14.4 ± 4.6 cmH2O. Compared with TLV, patients receiving OLV had lower VT and higher peak, plateau and driving pressures, higher PEEP and respiratory rate, and received more recruitment maneuvers. There was no difference in the incidence of PPCs in OLV vs. TLV or in endoscopic vs. open procedures. Patients at high risk had a higher incidence of PPCs compared with patients at low risk (48.1% vs. 28.9%; hazard ratio, 1.95; 95% CI 1.05-3.61; p = 0.033). There was no difference in the incidence of severe PPCs. The in-hospital length of stay (LOS) was longer in patients who developed PPCs. Patients undergoing OLV, endoscopic procedures and at low risk for PPC had shorter LOS. CONCLUSION: PPCs occurred frequently and prolonged hospital LOS following thoracic surgery. Proportionally large tidal volumes and high driving pressure were commonly used in this sub-population. However, large RCTs are needed to confirm these findings. TRIAL REGISTRATION: This trial was prospectively registered at the Clinical Trial Register (www.clinicaltrials.gov; NCT01601223 ; registered May 17, 2012.).

Nutritional risk is associated with an increase of in-hospital mortality and a reduction of being discharged home: Results of the 2009-2015 nutritionDay survey.

BACKGROUND: Disease-related malnutrition is a known factor for poor outcomes. However, there is a lack of knowledge about the prevalence and the impact of nutritional risk on outcomes in Colombia. The aim of the present study was to determine the prevalence of nutritional risk, to know how nutrition screening is routinely performed and to determine the impact of nutritional risk on the outcomes of in-hospital mortality and being discharged home outcomes. METHODS: We conducted a descriptive analysis of selected data from 7 consecutive, annual, and cross-sectional nutritionDay samples (2009-2015) including a total of 7,994 adult patients in 248 units in Colombia. Data is contrasted with the Latin American and worldwide results. The prevalence of nutritional risk was determined according to the malnutrition screening tool (MST). The impact of nutritional risk in Colombian patients regarding outcomes was assessed by a Fine and Gray competing risk regression model controlling for PANDORA score (age, BMI, length of stay before nutritionDay, cancer diagnosis, and mobility). RESULTS: The prevalence of nutritional risk (MST score ≥ 2) in Colombia was 38%, 41% in Latin America, and 32% worldwide. Half of the Colombian units screened patients for malnutrition or nutritional risk on admission to hospital, compared to 80% in Latin America and 62% worldwide. Only 23% of the Colombian patients identified as being at nutritional risk in the nutritionDay survey received any nutritional therapy. The hospital mortality hazard ratio of Colombian patients at nutritional risk defined by MST was 1.94 (95% CI, 1.53,2.46; p < 0.001) and 0.82 of being discharged home (95% CI, 0.76,0.88, p < 0.001). CONCLUSIONS: This is the first large-scale study in Colombia evaluating the impact of nutritional risk on clinical outcomes showing an increase of in-hospital mortality and a reduction of being discharged home. Moreover, the study shows that nutritional risk is still highly prevalent worldwide implying the need to promote an optimal nutritional care. The participation of Latin American countries in the nutritionDay survey is an opportunity to increase knowledge and awareness of these issues.

Influence of hemoadsorption during cardiopulmonary bypass on blood vesicle count and function.

BACKGROUND: Extracorporeal circulation during major cardiac surgery triggers a systemic inflammatory response affecting the clinical course and outcome. Recently, extracellular vesicle (EV) research has shed light onto a novel cellular communication network during inflammation. Hemoadsorption (HA) systems have shown divergent results in modulating the systemic inflammatory response during cardiopulmonary bypass (CPB) surgery. To date, the effect of HA on circulating microvesicles (MVs) in patients undergoing CPB surgery is unknown. METHODS: Count and function of MVs, as part of the extracellular vesicle fraction, were assessed in a subcohort of a single-center, blinded, controlled study investigating the effect of the CytoSorb device during CPB. A total of 18 patients undergoing elective CPB surgery with (n = 9) and without (n = 9) HA device were included in the study. MV phenotyping and counting was conducted via flow cytometry and procoagulatory potential was measured by tissue factor-dependent MV assays. RESULTS: Both study groups exhibited comparable counts and post-operative kinetics in MV subsets. Tissue factor-dependent procoagulatory potential was not detectable in plasma at any timepoint. Post-operative course and laboratory parameters showed no correlation with MV counts in patients undergoing CPB surgery. CONCLUSION: Additional artificial surfaces to the CPB-circuit introduced by the use of the HA device showed no effect on circulating MV count and function in these patients. Larger studies are needed to assess and clarify the effect of HA on circulating vesicle counts and function. Trial registration ClinicalTrials.Gov Identifier: NCT01879176; registration date: June 17, 2013; https://clinicaltrials.gov/ct2/show/NCT01879176.

Perioperative nutrition: Recommendations from the ESPEN expert group.

BACKGROUND & AIMS: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. METHODS: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. RESULTS: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. CONCLUSIONS: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

Very early changes in serum creatinine are associated with 30-day mortality after cardiac surgery: A cohort study.

BACKGROUND: Acute kidney injury predicts adverse outcomes after cardiac surgery. OBJECTIVES: To determine whether ultra-short-term changes (within 120 min) in serum creatinine (SCrea) levels after cardiac surgery predict clinical outcomes (30-day mortality). DESIGN: Observational cohort study. SETTING: Austrian tertiary referral centre. PATIENTS: A total of 7651 patients scheduled to undergo elective cardiac surgery. MAIN OUTCOME MEASURES: We analysed SCrea levels measured pre-operatively (baseline) and within 120 min after surgery. We also adjusted the postoperative SCrea levels for fluid balance. Patients were grouped according to the difference between the pre and postoperative SCrea levels (ΔSCreaAdmICU). We performed univariable and multivariable analyses to determine the association between changes in SCrea levels and 30-day mortality. RESULTS: After cardiac surgery, the SCrea level decreased in 5923 patients and increased in 1728 patients. Increased SCrea levels were associated with a 21% increase in 30-day mortality. Even minimal increases in SCrea (0 to <26.5 µmol l) were significantly associated with 30-day mortality [hazard ratio (HR), 1.98; 95% confidence interval (CI), 1.54 to 2.55; P < 0.001]. Adjustments for fluid balance strengthened the above association (increases of 0 to <26.5 µmol l: HR, 1.78; 95% CI, 1.40 to 2.26; P < 0.001; increases of at least 26.5 µmol l: HR, 2.40; 95% CI, 1.68 to 3.42; P < 0.001). CONCLUSION: Even minimal, ultra-short-term increases in SCrea levels after cardiac surgery are associated with increased 30-day mortality. Adjustment for fluid balance strengthens this association. The change in SCrea between baseline and after admission to the Intensive Care Unit (ΔSCreaAdmICU) can serve as a simple, cheap and widely available marker for very early risk stratification after cardiac surgery.

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study.

BACKGROUND: Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients. METHODS: Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs. RESULTS: Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (VT) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH20. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs. CONCLUSIONS: Neurosurgical patients are ventilated with low VT and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs.

A negative impact of recent weight loss on in-hospital mortality is not modified by overweight and obesity.

BACKGROUND: Obesity [Body Mass Index (BMI) > 30 kg/m2] is a risk factor for disease conditions enhancing hospitalization and mortality risks, but higher BMI was paradoxically reported to reduce mortality in several acute and chronic diseases. Unintentional weight loss (WL) is conversely associated with disease development and may worsen patient outcome, but the impact of weight loss and its interaction with obesity in modulating risk of death in hospitalized patients remain undefined. METHODS: We investigated the ESPEN nutritionDay database of non-critically ill hospitalized patients to assess the impact of self-reported 3-month WL (WL1:2.5-6.6%; WL2: 6.6-12.6%, WL3: >12.6%) and its interaction with BMI in modulating 30-day in-hospital mortality. Multivariate Cox regression was used to estimate hazard ratios (HR), with stable weight (WL0) as reference category. RESULTS: In 110835 nDay patients, 30-day mortality increased with increasing WL. Male gender, increasing disease severity index PANDORA score (age, nutrient intake, mobility, fluid status, cancer and main patient group) and not having had surgery also predicted 30-day mortality. HR for 30-day mortality remained significantly higher compared to WL0 for WL2 and WL3 after multiple adjustment. Adjusted HR and its increments through increasing weight loss categories were comparable in lean (BMI<25), overweight (BMI 25-30) and obese individuals (BMI>30 kg/m2). Impact of gender, PANDORA score and surgery on 30-day mortality were conversely comparable in the three BMI groups. CONCLUSIONS: These results indicate that self-reported WL could represent a relevant prognostic factor in every hospitalized patient. Overweight and obesity per se have no protective impact against WL-associated mortality.