Prevalence of Delirium After Abdominal Surgery and Association With Ketamine: A Retrospective, Propensity-Matched Cohort Study.

IMPORTANCE: Delirium is a common postoperative complication for older patients in the ICU. Ketamine, used primarily as an analgesic, has been thought to prevent delirium. OBJECTIVE: Determine the prevalence and association of delirium with low-dose ketamine use in ICU patients after abdominal surgery. DESIGN: Single-center, retrospective, propensity-matched cohort study. SETTING: Eight hospital academic medical center. PATIENTS: Cohort comprising 1836 patients admitted to the ICU after abdominal surgery between June 23, 2018 and September 1, 2022. MAIN OUTCOMES AND MEASURES: Propensity score matching (PSM) with a 3:1 ratio between no-ketamine use and ketamine use was performed through a greedy algorithm (caliper of 0.005). Outcomes of interest included: delirium (assessed by Confusion Assessment Method-ICU), mean pain score (Numeric Pain Scale or Critical Care Pain Observation Tool score as available), mean opioid consumption (morphine milligram equivalents), length of stay (d), and mortality. RESULTS: Prevalence of delirium was 47.71% (95% CI, 45.41-50.03%) in the cohort. Of 1836 patients, 120 (6.54%) used low-dose ketamine infusion. After PSM, the prevalence of delirium was 56.02% (95% CI, 51.05-60.91%) in all abdominal surgery patients. The ketamine group had 41% less odds of delirium (odds ratio [OR] = 0.59; 95% CI, 0.37-0.94; p = 0.026) than patients with no-ketamine use. Patients with ketamine use had higher mean pain scores (3.57 ± 2.86 vs. 2.21 ± 2.09, p < 0.001). In the subgroup analysis, patients in the ketamine-use group 60 years old or younger had 64% less odds of delirium (OR = 0.36; 95% CI, 0.13-0.95; p = 0.039). The mean pain scores were higher in the ketamine group for patients 60 years old or older. There was no significant difference in mortality and opioid consumption. CONCLUSIONS AND RELEVANCE: Low-dose ketamine infusion was associated with lower prevalence of delirium in ICU patients following abdominal surgery. Prospective studies should further evaluate ketamine use and delirium.

ICU Delirium in Cardiac Patients.

Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients.

Development and Validation of a Risk Score for Respiratory Failure After Cardiac Surgery.

BACKGROUND: Postoperative respiratory failure, defined as ventilator dependency for more than 48 hours or unplanned reintubation within 30 days, is a costly complication of cardiac surgery that increases mortality and length of stay. Stratification of patients by risk upon intensive care unit admission could identify cases requiring early measures to prevent respiratory failure. This study aimed to develop and validate a risk score for postoperative respiratory failure after cardiac surgery. METHODS: This retrospective analysis of 4262 patients admitted to the cardiovascular intensive care unit after major cardiac surgery between January 2013 and December 2017, used The Society of Thoracic Surgeons database and ventilator data from the respiratory therapy department. Patients were randomly and equally assigned to development and validation cohorts. Covariates used in the multivariable models were assigned weighted points proportional to their ß regression coefficient values to create the risk score, which categorized patients into low, medium, and high risk of postoperative respiratory failure. RESULTS: In both cohorts, postoperative respiratory failure risk was significantly different between risk categories. Compared with low-risk patients, moderate-risk patients had a 2 times greater risk, and high-risk patients had a 4-7 times greater risk. Body mass index, previous cardiac surgery, cardiopulmonary bypass, cardiogenic shock, pulmonary disease presence, baseline functional status, hemodynamic instability, and number of blood products used intraoperatively were significant predictors of respiratory failure. CONCLUSIONS: This risk score can stratify patients by risk for developing postoperative respiratory failure after major cardiac surgery, which may help in the development of preventive measures.

Cardiogenic Shock in Perioperative and Intraoperative Settings: A Team Approach.

Cardiogenic shock (CS) is a multifactorial disease process with high morbidity and mortality. When it occurs in a peri- or intraoperative setting, factors such as surgery, anesthesia, and post-surgical physiology can negatively affect patient outcomes. Since patient needs often escalate during CS-from medications to mechanical support to palliative care-this disease demands a multidisciplinary approach that encompasses all aspects of medical delivery. Preliminary studies have indicated that a multidisciplinary team approach to CS results in earlier diagnosis and treatment and improves patient outcomes. Here we discuss various management strategies for CS from an anesthesiology, surgery, and critical care perspective.

An update on the management of pancreatic neuroendocrine tumors.

Pancreatic neuroendocrine tumors (PNETs) are a rare and heterogeneous group of neoplasia and differ in their clinical presentation, behavior, and prognosis based on both histological features and cancer stage at the time of diagnosis. Although small-sized tumors can be surgically resected, locally advanced and metastatic tumors confer a poor prognosis. In addition, only limited treatment options are available to the latter group of patients with PNETs, such as hormonal analogs, cytotoxic agents, and targeted therapy. In selected patients, liver-directed therapies are also used. As expected, clinicians taking care of these patients are challenged to develop an effective and comprehensive treatment strategy for their patients amid a wide variety of treatment modalities. Targeted therapy for PNETs is limited to sunitinib and everolimus. Presently, a number of clinical studies are ongoing to assess the efficacy of newer targeted agents alone and in combination with previous agents for the treatment of advanced PNETs. The authors reviewed the current treatment and also discussed the emerging agents and emphasized the need to identify biomarkers.

Enhanced recovery after thoracic surgery reduces discharge on highly dependent narcotics.

BACKGROUND: There is large prescription drug epidemic in United States. We want to determine if ERATS (enhanced recovery after thoracic surgery) program can reduce discharge on highly dependent narcotics. METHODS: We performed a retrospective analysis of prospectively collected data on patients who underwent lung resection and foregut procedures on thoracic surgery service over an 8-month time period. Patients underwent preoperative conditioning instructions, multimodal non-narcotic pharmaceutical usage, total intravenous anesthesia (TIVA) and minimizing highly addictive narcotics during the post-operative period. We gathered information on demographics, indication and type of surgery, morbidity, mortality and length of stay. We also recorded the type of pain medication patients were given as a prescription based on the Drug Enforcement Agency's classification schedule. RESULTS: Fifty-two patients underwent lung resection and 54 patients underwent foregut surgery. There were no mortalities in either group. Ten percent of patients after lung surgery and 6% after foregut surgery had a greater than grade II complication. The median length of stay after lung resection was 2 days and foregut surgery was 1 day. Only 10% of patients went home after lung resection and 2% after foregut surgery with a prescription for schedule II narcotics. We found that patients who were on schedule II narcotics prior to surgery all went home with schedule II narcotics. CONCLUSIONS: We found that ERATS program for thoracic surgical cases can reduce the number of patients going home with highly dependent narcotics. This strategy will decrease the availability of highly addictive prescription drugs in the community.

Metformin and pancreatic cancer: Is there a role?

Pancreatic cancer is the fourth leading cause of cancer-related deaths in the USA, with a 5-year survival rate of 6 %. Anti-hyperglycemic treatments for type 2 diabetes mellitus that induce hyperinsulinemia (i.e., sulfonylureas) are thought to increase cancer risk, whereas treatments that lower insulin resistance and hyperinsulinemia (i.e., metformin) are considered cancer prevention strategies. Metformin is a cornerstone in the treatment of diabetes mellitus type 2. Retrospective studies have shown a survival benefit in diabetic patients with many solid tumors including pancreatic cancer that have been treated with metformin compared with patients treated with insulin or sulfonylureas. Metformin influences various cellular pathways, including activation of the LKB1/AMPK pathway, inhibition of cell division, promotion of apoptosis and autophagy, down-regulation of circulating insulin, and activation of the immune system. Ongoing research is redefining our understanding about how metformin modulates the molecular pathways implicated in pancreatic cancer. The authors review the topic critically and also give their opinion. Further studies investigating the effect of metformin in combination with chemotherapy, targeted agents, or radiation therapy are undergoing. In addition, the role of metabolic and other biomarkers is needed.

Diabetes Type 2 and Pancreatic Cancer: A History Unfolding.

Pancreatic Cancer is the fourth cause of cancer-related deaths in the United States. Up to 80% of pancreatic cancer patients present with either new-onset type 2 diabetes or impaired glucose tolerance at the time of diagnosis. Recent literature suggests that diabetes mellitus type 2 is a risk factor, a manifestation and a prognostic factor for pancreatic cancer. This article is intended to clarify the evidence about diabetes as a risk factor for pancreatic cancer.

Comparison of dexmedetomidine versus propofol for sedation in mechanically ventilated patients after cardiovascular surgery.

Many cardiovascular surgeries are fast-tracked to extubation and require short-term sedation. Dexmedetomidine and propofol have very different mechanisms of action and pharmacokinetic profiles that make them attractive sedative agents in this patient population. Recently, there has been increased use of dexmedetomidine in the intensive care unit (ICU), but few studies exist or have been published directly comparing both agents in this setting. We conducted a retrospective cohort study with patients admitted to the ICU after cardiovascular surgery from January through June 2011. Adult patients who underwent coronary artery bypass and/or cardiac valve surgery received either dexmedetomidine or propofol continuous infusion for short-term sedation after cardiovascular surgery. The primary end point was time (hours) on mechanical ventilation after surgery. Secondary end points included ICU length of stay (LOS), hospital LOS, incidence of delirium, and requirement of a second sedative agent. A total of 352 patients met study inclusion criteria, with 33 enrolled in the dexmedetomidine group and 319 in the propofol group. Time on mechanical ventilation was shorter in the dexmedetomidine group (7.4 hours vs. 12.9 hours, P = .042). No difference was seen in ICU or hospital LOS. The need for a second sedative agent to achieve optimal sedation (24% vs. 27%, P = .737) and incidence of delirium (9% vs. 7.5%, P = .747) were similar between both groups. Sedation with dexmedetomidine resulted in a significant reduction in time on mechanical ventilation. However, no difference was seen in ICU or hospital LOS, incidence of delirium, or mortality.

Chemotherapy and metformin in pancreatic adenocarcinoma and neuroendocrine tumors.

Pancreatic cancer, despite being a relatively less commonly occurring cancer is among the deadliest ones, leading to a grave prognosis. Surgery stands as the mainstay of treatment of pancreatic cancer but is an option in less than 15% patients owing to the late presentation of the tumor. Chemotherapy offers an important part of treatment but can adversely affect the quality of life because of devastating side effects and has limited survival benefit. Unavailability of effective and less toxic treatment options for pancreatic cancer has prompted the search for new treatment strategies. One such drug being considered for its potential anti-neoplastic role is the time-tested and widely used oral hypoglycemic drug, metformin. Metformin is proposed to target metabolic pathways involved in tumorigenesis, specifically the AMPK-mTOR complex. Epidemiological evidence is mounting in favor of its role in various cancers both for treatment and prophylaxis. Herein, we aim to summarize the epidemiological data on metformin as a potential anti-cancer drug in various cancers followed by a look at some of the abstracts relating to this topic that were presented at the American Society of Clinical Oncology (ASCO) Annual Meeting 2014.

Diabetes and pancreatic cancer.

Research suggests a possible link between type 2 diabetes and several malignancies. Animal models have shown that hyperinsulinemic state underlying diabetes promotes tumor formation through stimulation of insulin-IGF-1 pathway; a possible role of inflammation is also proposed. One such link which has been under considerable study for years is that between diabetes and pancreatic cancer. Although epidemiological evidence points towards a reciprocal link between the two, the cause-effect relationship still remains unclear. This link was the subject of a large German epidemiological study presented at the American Society of Clinical Oncology Annual Meeting 2014 (Abstract #1604), which underscored the link between diabetes and some cancers. Schmidt et al. performed a retrospective database analysis over a 12 year period and reported an increased risk of certain types of cancer in diabetic patients. The most significant association (HR 2.17) was found for pancreatic cancer. Given the high mortality of pancreatic cancer, prevention through timely screening could play an important role in improving prognosis. Older subjects with recent-onset diabetes represent a high-risk group and hence are potential targets for pancreatic cancer screening thereby enabling its early diagnosis at a curable stage.

Updates on critical care management of cardiovascular patients.

Cardiology and cardiovascular surgery patients have historically been one of the sickest populations that physicians encounter. With the inherent compromise of the cardiac and/or respiratory system and the added complexity of a major surgical procedure, this patient group requires a demanding level of care. As innovations in the treatment of cardiac patients have prolonged life, we have encountered patients who require redo-redo-redo procedures. There has been a tremendous increase in the use of a wide variety of mechanical assist devices, transplantation procedures, robotic surgery, and hybrid approaches in which cardiac surgeons and cardiologists work in the same room on the same patient. Against this background, there have been quite a few changes taking place in the field of critical care. This report discusses the transformations being made in blood pressure management, blood product transfusion, prevention of healthcareassociated infections, physical therapy in cardiothoracic intensive care units (ICUs), ventilatory management, and the role of intensivists in cardiothoracic ICUs.

Establishing a culture of blood management through education: a quality initiative study of postoperative blood use in CABG patients at Methodist DeBakey Heart & Vascular Center.

Blood management strategies are crucial in light of transfusion-related health risks to patients and the relative scarcity and cost of blood products. The authors describe a collaborative quality initiative to reduce blood use in their coronary artery bypass graft (CABG) population and other cardiovascular intensive care unit (CVICU) patients. A multidisciplinary team was engaged at all levels of patient care. The 2-part initiative involved a direct educational component emphasizing transfusion risk awareness and patient-centered blood management strategies accompanied by a data-based component that included monthly dissemination of blood product use to the relevant service lines. The authors observed a reduction in postoperative blood product use among CABG patients (14.3% decrease in the first year; 30.6% from 2006 to 2008) and an 18.2% reduction in blood product volume used in the entire CVICU, with no additional harm to patients and a trend toward better outcomes. This team-driven paradigm change has made blood management everyone's initiative.

Preventing healthcare-associated infections in cardiac surgical patients as a hallmark of excellence.

Healthcare-associated infections (HAI) are the tenth-leading cause of death in the United States. The Centers for Disease Control and Prevention (CDC) estimate that HAIs annually account for 1.7 million infections, 99,000 associated deaths, and a cost of approximately $30 billion. Nonreimbursement of some of these HAIs by the Centers for Medicare and Medicaid Services, public reporting of data (currently in 27 states), and the statistics listed above are driving quality initiatives to reduce or eliminate HAIs. However, a 2009 report from the Agency for Healthcare Research & Quality showed that little progress has been made towards eliminating HAIs. Reducing the risk of healthcare-associated infections is the Joint Commission's National Patient Safety Goal Number 7. Cardiac surgery has always been at the leading edge of innovation and quality care. Improvements in this field have been brought about by the needs of critically ill patients who are at high risk of death and by leaders such as Dr. Michael DeBakey who were driven to provide excellence in patient care. One of the prime examples of quality initiatives in cardiac surgery has been the development of the Society of Thoracic Surgeons (STS) National Database. This has helped to develop benchmarks by which different institutions are measured. The STS database will lead another initiative by providing public presentation of hospital- and surgeon-specific data in the near future. Even so, cardiac surgery patients are at especially high risk of developing HAIs. Use of invasive devices such as central lines, urinary catheters, ventilators, etc. - all of which are commonly utilized in the care of cardiac surgical patients - is one of the most significant risk factors for acquiring HAIs. Cardiac patients also have significant co-morbidities such as diabetes, obesity, increasing frailty, advanced age, and multiple redo-operations. This combination makes our patients more vulnerable to HAIs. Accordingly, in 2010 the Society of Cardiovascular Anesthesiologists (SCA) Foundation launched the FOCUS (Flawless Operative Cardiovascular Unified Systems) Cardiac Surgery Patient Safety Initiative to help eliminate infections in cardiac surgery patients, especially catheter-related infections. This publication will briefly discuss the four most common infections and strategies to reduce HAIs and will touch on some of the infection-control experiences from the Methodist DeBakey Heart & vascular Center (MDHVC).

Outcomes before and after initiation of an acute aortic treatment center.

BACKGROUND: Acute aortic syndromes remain life-threatening. Time is of the essence, as mortality rises with increasing time after the acute episode. The aim of this report is to show changes in practice and outcomes after the establishment of an acute aortic treatment center (AATC) to expedite the care of acute aortic syndromes in a major metropolitan area with the belief that "door to intervention time under 90 minutes" reduces mortality and morbidity from acute aortic disease. METHODS: A database of patients admitted with acute aortic disease (Type A and B aortic dissections, acute thoraco-abdominal aortic aneurysms, acute and ruptured abdominal aortic aneurysms) for 1 year prior to initiation (2007) and 1 year after initiation of the pathway (AATC) in 2008 was developed. Comorbidities were scored according to Society of Vascular Surgery criteria. Anatomic and functional outcomes were determined and categorized by Society of Vascular Surgery reporting criteria. Multivariate analysis was performed for categorical outcomes and Cox proportional hazard analyses for time-dependent outcomes. RESULTS: Six hundred twenty-one patients reported with aortic disease to the cardiovascular services; 306 patients were considered to have acute disease. When compared with the year before the AATC was instituted, there was a 30% increase in the total number of admissions and a 25% increase in acute pathology after setting up the AATC (P = .02). There was a two-fold increase in thoracic aortic dissections admitted to the service. Initiation of the treatment pathway resulted in a highly significant 64% reduction in time to definitive therapy (526 ± 557 vs 187 ± 258 minutes, mean ± SD pre-AATC vs AATC; P = .0001). Comorbidity scores were equivalent between the two cohorts. Despite the increase in acuity, mortality (4% vs 6%) and morbidity (41% vs 45%) rates were unchanged, and there was a significant decrease in intensive care unit length of stay (5 vs 4 days, pre-AATC cohort vs the AATC cohort), but total hospital length of stay (11 vs 10 days) was unchanged. There was no correlation between deaths within 30 days and length of stay in the intensive care unit. CONCLUSION: Establishment of a multidisciplinary AATC pathway was associated with a 30% increase in volume, 64% reduction in time to definitive treatment, improved throughput with reduced intensive care unit time, and maintained clinical efficacy despite an increase in acute admissions. These results suggest the concept be further evaluated.

Recombinant factor VIIa treatment of severe bleeding in cardiac surgery patients: a retrospective analysis of dosing, efficacy, and safety outcomes.

OBJECTIVE: To describe rFVIIa dosing and clinical outcomes in cardiovascular surgery patients with refractory bleeding. DESIGN: Retrospective chart review of patients receiving rFVIIa from January 1, 2004 to September 30, 2005, in the cardiovascular surgery setting. SETTING: Tertiary care, private teaching hospital. PARTICIPANTS: Ninety-three patients who received rFVIIa after cardiovascular surgery for the management of refractory bleeding. INTERVENTIONS: None. MEASURES AND MAIN RESULTS: Patients received an average of 7.6 +/- 6.8 units of red blood cells (RBCs) before rFVIIa dosing (mean dose, 56.2 +/- 26.5 microg/kg). Median and 25th and 75th quartile blood product consumption was significantly reduced 6 hours after rFVIIa versus 6 hours before (RBCs, -3 units, [-1, -7]; cryoprecipitate, -7.5 units [0, -20]; platelet, -3 units [-1, -4]; fresh frozen plasma, -4 units [-2, -7]). Repeated rFVIIa dosing occurred in 10% of patients, with 8 (8.6%) and 2 (2.25%) patients receiving second and third doses, respectively. Subgroup analysis of each rFVIIa dosing quartile >30 microg/kg showed a significant reduction in RBCs; however, no significant differences were found in the magnitude of RBC reduction or percent of patients requiring massive transfusion among the quartiles. No adverse thrombotic episodes were noted, and the observed mortality (22.6%) was not attributed to rFVIIa therapy. CONCLUSIONS: rFVIIa effectively reduces blood product use in cardiovascular surgery patients having massive blood loss. Although the optimal dose of rFVIIa for use in cardiovascular surgery remains undetermined, these data provide evidence that dosing regimens using <90 microg/kg are effective in this population and may provide guidance for centers establishing standardized protocols for rFVIIa use in cardiovascular surgery patients.