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3.
J Intensive Care Med ; : 8850666221094506, 2022 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-35437045

RESUMO

Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 - -0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.

4.
Surgery ; 172(1): 470-475, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35489978

RESUMO

BACKGROUND: Delays in admitting high-risk emergency surgery patients to the intensive care unit result in worse outcomes and increased health care costs. We aimed to use interpretable artificial intelligence technology to create a preoperative predictor for postoperative intensive care unit need in emergency surgery patients. METHODS: A novel, interpretable artificial intelligence technology called optimal classification trees was leveraged in an 80:20 train:test split of adult emergency surgery patients in the 2007-2017 American College of Surgeons National Surgical Quality Improvement Program database. Demographics, comorbidities, and laboratory values were used to develop, train, and then validate optimal classification tree algorithms to predict the need for postoperative intensive care unit admission. The latter was defined as postoperative death or the development of 1 or more postoperative complications warranting critical care (eg, unplanned intubation, ventilator requirement ≥48 hours, cardiac arrest requiring cardiopulmonary resuscitation, and septic shock). An interactive and user-friendly application was created. C statistics were used to measure performance. RESULTS: A total of 464,861 patients were included. The mean age was 55 years, 48% were male, and 11% developed severe postoperative complications warranting critical care. The Predictive OpTimal Trees in Emergency Surgery Risk Intensive Care Unit application was created as the user-friendly interface of the complex optimal classification tree algorithms. The number of questions (ie, tree depths) needed to predict intensive care unit admission ranged from 2 to 11. The Predictive OpTimal Trees in Emergency Surgery Risk Intensive Care Unit application had excellent discrimination for predicting the need for intensive care unit admission (C statistics: 0.89 train, 0.88 test). CONCLUSION: We recommend the Predictive OpTimal Trees in Emergency Surgery Risk Intensive Care Unit application as an accurate, artificial intelligence-based tool for predicting severe complications warranting intensive care unit admission after emergency surgery. The Predictive OpTimal Trees in Emergency Surgery Risk Intensive Care Unit application can prove useful to triage patients to the intensive care unit and to potentially decrease failure to rescue in emergency surgery patients.


Assuntos
Inteligência Artificial , Smartphone , Adulto , Cuidados Críticos , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
5.
Artigo em Inglês | MEDLINE | ID: mdl-35267051

RESUMO

INTRODUCTION: Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. METHODS: We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. RESULTS: A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15-0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36-7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15-2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06-1.87) compared to controls. CONCLUSION: Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.

6.
J Trauma Acute Care Surg ; 93(1): 21-29, 2022 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-35313325

RESUMO

BACKGROUND: Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion. METHODS: Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality. RESULTS: A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT >2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP >2 (1,160 [12.6%]) (p < 0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p < 0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18-2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74-4.24]). CONCLUSION: Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.


Assuntos
Plaquetas , Transfusão de Eritrócitos , Adulto , Transfusão de Componentes Sanguíneos , Eritrócitos , Humanos , Estudos Retrospectivos
7.
J Surg Res ; 274: 185-195, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35180495

RESUMO

INTRODUCTION: Intraoperative deaths (IODs) are rare but catastrophic. We systematically analyzed IODs to identify clinical and patient safety patterns. METHODS: IODs in a large academic center between 2015 and 2019 were included. Perioperative details were systematically reviewed, focusing on (1) identifying phenotypes of IOD, (2) describing emerging themes immediately preceding cardiac arrest, and (3) suggesting interventions to mitigate IOD in each phenotype. RESULTS: Forty-one patients were included. Three IOD phenotypes were identified: trauma (T), nontrauma emergency (NT), and elective (EL) surgery patients, each with 2 sub-phenotypes (e.g., ELm and ELv for elective surgery with medical arrests or vascular injury and bleeding, respectively). In phenotype T, cardiopulmonary resuscitation was initiated before incision in 42%, resuscitative thoracotomy was performed in 33%, and transient return of spontaneous circulation was achieved in 30% of patients. In phenotype NT, ruptured aortic aneurysms accounted for half the cases, and median blood product utilization was 2,694 mL. In phenotype ELm, preoperative evaluation did not include electrocardiogram in 12%, cardiac consultation in 62%, stress test in 87%, and chest x-ray in 37% of patients. In phenotype ELv, 83% had a single peripheral intravenous line, and vascular injury was almost always followed by escalation in monitoring (e.g., central/arterial line), alert to the blood bank, and call for surgical backup. CONCLUSIONS: We have created a framework for IOD that can help with intraoperative safety and quality analysis. Focusing on interventions that address appropriateness versus futility in care in phenotypes T and NT, and on prevention and mitigation of intraoperative vessel injury (e.g., intraoperative rescue team) or preoperative optimization in phenotype EL may help prevent IODs.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca , Lesões do Sistema Vascular , Parada Cardíaca/etiologia , Parada Cardíaca/prevenção & controle , Hemorragia , Humanos , Toracotomia
8.
J Card Surg ; 37(4): 808-817, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35137981

RESUMO

BACKGROUND: Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery. METHODS: All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC. RESULTS: Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre- or intraoperative utilization of intra-aortic balloon pump or catheter-based assist devices (OR = 4.54), intraoperative transfusion requirement of >4 RBC units(OR = 2.47), and cardiopulmonary bypass > 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC. CONCLUSIONS: We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above-identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Gastroenteropatias , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Gastroenteropatias/etiologia , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
9.
Surgery ; 172(1): 421-426, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35184891

RESUMO

BACKGROUND: In military combat settings, noncompressible closed cavity exsanguination is the leading cause of potentially survivable deaths, with no effective treatment available at point of injury. The aim of this study was to assess whether an expanding foam based on hydrophobically modified chitosan (hm-chitosan) may be used as a locally injectable hemostatic agent for the treatment of noncompressible bleeding in a swine model. METHODS: A closed-cavity, grade V hepato-portal injury was created in all animals resulting in massive noncoagulopathic, noncompressible bleeding. Animals received either fluid resuscitation alone (control, n = 8) or fluid resuscitation plus intraperitoneal hm-chitosan agent through an umbilical port (experimental, n = 18). The experiment was terminated at 180 minutes or death (defined as end-tidal CO2 <8mmHg or mean arterial pressure [MAP] <15mmHg), whichever came first. RESULTS: All animals had profound hypotension and experienced a near-arrest from hypovolemic shock (mean MAP = 24 mmHg at 10 minutes). Mean survival time was higher than 150 minutes in the experimental arm versus 27 minutes in the control arm (P < .001). Three-hour survival was 72% in the experimental group and 0% in the control group (P = .002). Hm-chitosan stabilized rising lactate, preventing acute lethal acidosis. MAP improved drastically after deployment of the hm-chitosan and was preserved at 60 mmHg throughout the 3 hours. Postmortem examination was performed in all animals and the hepatoportal injuries were anatomically similar. CONCLUSION: Intraperitoneal administration of hm-chitosan-based foam for massive, noncompressible abdominal bleeding improves survival in a lethal, closed-cavity swine model. Chronic safety and toxicity studies are required.


Assuntos
Quitosana , Hemostáticos , Animais , Modelos Animais de Doenças , Hidratação/efeitos adversos , Hemorragia/etiologia , Hemorragia/terapia , Técnicas Hemostáticas , Hemostáticos/uso terapêutico , Humanos , Suínos
10.
JPEN J Parenter Enteral Nutr ; 46(1): 130-140, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34599785

RESUMO

BACKGROUND: Outcomes of early enteral nutrition (EEN) in critically ill patients on vasoactive medications remain unclear. We aimed to compare in-hospital outcomes for EEN vs late EN (LEN) in mechanically ventilated patients receiving vasopressor support. METHODS: This was a retrospective study using the national eICU Collaborative Research Database. Adult patients requiring vasopressor support and mechanical ventilation within 24 h of admission and for ≥2 days were included. Patients with an admission diagnosis that could constitute a contraindication for EEN (eg, gastrointestinal [GI] perforation, GI surgery) and patients with an intensive care unit (ICU) length of stay (LOS) <72 h were excluded. EEN and LEN were defined as tube feeding within 48 h and between 48 h and 1 week (nothing by mouth during the first 48 h) of admission, respectively. Propensity score matching was performed to derive two cohorts receiving EEN and LEN that were comparable for baseline patient characteristics. RESULTS: Among 1701 patients who met the inclusion criteria (EEN: 1001, LEN: 700), 1148 were included in propensity score-matched cohorts (EEN: 574, LEN: 574). Median time to EN was 29 vs 79 h from admission in the EEN and LEN groups, respectively. There was no significant difference in mortality or hospital LOS between the two nutrition strategies. EEN was associated with shorter ICU LOS, lower need for renal replacement therapy, and lower incidence of electrolyte abnormalities. CONCLUSION: This study showed no difference in 28-day mortality between EEN and LEN in critically ill patients receiving vasopressor support.


Assuntos
Estado Terminal , Nutrição Enteral , Adulto , Estado Terminal/terapia , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Respiração Artificial , Estudos Retrospectivos
11.
Eur J Trauma Emerg Surg ; 48(2): 1197-1204, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34296323

RESUMO

PURPOSE: The Emergency Surgery Score (ESS) is a reliable point-based score that predicts mortality and morbidity in emergency surgery patients. However, it has been validated only in the U.S. PATIENTS: We aimed to prospectively validate ESS in a Greek patient population. METHODS: All patients who underwent an emergent laparotomy were prospectively included over a 15-month period. A systematic chart review was performed to collect relevant preoperative, intraoperative, and postoperative variables based on which the ESS was calculated for each patient. The relationship between ESS and 30-day mortality, morbidity (i.e., the occurrence of at least one complication), and the need for intensive care unit (ICU) admission was evaluated and compared between the Greek and U.S. patients using the c-statistics methodology. The study was registered on "Research Registry" with the unique identifying number 5901. RESULTS: A total of 214 patients (102 Greek) were included. The mean age was 64 years, 44% were female, and the median ESS was 7. The most common indication for surgery was hollow viscus perforation (25%). The ESS reliably and incrementally predicted mortality (c-statistics = 0.79 [95% CI 0.67-0.90] and 0.83 [95% CI 0.74-0.92]), morbidity (c-statistics = 0.83 [95% CI 0.76-0.91] and 0.79 [95% CI 0.69-0.88]), and ICU admission (c-statistics = 0.88 [95% CI 0.81-0.96] and 0.84 [95% CI 0.77-0.91]) in both Greek and U.S. CONCLUSION: The correlation between the ESS and the surgical outcomes was statistically significant in both Greek and U.S. patients undergoing emergency laparotomy. ESS could prove globally useful for preoperative patient counseling and quality-of-care benchmarking.


Assuntos
Complicações Pós-Operatórias , Estudos de Coortes , Feminino , Grécia/epidemiologia , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Medição de Risco/métodos
12.
J Intensive Care Med ; 37(6): 728-735, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34231406

RESUMO

BACKGROUND: There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes. MATERIALS AND METHODS: We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit. RESULTS: 10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001). CONCLUSION: The previously described volume-outcome association in septic patients was not identified in an intensive care setting.

13.
Artigo em Inglês | MEDLINE | ID: mdl-34845499

RESUMO

PURPOSE: Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. RESULTS: In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). CONCLUSION: Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL. LEVEL OF EVIDENCE: 2B.

14.
Artigo em Inglês | MEDLINE | ID: mdl-34807273

RESUMO

PURPOSE: To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression. RESULTS: A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively. CONCLUSIONS: Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

15.
Surg Infect (Larchmt) ; 22(6): 626-634, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34270361

RESUMO

Background: The use of machine learning (ML) and artificial intelligence (AI) in medical research continues to grow as the amount and availability of clinical data expands. These techniques allow complex interpretation of data and capture non-linear relations not immediately apparent by classic statistical techniques. Methods: This review of the ML/AI literature provides a brief overview for practicing surgeons and clinicians of the current and future roles these methods will have within surgical infection research. Results: A conceptual overview of the techniques is provided along with concrete examples in the surgical infections literature. Further examples of ML/AI techniques in clinical decision support as well as therapy discovery with model-based deep reinforcement learning are illustrated. Conclusions: Artificial intelligence and ML are important and increasingly utilized techniques within the expanding body of surgical infection research. This article provides a minimal baseline literacy in ML/AI to be able to view such projects in an appropriately critical fashion.


Assuntos
Inteligência Artificial , Tomada de Decisões , Aprendizado de Máquina , Cirurgiões/psicologia , Procedimentos Cirúrgicos Operatórios/tendências , Difusão de Inovações , Humanos , Cirurgia Assistida por Computador
16.
J Trauma Acute Care Surg ; 91(1): 100-107, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34144559

RESUMO

BACKGROUND: Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population. METHODS: We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head. RESULTS: Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001). CONCLUSION: Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury. LEVEL OF EVIDENCE: Therapeutic study, level IV.


Assuntos
Traumatismos Abdominais/cirurgia , Delírio/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adulto , Analgésicos Opioides/administração & dosagem , Delírio/etiologia , Feminino , Humanos , Incidência , Escala de Gravidade do Ferimento , Laparotomia/efeitos adversos , Tempo de Internação , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Sono , Estados Unidos , Adulto Jovem
17.
Surgery ; 170(5): 1501-1507, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34176601

RESUMO

BACKGROUND: The Emergency Surgery Score was recently validated in a prospective multicenter study as an accurate predictor of mortality in emergency general surgery patients. The Emergency Surgery Score is easily calculated using multiple demographic, comorbidity, laboratory, and acuity of disease variables. We aimed to investigate whether the Emergency Surgery Score can predict 30-day postoperative mortality across patients undergoing emergency surgery in multiple surgical specialties. METHODS: Our study is a retrospective cohort study using data from the national American College of Surgeons National Surgical Quality Improvement Program database (2007-2017). We included patients that underwent emergency gynecologic, urologic, thoracic, neurosurgical, orthopedic, vascular, cardiac, and general surgical procedures. The Emergency Surgery Score was calculated for each patient, and the correlation between the Emergency Surgery Score and 30-day mortality was assessed for each specialty using the c-statistics methodology. RESULTS: Of 6,485,915 patients, 173,890 patients were included. The mean age was 60 years, 50.6% were female patients, and the overall mortality was 9.7%. The Emergency Surgery Score predicted mortality best in emergency gynecologic, general, and urologic surgery (c-statistics: 0.97, 0.87, 0.81, respectively). The Emergency Surgery Score predicted mortality moderately well in emergency thoracic, neurosurgical, orthopedic, and vascular surgery (c-statistics 0.73-0.79). For example, the mortality of gynecology patients with an Emergency Surgery Score of 5, 9, and 13 was 2%, 27%, and 50%, respectively. The Emergency Surgery Score performed poorly in cardiac surgery. CONCLUSION: The Emergency Surgery Score accurately predicts mortality across patients undergoing emergency surgery in multiple surgical specialties, especially general, gynecologic, and urologic surgery. The Emergency Surgery Score can prove useful for perioperative patient counseling and for benchmarking the quality of surgical care.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Indicadores Básicos de Saúde , Procedimentos Cirúrgicos Operatórios/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Estados Unidos/epidemiologia
18.
J Surg Res ; 266: 35-43, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33975028

RESUMO

BACKGROUND: Bedside experience and studies of critically ill patients with coronavirus disease 2019 (COVID-19) indicate COVID-19 to be a devastating multisystem disease. We aim to describe the incidence, associated variables, and outcomes of rhabdomyolysis in critically ill COVID-19 patients. MATERIALS AND METHODS: Data for all critically ill adult patients (≥18 years old) admitted to the ICU at a large academic medical center with confirmed COVID-19 between March 13, 2020 and April 18, 2020 were prospectively collected. Patients with serum creatine kinase (CK) concentrations greater than 1000 U/L were diagnosed with rhabdomyolysis. Patients were further stratified as having moderate (serum CK concentration 1000-4999 U/L) or severe (serum CK concentration ≥5000 U/L) rhabdomyolysis. Univariate and multivariate analyses were performed to identify outcomes and variables associated with the development of rhabdomyolysis. RESULTS: Of 235 critically ill COVID-19 patients, 114 (48.5%) met diagnostic criteria for rhabdomyolysis. Patients with rhabdomyolysis more often required mechanical ventilation (P < 0.001), prone positioning (P < 0.001), pharmacological paralysis (P < 0.001), renal replacement therapy (P = 0.010), and extracorporeal membrane oxygenation (ECMO) (P = 0.025). They also had longer median ICU length of stay (LOS) (P < 0.001) and hospital LOS (P < 0.001). No difference in mortality was observed. Male sex, patients with morbid obesity, SOFA score, and prone positioning were independently associated with rhabdomyolysis. CONCLUSIONS: Nearly half of critically ill COVID-19 patients in our cohort met diagnostic criteria for rhabdomyolysis. Male sex, morbid obesity, SOFA score, and prone position were independently associated with rhabdomyolysis.


Assuntos
COVID-19/complicações , Obesidade Mórbida/epidemiologia , Rabdomiólise/epidemiologia , Idoso , Índice de Massa Corporal , COVID-19/diagnóstico , COVID-19/epidemiologia , COVID-19/virologia , Comorbidade , Creatina Quinase/sangue , Estado Terminal , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Obesidade Mórbida/diagnóstico , Escores de Disfunção Orgânica , Decúbito Ventral , Estudos Prospectivos , Rabdomiólise/sangue , Rabdomiólise/diagnóstico , Rabdomiólise/etiologia , Medição de Risco/estatística & dados numéricos , Fatores de Risco , SARS-CoV-2/isolamento & purificação , Fatores Sexuais
19.
Crit Care Med ; 49(10): e1025-e1036, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33967205

RESUMO

OBJECTIVES: To combine evidence on andexanet alfa and prothrombin complex concentrates for factor Xa inhibitor-associated bleeding to guide clinicians on reversal strategies. DATA SOURCES: Embase, Pubmed, Web of Science, and the Cochrane Library. STUDY SELECTION: Observational studies and randomized clinical trials studying hemostatic effectiveness of andexanet alfa or prothrombin complex concentrate for acute reversal of factor Xa inhibitor-associated hemorrhage. DATA EXTRACTION: Two independent reviewers extracted the data from the studies. Visualization and comparison of hemostatic effectiveness using Sarode et al or International Society of Thrombosis and Hemostasis Scientific and Standardization Committee criteria at 12 and 24 hours, (venous) thrombotic event rates, and inhospital mortality were performed by constructing Forest plots. Exploratory analysis using a logistic mixed model analysis was performed to identify factors associated with effectiveness and venous thromboembolic event. DATA SYNTHESIS: A total of 21 studies were included (andexanet: 438 patients; prothrombin complex concentrate: 1,278 patients). The (weighted) mean effectiveness for andexanet alfa was 82% at 12 hours and 71% at 24 hours. The (weighted) mean effectiveness for prothrombin complex concentrate was 88% at 12 hours and 76% at 24 hours. The mean 30-day symptomatic venous thromboembolic event rates were 5.0% for andexanet alfa and 1.9% for prothrombin complex concentrate. The mean 30-day total thrombotic event rates for andexanet alfa and prothrombin complex concentrate were 10.7% and 3.1%, respectively. Mean inhospital mortality was 23.3% for andexanet versus 15.8% for prothrombin complex concentrate. Exploratory analysis controlling for potential confounders did not demonstrate significant differences between both reversal agents. CONCLUSIONS: Currently, available evidence does not unequivocally support the clinical effectiveness of andexanet alfa or prothrombin complex concentrate to reverse factor Xa inhibitor-associated acute major bleeding, nor does it permit conventional meta-analysis of potential superiority. Neither reversal agent was significantly associated with increased effectiveness or a higher rate of venous thromboembolic event. These results underscore the importance of randomized controlled trials comparing the two reversal agents and may provide guidance in designing institutional guidelines.


Assuntos
Inibidores do Fator Xa/efeitos adversos , Fator Xa/farmacologia , Hemorragia/tratamento farmacológico , Protrombina/farmacologia , Proteínas Recombinantes/farmacologia , Coagulantes/administração & dosagem , Coagulantes/farmacologia , Fator Xa/administração & dosagem , Inibidores do Fator Xa/farmacologia , Humanos , Protrombina/administração & dosagem , Proteínas Recombinantes/administração & dosagem
20.
J Trauma Acute Care Surg ; 90(5): 880-890, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33891572

RESUMO

BACKGROUND: We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts. METHODS: This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality. RESULTS: A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality. CONCLUSION: We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities. LEVEL OF EVIDENCE: Prognostic, level III.


Assuntos
COVID-19/complicações , COVID-19/mortalidade , Mortalidade Hospitalar , Gravidade do Paciente , Injúria Renal Aguda/virologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Antimaláricos/uso terapêutico , Boston/epidemiologia , COVID-19/fisiopatologia , COVID-19/terapia , Comorbidade , Creatina Quinase/sangue , Cuidados Críticos , Estado Terminal , Oxigenação por Membrana Extracorpórea , Feminino , Gastroenteropatias/virologia , Humanos , Hidroxicloroquina/uso terapêutico , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Bloqueio Neuromuscular , Escores de Disfunção Orgânica , Pneumonia Bacteriana/virologia , Lesão por Pressão/etiologia , Decúbito Ventral , Estudos Prospectivos , Síndrome do Desconforto Respiratório/fisiopatologia , Síndrome do Desconforto Respiratório/virologia , Fatores de Risco , SARS-CoV-2 , Choque/virologia , Esteroides/uso terapêutico , Taxa de Sobrevida , Tromboembolia/virologia , Resultado do Tratamento
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