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OBJECTIVES: It remains unclear whether intraoperative lung-protective strategies can reduce the rate of respiratory complications after cardiac surgery, partly because low-risk patients have been studied in the past. The authors established a screening model to easily identify a high-risk group for severe pulmonary complications (ie, pneumonia or acute respiratory distress syndrome) that may be the ideal target population for the assessment of the potential benefits of such measures. DESIGN: Retrospective observational trial. SETTING: Departments of cardiac surgery and cardiac anesthesia of a university hospital. PARTICIPANTS: Consecutive patients undergoing cardiac surgery on cardiopulmonary bypass and subsequent treatment at a dedicated cardiosurgical intensive care unit between January 2019 and March 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 2,572 patients undergoing surgery, 84 (3.3%) developed pneumonia/acute respiratory distress syndrome that significantly affected the outcome (ie, longer ventilatory support [66% vs 11%], higher reintubation rate [39% vs 3%]), prolonged length of intensive care unit [33 ± 36 vs 4 ± 10 days] and hospital stay [10 ± 15 vs 6 ± 7 days], and higher in-hospital [43% vs 9%] as well as 30-day [7% vs 3%] mortality). The screening model for severe pulmonary complications included left ventricular ejection fraction <52%, EuroSCORE II (European System for Cardiac Operative Risk Evaluation II) >5.9, cardiopulmonary bypass time >123 minutes, left ventricular assist device or aortic repair surgery, and bronchodilatory therapy. A cutoff for the predicted risk of 2.5% showed optimal sensitivity and specificity, with an area under the receiver operating characteristic curve of 0.82. CONCLUSIONS: The authors suggest that future research on intraoperative lung-protective measures focuses on this high-risk population, primarily aiming to mitigate severe forms of postoperative pulmonary dysfunction associated with poor outcomes and increased resource consumption.
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Pneumonia , Síndrome do Desconforto Respiratório , Humanos , Estudos Retrospectivos , Volume Sistólico , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Função Ventricular Esquerda , Pulmão , Síndrome do Desconforto Respiratório/etiologia , Pneumonia/complicaçõesRESUMO
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.
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Pressão Arterial , Hidratação , Humanos , Volume Sistólico , Estudos Prospectivos , Pressão Sanguínea , Hemodinâmica , Curva ROC , Procedimentos Cirúrgicos VascularesRESUMO
OBJECTIVE: The aim of this study was to identify perioperative risk factors associated with intensive care unit readmission and in-hospital death after cardiac surgery. DESIGN: Retrospective analysis using a multivariate regression model to identify independent risk factors for intensive care unit [ICU] readmission and in-hospital mortality. SETTING: The study was carried out in a single tertiary-care hospital. PARTICIPANTS: This was an analysis of 2,789 adult patients. INTERVENTIONS: All patients underwent cardiac surgery and were admitted to the intensive care unit perioperatively at the General Hospital Vienna. MEASUREMENTS AND MAIN RESULTS: Among the 2,789 patients included in the analysis, 167 (6%) were readmitted to the intensive care unit during the same hospital stay. Preoperative risk factors associated with ICU readmission included end-stage renal failure (odds ratio [OR] 2.80, 95% CI: 1.126-6.964), arrhythmia (OR 1.59, 95% CI: 1.019-2.480), chronic obstructive pulmonary disease (OR 1.51, 95% CI: 1.018-2.237), age >80 (OR 2.55, 95% CI: 1.189-5.466), and European System for Cardiac Operative Risk Evaluation II >8 (OR 1.40, 95% CI: 1.013-1.940). Readmitted patients were more likely to die than nonreadmitted patients (OR 5.3, 95% CI: 3.284-8.558). In-hospital mortality in readmitted patients was 19.2%, whereas that in the nonreadmitted study population was 5.1%. CONCLUSION: Preoperative risk assessment is crucial for identifying cardiac surgery patients at risk of ICU readmission and in-hospital death. The potentially modifiable risk factors pinpointed by this study call for the optimization of care before surgery and after ICU discharge.
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Procedimentos Cirúrgicos Cardíacos , Readmissão do Paciente , Adulto , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: To evaluate the association of postoperative hemoglobin values and mortality in patients undergoing double- lung transplantation with intraoperative transfusion. DESIGN: Retrospective cohort study. SETTING: University hospital. PARTICIPANTS: Adult patients who underwent double-lung transplantation at the authors' institution, with intraoperative transfusion of packed red blood cells between 2009 and 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intraoperative transfusion requirements and general characteristics of 554 patients were collected. A generalized additive model, controlling for postoperative hemoglobin levels, number of transfused units of packed red blood cells, perioperative change in hemoglobin levels, disease leading to lung transplantation, and postoperative extracorporeal membrane oxygenation, was created to predict one-year mortality. A postoperative hemoglobin level of 11.3 g/dL was calculated as an optimal cutoff point. The patients were stratified according to this level. The end -point was all-cause one-year mortality after double-lung transplantation, assessed using the Kaplan-Meier analysis with log-rank test. All-cause mortality of the 554 patients was 17%. Postoperatively, 171 patients (31%) were categorized as being below the cutoff point. Improved survival was observed in the group with higher postoperative hemoglobin values (pâ¯=â¯0.002). CONCLUSION: Lower postoperative hemoglobin levels in double-lung transplantation recipients were associated with increased mortality during the first year after surgery. Confirmation of these findings in additional investigations could alter patient blood management for double-lung transplantation.
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Transplante de Pulmão , Transfusão de Sangue , Hemoglobinas , Humanos , Período Pós-Operatório , Estudos RetrospectivosRESUMO
BACKGROUND: Systemic blood flow in patients on extracorporeal assist devices is frequently not or only minimally pulsatile. Loss of pulsatile brain perfusion, however, has been implicated in neurological complications. Furthermore, the adverse effects of absent pulsatility on the cerebral microcirculation are modulated similarly as CO2 vasoreactivity in resistance vessels. During support with an extracorporeal assist device swings in arterial carbon dioxide partial pressures (PaCO2) that determine cerebral oxygen delivery are not uncommon-especially when CO2 is eliminated by the respirator as well as via the gas exchanger of an extracorporeal membrane oxygenation machine. We, therefore, investigated whether non-pulsatile flow affects cerebrovascular CO2 reactivity (CVR) and regional brain oxygenation (rSO2). METHODS: In this prospective, single-centre case-control trial, we studied 32 patients undergoing elective cardiac surgery. Blood flow velocity in the middle cerebral artery (MCAv) as well as rSO2 was determined during step changes of PaCO2 between 30, 40, and 50 mmHg. Measurements were conducted on cardiopulmonary bypass during non-pulsatile and postoperatively under pulsatile blood flow at comparable test conditions. Corresponding changes of CVR and concomitant rSO2 alterations were determined for each flow mode. Each patient served as her own control. RESULTS: MCAv was generally lower during hypocapnia than during normocapnia and hypercapnia (p < 0.0001). However, the MCAv/PaCO2 slope during non-pulsatile flow was 14.4 cm/s/mmHg [CI 11.8-16.9] and 10.4 cm/s/mmHg [CI 7.9-13.0] after return of pulsatility (p = 0.03). During hypocapnia, non-pulsatile CVR (4.3 ± 1.7%/mmHg) was higher than pulsatile CVR (3.1 ± 1.3%/mmHg, p = 0.01). Independent of the flow mode, we observed a decline in rSO2 during hypocapnia and a corresponding rise during hypercapnia (p < 0.0001). However, the relationship between ΔrSO2 and ΔMCAv was less pronounced during non-pulsatile flow. CONCLUSIONS: Non-pulsatile perfusion is associated with enhanced cerebrovascular CVR resulting in greater relative decreases of cerebral blood flow during hypocapnia. Heterogenic microvascular perfusion may account for the attenuated ΔrSO2/ΔMCAv slope. Potential hazards related to this altered regulation of cerebral perfusion still need to be assessed. TRIAL REGISTRATION: The study was retrospectively registered on October 30, 2018, with Clinical Trial.gov (NCT03732651).
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Dióxido de Carbono/metabolismo , Circulação Cerebrovascular/fisiologia , Fluxo Pulsátil/fisiologia , Fluxo Sanguíneo Regional/fisiologia , Idoso , Dióxido de Carbono/antagonistas & inibidores , Estudos de Casos e Controles , Circulação Cerebrovascular/efeitos dos fármacos , Cérebro/irrigação sanguínea , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/normas , Feminino , Humanos , Hipercapnia/metabolismo , Hipercapnia/fisiopatologia , Hipocapnia/metabolismo , Hipocapnia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Pressão Parcial , Estudos Prospectivos , Fluxo Pulsátil/efeitos dos fármacos , Fluxo Sanguíneo Regional/efeitos dos fármacos , SuíçaRESUMO
OBJECTIVE: The prognostic impact of thrombocytopenia in patients supported by extracorporeal membrane oxygenation after cardiac surgery is uncertain. We investigated whether thrombocytopenia is independently predictive of poor outcome and describe the incidence and time course of thrombocytopenia in extracorporeal membrane oxygenation patients. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Cardiosurgical ICU at a tertiary referral center. PATIENTS: Three hundred adult patients supported with venoarterial extracorporeal membrane oxygenation for more than 24 hours because of refractory cardiogenic shock after heart surgery between January 2001 and December 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two-way analysis of variance was used to compare the time course of platelet count changes between survivors and nonsurvivors. Using multiple Cox regression with time-dependent covariates, we investigated the impact of platelet count on 90-day mortality. In nonsurvivors, the daily incidence of moderate (< 100 - 50 × 10/L), severe (49 - 20 × 10/L), and very severe (< 20 × 10/L) thrombocytopenia was 50%, 54%, and 7%, respectively. Platelet count had a biphasic temporal pattern with an initial decrease until day 4-5 after the initiation of extracorporeal membrane oxygenation. Although a significant recovery of the platelet count was observed in survivors, a recovery did not occur in nonsurvivors (p = 0.0001). After adjusting for suspected confounders, moderate, severe, and very severe thrombocytopenia were independently associated with 90-day mortality. The highest risk was associated with severe (hazard ratio, 5.9 [2.7-12.6]; p < 0.0001) and very severe thrombocytopenia (hazard ratio, 25.9 [10.7-62.9], p < 0.0001). CONCLUSION: Thrombocytopenia is an independent risk factor for poor outcome in extracorporeal membrane oxygenation patients after cardiac surgery, with persistent severe thrombocytopenia likely reflecting a high degree of physiologic imbalance.
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Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Trombocitopenia/diagnóstico , Trombocitopenia/etiologia , Disfunção Ventricular Esquerda/diagnóstico , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Contagem de Plaquetas , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Trombocitopenia/mortalidade , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/mortalidadeRESUMO
BACKGROUND: The effects of neuromuscular electrical stimulation (NMES) in critically ill patients after cardiothoracic surgery are unknown. The objectives were to investigate whether NMES prevents loss of muscle layer thickness (MLT) and strength and to observe the time variation of MLT and strength from preoperative day to hospital discharge. METHODS: In this randomized controlled trial, 54 critically ill patients were randomized into four strata based on the SAPS II score. Patients were blinded to the intervention. In the intervention group, quadriceps muscles were electrically stimulated bilaterally from the first postoperative day until ICU discharge for a maximum of 14 days. In the control group, the electrodes were applied, but no electricity was delivered. The primary outcomes were MLT measured by ultrasonography and muscle strength evaluated with the Medical Research Council (MRC) scale. The secondary functional outcomes were average mobility level, FIM score, Timed Up and Go Test and SF-12 health survey. Additional variables of interest were grip strength and the relation between fluid balance and MLT. Linear mixed models were used to assess the effect of NMES on MLT, MRC score and grip strength. RESULTS: NMES had no significant effect on MLT. Patients in the NMES group regained muscle strength 4.5 times faster than patients in the control group. During the first three postoperative days, there was a positive correlation between change in MLT and cumulative fluid balance (r = 0.43, P = 0.01). At hospital discharge, all patients regained preoperative levels of muscle strength, but not of MLT. Patients did not regain their preoperative levels of average mobility (P = 0.04) and FIM score (P = 0.02) at hospital discharge, independent of group allocation. CONCLUSIONS: NMES had no effect on MLT, but was associated with a higher rate in regaining muscle strength during the ICU stay. Regression of intramuscular edema during the ICU stay interfered with measurement of changes in MLT. At hospital discharge patients had regained preoperative levels of muscle strength, but still showed residual functional disability and decreased MLT compared to pre-ICU levels in both groups. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT02391103. Registered on 7 March 2015.
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Estado Terminal/terapia , Estimulação Elétrica/métodos , Força Muscular/fisiologia , Avaliação de Resultados da Assistência ao Paciente , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Physicians refer proteinuric patients to kidney biopsy in order to clarify the issue of underlying renal disease. We compared kidney biopsy results with classical outcome parameters in a large cohort of patients with biopsy proven glomerulonephritis (GN). METHODS: In a retrospective analysis, 2687 patients with different forms of GN from 123 Austrian centres were investigated. Patient characteristics, the diagnosis of GN and its respective subtype and clinical symptoms such as arterial hypertension, haematuria, amount of proteinuria and estimated glomerular filtration rate (eGFR) were tested for their association with all-cause mortality and progression to end-stage renal disease (ESRD). RESULTS: During a median follow-up of 129·9 months (IQR 89·6; 177·7), 688 patients (25·6%) died and 718 patients required dialysis (29·4%). In multivariate Cox's regression analysis age (HR 1·06), female sex (HR 0·71), eGFR (HR 0·74), the diagnosis of GN and its subtypes predicted patient survival (all P < 0·01), whereas the amount of proteinuria was not associated with patient survival. The incidence of progression to ESRD was associated with female sex (HR 0·71), eGFR (HR 0·65), amount of proteinuria (HR 1·15) and the diagnosis of GN and its subtypes (all P < 0·01). Nephrotic or nephritic syndromes were not associated with patient survival or progression to ESRD and did not add further predictive value to outcome of GN. CONCLUSIONS: Our study demonstrates histological diagnosis of GN and its specific subtype predicts patient survival and dialysis incidence. Therefore, kidney biopsy should be an integral part of routine diagnostic assessment in patients with any forms of suspected GN.
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Glomerulonefrite/patologia , Falência Renal Crônica/patologia , Rim/patologia , Biópsia/mortalidade , Progressão da Doença , Feminino , Taxa de Filtração Glomerular/fisiologia , Glomerulonefrite/mortalidade , Humanos , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Diálise Renal/mortalidade , Estudos RetrospectivosRESUMO
BACKGROUND: Aortic valve replacement is one of the most common cardiac surgical procedures, especially in elderly patients. Whether or not there is a net life gain over a long period of time is a matter for debate. OBJECTIVE: To compare survival of patients with that of the age, sex, and follow-up year-matched normal population (relative survival). DESIGN: Single-centre, prospectively collected data. SETTING: Tertiary care centre, Vienna, Austria. PATIENTS: We enrolled 1848 patients undergoing elective aortic valve replacement between 1997 and the end of 2008. INTERVENTIONS: None. MAIN OUTCOME MEASUREMENT: Relative survival at the end of 2011 as determined by relative Cox regression analysis. RESULTS: Sixty-nine patients (3.7%) died within the first 30 days. Another 70 patients (3.8%) died within the first year and 429 (23.2%) died during the remaining follow-up period. The longest follow-up period was 14 years (median, 5.8; interquartile range, 3.2 to 8.9). Medical risk indicators for relative survival were diabetes mellitus [hazard ratio 1.69, 95% confidence interval, CI 1.37 to 2.07, P<0.001], pulmonary disease (hazard ratio 1.45, 95% CI 1.16 to 1.81, P=0.001), history of atrial fibrillation (hazard ratio 1.35, 95% CI 1.10 to 1.66, P=.005) and angiotensin-converting enzyme inhibitor medication (hazard ratio 1.21, 95% CI 1.02 to 1.44, P=0.031). Perioperative risk indicators were urgent surgery (hazard ratio 1.40, 95% CI 1.00 to 1.94, P=0.047), resternotomy at 48 h or less (hazard ratio 1.87, 95% CI 1.29 to 2.70, P=0.001), resternotomy at more than 48 h (hazard ratio 1.80, 95% CI 1.32 to 2.45, P<0.001), blood transfusion (hazard ratio 1.06, 95% CI 1.01 to 1.12, P=0.018) and renal replacement therapy (hazard ratio 2.02, 95% CI 1.41 to 2.90, P<0.001). Relative survival was highest in the oldest age quartile (76 to 94 years) and lowest in the youngest (19 to 58 years) (hazard ratio 0.27, 95% CI 0.21 to 0.36; P<0.001). CONCLUSION: Patients who survived the first year after aortic valve replacement had a similar chance of survival as the matched normal population. Relative survival benefit was higher in the oldest age quartile.
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Valva Aórtica/cirurgia , Doenças das Valvas Cardíacas/terapia , Implante de Prótese de Valva Cardíaca/métodos , Adulto , Idoso , Feminino , Doenças das Valvas Cardíacas/mortalidade , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Risco , Resultado do Tratamento , Adulto JovemRESUMO
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.
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Coração Auxiliar , Consumo de Oxigênio , Humanos , Microcirculação , Débito Cardíaco , Procedimentos Cirúrgicos Cardíacos , Complicações Pós-Operatórias , Insuficiência Cardíaca/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , IdosoRESUMO
Objectives: Data on anesthetic proceedings during cardiac implantable electronic device (CIED) implant procedures are scarce and it remains unclear whether anesthetic care is still required in selected patients. Methods: In this retrospective, single center study we assessed the prevalence of intraoperative anesthetic management comprising anesthetic standby, sedation or general anesthesia as well as anesthetic and procedural complications. We analyzed pre-existing and perioperative risk factors related to procedure-related adverse outcome such as perioperative cardiopulmonary resuscitation (CPR) and 30-day mortality in a uni- and multivariable analysis. Results: In total, PM and ICD insertion were performed in up to 85% and 58% under anesthetic standby, with an increasing tendency over time.Overall, Cardiopulmonary resuscitation (CPR) was required in 59 patients. Acute heart failure (AHF) was the only independent pre-existing risk factor for CPR and for 30-day mortality. Sedation and general anesthesia had a significantly increased odds ratio for CPR compared to anesthetic standby. The risk for CPR significantly decreased during the study period. Conclusions: Over the years anesthetic practice during CIED implant procedures shifted from mixed anesthetic proceedings to mainly standby duties. The prevalence of complications and emergency measures is low, however not uncommon. Accordingly, the presence of an anesthesiologist should be further guaranteed when sedatives were titrated and in AHF patients. However, in patients receiving local anesthetic infiltration only, it seems safe to perform CIED implant procedures without anesthetic standby.
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Neurological complications after heart surgery are associated with tremendous morbidity and mortality. Nonconvulsive status epilepticus (NCSE), which can only be verified by EEG, may cause secondary brain damage. Its frequency and its impact on outcomes after cardiac surgery is still unclear. We collected the neurological files and clinical data of all our patients after heart surgery who, in the course of their ICU stay, had been seen by a neurologist who ordered an EEG. Within 18 months, 1457 patients had cardiac surgery on cardiopulmonary bypass. EEG was requested for 89 patients. Seizures were detected in 39 patients and NCSE was detected in 11 patients. Open heart surgery was performed in all 11 NSCE patients, of whom eight showed concomitant brain insults. None had a history of epilepsy. Despite the inhibition of seizure activity with antiseizure medication, clinical improvement was only noted in seven NCSE patients, three of whom were in cerebral performance category 2 and four in category 3 at hospital discharge. The four patients without neurological benefit subsequently died in the ICU. The occurrence of NCSE after open cardiac surgery is significant and frequently associated with brain injury. It seems prudent to perform EEG studies early to interrupt seizure activity and mitigate secondary cerebral injury.
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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.
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Procedimentos Cirúrgicos Cardíacos , Consumo de Oxigênio , Metabolismo Energético , Humanos , Microcirculação , OxigênioRESUMO
Background: Heart failure patients are frequently on coagulation-active medications before LVAD implantation and perioperative bleeding is a frequent complication after left ventricular assist device (LVAD) implantation. The role of point-of-care coagulation tests in assessing bleeding risk for LVAD implantation and the early postoperative time course of these tests is not well established. Methods: We prospectively enrolled 25 patients with terminal heart failure undergoing LVAD implantation. Study related TRAP-, ASPI- and ADP- tests of Multiplate® platelet aggregometry, ROTEM® rotational thromboelastometry (INTEM, EXTEM, FIBTEM), thrombin generation assay and conventional laboratory studies were measured at 11 predefined time-points during the first 21 postoperative days. We examined if preoperative TRAP-, ASPI-, ADP- and ROTEM values are correlated with estimated total blood loss (primary outcome parameter) during the first 21 days after LVAD implantation and compared the baseline values of these measurements between patients with a bleeding event to those without. We performed Spearman's correlation and non-parametric tests for paired and non-paired comparisons. Results: 7 out of 25 (28%) patients experienced a bleeding event of which 4 required surgical revision. Of the preoperatively performed measurements the TRAP test [Spearman's Rho (ρ) = -0.5, p = 0.01], INTEM CFT (ρ = 0.72, p < 0.001), INTEM alpha (-0.7, p < 0.001), EXTEM MCF (ρ = -0.63; p < 0.001), EXTEM alpha (ρ = -0.67; p < 0.001), FIBTEM MCF (ρ = -0.41; p = 0.042), Fibrinogen (Clauss) (ρ = -0.5; p = 0.011), Anti-thrombin activity (ρ = -0.49; p = 0.013) and platelet count (ρ = -0.42; p = 0.034) were significantly correlated to total blood loss. Patients undergoing a surgical bleeding revision had significantly reduced values in TRAP-[31.5 IQR (17.25-43.5U) vs. 69 IQR (52.5-87U); p = 0.004], ASPI-[16.5 IQR (5.5-35.7U) vs. 39 IQR (24.5-62.5U); p = 0.038], ADP-[30 IQR (22-69U) vs. 12.5 IQR (8.7-21.5U); p = 0.01], EXTEM MCF-[63 IQR (57.7-63.7) vs. 67 IQR (65-75.5); p = 0.019] and EXTEM alpha [74 IQR (68.75-74) vs. 79 IQR (78-80.5); p = 0.002] values before LVAD implantation. Conclusion: Multiplate® and ROTEM® measurements before LVAD implantation may identify LVAD candidates with platelet dysfunction and alterations of the primary hemostasis and could guide anesthetists and intensive care practitioners in bleeding risk stratification and in the perioperative clinical management.
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Hospital length of stay (LOS) is an important clinical and economic outcome and knowing its predictors could lead to better planning of resources needed during hospitalization. This analysis sought to identify structure, patient, and nutrition-related predictors of LOS available at the time of admission in the global nutritionDay dataset and to analyze variations by country for countries with n > 750. Data from 2006-2015 (n = 155,524) was utilized for descriptive and multivariable cause-specific Cox proportional hazards competing-risks analyses of total LOS from admission. Time to event analysis on 90,480 complete cases included: discharged (n = 65,509), transferred (n = 11,553), or in-hospital death (n = 3199). The median LOS was 6 days (25th and 75th percentile: 4-12). There is robust evidence that LOS is predicted by patient characteristics such as age, affected organs, and comorbidities in all three outcomes. Having lost weight in the last three months led to a longer time to discharge (Hazard Ratio (HR) 0.89; 99.9% Confidence Interval (CI) 0.85-0.93), shorter time to transfer (HR 1.40; 99.9% CI 1.24-1.57) or death (HR 2.34; 99.9% CI 1.86-2.94). The impact of having a dietician and screening patients at admission varied by country. Despite country variability in outcomes and LOS, the factors that predict LOS at admission are consistent globally.
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Testes Diagnósticos de Rotina/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Avaliação Nutricional , Admissão do Paciente/estatística & dados numéricos , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Testes Diagnósticos de Rotina/métodos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estado Nutricional , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND AND AIMS: European and North American guidelines on Parenteral Nutrition (PN) and large Randomized Controlled Trials give divergent advices on nutritional therapeutic strategies for critically ill patients. We therefore investigated differences in therapeutic strategies of clinicians between European and Non-European Intensive Care Units (ICU) regarding start day of PN, preferred route of administration and prescription of total energy targets over the years. METHODS: In this study 16,032 patients from 1389 different ICUs were included. Data collection was performed in 28 different European and Non-European ICUs from 2007 to 2018 via nutritionDay, a worldwide-standardized one-day multinational cross-sectional audit. RESULTS: In this analysis an abrupt delay in PN start days was observed in 2011 (7.64 days (4.31; 19.97); p = 0.001) and 2012 (6.41 days (3.1; 9.72); p = 0.001), which was significantly reversed within the following years until 2018. In European, compared to Non-European countries PN prescription was increased (27% versus 13%). Patients from North-America received significantly less kcal per day compared to Europe (-4.3 kcal kg-1 (-6.9; -1.6); p = 0.001). CONCLUSIONS: Our study provides further evidence on transatlantic discrepancies in nutritional therapy of ICU patients. Regular audits, such as nutritionDay are substantial for self-reflection of clinical daily practice of intensivists. It is time for worldwide consensus in nutritional therapy by developing worldwide guidelines and supporting standardization in nutrition care of critically ill patients.
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Nutrição Enteral , Nutrição Parenteral , Estado Terminal/terapia , Estudos Transversais , Humanos , Unidades de Terapia IntensivaRESUMO
Background: The use of left ventricular assist device (LVAD) has increased considerably over the past decade; however, there is limited literature to assist in patient selection and monitoring. The frequency of adverse events remains high. We examined the early expression of circulating soluble ST2 (sST2), a biomarker with immunosuppressive and profibrotic activity, and assessed the risk of death at 1 year in patients receiving LVAD implant. Methods: We prospectively enrolled 20 heart failure patients and measured sST2, IL-33, and IL-6 serum concentrations over three weeks after LVAD implantation. We compared the kinetics of IL-6, sST2, and IL-33 release in survivors with those of nonsurvivors using mixed model two-way analysis of variance for repeated measures. We also collected data on hemodynamic parameters (i.e., cardiac output) and frequency of infections during the hospital stay. Results: LVAD therapy led to an immediate and significant improvement of the hemodynamic parameters in 1-year survivors and nonsurvivors alike. The 1-year survival rate was 65%. IL-6 concentrations showed a significant (p = 0.03) peak at admission to the intensive care unit following LVAD implantation, whereas sST2 levels were massively increased (p < 0.0003) on day 1. While 1-year survivors had persistently lower sST2 values compared to nonsurvivors during the first 3 weeks after LVAD implantation (p = 0.012), no differences were observed in the temporal pattern of IL-6 or IL-33. The odds of detecting Candida species in the bronchoalveolar lavage fluid were 14 times higher in nonsurvivors than in survivors (OR 13.7, CI 1.4-127, p = 0.02). Conclusion: In patients implanted with LVAD, circulating sST2 levels and frequency of Candida colonisation were associated with higher mortality. Awareness of this early immune response can guide physicians in risk-benefit analysis.
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Disease-related malnutrition (DRM) is prevalent in hospitals and is associated with increased care needs, prolonged hospital stay, delayed rehabilitation and death. Nutrition care process related activities such as screening, assessment and treatment has been advocated by scientific societies and patient organizations but implementation is variable. We analysed the cross-sectional nutritionDay database for prevalence of nutrition risk factors, care processes and outcome for medical, surgical, long-term care and other patients (n = 153,470). In 59,126 medical patients included between 2006 and 2015 the prevalence of recent weight loss (45%), history of decreased eating (48%) and low actual eating (53%) was more prevalent than low BMI (8%). Each of these risk factors was associated with a large increase in 30 days hospital mortality. A similar pattern is found in all four patient groups. Nutrition care processes increase slightly with the presence of risk factors but are never done in more than 50% of the patients. Only a third of patients not eating in hospital receive oral nutritional supplements or artificial nutrition. We suggest that political action should be taken to raise awareness and formal education on all aspects related to DRM for all stakeholders, to create and support responsibilities within hospitals, and to create adequate reimbursement schemes. Collection of routine and benchmarking data is crucial to tackle DRM.
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BACKGROUND: Active decision support systems implementing goal directed therapy may be an approach to reduce disparities in outcome between different health care providers. We assessed feasibility of and adherence to an active decision support system (ADSS) comprising fluids, vasopressors, and dobutamine to optimize hemodynamics during high-risk vascular surgery. METHODS: In this prospective observational trial a closed-loop goal-directed therapy protocol, employing the minimally-invasive LiDCOrapid device, was used to actively provide advice to the anesthesiologist during surgery. All given suggestions and all interventions were recorded. Every intervention without or against the given advice had to be justified. The primary outcome parameters were the number of interventions done according to the ADSS and its duration of use. Reasons for non-compliance served to describe its limitations. RESULTS: The active decision support system was employed in 32 patients for 137 hours. Median (IQR) use of the ADSS as percentage of surgery time was 100% (94-100%) with 743 interventions being executed. 634 interventions were done according to ADSS proposals. Reasons to act against or without advice were: hemodynamic instability (6%), foreseeing a surgical event (2%), medical reasons (2%), awaiting hemodynamic improvement (1%) and orders by senior physician or surgeons (1%). In five patients the anesthesiologist decided to modify intervention thresholds of the underlying protocol. CONCLUSIONS: High rates of compliance underline clinical acceptability and feasibility of this ADSS during vascular surgery. It may therefore facilitate the work of anesthesiologists and reduce disparities in patient outcomes due to different healthcare providers. Particularly, rapidly developing hemodynamic perturbances as well as co-factors the ADSS as of now does not anticipate are current limitations. These findings may serve to further improve this stand-alone real-time ADSS.
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Anestesiologia/métodos , Anestesiologia/normas , Sistemas de Apoio a Decisões Clínicas , Procedimentos Cirúrgicos Eletivos , Fidelidade a Diretrizes/estatística & dados numéricos , Hemodinâmica , Cuidados Intraoperatórios , Procedimentos Cirúrgicos Vasculares , Idoso , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
OBJECTIVES: To assess the incidence and outcome of heparin-induced thrombocytopaenia (HIT) in patients after cardiac surgery on cardiopulmonary bypass (CPB) and to review the time course of platelet counts and the use of different immunological diagnostic tests. METHODS: All patients ≥18 years of age who underwent CPB from 2006 to 2015 and who were postoperatively admitted to our cardiac intensive care unit (ICU) were included in this retrospective study. Screening for heparin/platelet factor-4 antibodies was performed using an antibody test, which was later replaced with a screening test specific for IgG antibodies without IgA/IgM cross-reactivity. The enzyme immunoassay (EIA) for the detection of antibodies of all immunoglobulin classes against heparin/PF4 complexes was replaced with an IgG-specific EIA. HIT was confirmed by a heparin-induced platelet aggregation test until 2014. RESULTS: Among 4978 patients admitted between 2006 and 2015, 539 (11%) patients were evaluated for HIT. Patients were excluded because of age <18 years (n = 9), non-cardiac surgery without CPB (n = 10) or incomplete data (n = 3). Of the remaining 517 patients, 43 (8.3%) patients were HIT-positive. HIT incidence was 0.86%. The proportion of HIT-positive patients was similar in men and women (8.4% and 8.2%, respectively). Men and women with suspected HIT also had similar in-hospital mortality (odds ratio ≈ 1; P = 0.926). CONCLUSIONS: The incidence of HIT was lower in our study than previously reported. Novel immunological tests have improved to specifically detect IgG antibodies. Furthermore, they are able to detect anti-protamine antibodies, which may be present in patients with high clinical probability of testing negative for HIT. Incidence and clinical relevance of heparin/protamine antibodies will be subjects of future investigation.