ROX index as predictor of high flow nasal cannula therapy success in acute respiratory failure due to SARS-CoV-2.

BACKGROUND: High-Flow Nasal Cannula (HFNC) therapy is useful treatment in patients with acute respiratory failure (ARF). The ROX index (ratio of pulse oximetry/fraction of inspired oxygen to respiratory rate) has been evaluated to predict success of HFNC in patients with pneumonia. OBJECTIVE: The aim of this study was to determine whether the ROX Index could predict HFNC therapy success in patients with ARF due to SARS-CoV-2 pneumonia. METHODS: An observational, prospective study was performed including patients admitted with ARF secondary to SARS-CoV-2 pneumonia who met criteria for HFNC therapy initiation. Demographic, radiological, laboratory and clinical course data were collected. The ROX index was calculated at 1 h, 6 h, 12 h and 24 h after starting HFNC. RESULTS: In total 85 patients were included (age, 64.51 + 11.78 years; male, 69.4%). HFNC failed in 47 (55.3%) patients, of whom 45 (97.8%) were initially managed with noninvasive ventilation (NIV). ROX index at 24 h was the best predictor of HFNC success (AUC 0.826, 95%CI 0.593-1.00, p = 0.015) with a cut-off point of 5.35 (S 0.91, Sp 0.79, PPV 0.92, NPP 0.79). In multivariate logistic regression analysis ROX index at 24 h proved the best predictor of HFNC success. CONCLUSIONS: ROX index at 24 h with a cut-off point of 5.35 predicts HFNC success in patients with SARS-Cov-2-induced ARF.

Tracheostomy in patients with COVID-19: predictors and clinical features.

BACKGROUND: Around 20% of patients hospitalized for COVID-19 need mechanical ventilation (MV). MV may be prolonged, thus warranting tracheostomy. METHODS: Observational cohort study enrolling patients admitted due to COVID-19. Demographic and clinical data at hospital and ICU admission were collected. The primary endpoint was to identify parameters associated with a need for tracheostomy; secondary endpoints were to analyze the clinical course of patients who needed tracheostomy. RESULTS: 118 patients were enrolled; 37 patients (31.5%) were transferred to ICU, of which 11 (29.72%) needed a tracheostomy due to prolonged MV. Sequential Organ Failure Assessment (SOFA) score at ICU admission (OR 0.65, 95% CI 0.47-0.92, p 0.015) was the only variable found to be associated with increased risk of the need for tracheostomy, with a cut-off point of 4.5 (sensitivity 0.72, specificity 0.73, positive predictive value 0.57 and negative predictive value 0.85). The main complications were nosocomial infection (100%), supraventricular cardiac arrhythmia (45.5%), agitation (54.5%), pulmonary thromboembolism (9.1%) and depression (9.1%). All patients presented with hypoalbuminemia and significant critical illness polyneuropathy. CONCLUSION: SOFA at ICU admission is associated with an increased risk of tracheostomy in patients with COVID-19. Moreover, they present clinical features similar to those with chronic critical illness and suffer SARS-CoV-2-related complications.

Implementation of the Spanish ERAS program in bariatric surgery.

Introduction: The essence of Enhanced Recovery After Surgery (ERAS) programs is the multimodal approach, and many authors have demonstrated safety and feasibility in fast track bariatric surgery. According to this concept, a multidisciplinary ERAS program for bariatric surgery has been developed by the Spanish Fast Track Group (ERAS Spain). The aim of this study was to analyze the initial implementation of this Spanish National ERAS protocol in bariatric surgery, comparing it with a historical cohort receiving standard care. Material and methods: A multi-centric prospective study was performed, including 233 consecutive patients undergoing bariatric surgery during 2015 and following ERAS protocol. It was compared with a historical cohort of 286 patients, who underwent bariatric surgery at the same institutions between 2013 and 2014 and following standard care. Compliance with the protocol, morbidity, mortality, hospital stay and readmission were evaluated. Results: Bariatric techniques performed were Roux-en-Y gastric bypass and sleeve gastrectomy. There were no significant differences in complications, mortality and readmission. Postoperative pain and hospital stay were significantly lower in the ERAS group. The total compliance to protocol was 80%. Conclusion: The Spanish National ERAS protocol is a safe issue, obtaining similar results to standard care in terms of complications, reoperations, mortality and readmissions. It is associated with less postoperative pain and earlier hospital discharge.

Implementation of the Spanish National Enhanced Recovery Program (ERAS) in Bariatric Surgery: A Pilot Study.

INTRODUCTION: The essence of Enhanced Recovery After Surgery (ERAS) programs is the multimodal approach, and many authors have demonstrated safety and feasibility in fast track bariatric surgery. According to this concept, a multidisciplinary ERAS program for bariatric surgery has been developed by the Spanish fast track group (ERAS Spain). The aim of this study was to analyze the initial implementation of this Spanish National ERAS protocol in bariatric surgery. PATIENTS AND METHODS: A multicentric prospective pilot study was performed, including 125 consecutive patients undergoing bariatric surgery at 3 Spanish hospitals between January and June 2015, after the Spanish National ERAS protocol in bariatric surgery. Compliance with the protocol, morbidity, mortality, hospital stay, and readmission were evaluated. RESULTS: Bariatric techniques performed included 68 Roux-en-Y gastric bypass (54.4%) and 57 laparoscopic sleeve gastrectomy (45.6%) cases. All surgeries were laparoscopically performed with conversion in only 1 case (0.8%). Median postoperative pain evaluated by visual analogic scale 24 hours after surgery was 2 (range, 0 to 5). Postoperative nausea or vomiting appeared in 7 patients (5.6%). Complications appeared in 6 patients (4.8%). The reoperation rate was 4%. The mortality rate was 0.8%. The median hospital stay was 2 days (range, 2 to 10 d) and readmission rate was 2.4%. The compliance of all the items of the protocol was achieved in 78.4% of the patients. CONCLUSIONS: The Spanish National ERAS protocol is a safe issue with a high implementation rate. It can be recommended to establish this protocol to other institutions.

Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS.

PURPOSE: ERAS (enhanced recovery after surgery) programs have proven to reduce morbidity and hospital stay in colorectal surgery. However, the feasibility of these programs in elderly patients has been questioned. The aim of this study is to assess the implementation and outcomes of an ERAS program for colorectal cancer in elderly patients. METHODS: This is a multicenter observational study of a cohort of elderly patients undergoing colorectal surgery within an ERAS program. A total of 188 consecutive patients over 70 years who underwent elective colorectal surgery within an ERAS program at three institutions during a 2-year period were included. The compliance with the ERAS protocol interventions was measure. Complications were evaluated according to Clavien-Dindo classification. Data on length of stay and readmission rates were analyzed. RESULTS: Early intake and early mobilization were the most successfully carried out interventions. There was a global compliance rate of 56 % of patients for whom compliance was achieved with all measured interventions. The median hospital length of stay was 6 days. Almost 60 % of patients had no complications, 24 % had minor complications while 13 % had major complications; of them, 8 % patients were reoperated. The readmission rate was 6.4 %. CONCLUSIONS: ERAS after colorectal surgery in elderly patients presents as safe and feasible based on good reported outcomes of compliance rates, complications, readmissions, and needs for reoperation.

Celsior versus University of Wisconsin preserving solutions for liver transplantation: postreperfusion syndrome and outcome of a 5-year prospective randomized controlled study.

BACKGROUND: Celsior solution (CS) is a high-sodium, low-potassium, low-viscosity extracellular solution that has been used for liver graft preservation in recent years, although experience with it is still limited. We performed an open-label randomized active-controlled trial comparing CS with the University of Wisconsin solution (UW) for liver transplantation (LT), with a follow-up period of 5 years. METHODS: Adult transplant recipients (n=102) were prospectively randomized to receive either CS (n=51) or UW (n=51). The two groups were comparable with respect to donor and recipient characteristics. The primary outcome measure was the incidence of postreperfusion syndrome (PRS). Secondary outcome measures included primary nonfunction (PNF) or primary dysfunction (PDF), liver retransplantation, and graft and patient survival. Other secondary outcome measures were days in the intensive care unit (ICU) and the rates of acute rejection, chronic rejection, infectious complications, postoperative reoperations, and vascular and biliary complications. RESULTS: In all, 14 posttransplant variables revealed no significant differences between the groups. There were no cases of PNF or PDF. The incidence of PRS was 5.9% in the CS group and 21.6% in the UW group (P=0.041). After reperfusion, CS revealed greater control of serum potassium (P=0.015), magnesium levels (P=0.005), and plasma glucose (P=0.042) than UW. Respective patient survivals at 3, 12, and 60 months were 95.7, 87.2, and 82.0% for the CS group and 95.7, 83.3, and 66.6% for the UW group (P=0.123). CONCLUSIONS: While retaining the same degree of safety and effectiveness as UW for LT, CS may yield postliver graft reperfusion benefits, as shown in this study by a significant reduction in the incidence of PRS and greater metabolic control.

Postoperative morbidity of biliopancreatic diversion depending on common limb length.

BACKGROUND: Laparoscopic gastric bypass, currently the most popular surgical method for bariatric therapy, have proved to be effective in weight loss, but some matters regarding its long-term efficacy for super-obese patients (BMI >50 kg/m2) have arisen. Biliopancreatic diversion (BPD) is a complex technique that has shown good results in the treatment of the super-obese patient. We analyze our >5 years results, evaluating weight loss, morbidity and mortality of this operation, depending on the length of the common and alimentary limbs. METHODS: We studied two series of patients: 150 patients with BPD of Scopinaro (50-200 cm) and 70 patients with modified BPD (75-225 cm). The results have been analyzed in terms of weight loss, co-morbidity improvement, and postoperative morbidity using BAROS. RESULTS: Range of follow-up is 1-12 years. Weight loss was slightly higher for the Scopinaro group than for the Modified group but with no significant difference. There was more prevalence of malnutrition and of iron deficiency in the Scopinaro group (16% and 60%) than in the modified group (2% and 40%), with similar postoperative morbidities. CONCLUSION: The modified BPD method (75-225 cm) shows long-term effectiveness in weight loss and comorbidity improvement for super-obesity. Proteins, vitamins and oligoelement deficits appear distant in time, and thus it is necessary to maintain strict followup of these patients and supplement against deficiencies for the rest of their lives.