High-frequency power of heart rate variability can predict the outcome of thoracic surgical patients with acute respiratory distress syndrome on admission to the intensive care unit: a prospective, single-centric, case-controlled study.

BACKGROUND: The morbidity and mortality of acute respiratory distress syndrome (ARDS) remains high, and the strategic focus of ARDS research has shifted toward identifying patients at high risk of mortality early in the course of illness. This study intended to identify the heart rate variability (HRV) measure that can predict the outcome of patients with ARDS on admission to the surgical intensive care unit (SICU). METHODS: Patients who had lung or esophageal cancer surgery were included either in the ARDS group (n = 21) if they developed ARDS after surgery or in the control group (n = 11) if they did not. The ARDS patients were further stratified into survivors and non-survivors subgroups according to their outcomes. HRV measures of the patients were used for statistical analysis. RESULTS: The mean RR interval (mRRI), high-frequency power (HFP) and product of low-/high-frequency power ratio tidal volume and tidal volume (LHR*VT) were significantly lower (p < 0.05), while the normalized HFP to VT ratio (nHFP/VT) was significantly higher in the ARDS patients (p = 0.011). The total power (TP), low-frequency power (LFP), HFP and HFP/VT were all significantly higher in the non-survived ARDS patients, whereas Richmond Agitation-Sedation Scale (RASS) was significantly lower in the non-survived ARDS patients. After adjustment for RASS, age and gender, firth logistic regression analysis identified the HFP, TP as the significant independent predictors of mortality for ARDS patients. CONCLUSIONS: The vagal modulation of thoracic surgical patients with ARDS was enhanced as compared to that of non-ARDS patients, and the non-survived ARDS patients had higher vagal activity than those of survived ARDS patients. The vagal modulation-related parameters such as TP and HFP were independent predictors of mortality in patients with ARDS on admission to the SICU, and the HFP was found to be the best predictor of mortality for those ARDS patients. Increased vagal modulation might be an indicator for poor prognosis in critically ill patients following thoracic surgery.

Predictors of survival in adults undergoing extracorporeal membrane oxygenation with severe infections.

BACKGROUND: To identify novel factors associated with the survival of septic adults receiving extracorporeal membrane oxygenation (ECMO) to improve patient selection and outcomes. METHODS: Cases were identified from our ECMO registry from 2001 to 2011 if they were ≥16 years and received ECMO for life-threatening sepsis. RESULTS: A total of 151 adults with a median (25th-75th percentile) age of 51 (37-63) years were analyzed. Pneumonia (50%), myocarditis (20%), and primary bloodstream infections (15%) were the main types of infection, caused by predominantly nonfermentative Gram-negative bacteria (NFGNB) (26%), Enterobacteriaceae (24%), and Gram-positive cocci (21%). The in-hospital mortality of patients with NFGNB, enteric, and Gram-positive bacterial pneumonias were 100%, 68%, and 14%, respectively. Using the Cox-proportional hazards model, we found that age >75 years (hazard ratio [HR], 1.98, 95% confidence interval [95% CI], 1.30-3.02), pre-ECMO dialysis (HR, 3.20, 95% CI, 1.34-7.63), longer door-to-ECMO intervals (HR, 1.01, 95% CI, 1.00-1.02), venoarterial mode (HR, 2.58, 95% CI, 1.55-4.21), and fungal (HR, 2.83, 95% CI, 1.36-5.88) and NFGNB sepsis (HR, 2.48, 95% CI, 1.44-4.27) were associated with mortality. Gram-positive sepsis (HR, 0.20, 95% CI, 0.08-0.57), myocarditis (HR, 0.12, 95% CI, 0.06-0.27), pneumonia (HR, 0.54, 95% CI, 0.30-0.90), and effective empirical antimicrobial therapy were predictive of survival (HR, 0.57, 95% CI, 0.37-0.89); all P < .05. Excluding the 67 heavily premorbid patients, we found that 54% survived ECMO and 42% survived to discharge, with significantly more survivors with door-to-ECMO times of ≤96 hours than >96 hours (59% vs 15%, P < .0001). CONCLUSIONS: Better outcomes were associated with door-to ECMO times of 96 hours or less, for Gram-positive rather than Gram-negative sepsis, and for pneumonia rather than primary bloodstream infections.

Peroxiredoxin 1 induces inflammatory cytokine response and predicts outcome of cardiogenic shock patients necessitating extracorporeal membrane oxygenation: an observational cohort study and translational approach.

BACKGROUND: Extracellular peroxiredoxin 1 (Prdx1) has been implicated to play a pivotal role in regulating inflammation; however, its function in tissue hypoxia-induced inflammation, such as severe cardiogenic shock patients, has not yet been defined. Thus, the objective of this study was to test the hypothesis that Prdx1 possesses prognostic value and instigates systemic inflammatory response syndrome in cardiogenic shock patients undergoing extracorporeal membrane oxygenation (ECMO) support. METHODS: We documented the early time course evolution of circulatory Prdx1, hypoxic marker carbonic anhydrase IX, inflammatory cytokines including IL-6, IL-8, IL-10, MCP-1, TNF-α, IL-1ß, and danger signaling receptors (TLR4 and CD14) in a cohort of cardiogenic shock patients within 1 day after ECMO support. In vitro investigations employing cultured murine macrophage cell lines and human monocytes were applied to clarify the relationship between Prdx1 and inflammatory response. RESULTS: Prdx1 not only peaked earlier than all the other cytokines we studied during the initial course, but also predicted a worse outcome in patients who had higher initial Prdx1 plasma levels. The Prdx1 levels in patients positively correlated with hypoxic markers carbonic anhydrase IX and lactate, and inflammatory cytokines. In vitro study demonstrated that hypoxia/reoxygenation induced Prdx1 release from human monocytes and enhanced the responsiveness of the monocytes in Prdx1-induced cytokine secretions. Furthermore, functional inhibition by Prdx1 antibody implicated a crucial role of Prdx1 in hypoxia/reoxygenation-induced IL-6 secretion. CONCLUSIONS: Prdx1 release during the early phase of ECMO support in cardiogenic shock patients is associated with the development of systemic inflammatory response syndrome and poor clinical outcomes. Thus, circulating Prdx1 provides not only prognostic information but may be a promising target against ischemia/reperfusion injury.

Increased flow resistance and decreased flow rate in patients with acute respiratory distress syndrome: The role of autonomic nervous modulation.

BACKGROUND: The aim of this study was to investigate the flow resistance and flow rate in patients with acute respiratory distress syndrome (ARDS) in the surgical intensive care unit and their relation with autonomic nervous modulation. METHODS: Postoperative patients of lung or esophageal cancer surgery without ARDS were included as the control group (n = 11). Patients who developed ARDS after lung or esophageal cancer surgery were included as the ARDS group (n = 21). The ARDS patients were further divided into survivor and nonsurvivor subgroups according to their outcomes. All patients required intubation and mechanical ventilation. RESULTS: The flow rate was significantly decreased, while the flow resistance was significantly increased, in ARDS patients. The flow rate correlated significantly and negatively with positive end-expiratory pressure (PEEP), while the flow resistance correlated significantly and positively with PEEP in ARDS patients. Furthermore, the flow rate correlated significantly and negatively with the tidal volume-corrected normalized high-frequency power but correlated significantly and positively with the tidal volume-corrected low-/high-frequency power ratio. In contrast, the flow resistance correlated significantly and negatively with normalized very low-frequency power and tidal volume-corrected low-/high-frequency power ratio, but correlated significantly and positively with tidal volume-corrected normalized high-frequency power. CONCLUSION: The flow rate is decreased and the flow resistance increased in patients with ARDS. PEEP is one of the causes of increased flow resistance and decreased flow rate in patients with ARDS. Another cause of decreased flow rate and increased flow resistance in ARDS patients is the increased vagal activity and decreased sympathetic activity. The monitoring of flow rate and flow resistance during mechanical ventilation might be useful for the proper management of ARDS patients.

Severe Sepsis and Septic Shock: Timing of Septic Shock Onset Matters.

INTRODUCTION: Timing of septic shock onset may play a prognostic role in severe sepsis; however, clinical evidence provides contradictory results. This study aimed to investigate possible associations between timing of onset of septic shock and patient outcome. METHODS: In a university-affiliated hospital, all patients admitted to the intensive care unit (ICU) for severe sepsis or septic shock from November 2007 to March 2011 were included. The primary outcome of interest was the impact of timing of septic shock onset on in-hospital mortality. We also sought to identify potential factors predicting development of septic shock after ICU admission. RESULTS: In total, 772 patients were identified to have severe sepsis; approximately two-thirds (487/772) of them experienced septic shock and overall in-hospital mortality was 57%. Timing of onset of septic shock was an independent predictor of in-hospital outcome, and there was an increasing trend of in-hospital mortality with later onset of septic shock. In addition, timing of septic shock onset provided further mortality risk stratification in patients with APACHE II scores of less than 20 and 20 to 25. We also found that patients who underwent cardiovascular surgery were more likely to experience septic shock after admission and those receiving neurosurgery were at lower risk of developing septic shock. CONCLUSIONS: This study showed the significance of timing of septic shock onset in prognosis among ICU patients with severe sepsis. Timing of shock onset further stratified patients with similar disease severity into different mortality risk groups. These findings deliver useful information regarding risk stratification of septic patients.

Pharmacokinetics of vancomycin in adults receiving extracorporeal membrane oxygenation.

BACKGROUND/PURPOSE: Extracorporeal membrane oxygenation (ECMO) alters the pharmacokinetics (PK) of vancomycin in neonates; but data on adults is limited. METHODS: This is a prospective, matched cohort, single center, pharmacokinetic study. For each adult patient who received vancomycin therapy in the ECMO group (with either centrifugal pump or roller pump), a control patient was matched by age (≥ 60 years or < 60 years), gender, and creatinine clearance (CLCr) in intensive care units. After vancomycin was administered for at least four doses, serial blood samples were drawn at 0.5 hours, 1 hour, 2 hours, 3 hours, 5 hours, 7 hours, 11 hours, 23 hours, 35 hours, and 47 hours post vancomycin infusion according to the dosing intervals. The serum concentration-time profile was fitted to a noncompartment model and a nonlinear mixed effect model to determine the PK parameters. RESULTS: Twenty-two critically ill adults without renal replacement therapy were enrolled. There were no significant differences between the ECMO group and the matched group in demographics, renal function, and PK parameters. However, vancomycin clearance in the roller pump group was significantly lower than that in the matched control (0.83 ± 0.43 mL/min/kg vs. 0.97 ± 0.43 mL/min/kg, p = 0.002). CONCLUSION: Vancomycin clearance in patients receiving ECMO with a roller pump was significantly lower than that in the matched cohort. Vancomycin PK parameters in patients on ECMO with a centrifugal pump were comparable to those in the matched control group.

Epidemiology and Outcome of Severe Sepsis and Septic Shock in Surgical Intensive Care Units in Northern Taiwan.

Severe sepsis remains the leading cause of mortality in the critically ill. Local epidemiological studies on sepsis are of paramount importance to increase our knowledge about sepsis features and to improve patient care and prognosis.Adult patients (≥20 years) admitted to the surgical intensive care units with severe sepsis or septic shock from 2009 to 2010 were retrospectively retrieved and analyzed. The primary outcome of interest was 28-day mortality.Of 7795 admissions, 536 (6.9%) patients had severe sepsis. The most common sites of infection were the respiratory tract (38%) and abdomen (33%). Gram-negative bacteria, particularly Klebsiella pneumoniae (8.6%) and Escherichia coli (6.0%), were the major infecting micro-organisms, responsible for approximately two-thirds of the severe sepsis episodes. The overall 28-day mortality rate was 61%, and a higher sequential organ failure assessment score and the use of mechanical ventilation were independently associated with a worse outcome.Admissions with severe sepsis are not uncommon and are associated with substantial 28-day mortality in surgical intensive care units in northern Taiwan. Establishment and optimization of each institutional sepsis care standard to improve the outcome of sepsis are warranted.

Effect of preoperative statin therapy on postoperative acute kidney injury in patients undergoing major surgery: systemic review and meta-analysis.

We aimed to examine the association between preoperative use of statins and postoperative acute kidney injury (AKI) in patients undergoing major surgery by performing a systemic review and meta-analysis. MEDLINE and EMBASE, from inception to April 2013, and the reference lists of related articles were searched for relevant studies. Trials comparing preoperative statin therapy with no preoperative statin in patients undergoing major surgery were included. Outcome measures of interest were the risk of cumulative postoperative AKI and postoperative AKI requiring renal replacement therapy (RRT). Fixed or random effect meta-analysis was performed to derive summary effect estimates. In five randomized controlled trials (RCTs) and 19 observational studies, comprising a total of 989 173 patients undergoing major surgery, 112 840 patients (11.41%) received preoperative statin therapy. The specific type, dosage, and duration of statin therapy were not available in most studies. Preoperative statin therapy was associated with a significant risk reduction for cumulative postoperative AKI (weighted summary odds ratio (OR) 0.87, 95% CI 0.79 to 0.95). The effect of risk reduction was also significant when considering postoperative AKI requiring RRT (OR 0.80, 95% CI 0.72 to 0.90). When restricting the analysis to the five RCTs, preoperative statin therapy did not show significant protective effect on postoperative AKI (OR 0.49, 95% CI 0.22 to 1.09). In patients undergoing major surgery, preoperative statin therapy could associate with a reduced risk for postoperative AKI. However, considerable heterogeneity existed among included studies. Future randomized trials were warranted for this critical clinical question.

Impact of body mass on outcomes of geriatric postoperative acute kidney injury patients.

BACKGROUND: Acute kidney injury (AKI) frequently occurs in hospitalized patients, particularly in the elderly. However, studies on outcome-modifying factors in geriatric patients with AKI are absent, especially the influence of body mass index (BMI). METHODS: We performed a retrospective analysis of a prospectively collected multicenter observational cohort, which enrolled elderly (≥65 years) who developed AKI after major surgery in the intensive care units. We analyzed in-hospital mortality within BMI category utilizing Cox proportional hazard regression analysis and generalized additive modeling. RESULTS: Data of a total of 2,015 postoperative elderly patients were retrieved and analyzed. Generalized additive modeling showed that elderly AKI patients with a BMI between 21 and 31 kg/m(2) ("normal") had a lower mortality risk than those with a BMI of less than 21 kg/m(2) ("underweight") or 31 kg/m(2) or greater ("obese"). Both "underweight" and "obese" individuals had a greater risk of mortality compared with patients with "normal" BMI. CONCLUSIONS: The U-shaped association of BMI with hospital mortality in geriatric AKI patients contains a widened base and a shifted nadir comparing with chronic dialysis and other AKI patients. This finding is interesting and warrants our attention.

Dialysis-requiring acute kidney injury increases risk of long-term malignancy: a population-based study.

BACKGROUND: Acute kidney injury (AKI) is gaining worldwide attention recently, emerging as a major public health threat. However, the association between the development of AKI and subsequent malignancy has not been studied before. METHODS: We conducted a population study based on the Taiwan National Health Insurance database, using 1,000,000 representative database during 2000-2008. All patients' survival to discharge from index hospitalization with recovery from dialysis-requiring AKI were identified (recovery group), and matched with those without recovery and those without AKI, at a 1:1:1 ratio. RESULTS: We identified 625 individuals more than 18 years old [352 male (56.5%); mean age, 63.3 years] in recovery group and matched 625 individuals in each group. During a mean followed-up of 3.7 years, the incidences of new-onset malignancy were 4.2, 2.9, and 2.6 per 100 person-year among the non-recovery, the recovery, and the non-AKI group, respectively. After adjustment, the recovery group was more likely to develop long-term de novo malignancy than those without AKI [hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.02-2.03; p = 0.04], while less likely than those who did not recover (HR 0.66, 95% CI 0.45-0.98; p = 0.04). CONCLUSIONS: Dialysis-requiring AKI can post a long-term risk of de novo malignancy for those who survive from the initial insult. Even patients who have recovered from dialysis still carry a significantly higher possibility of developing malignancy than those without AKI episode.

Laparoscopy decreases the laparotomy rate in hemodynamically stable patients with blunt abdominal trauma.

BACKGROUND: This study evaluated the use of laparoscopy in hemodynamically stable patients with blunt abdominal trauma. METHODS: We retrospectively reviewed the medical records of hemodynamically stable blunt abdominal trauma patients. Patients admitted from July 1, 2003, to June 30, 2006 (prior to the adoption of laparoscopy for patients with blunt abdominal trauma) were categorized as group A. Patients admitted from July 1, 2007, to June 30, 2010, when laparoscopy was included in the algorithm for the management of blunt abdominal trauma, were categorized as group B. RESULTS: There were 47 patients in group A and 57 patients in group B. There were no significant differences in demographic characteristics, injury severity score, and injuries requiring surgical intervention between the groups (all, P > .05). Patients in group B had a shorter hospital stay (11 days vs 21 days, P < .001) and shorter ICU stay (0 [0, 1] days vs. 0 [0, 9] days, P = .029). In group A, 6 of 47 patients (12.8%) underwent a nontherapeutic laparotomy. In contrast, 9 of 57 patients (15.8%) in group B avoided a nontherapeutic laparotomy because no significant intra-abdominal findings warranting an intervention were disclosed by laparoscopy. The incidence of laparotomy for patients with significant injuries in group B was lower than in group A (4.2% vs. 100.0%; P < .001). There was no difference in the complication rate between the groups. CONCLUSIONS: Laparoscopy is feasible and safe for the diagnosis and treatment of hemodynamically stable patients with blunt abdominal trauma and can reduce the laparotomy rate.

After-hours physician care for patients with do-not-resuscitate orders: an observational cohort study.

BACKGROUND: Medical care at night for patients with do-not-resuscitate orders and the practice patterns of the on-call residents have rarely been reported. AIM: To evaluate the after-hours physician care for patients with do-not-resuscitate orders in the general medicine ward. DESIGN: Observational study. SETTING/PARTICIPANTS: This study was conducted at an urban, university-affiliated academic medical center in Taiwan. The night shift nurses consecutively recorded every event that required calling the duty residents. Patients with and without a do-not-resuscitate order were compared in demographics, reasons for calling, residents' response, and nurses' satisfaction. A standard report form was established for the nurses to record events. RESULTS: From October 2009 to September 2010, 1379 inpatients contributed to 456 after-hours calls. do-not-resuscitate patients accounted for 256 (18.7%) of all inpatients, and 160 (35.1%) of all after-hours calls. The leading reason for calls was abnormal vital signs, which was significantly higher for patients with do-not-resuscitate orders compared to patients without a do-not-resuscitate order (64.4% vs 36.1%, p < 0.001). The pattern of residents' responses showed a significant difference with more bedside visits for patients with do-not-resuscitate orders (p < 0.001). The nurses were usually satisfied with the residents' management of both groups. CONCLUSION: Abnormal vital sign, rather than symptom, was the leading reason for after-hours calls. The existence of do-not-resuscitate order produced different medical needs and physician workload. Patients with do-not-resuscitate orders accounted for one-third of night calls and nearly half of bedside visits by on-call residents and may require a different care approach.

When and how should physicians determine the need for palliative and hospice care for patients with end-stage liver disease?: an experience in Taiwan.

We analyzed one case of end-stage liver disease and discussed whether the palliative care should be considered for this case. The medical record of a 56-year-old woman with alcoholic liver cirrhosis admitted to our hospital due to hypovolemic shock and esophageal varices (EV) was reviewed. The EV with active bleeding were arrested by panendoscopic intervention. However, repeat surgery revealed transmural laceration over the cardia, and immediate surgery and splenectomy were needed. The patient died postoperatively in the surgical intensive care unit due to bleeding tendency and hypovolemic shock. We suggest that palliative care and/or hospice care should have been considered for this patient before the crisis developed and that physicians require education about timely palliative and hospice care for patients with end-stage nonmalignant disease.

Hemojuvelin modulates iron stress during acute kidney injury: improved by furin inhibitor.

AIMS: Free iron plays an important role in the pathogenesis of acute kidney injury (AKI) via the formation of hydroxyl radicals. Systemic iron homeostasis is controlled by the hemojuvelin-hepcidin-ferroportin axis in the liver, but less is known about this role in AKI. RESULTS: By proteomics, we identified a 42 kDa soluble hemojuvelin (sHJV), processed by furin protease from membrane-bound hemojuvelin (mHJV), in the urine during AKI after cardiac surgery. Biopsies from human and mouse specimens with AKI confirm that HJV is extensively increased in renal tubules. Iron overload enhanced the expression of hemojuvelin-hepcidin signaling pathway. The furin inhibitor (FI) decreases furin-mediated proteolytic cleavage of mHJV into sHJV and augments the mHJV/sHJV ratio after iron overload with hypoxia condition. The FI could reduce renal tubule apoptosis, stabilize hypoxic induced factor-1, prevent the accumulation of iron in the kidney, and further ameliorate ischemic-reperfusion injury. mHJV is associated with decreasing total kidney iron, secreting hepcidin, and promoting the degradation of ferroportin at AKI, whereas sHJV does the opposite. INNOVATION: This study suggests the ratio of mHJV/sHJV affects the iron deposition during acute kidney injury and sHJV could be an early biomarker of AKI. CONCLUSION: Our findings link endogenous HJV inextricably with renal iron homeostasis for the first time, add new significance to early predict AKI, and identify novel therapeutic targets to reduce the severity of AKI using the FI.

Acute kidney injury network staging in geriatric postoperative acute kidney injury patients: shortcomings and improvements.

BACKGROUND: The incidence of acute kidney injury (AKI) is rising, particularly among the elderly. However, the optimal risk stratification scheme for these patients is unknown. The Acute Kidney Injury Network (AKIN) classification application in geriatric patients has not been previously confirmed. STUDY DESIGN: In this multicenter study, elderly patients (>65 years old) who had major surgery and were admitted to ICUs between January 1, 2002 and December 31, 2008 were recruited and grouped according to the AKIN creatinine criteria. The utility of the AKIN criteria for the prediction of in-hospital mortality was determined using Cox proportional hazard regression modeling. RESULTS: A total of 4,240 eligible patients were identified and separated into "non-AKI" (n = 3,259), AKIN 1 (n = 582), AKIN 2 (n = 78), and AKIN 3 groups (n = 321). Cox proportional hazard regression analysis revealed that the AKIN 3 group has a significantly higher hospital mortality compared with the non-AKI group (hazard ratio [HR] 3.19, 95% CI 2.16 to 4.71; p < 0.001); the AKIN 1 (p = 0.611) and AKIN 2 (p = 0.104) groups have no significant differences compared with the non-AKI group. After excluding patients who received hemodialysis 1 week postoperatively, the AKIN 2 group predicted a significantly higher risk of hospital mortality compared with the non-AKI group (HR 2.31; p = 0.008). CONCLUSIONS: This is the first study to demonstrate the poor applicability of the AKIN classification in the prediction of in-hospital mortality in geriatric postoperative AKI patients. Consideration of late dialysis status may enhance the discriminative power of AKIN in this specific population.

Demand and predictors for post-discharge medical counseling in home care patients: a prospective cohort study.

RATIONALE: Post-discharge care is challenging due to the high rate of adverse events after discharge. However, details regarding post-discharge care requirements remain unclear. Post-discharge medical counseling (PDMC) by telephone service was set-up to investigate its demand and predictors. METHODS: This prospective study was conducted from April 2011 to March 2012 in a tertiary referral center in northern Taiwan. Patients discharged for home care were recruited and educated via telephone hotline counseling when needed. The patient's characteristics and call-in details were recorded, and predictors of PDMC use and worsening by red-flag sign were analyzed. RESULTS: During the study period, 224 patients were enrolled. The PDMC was used 121 times by 65 patients in an average of 8.6 days after discharge. The red-flag sign was noted in 17 PDMC from 16 patients. Of the PDMC used, 50% (n = 60) were for symptom change and the rest were for post-discharge care problems and issues regarding other administrative services. Predictors of PDMC were underlying malignancy and lower Barthel index (BI). On the other hand, lower BI, higher adjusted Charlson co-morbidity index (CCI), and longer length of hospital stay were associated with PDMC and red-flag sign. CONCLUSIONS: Demand for PDMC may be as high as 29% in home care patients within 30 days after discharge. PDMC is needed more by patients with malignancy and lower BI. More focus should also be given to those with lower BI, higher CCI, and longer length of hospital stay, as they more frequently have red flag signs.

Airway obstruction following bronchoscopic photodynamic therapy in early centrally located lung cancer requiring extracorporeal membrane oxygenation.

Photodynamic therapy (PDT) is a treatment modality of early central located non-small-cell lung cancer, and in patients who are unsuitable for surgical intervention. Most complications of PDT reported in the literature are minor and can be easily handled. We report a case presenting with nearly fatal complication: airway obstruction following bronchoscopic photodynamic therapy for early endobronchial lung cancer, requiring extracorporeal membrane oxygenation. An 81-year-old man was admitted to thoracic surgery division due to an early centrally located lung cancer. Due to multiple comorbidity and high surgical risk we performed bronchoscopic PDT instead of aggressive lung resection for the patient. After the procedure, he developed severe airway obstruction by tumor debris and required temporary cardiopulmonary support with extracorporeal membrane oxygenation. The patient recovered smoothly after the episode and was free from tumor recurrence for >2 years without any neurological sequelae.

Extracorporeal membrane oxygenation resuscitation in adult patients with refractory septic shock.

OBJECTIVES: Experience with extracorporeal membrane oxygenation for adult patients with refractory septic shock remains limited. We aimed to study the clinical features and outcomes of this patient group in an extracorporeal membrane oxygenation referral center in Taiwan. METHODS: From January 2005 to December 2010, all adult patients in refractory septic shock and requiring venoarterial extracorporeal membrane oxygenation for circulatory support were included in the present study. The variables analyzed included patient demographics; comorbidities; smoking status; hemodynamic, ventilatory, and laboratory parameters just before extracorporeal membrane oxygenation support; clinical course; extracorporeal membrane oxygenation details; complications; microbiology results; and outcomes. The primary endpoint was survival to hospital discharge. RESULTS: A total of 52 patients, 39 men and 13 women, were included during a 6-year period. Their median age and body mass index was 56.8 years and 24.1 kg/m(2), respectively. Of the 52 patients, 39 (75%) had failure of at least 3 organ systems and 21 (40%) had developed cardiac arrest and received cardiopulmonary resuscitation at extracorporeal membrane oxygenation implantation. Of these 52 patients, 8 (15%) survived to hospital discharge. The nonsurvivors were significantly older than the survivors (59.3 vs 43.8 years; P = .009), and all 20 patients (38%) aged 60 years or older died. CONCLUSIONS: In our single-center experience with extracorporeal membrane oxygenation for adults with refractory septic shock, the outcomes of these patients remain unsatisfactory. From our findings, we suggest that if extracorporeal membrane oxygenation were to be used in this patient population, age 60 years or older might be a contraindication. Also, central extracorporeal membrane oxygenation could possibly be beneficial according to the favorable pediatric experience in published studies.

Noncancer palliative care: the lost pieces in an acute care setting in Taiwan.

Little is known about the picture of patients receiving palliative care in the acute care setting. The study was conducted in a medical center in Taiwan. Cancer palliative care (CPC) was performed for terminal do-not-resuscitate (DNR) patients with advanced cancers. Noncancer palliative care (NCPC) was performed for DNR patients who did not fulfill the criteria of CPC. Of the 1379 consecutive admissions, 258 patients were identified, with 193 (74.8%) requiring NCPC and 65 (25.2%) requiring CPC. The NCPC patients were older and had lower Charlson comorbidity index (2.6 vs 8.6, P < .001) than CPC patients and had poorer consciousness and more organ failure than CPC patients when recognized. Many noncancer patients without access to specialist palliative care services were treated in the acute care setting with delayed recognition.

Correlation between early sublingual small vessel density and late blood lactate level in critically ill surgical patients.

BACKGROUND: Surgical stress may cause excessive inflammation and lead to microcirculatory dysfunction. The hypothesis of this study was that early microcirculatory dysfunction may result in anaerobic glycolysis and lead to elevated blood lactate levels in patients admitted to surgical intensive care units. METHODS: This prospective observational study enrolled adult patients admitted to surgical intensive care units after general surgery or thoracic surgery. We measured blood lactate levels before the operation and at 1 h and 24 h after the operation. We obtained images of sublingual microcirculation using a sidestream dark field video microscope and analyzed them employing automated analysis software. RESULTS: A total of 31 patients completed the study. Perioperative total and perfused small vessel densities were lower in patients with a blood lactate level ≥3 mmol/L. We observed a significant correlation between the total small vessel density at 1 h and the blood lactate level at 24 h (r = -0.573; P = 0.001). In addition, we saw a significant correlation between the perfused small vessel density at 1 h and the blood lactate level at 24 h (r = -0.476; P = 0.008). CONCLUSIONS: Early total and perfused small vessel density may be used as an early predictor or therapeutic goal for critically ill surgical patients in further studies.