Validity of the total SOFA score in patients ≥ 80 years old acutely admitted to intensive care units: a post-hoc analysis of the VIP2 prospective, international cohort study.

BACKGROUND: Little is known about the performance of the Sequential Organ Failure Assessment (SOFA) score in older critically ill adults. We aimed to evaluate the prognostic impact of physiological disturbances in the six organ systems included in the SOFA score. METHODS: We analysed previously collected data from a prospective cohort study conducted between 2018 and 2019 in 22 countries. Consecutive patients ≥ 80 years old acutely admitted to intensive care units (ICUs) were eligible for inclusion. Patients were followed up for 30 days after admission to the ICU. We used logistic regression to study the association between increasing severity of organ dysfunction and mortality. RESULTS: The median SOFA score among 3882 analysed patients was equal to 6 (IQR: 4-9). Mortality was equal to 26.1% (95% CI 24.7-27.5%) in the ICU and 38.7% (95% CI 37.1-40.2%) at day 30. Organ failure defined as a SOFA score ≥ 3 was associated with variable adjusted odds ratios (aORs) for ICU mortality dependant on the organ system affected: respiratory, 1.53 (95% CI 1.29-1.81); cardiovascular 1.69 (95% CI 1.43-2.01); hepatic, 1.74 (95% CI 0.97-3.15); renal, 1.87 (95% CI 1.48-2.35); central nervous system, 2.79 (95% CI 2.34-3.33); coagulation, 2.72 (95% CI 1.66-4.48). Modelling consecutive levels of organ dysfunction resulted in aORs equal to 0.57 (95% CI 0.33-1.00) when patients scored 2 points in the cardiovascular system and 1.01 (0.79-1.30) when the cardiovascular SOFA equalled 3. CONCLUSIONS: Different components of the SOFA score have different prognostic implications for older critically ill adults. The cardiovascular component of the SOFA score requires revision.

Reporting SOFA in research: we should always present each of the SOFA subscores.

INTRODUCTION: The Sequential Organ Failure Assessment (SOFA) score is the sum of 6 components, each representing one organ system with dysfunction classified on a 4-point scale. In research, usually by default, the total SOFA score is taken into account, but it may not reflect the severity of the condition of the individual organs. Often, these values are expected to predict mortality. MATERIAL AND METHODS: In this study, we reanalysed 2 cohorts of critically ill elderly patients to explore the distribution of SOFA subscores and to assess the between-group differences. Both cohorts were adjusted to maintain similarity in terms of age and the primary cause of admission (respiratory cause). RESULTS: In total, 910 (non-COVID-19 cohort) and 551 patients (COVID-19 cohort) were included in the analysis. Both cohorts were similar in terms of the total SOFA score (median 5 vs. 5 points); however, the groups differed significantly in 4/6 SOFA subscores (respiratory, neurological, cardiovascular, and coagulation subscores). Moreover, the cohorts had different fractions of organ failures (defined as a SOFA subscore ≥ 3). CONCLUSIONS: This analysis revealed significant differences in SOFA subscores between the COVID-19 and non-COVID-19 respiratory cohorts, highlighting the importance of considering individual organ dysfunction rather than relying solely on the total SOFA score when reporting organ dysfunction in clinical research.

The impact of intraoperative blood pressure variability on the risk of postoperative adverse outcomes in non-cardiac surgery: a systematic review.

Hemodynamic stability during surgery seems to account for positive postoperative outcomes in patients. However, little is known about the impact of intraoperative blood pressure variability (IBPV) on the postoperative complications. The aim was to investigate whether IBPV is associated with the development of postoperative complications and what is the nature of this association. We conducted a systematic search in PubMed, Medical Subject Headings, Embase, Web of Science, SCOPUS, clinicaltrials.gov, and Cochrane Library on the 8th of April, 2021. We included studies that only focused on adults who underwent primarily elective, non-cardiac surgery in which intraoperative blood pressure variation was measured and analyzed in regard to postoperative, non-surgical complications. We identified 11 papers. The studies varied in terms of applied definitions of blood pressure variation, of which standard deviation and average real variability were the most commonly applied definitions. Among the studies, the most consistent analyzed outcome was a 30-day mortality. The studies presented highly heterogeneous results, even after taking into account only the studies of best quality. Both higher and lower IBPV were reported to be associated for postoperative complications. Based on a limited number of studies, IBPV does not seem to be a reliable indicator in predicting postoperative complications. Existing premises suggest that either higher or lower IBPV could contribute to postoperative complications. Taking into account the heterogeneity and quality of the studies, the conclusions may not be definitive.

What Is the Role of Therapeutic Plasma Exchange as an Adjunctive Treatment in Severe COVID-19: A Systematic Review.

INTRODUCTION: Since the COVID-19 pandemic outbreak, multiple promising treatment modalities have been tested, however, only several of them were proven to be effective. Therapeutic plasma exchange (TPE) has been recently discussed as a possible supportive treatment for severe cases. METHODS: To investigate a possible role of TPE in severe COVID-19 we used a structured systematic search strategy to retrieve all relevant publications in the field. We screened in PubMed, EMBASE, Web of Science, Cochrane Library and clinicaltrials.gov for data published until the 4 June 2021. RESULTS: We identified 18 papers, enrolling 384 patients, 220 of whom received TPE. The number of TPE sessions ranged from 1 to 9 and the type of replacement fluid varied markedly between studies (fresh frozen plasma or 5% albumin solution, or convalescent plasma). Biochemical improvement was observed in majority of studies as far as C-reactive protein (CRP), interleukin-6 (IL-6), ferritin, lactate dehydrogenase (LDH), D-dimer concentrations and lymphocyte count are concerned. The improvement at a laboratory level was associated with enhancement of respiratory function. Adverse effects were limited to five episodes of transient hypotension and one femoral artery puncture and thrombophlebitis. CONCLUSIONS: Although the effect of therapeutic plasma exchange on mortality remains unclarified, the procedure seems to improve various secondary end-points such as PaO2/FiO2 ratio or biomarkers of inflammation. Therapeutic plasma exchange appears to be a safe treatment modality in COVID-19 patients in terms of side effects.

Electrical impedance tomography as a tool for monitoring mechanical ventilation. An introduction to the technique.

Electrical impedance tomography (EIT) is a non-invasive, radiation-free method of diagnostics imaging, allowing for a bedside, real-time dynamic assessment of lung function. It stands as an alternative for other imagining methods, such as computed tomography (CT) or ultrasound. Even though the technique is rather novel, it has a wide variety of possible applications. In the era of modern mechanical ventilation, a dynamic assessment of patient's respiratory condition appears to fulfil the idea of personalized treatment. Additionally, an increasing frequency of respiratory failure among intensive care populations raises demand for improved monitoring tools. This review aims to raise awareness and presents possible implications for the use of EIT in the intensive care setting.

Veno-Venous Extracorporeal Membrane Oxygenation in COVID-19-Where Are We Now?

The recent development in extracorporeal life support (ECLS) has created new therapeutic opportunities for critically ill patients. An interest in extracorporeal membrane oxygenation (ECMO), the pinnacle of ECLS techniques, has recently increased, as for the last decade, we have observed improvements in the survival of patients suffering from severe acute respiratory distress syndrome (ARDS) while on ECMO. Although there is a paucity of conclusive data from clinical research regarding extracorporeal oxygenation in COVID-19 patients, the pathophysiology of the disease makes veno-venous ECMO a promising option.

Postoperative Neurocognitive Disorders in Cardiac Surgery: Investigating the Role of Intraoperative Hypotension. A Systematic Review.

Perioperative neurocognitive disorders remain a challenging obstacle in patients after cardiac surgery, as they significantly contribute to postoperative morbidity and mortality. Identifying the modifiable risk factors and mechanisms for postoperative cognitive decline (POCD) and delirium (POD) would be an important step forward in preventing such adverse events and thus improving patients' outcome. Intraoperative hypotension is frequently discussed as a potential risk factor for neurocognitive decline, due to its significant impact on blood flow and tissue perfusion, however the studies exploring its association with POCD and POD are very heterogeneous and present divergent results. This review demonstrates 13 studies found after structured systematic search strategy and discusses the possible relationship between intraoperative hypotension and postoperative neuropsychiatric dysfunction.

Basics of mechanical ventilation for non-anaesthetists. Part 1: Theoretical aspects.

The expanding number of chronic respiratory diseases and the new Covid-19 outbreak create an increasing demand for mechanical ventilation (MV). As MV is no longer limited to intensive care units (ICU) and operating rooms (OR), more clinicians should acquaint themselves with the principles of mechanical ventilation. To fully acknowledge contemporary concepts of MV, it is crucial to understand the elemental physiology and respiratory machine nuances. This paper addresses the latter issues and provides insight into ventilation modes and essential monitoring of MV.

Investigating Association between Intraoperative Hypotension and Postoperative Neurocognitive Disorders in Non-Cardiac Surgery: A Comprehensive Review.

Postoperative delirium (POD) and postoperative cognitive decline (deficit) (POCD) are related to a higher risk of postoperative complications and long-term disability. Pathophysiology of POD and POCD is complex, elusive and multifactorial. Intraoperative hypotension (IOH) constitutes a frequent and vital health hazard in the perioperative period. Unfortunately, there are no international recommendations in terms of diagnostics and treatment of neurocognitive complications which may arise from hypotension-related hypoperfusion. Therefore, we performed a comprehensive review of the literature evaluating the association between IOH and POD/POCD in the non-cardiac setting. We have concluded that available data are quite inconsistent and there is a paucity of high-quality evidence convincing that IOH is a risk factor for POD/POCD development. Considerable heterogeneity between studies is the major limitation to set up reliable recommendations regarding intraoperative blood pressure management to protect the brain against hypotension-related hypoperfusion. Further well-designed and effectively-performed research is needed to elucidate true impact of intraoperative blood pressure variations on postoperative cognitive functioning.

Does pop-culture affect perception of medical procedures? Report on knowledge and attitude towards electroconvulsive therapy among Polish students. / Czy popkultura wplywa na postrzeganie procedur medycznych? Raport o stanie wiedzy i nastawieniu polskich studentów do terapii elektrowstrzasowej.

OBJECTIVES: The aim of the study was to investigate the general knowledge and attitudes towards ECT among Polish students, including students of medical faculties. Furthermore, the influence of pop-culture on society's opinion about ECT was investigated. METHODS: For this purpose, 1,370 students have been examined with the usage of the author's questionnaire, which consisted of questions about socio-demographic data, detailed questions about ECT as well as questions about their opinion about influence of pop-culture on the reception of this procedure. The respondents were divided into four subgroups depending on the faculty of their studies: human sciences, technical, medical and health sciences. RESULTS: The results show that the knowledge about ECT among Polish students is on avery low level, as in many cases the therapy is considered as painful, ineffective or even illegal. CONCLUSIONS: The influence of the media, especially film industry, on creating a negative opinion on the subject of ECT is significant. Furthermore, many respondents obtain their knowledge about this procedure from television or from the Internet, where the information is often incorrect.

Is Antimicrobial Treatment Effective During Therapeutic Plasma Exchange? Investigating the Role of Possible Interactions.

Antimicrobial treatment during therapeutic plasma exchange (TPE) remains a complex issue. Recommendations based on a limited number of experimental studies should be implemented in clinical practice with caution. Effective management of infections due to plasma or albumin-related interactions, as well as impaired pharmacokinetics, in critical illness is difficult. Knowing the pharmacokinetics of the drugs concerned and the procedural aspects of plasmapheresis should be helpful in planning personalized treatment. In general, possessing a low distribution volume, a high protein-binding affinity, a low endogenous clearance rate, and long distribution and elimination half-lives make a drug more prone to elimination during TPE. A high frequency and longer duration of the procedure may also contribute to altering a drug's concentration. The safest choice would be to start and finish TPE before antimicrobial agent infusion. If this not feasible, a reasonable alternative is to avoid administering the drug just before TPE and to delay the procedure for the time of the administered drug's distributive phase. Ultimately, if plasma exchange must be performed urgently or the drug has a very narrow therapeutic index, monitoring its plasma concentration is advised.

Should we change reference range for serum albumin in major gastrointestinal surgery? Preoperative serum albumin as an important prognostic factor.

INTRODUCTION: The aim of the study was to analyse prognostic value of laboratory markers of nutritional status in gastrointestinal surgery. METHODS: We performed a retrospective analysis of clinical and laboratory data of 102 patients admitted to an Intensive Care Unit following elective gastrointestinal surgery. The outcome measures included hospital mortality, infectious complications, surgical complications and length of stay. RESULTS: Forty-eight patients had all three laboratory markers of nutritional status determined before surgery and these patients constituted our study group. We found correlations between preoperative serum albumin and hospital mortality, risk of reoperation and urinary tract infection. Preoperative total serum protein correlated with urinary tract infection. Total lymphocyte count was predictive of bacteraemia. No statistically significant correlations were found between markers of nutritional status and length of stay. CONCLUSIONS: Serum albumin concentration at the lower limit is associated with increased mortality, reoperation, urinary tract infection. Total serum protein predicts urinary tract infection, whereas total lymphocyte count predicts bacteraemia.

Basics of mechanical ventilation for non-aneasthetists. Part 2: Clinical aspects.

Invasive and non-invasive mechanical ventilation (MV) continues to be the most significant life support method. It is, however, coupled with many risks. Historically, concepts of MV did focus on improving the arterial blood gas results rather than preventing harmful side-effects of positive pressure ventilation. Since then, multiple studies exploring this matter emerged and led to the protective MV concept. The golden mean between assuring the best oxygenation and limiting the ventilator-induced lung injury (VILI) is still a matter of debate. These considerations are especially impactful while treating patients with adult respiratory distress syndrome (ARDS), where the limitation of MV's negative effect is specifically important. This paper explores the protective ventilation concept and clinical implications of the latter.

Simplified diagnostic algorithm for classification of preoperative anaemia based on complete blood count and its application in elective gastrointestinal surgery.

Introduction Anaemia is associated with increased morbidity, mortality, length of stay, requirement for blood transfusion. Early differential diagnosis of anaemia may expedite treatment and outcome in the perioperative setting. The aim of our study was to create simplified diagnostic algorithm for classification of anaemia based on complete blood count and test its applicability in elective gastrointestinal surgical population. Material and methods Selected red blood cell (RBC) parameters derived from CBC test performed by the Central Laboratory of the University Clinical Centre of Medical University of Silesia, Katowice, Poland were reviewed retrospectively for the group of 442 consecutive patients scheduled for elective, high-risk (according to) GI surgery between January 2016 and August 2018. Based on pathophysiologic data we created a simplified diagnostic algorithm for classification of preoperative anaemia and applied it to the study population. Results Using the cut-off value of 130 g L-1 for both sexes, anaemia was diagnosed in 166 patients (37.5%). As many as 29 (17.5%) anaemic patients had aetiology of anaemia accurately established by using our simplified diagnostic algorithm - either iron or vitamin B12/folate deficiency. Discussion Preoperative anaemia is common in elective gastrointestinal surgery. Simplified diagnostic algorithm based solely on complete blood count parameters might be helpful in the preliminary identification of patients with iron and vitamin B12/folic acid deficiencies so haematinic supplementation can be started early.

Association between depression and hemodialysis in patients with chronic kidney disease.

Depression is the most common and serious psychiatric disorder that affects patients with chronic kidney disease and end-stage renal disease, and, has a significant impact on their quality of life. The aim of this study was to investigate and compare prevalence rates of depression among hemodialyzed patients, and non-dialyzed patients with a glomerular filtration rate<30 ml/min/1.73m2 receiving conservative treatment or following kidney transplantation. A total of 50 hemodialyzed and 50 non-dialyzed patients with stage 4/5 of CKD was assessed using the following questionnaires: Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D), The Satisfaction with Life Scale (SWLS), The Acceptance of Illness Scale (AIS), and The Life Orientation Test-Revised (LOT-R). The use of steroids and immunosuppressant drugs was also investigated. Symptoms of depression and anxiety were present in both groups, however the proportion of persons with mild or severe depression was higher among dialyzed patients. The AIS, LOT-R and SWLS scores were very similar in both the groups. The patients using steroids and/or immunosuppressant drugs were more prone to develop mild or severe depression according to the HAM-D scores. The results indicated a high prevalence of depression and anxiety among patients with CKD. Furthermore, the fraction of patients with depression is greater among hemodialyzed patients. This indicates the importance of monitoring the mental state of the patients as well as the necessity of providing timely psychological care for patients with CKD.

Association between affective disorders and the usage of low and medium doses of corticosteroids.

It is well known that high doses of corticosteroids can induce psychiatric disorders, especially the maniacal states. However there are only a few studies that investigate the effects of low and medium doses of such drugs used for a long period of time on the patient's mental health. The aim of the study was to investigate the prevalence and severity of affective disorders among the patients using up to 40 mg of corticosteroids (prednisone or equivalent). 54 patients during the corticosteroid therapy and 51 healthy controls were assessed with the use of the following questionnaires: Hypomania Checklist 16 (HCL-16), Beck Depression Inventory (BDI) and authors' questionnaire. The results were analysed using SPSS Statistics version 12.5. The results indicated statistically significant differences in the prevalence of hypomania and depression between controls and study group. There were no evident correlations between either the dose or the length of the therapy and the severity of affective disorders. The study has shown that the usage of corticosteroids doses below 40 mg does have an effect on the prevalence of affective disorders. The occurrence of hypomania and depression was more common among the study group. To assess correlations further studies are needed.