Long-term survival and functional outcomes of critically ill patients with hematologic malignancies: a Canadian multicenter prospective study.

PURPOSE: Patients with hematologic malignancy (HM) commonly develop critical illness. Their long-term survival and functional outcomes have not been well described. METHODS: We conducted a prospective, observational study of HM patients admitted to seven Canadian intensive care units (ICUs) (2018-2020). We followed survivors at 7 days, 6 months and 12 months following ICU discharge. The primary outcome was 12-month survival. We evaluated functional outcomes at 6 and 12 months using the functional independent measure (FIM) and short form (SF)-36 as well as variables associated with 12-month survival. RESULTS: We enrolled 414 patients including 35% women. The median age was 61 (interquartile range, IQR: 52-69), median Sequential Organ Failure Assessment (SOFA) score was 9 (IQR: 6-12), and 22% had moderate-severe frailty (clinical frailty scale [CFS] ≥ 6). 51% had acute leukemia, 38% lymphoma/multiple myeloma, and 40% had received a hematopoietic stem cell transplant (HCT). The most common reasons for ICU admission were acute respiratory failure (50%) and sepsis (40%). Overall, 203 (49%) were alive 7 days post-ICU discharge (ICU survivors). Twelve-month survival of the entire cohort was 21% (43% across ICU survivors). The proportion of survivors with moderate-severe frailty was 42% (at 7 days), 14% (6 months), and 8% (12 months). Median FIM at 7 days was 80 (IQR: 50-109). Physical function, pain, social function, mental health, and emotional well-being were below age- and sex-matched population scores at 6 and 12 months. Frailty, allogeneic HCT, kidney injury, and cardiac complications during ICU were associated with lower 12- month survival. CONCLUSIONS: 49% of all HM patients were alive at 7 days post-ICU discharge, and 21% at 12 months. Survival varied based upon hematologic diagnosis and frailty status. Survivors had important functional disability and impairment in emotional, physical, and general well-being.

Survival with optimal medical management in a cohort of severe necrotizing bacterial lung infections.

Background: Necrotizing pneumonia and lung gangrene represent a continuum of severe lung infection. Traditionally, severe cases have been referred for surgical debridement. However, this has been linked to high mortality. Some groups have published encouraging results using a conservative medical approach. Unfortunately, lack of a standardized definition of necrotizing pneumonia has precluded meaningful comparison between medical and surgical approach in severe cases. Our objective was to describe the outcome of a cohort of severe necrotizing pneumonia treated with optimal medical management. Methods: We conducted an observational retrospective study by reviewing charts and radiology records of patients hospitalized between 2006-2019 in a tertiary center. We included all patients with severe necrotizing infection, defined as a necrotizing cavity involving at least 50% of a lobe, or smaller multilobar cavities. We made no distinction between necrotizing pneumonia and gangrene as there are no standardized criteria. Results: A total of 50 consecutive patients were included. On imaging, 42% had multilobar cavities and mean diameter of the largest cavity in each case was 5.9 cm. 50% required mechanical ventilation (median duration 12 days) and 44% needed vasopressors. Four patients (8%) had decortication surgery, while none underwent lung resection. Four patients (8%) died. The extent of infiltrates and number of cavities were not associated with mortality but the extent of infiltrates was associated with risk of intubation (P=0.004). Conclusions: We presented one of the largest series of medically-treated severe necrotizing lung infections in the pre-coronavirus disease-2019 (COVID-19) era. The overwhelming majority of patients recovered with optimal medical management alone. Our results strongly support avoiding pulmonary resection in patients with severe necrotizing bacterial lung infections.

Vitamin C-Induced Oxalate Nephropathy in a Septic Patient.

Vitamin C is a novel treatment currently under investigation in the management of sepsis. Adverse renal effects of vitamin C through hyperoxaluria have been described in the past. DATA SOURCES: We report the case of a 63-year-old man admitted in a community-based hospital with a diagnosis of sepsis of pulmonary origin. DATA EXTRACTION: On day 19, despite a having developed oligoanuric acute kidney injury, a regimen of IV vitamin C, hydrocortisone, and thiamine was undertaken for 4 days. On day 23, the patient required renal replacement therapy with an estimated glomerular filtration rate of 7 mL/min. Renal biopsy revealed extensive acute tubular necrosis associated with the presence of intratubular crystal of calcium oxalate. CONCLUSION: Although vitamin C seems to be a possible therapeutic asset in the supportive care of sepsis patients, larger cohorts are required to ensure its safety and underlying or novel kidney injury should forewarn clinicians as to its use.

Minimizing the Risk of Aerosol Contamination During Elective Lung Resection Surgery.

BACKGROUND: In the setting of the COVID-19 pandemic, the conduct of elective cancer surgery has become an issue because of the need to balance the requirement to treat patients with the possibility of transmission of the virus by asymptomatic carriers. A particular concern is the potential for viral transmission by way of aerosol which may be generated during perioperative care. There are currently no guidelines for the conduct of elective lung resection surgery in this context. METHODS: A working group composed of 1 thoracic surgeon, 2 anesthesiologists and 1 critical care specialist assessed the risk for aerosol during lung resection surgery and proposed steps for mitigation. After external review, a final draft was approved by the Committee for the Governance of Perioperative and Surgical Activities of the Hôpital Maisonneuve-Rosemont, in Montreal, Canada. RESULTS: The working group divided the risk for aerosol into 6 time-points: (1) intubation and extubation; (2) Lung isolation and patient positioning; (3) access to the chest; (4) conduct of the surgical procedure; (5) procedure termination and lung re-expansion; (6) chest drainage. Mitigating strategies were proposed for each time-point. CONCLUSIONS: The situation with COVID-19 is an opportunity to re-evaluate operating room protocols both for the purposes of this pandemic and similar situations in the future. In the context of lung resection surgery, specific time points during the procedure seem to pose specific risks for the genesis of aerosol and thus should be the focus of attention.

Outcomes of vulnerable elderly patients undergoing elective major surgery: a prospective cohort study.

PURPOSE: Identifying patients at risk of postoperative complications and trying to prevent these complications are the essence of preoperative evaluation. While not overtly frail or disabled, vulnerable patients with mild frailty may be missed by routine assessments and may still have a worse postoperative course. METHODS: We performed a prospective cohort study evaluating vulnerability in older patients undergoing elective surgery. Vulnerability was assessed using the Clinical Frailty Scale. Our primary outcome was postoperative hospital length of stay (LOS) and our secondary outcome was non-home hospital discharge. We performed multivariable analyses to assess the association between vulnerability and our primary and secondary outcome. RESULTS: Between 1 January 2017 and 1 January 2018, 271 older patients with a median [interquartile range (IQR)] age of 72 [69-76] yr underwent frailty assessment prior to surgery. Eighty-eight (32.5%) of the cohort were classified as vulnerable. The median [IQR] duration of hospital LOS was 4 [2-7] days for vulnerable patients, 4 [2-6] days for robust patients, and 7 [3-10] days for frail patients. After adjusting for confounders, hospital LOS was not longer for vulnerable patients than for robust patients, but was associated with a higher rate of non-home discharge (odds ratio, 3.7; 95% confidence interval, 1.1 to 12.9; P = 0.04). CONCLUSIONS: Vulnerability was not associated with a longer hospital LOS but with higher risk of non-home discharge. Vulnerable patients might benefit from early identification and advanced planning with earlier transfer to rehabilitation centres.

RéSUMé: OBJECTIF: L'identification des patients à risque de complications postopératoires et la prévention de ces complications constituent le fondement de l'évaluation préopératoire. Sans être ouvertement fragiles ou handicapés, les patients vulnérables avec une fragilité légère pourraient passer entre les mailles des évaluations de routine et tout de même souffrir d'un parcours postopératoire plus difficile. MéTHODE: Nous avons réalisé une étude de cohorte prospective évaluant la vulnérabilité des patients âgés subissant une chirurgie élective. La vulnérabilité a été évaluée à l'aide de l'Échelle Clinical Frailty Scale. Notre critère d'évaluation principal était la durée de séjour hospitalier postopératoire; notre critère d'évaluation secondaire était le congé de l'hôpital sans retour au foyer. Nous avons réalisé des analyses multivariées afin d'évaluer l'association entre la vulnérabilité et nos critères d'évaluation principal et secondaire. RéSULTATS: Entre le 1er janvier 2017 et le 1er janvier 2018, 271 patients d'un âge médian [écart interquartile (ÉIQ)] de 72 [69­76] ans ont passé une évaluation de fragilité avant leur chirurgie. Quatre-vingt-huit personnes (32,5 %) de la cohorte ont été catégorisées comme vulnérables. La durée médiane [ÉIQ] de séjour hospitalier était de 4 [2­7] jours pour les patients vulnérables, 4 [2­6] pour les patients robustes, et 7 [3­10] pour les patients fragiles. Après l'ajustement pour tenir compte des facteurs confondants, la durée de séjour hospitalier n'était pas plus longue pour les patients vulnérables que pour les patients robustes, mais était associée à un taux plus élevé de congé sans retour au foyer (rapport de cotes, 3,7; intervalle de confiance 95 %, 1,1 à 12,9; P = 0,04). CONCLUSION: La vulnérabilité n'a pas été associée à une durée de séjour hospitalier plus longue mais à un risque plus élevé de congé sans retour au foyer. Les patients vulnérables pourraient bénéficier d'une identification précoce et d'une planification avancée avec un transfert plus rapide vers les centres de réadaptation.

New Opioid Use after Invasive Mechanical Ventilation and Hospital Discharge.

Rationale: Patients who receive invasive mechanical ventilation (IMV) are usually exposed to opioids as part of their sedation regimen. The rates of posthospital prescribing of opioids are unknown.Objectives: To determine the frequency of persistent posthospital opioid use among patients who received IMV.Methods: We assessed opioid-naive adults who were admitted to an ICU, received IMV, and survived at least 7 days after hospital discharge in Ontario, Canada over a 26-month period (February, 2013 through March, 2015). The primary outcome was new, persistent opioid use during the year after discharge. We assessed factors associated with persistent use by multivariable logistic regression. Patients receiving IMV were also compared with matched hospitalized patients who did not receive intensive care (non-ICU).Measurements and Main Results: Among 25,085 opioid-naive patients on IMV, 5,007 (20.0%; 95% confidence interval [CI], 19.5-20.5) filled a prescription for opioids in the 7 days after hospital discharge. During the next year, 648 (2.6%; 95% CI, 2.4-2.8) of the IMV cohort met criteria for new, persistent opioid use. The patient characteristic most strongly associated with persistent use in the IMV cohort was being a surgical (vs. medical) patient (adjusted odds ratio, 3.29; 95% CI, 2.72-3.97). The rate of persistent use was slightly higher than for matched non-ICU patients (2.6% vs. 1.5%; adjusted odds ratio, 1.37 [95% CI, 1.19-1.58]).Conclusions: A total of 20% of IMV patients received a prescription for opioids after hospital discharge, and 2.6% met criteria for persistent use, an average of 300 new persistent users per year in a population of 14 million. Receipt of surgery was the factor most strongly associated with persistent use.

Potentially Inappropriate Medication Use in Older Adults in the Preoperative Period: A Retrospective Study of a Noncardiac Surgery Cohort.

BACKGROUND: Few studies have evaluated the prevalence of potentially inappropriate medications (PIMs) and its association with postoperative outcomes in a geriatric population in the preoperative setting. OBJECTIVES: The purpose of this study was to evaluate the prevalence of PIMs in an older elective surgery population and to explore associations between PIMs and postoperative length of stay (LOS) and emergency department (ED) visits in the 90 days post hospital discharge, depending on frailty status. METHODOLOGY: We performed a retrospective cohort study of older adults awaiting major elective noncardiac surgery and undergoing an evaluation in the preoperative clinic at a tertiary academic center between 2017 and 2018. We identified PIMs using MedSafer, a software tool built to improve the safety of prescribing. Frailty status was assessed using the 7-point Clinical Frailty Scale. We estimated the association between PIMs and postoperative LOS and ED visits in the 90 days post hospital discharge. RESULTS: The MedSafer software generated 394 recommendations on PIMs in 1619 medications for 252 patients. In total, 197 (78%) patients had at least one PIM. The cohort included 138 (51%) robust, 87 (32.2%) vulnerable and 45 (16.7%) frail patients. The association between PIMs and LOS was not significant for the robust and frail subgroups. For the vulnerable patients, every additional PIM increased LOS by 20% (incidence rate ratio 1.20; 95% confidence interval 0.90-1.44; p = 0.089) without reaching statistical significance. No association was found between PIMs and ED visits. CONCLUSION: PIMs identified by the MedSafer software were prevalent. Preoperative evaluation represents an opportunity to plan deprescribing of PIMs.

Preoperative Diaphragm Function Is Associated With Postoperative Pulmonary Complications After Cardiac Surgery.

OBJECTIVES: Postoperative pulmonary complications increase mortality, length, and cost of hospitalization. A better diaphragmatic strength may help face an increased work of breathing postoperatively. We, therefore, sought to determine if a low preoperative diaphragm thickening fraction (TFdi) determined by ultrasonography helped predict the occurrence of postoperative pulmonary complications after cardiac surgery independently of indicators of frailty, sarcopenia, and pulmonary function. DESIGN: Prospective observational cohort study. SETTING: Montreal Heart Institute, an academic cardiac surgery center in Canada. PATIENTS: Adults undergoing nonemergency cardiac surgery. INTERVENTIONS: We measured the preoperative thickness of the right and left hemidiaphragms at their zone of apposition at end-expiration (Tdi,ee) and peak-inspiration (Tdi,ei) with ultrasonography. Maximal thickening fraction of the diaphragm during inspiration (TFdi,max) was calculated using the following formula: TFdi,max = (Tdi,ei-Tdi,ee)/Tdi,ee. We also evaluated other potential risk factors including demographic parameters, comorbidities, Clinical Frailty Scale, grip strength, 5-meter walk test, and pulmonary function tests. We repeated TFdi,max measurements within 24 hours of extubation. The primary composite outcome of this study was the occurrence of postoperative pulmonary complications, defined as pneumonia, clinically significant atelectasis, or prolonged mechanical ventilation (> 24 hr). MEASUREMENT AND MAIN RESULTS: Of the 115 patients included, 34 (29.6%) developed postoperative pulmonary complications, including two with pneumonia, four with prolonged mechanical ventilation, and 32 with clinically significant atelectasis. Those with postoperative pulmonary complications had prolonged ICU and hospital length of stays. They had a lower TFdi,max (37% [interquartile range, 31-45%] vs 44% [interquartile range, 33-58%]; p = 0.03). In multiple logistic regression, a TFdi,max less than 38.1% was associated with postoperative pulmonary complications (odds ratio, 4.9; 95% CI, 1.81-13.50; p = 0.002). All patients who developed pneumonia or prolonged mechanical ventilation had a TFdi,max less than 38.1%. Respiratory rate and diabetes were also independently associated with postoperative pulmonary complications, while pulmonary function tests and the assessed indicators of frailty and sarcopenia were not. CONCLUSIONS: A low preoperative TFdi,max can help to identify patients at increased risk of postoperative pulmonary complications after cardiac surgery.

Frailty as a predictor of hospital length of stay after elective total joint replacements in elderly patients.

BACKGROUND: Total joint replacement procedures are increasing in number because of population aging and osteoarthritis development. Defined as a lack of physiological reserves and the inability to adequately respond to external stressors, frailty may be more common than expected in older patients with degenerative arthritis awaiting total joint replacements. The aim of the present study was to assess associations between frailty and adverse outcomes, frailty prevalence among elderly patients awaiting elective TJR, and agreement between 2 frailty screening instruments. METHODS: We undertook a prospective, observational, pilot study in our institution. We enrolled patients 65 years or older who were awaiting elective knee or hip replacement surgery and evaluated them in our preoperative clinic with planned postoperative hospital length of stay greater than 24 h. Patients were asked to grade their perceived well-being on the Clinical Frailty Scale and to answer questions on the FRAIL Scale. RESULTS: The Clinical Frailty Scale classified 40 patients (45.9%) as robust, 43 patients (49.4%) as prefrail and 4 patients (4.5%) as frail, while the FRAIL Scale categorized 12 patients (13.7%) as robust, 54 patients (62.0%) as prefrail, and 20 patients (22.9%) as frail. Robustness, ascertained on the Clinical Frailty Scale was, while the FRAIL Scale was not, significantly associated with shorter hospital length of stay and fewer discharges to the rehabilitation center. Both scales showed moderate mutual agreement. CONCLUSION: Screening for frailty identified between 5% and 10% of patients at risk of adverse outcomes. The Clinical Frailty Scale was, while the FRAIL scale was not, significantly associated with hospital length of stay and discharge to rehabilitation center in our cohort of total joint replacement patients.