The Long-Term Impact of Frailty After an Intensive Care Unit Admission Due to Chronic Obstructive Pulmonary Disease.

Rationale: Frailty is an increasingly recognized aspect of chronic obstructive pulmonary disease (COPD). The impact of frailty on long-term survival after admission to an intensive care unit (ICU) due to an exacerbation of COPD has not been described. Objective: The objective was to quantify the impact of frailty on time to death up to 4 years after admission to the ICU in Australia and New Zealand for an exacerbation of COPD. Methods: We performed a multicenter retrospective cohort study of adult patients admitted to 179 ICUs with a primary diagnosis of an exacerbation of COPD using the Australian and New Zealand Intensive Care Society Adult Patient Database from January 1, 2018, through December 31, 2020, in New Zealand, and March 31, 2022, in Australia. Frailty was measured using the clinical frailty scale (CFS). The primary outcome was survival up to 4 years after ICU admission. The secondary outcome was readmission to the ICU due to an exacerbation of COPD. Measurements and Main Results: We examined 7126 patients of which 3859 (54.1%) were frail (CFS scores of 5-8). Mortality in not-frail individuals versus frail individuals at 1 and 4 years was 19.8% versus 40.4%, and 56.8% versus 77.3% respectively (both p<0.001). Frailty was independently associated with a shorter time to death (adjusted hazard ratio 1.66; 95% confidence interval 1.54-1.80).There was no difference in the proportion of survivors with or without frailty who were readmitted to the ICU during a subsequent hospitalization. Conclusions: Frailty was independently associated with poorer long-term survival in patients admitted to the ICU with an exacerbation of COPD.

Continuous Renal Replacement Therapy during Extracorporeal Membrane Oxygenation: Circuit Haemodynamics and Circuit Failure.

INTRODUCTION: Treatment with continuous renal replacement therapy (CRRT) is common during extracorporeal membrane oxygenation (ECMO). Such ECMO-CRRT has specific technical characteristics, which may affect circuit life. Accordingly, we studied CRRT haemodynamics and circuit life during ECMO. METHODS: ECMO and non-ECMO-CRRT treatments in two adult intensive care units were compared using data collected over a 3-year period. A potential predictor of circuit survival identified in a 60% training data subset as a time-varying covariate within a Cox proportional hazard model was subsequently assessed in the complementary remaining data (40%). RESULTS: Median [interquartile range] CRRT circuit life was greater when associated with ECMO (28.8 [14.0-65.2] vs. 20.2 [9.8-40.2] h, p < 0.0001). Access, return, prefilter, and effluent pressures were also greater during ECMO. Higher ECMO flows were associated with higher access and return pressures. Classification and regression tree analysis identified an association between high access pressures and accelerated circuit failure, while both first access pressures ≥190 mm Hg (HR 1.58 [1.09-2.30]) and patient weight (HR 1.85 [1.15-2.97] third tertile vs. first tertile) were independently associated with circuit failure in a multivariable Cox model. Access dysfunction was associated with a stepwise increase in transfilter pressure, suggesting a potential mechanism of membrane injury. CONCLUSION: CRRT circuits used in conjunction with ECMO have a longer circuit life than usual CRRT despite exposure to higher circuit pressures. Markedly elevated access pressures, however, may predict early CRRT circuit failure during ECMO, possibly via progressive membrane thrombosis as evidenced by increased transfilter pressure gradients.

Undiagnosed gastric adenocarcinoma causing progressive respiratory failure.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare manifestation of malignancy. Pulmonary tumor emboli and associated fibrous intimal hyperplasia cause widespread pulmonary vascular stenosis/occlusion, which in turn increase pulmonary vascular resistance and lead to pulmonary hypertension. Gastric cancer is the most common underlying malignancy that leads to PTTM, and patients may present with dyspnea or other features of pulmonary hypertension prior to the diagnosis of cancer. In this short report, we describe a case of pulmonary hypertension due to gastric cancer associated PTTM. Endoscopic and histopathologic findings are shown, and a brief review of the literature is presented.

The association between erector spinae plane block timing and reduced rib fracture related respiratory complications: A cohort study.

STUDY OBJECTIVE: Is erector spinae plane (ESP) catheter insertion within 24 h of hospital admission for rib fractures associated with a lower incidence of respiratory complications compared to those having an ESP within 48 h or after 48 h of admission. DESIGN: Retrospective cohort study. SETTING: Hospital. PATIENTS: 199 patients admitted for rib fractures, who received an ESP catheter. INTERVENTIONS: Timing of ESP performance was assessed by dividing the study cohort into three subgroups: prompt block within 24 h, early block within 48 h and late block after 48 h of admission. MEASUREMENTS: The primary outcome of interest was the development of respiratory complications. This included pneumonia, pulmonary embolism and respiratory failure. Secondary outcomes included intensive care unit (ICU) length of stay and hospital length of stay. MAIN RESULTS: A prompt ESP within 24 h was performed in 14.5% (n = 29) of patients, 47% (n = 95) received an early block within 48 h and 37% (n = 75) of patients received a late block after 48 h from admission. There was a significantly higher rate of respiratory complications (p = 0.005) with late block. A late block was associated with a significantly longer ICU length of stay (7.82 ± 5.2 days) compared to patients who received an early block (5.84 ± 2.8 days; p = 0.044). There was no significant association with hospital length of stay (p = 0.06). There were no differences between the prompt (within 24 h) and early (within 48 h) block groups for any outcome. CONCLUSIONS: The performance of an ESP block after 48 h of admission was associated with an increased incidence of respiratory complications and ICU length of stay. There appears to be no added benefit associated with the provision of a prompt ESP within 24 h.

Classifying and tracking rehabilitation interventions through machine-learning algorithms in individuals with stroke.

INTRODUCTION: Stroke is the leading cause of disability worldwide. It has been well-documented that rehabilitation (rehab) therapy can aid in regaining health and function for individuals with stroke. Yet, tracking in-home rehab continues to be a challenge because of a lack of resources and population-scale demands. In order to address this gap, we implemented a methodology to classify and track rehab interventions in individuals with stroke. METHODS: We developed personalized classification algorithms, including neural network-based algorithms, to classify four rehab exercises performed by two individuals with stroke who were part of a week-long therapy camp in Jamaica, a low- and middle-income country. Accelerometry-based wearable sensors were placed on each upper and lower limb to collect movement data during therapy. RESULTS: The classification accuracy for traditional and neural network-based algorithms utilizing feature data (e.g., number of peaks) from the sensors ranged from 64 to 94%, respectively. In addition, the study proposes a new method to assess change in bilateral mobility over the camp duration. CONCLUSION: The results of this pilot study indicate that personalized supervised learning algorithms can be used to classify and track rehab activities and functional outcomes in resource limited settings such as LMICs.