Clinical outcomes of venoarterial extracorporeal life support in 462 patients: Single-center experience.

This study aims to investigate the outcomes of venoarterial extracorporeal life support (VA-ECLS) in a large single-center patient cohort regarding survival and adverse events. Between June 2009 and March 2019, 462 consecutive patients received VA-ECLS. The mean age was 66.2 ± 11.9 years. Two patient groups were identified: Group 1-patients with ECLS due to postcardiotomy shock (PCS) after cardiac surgery (PCS, n = 357); Group 2-patients with ECLS due to cardiogenic shock (CS) without previous surgery (nonPCS, n = 105). The primary end point was overall in-hospital survival, while secondary end points were adverse events during the study period. Overall, the in-hospital survival rate was 26%. There was no statistically significant difference between the groups: 26.3% for PCS and 24.8% for nonPCS, respectively (P > .05). Weaning from VA-ECLS was possible in 44.3% for PCS and in 29.5% for nonPCS (P = .004). The strong predictors of overall mortality were postoperative hepatic dysfunction (OR = 14.362, 95%CI = 1.948-105.858), cardiopulmonary resuscitation > 30 minutes (OR = 6.301, 95%CI = 1.488-26.673), bleeding with a need for revision (OR = 2.123, 95%CI = 1.343-3.355), and previous sternotomy (OR = 2.077, 95%CI = 1.021-4.223). Despite its low survival rates, VA-ECLS therapy is the last resort and the only lifesaving option for patients in refractory CS. In contrast, there is still a lack of evidence for VA-ECLS in PCS patients. Future studies are warranted to evaluate the outcomes of VA-ECLS therapy after cardiac surgery.

Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study.

RATIONALE: Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence. OBJECTIVES: To determine whether early HVHF decreases all-cause mortality 30 days after randomization. METHODS: This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury. MEASUREMENTS AND MAIN RESULTS: On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia. CONCLUSIONS: For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).

Vasopressin, when added to norepinephrine, was not associated with increased predicted mortality after cardiac surgery.

BACKGROUND AND AIMS: Arginin vasopressin (AVP) is a potent vasoconstrictor which has been used in vasodilatory shock when therapy with catecholamines and fluids has failed. In this study we evaluated the association of AVP with organ failure and mortality in cardiac surgical patients suffering from vasodilatory shock refractory to norepinephrine (NE) treatment. MATERIAL AND METHODS: Cardiac surgical patients who received AVP in addition to NE (N=33, AVP-group) and 33 control patients (NE group) who were treated with an equal dose of NE compared with AVP patients when AVP infusion started. Data on preoperative risk factors according to EuroSCORE and predicted mortality calculated by logistic EuroSCORE were collected preoperatively. Data on hemodynamics, organ dysfunctions, length of intensive care unit stay and mortality were collected. RESULTS: EuroSCORE did not differ between the groups, AVP:10.4 +/- 3.9 vs. NE 8.9 +/- 4.0. Observed 30 day mortality was lower than predicted in both groups, AVP: 7 (21.7%) vs. predicted mortality 25.9% and NE: 2 (6.1%) vs. 16.0%, respectively. There were more renal complications (36.4% vs. 9.1%, p = 0.008) and infections (30.3% vs. 3.0%, p = 0.003) in patients receiving AVP. Cardiovascular complications did not differ between the groups. CONCLUSIONS: In this prospectively observed cohort of cardiac surgical patients, AVP did not increase mortality predicted by Euroscore. Anyhow renal and infection complications were common.

Increased concentrations of cytokines and adhesion molecules in patients after repair of abdominal aortic aneurysm.

OBJECTIVE: To evaluate the association between inflammatory mediators and clinical outcome in patients after repair of abdominal aortic aneurysms. DESIGN: Prospective study. SETTING: University hospital, The Netherlands. PATIENTS: 30 Consecutive patients who had undergone elective or acute repair of abdominal aortic aneurysms. MAIN OUTCOME MEASURES: Plasma concentrations of the cytokines tumour necrosis factor (TNF), interleukin-6 (IL-6) and interleukin-8 (IL-8) as well as soluble TNF receptors and the soluble (s) adhesion molecules E-selectin and intercellular adhesion molecule 1 (ICAM-1) were measured and correlated with the degree of systemic hypotension (shock: hypotension more than 15 minutes) and clinical outcome. RESULTS: Peak plasma concentrations of TNF and IL-6 were significantly higher in shocked patients (p < 0.005 and p < 0.0005, respectively) and those who died (both p < 0.01), whereas concentrations of IL-8 increased only when shock complicated rupture of the aneurysm (p < 0.01). Increases in the concentrations of TNF receptors reflected impaired renal function. In contrast to sE-selectin concentrations, peak sICAM-1 concentrations were significantly higher in shocked patients (p < 0.01) and those that died (p < 0.01). CONCLUSIONS: These results strongly suggest that increased concentrations of sICAM-1 and IL-6 reflect the inflammatory response induced by ischaemia after repair of an abdominal aortic aneurysm, and indicate that the postoperative course is likely to be complicated.

[Etiology, pathogenesis, clinical aspects, diagnosis and treatment of posttraumatic pancreatitis]. / Etiologiia, patogenez, klinika, diagnostika i lechenie posttravmaticheskogo pankreatita.

The authors generalize their experience in the treatment of 41 patients with posttraumatic pancreatitis. This complication predominated in the early postoperative period in patients with various degree of injury to the pancreas. The main etiopathogenic factors of the development of posttraumatic pancreatitis are indicated. The therapeutic tactics was mainly nonoperative. The effect was positive in 24 cases. Seventeen (41.5%) patients had the pyodestructive form. The mortality rate was 29.3%. The leading principle of management was the initial attitude towards all patients with injury to the pancreas as if they were potential patients with posttraumatic pancreatitis, and the prescription of preventive treatment.

The early detection of the effects of surgical shock on the viscera.

One hundred and one patients, in shock after operations were reviewed to examine the visceral effects on their prognoses. The shock was caused in 65 cases by hypovolaemia and in 36 cases by sepsis. The effects were studied on the heart and cardiovascular system, liver, kidneys, gastrointestinal system, central nervous system, lungs and blood clotting system. Surgical shock affected more frequently the lung and liver (P less than 0.05 and P less than 0.01). The lungs were most frequently involved in hypovolaemia (25 patients) and sepsis (25 cases). Pathology of the lung was associated with the highest mortality rate (P less than 0.005), followed by kidney (P less than 0.01) then heart and central nervous system (P less than 0.025). Involvement of the gastrointestinal tract or clotting system alone was not associated with higher mortality rates, except in the presence of other visceral derangements. Lung affection also had a greater mortality followed by kidney and the central nervous system. Involvement of one or several organs in failure to survive septic shock is dealt with in the discussion. It is concluded that visceral involvement secondary to shock could be of importance for prognosis.

The use of arterial--central venous oxygen differences to calculate cardiac output and oxygen consumption in critically ill surgical patients.

Simultaneous determinations of cardiac output (using the cardiogreen indicator dilution technique) and arterial--central venous oxygen differences [C(a-cv)O2] were obtained in 200 critically ill surgical patients. The average initial values +/- SD included arterial--central venous oxygen differences of 3.6 +/- 1.6 vol%, cardiac index of 3.4 "/- 1.2 liter/min/sq m, and oxygen consumption of 100 ml/min/sqm. As might be expected, low arterial--central venous oxygen differences, especially if less than 2.0 vol%, were associated with high cardiac indices, but the oxygen consumptions were much lower than normal and the mortality rates were increased. The cardiac indices calculated from the C(a-cv)O2 averaged 4.1 liter/min/sq m and correlated rather well with the measured cardiac indices, particularly if the patients with a C(a-cv)O2 of less than 2.0 vol% were excluded. Arterial pH values did not correlate well with the calculated oxygen consumption. Arterial oxygen contents of more than 16.2 vol% equivalent to a hemoglobin of 12.5 gm/dl or higher with an oxygen saturation of 95%, provided better arteriovenous oxygen differences, oxygen consumptions, and survival rates than those found with lower hemoglobin values. Arterial--central venous oxygen differences and calculated oxygen consumptions can be practical clinical and prognostic value.

[Early mortality in geriatric-gynecologic surgery]. / Frühmortalität im geriatrisch-gynäkologischen Operationsgut

The death rate of 6662 major gynaecological operations on women of 60 years or more in 17 West-Berlin Gynaecological Departments (1960--1969) was 7,7% (512 cases). Of these, 89 women (16,8%) died either during operation or within 3 days after the operation. In all cases there was an adequate indications for surgical intervention. With few exceptions the procedures of the operations could not be criticized. Only a very small part of the intra- and postoperative mortality could be attributed to the anesthesia. In some cases medication was insulfficient (e.g. lack of preoperative treatment with digitalis or postoperative replacement with substitutes or blood). This may partly be explained by the fact that during the period under investigation in many cases the anesthesia had to be done by the gynaecologists. Publications on early postoperative mortailty supply better information on the quality of medical care given to the gynaecological patients, than surveys of so called "Anaesthetic dealths".

[Postoperative complications and mortality in acute intestinal obstruction]. / Posleoperatsionnye oslozhneniia i letal'nost' pri ostroi kishechoni neprokhodimosti

496 case reports of patients operated upon for various kinds of intestinal obstruction were analysed. Complications were studied in 202 (40.6%) patients. 93 patients died (19.7%). Peritonitis remains to be the main cause of death postoperatively (49.5 per cent to all lethal issues).