What Are the Real Issues in Providing Extracorporeal Membrane Oxygenation (ECMO) Support: A Survey.

INTRODUCTION: By using a novel survey our study aimed to assess the challenges ECMO and Critical Care (CC) teams face when initiating and managing patient's ECMO support. METHODS: A qualitative survey-based observational study was performed of members of 2 Critical Care Medicine organizations involved in decision-making around the practice of Extracorporeal Membrane Oxygenation (ECMO). The range of exploratory questions covered ethical principles of informed consent, autonomy and goals of care discussions, beneficence, non-maleficence (offering life-sustaining treatments in end-of-life care), and justice (insurance-related limitations of treatment). Questions also covered pragmatic practice and quality improvement areas, such as exploring whether palliative care or ethics teams were involved in such decision-making. RESULTS: 305 members received the survey links, and a total of 61 completed surveys were received, for an overall response rate of 20% among all eligible members. Only 70% of the participants who manage ECMO patients are involved in the ECMO initiation decision process. The majority do not involve Ethics or Palliative care at the initial ECMO initiation decision step. Of the ethical and moral dilemmas reported, the majority revolved around 1. Prognostication of patients receiving VV and VA ECMO support, 2. Lack of knowledge of patient's wishes and goals, 3. Disconnect between expectations of families and outcomes and 4. Staff moral distress around when to stop ECMO in case of futility. CONCLUSION: Our survey highlights areas of distress and dilemma which have been stressed before in the initiation, management, and outcomes of ECMO patients, however with the increasing use of this modality of cardiopulmonary mechanical support being offered, the survey results can offer a guidance using sound ethical principles.

Labor Analgesia Initiation With Dural Puncture Epidural Versus Conventional Epidural Techniques: A Randomized Biased-Coin Sequential Allocation Trial to Determine the Effective Dose for 90% of Patients of Bupivacaine.

BACKGROUND: The dural puncture epidural (DPE) technique has a faster onset, better sacral spread, and improved bilateral coverage when compared to the conventional epidural (EPL) technique. Whether these qualities translate into a lower bupivacaine dose to provide initial analgesia is unknown. We sought to determine the effective dose of bupivacaine to achieve initial (first 30 minutes) labor analgesia in 90% of patients (ED90) with the DPE and EPL techniques, using a biased-coin, sequential allocation method. METHODS: A total of 100 women of mixed parity with term, singleton gestation at ≤5 cm dilation with no major comorbidities were randomized to receive a DPE or an EPL technique. An experienced anesthesiologist performed these techniques and administered an allocated dose of plain bupivacaine diluted with isotonic sterile 0.9% saline to a total volume of 20 mL via the EPL catheter. Bupivacaine doses for each subject were determined by the response of the previous subject, using a biased-coin sequential allocation method, with success defined by a numeric rating scale (NRS) < 3 at 30 minutes. Outcome assessments were performed by an investigator blinded to the technique and bupivacaine dose. Sensory and motor blockade and maternal or fetal side effects were recorded every 5 minutes for the first 30 minutes. The ED90 of bupivacaine with each technique was estimated using centered isotonic regression. RESULTS: A total of 95 women were included in the final analysis. The ED90 of bupivacaine was estimated at 29.30 mg (90% confidence interval [CI], 28.55-31.56) with a DPE technique and 45.25 mg (90% CI, 42.80-52.03) with an EPL technique. CONCLUSIONS: Using a biased-coin, sequential allocation method, the DPE technique requires less bupivacaine to achieve effective initial analgesia (ED90) when compared to the EPL technique.

Evidence of within-facility patient-patient Clostridiodes difficile infection spread across diverse settings.

Previous studies have suggested that a hospital patient's risk of developing healthcare facility-onset (HCFO) Clostridioides difficile infections (CDIs) increases with the number of concurrent spatially proximate patients with CDI, termed CDI pressure. However, these studies were performed either in a single institution or in a single state with a very coarse measure of concurrence. We conducted a retrospective case-control study involving over 17.5 million inpatient visits across 700 hospitals in eight US states. We built a weighted, directed network connecting overlapping inpatient visits to measure facility-level CDI pressure. We then matched HCFO-CDIs with non-CDI controls on facility, comorbidities and demographics and performed a conditional logistic regression to determine the odds of developing HCFO-CDI given the number of coincident patient visits with CDI. On average, cases' visits coincided with 9.2 CDI cases, which for an individual with an average length of stay corresponded to an estimated 17.7% (95% CI 12.9-22.7%) increase in the odds of acquiring HCFO-CDI compared to an inpatient visit without concurrent CDI cases or fully isolated from both direct and indirect risks from concurrent CDI cases. These results suggest that, either directly or indirectly, hospital patients with CDI lead to CDIs in non-infected patients with temporally overlapping visits.

Accuracy of frailty instruments in predicting outcomes following perioperative cardiac arrest.

BACKGROUND: Frailty is associated with increased 30-day mortality and non-home discharge following perioperative cardiac arrest. We estimated the predictive accuracy of frailty when added to baseline risk prediction models. METHODS: In this retrospective cohort study using 2015-2020 NSQIP data for 3048 patients aged 50+ undergoing non-cardiac surgery and resuscitation on post-operative day 0 (i.e., intraoperatively or postoperatively on the day of surgery), baseline models including age, sex, ASA physical status, preoperative sepsis or septic shock, and emergent surgery were compared to models that added frailty indices, either RAI or mFI-5, to predict 30-day mortality and non-home discharge. Predictive accuracy was characterized by area under the receiver operating characteristic curve (AUC-ROC), integrated calibration index (ICI), and continuous net reclassification index (NRI). RESULTS: 1786 patients (58.6%) died in the study cohort within 30 days, and 38.6% of eligible patients experienced non-home discharge. The baseline model showed good discrimination (AUC-ROC 0.77 for 30-day mortality and 0.74 for non-home discharge). AUC-ROC and ICI did not significantly change after adding frailty for 30-day mortality or non-home discharge. Adding RAI significantly improved NRI for 30-day mortality and non-home discharge; however, the magnitude was small and difficult to interpret, given other results including false positive and negative rates showing no difference in predictive accuracy. CONCLUSIONS: Incorporating frailty did not significantly improve predictive accuracy of models for 30-day mortality and non-home discharge following perioperative resuscitation. Thus, demonstrated associations between frailty and outcomes of perioperative resuscitation may not translate into improved predictive accuracy. When engaging patients in shared decision-making regarding do-not-resuscitate orders perioperatively, providers should acknowledge uncertainty in anticipating resuscitation outcomes.

Sex, Atrial Fibrillation, and Long-Term Mortality After Cardiac Surgery.

Importance: There are limited data on the association of sex with the incidence of postoperative atrial fibrillation (poAF) and subsequent long-term mortality after cardiac surgery. Objective: To evaluate whether the incidence of poAF and associated long-term mortality after cardiac surgery differ by sex. Design, Setting, and Participants: This retrospective cohort study was conducted at 2 tertiary care centers in Massachusetts from January 1, 2002, until October 1, 2016, with follow-up until December 1, 2022. Adult (aged >20 years) women and men undergoing coronary artery bypass graft surgery, aortic valve surgery, mitral valve surgery, and combined procedures with cardiopulmonary bypass were examined using medical records. Patients who had data on poAF were included in data analyses. Exposures: Sex and poAF. Main Outcomes and Measures: Primary outcomes were the incidence of poAF and all-cause mortality. poAF was defined as any atrial fibrillation detected on electrocardiogram (EKG) during the index hospitalization in patients presenting for surgery in normal sinus rhythm. Data on poAF were obtained from EKG reports and supplemented by information from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. All-cause mortality was assessed via hospital records. The hypotheses were formulated prior to data analysis. Results: Among 21 568 patients with poAF data (mean [SD] age, 66.5 [12.4] years), 2694 of 6601 women (40.8%) and 5805 of 14 967 men (38.8%) developed poAF. In a multivariable logistic regression model, women had lower risk of poAF (odds ratio [OR], 0.85; 95% CI, 0.79-0.91; P < .001). During the follow-up study period, 1294 women (50.4%) and 2376 men (48.9%) in the poAF group as well as 1273 women (49.6%) and 2484 men (51.1%) in the non-poAF group died. Cox proportional hazards analysis found that the association between poAF and mortality was significantly moderated (ie, effect modified) by sex. Compared with same-sex individuals without poAF, men with poAF had a 17% higher mortality hazard (hazard ratio [HR], 1.17; 95% CI, 1.11-1.25; P < .001), and women with poAF had a 31% higher mortality hazard (HR, 1.31; 95% CI, 1.21-1.42; P < .001). Conclusions and Relevance: In this retrospective cohort study of 21 568 patients who underwent cardiac surgery, women were less likely to develop poAF than men when controlling for other relevant characteristics; however, women who did develop poAF had a higher risk of long-term mortality than men who developed poAF. This observed elevated risk calls for a tailored approach to perioperative care in women undergoing cardiac surgery.

Frailty and Outcomes Following Cardiopulmonary Resuscitation for Perioperative Cardiac Arrest.

Importance: Frailty is associated with mortality following surgery and cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. Despite the growing focus on frailty as a basis for preoperative risk stratification and concern that CPR in patients with frailty may border on futility, the association between frailty and outcomes following perioperative CPR is unknown. Objective: To determine the association between frailty and outcomes following perioperative CPR. Design, Setting, and Participants: This longitudinal cohort study of patients used the American College of Surgeons National Surgical Quality Improvement Program, including more than 700 participating hospitals in the US, from January 1, 2015, through December 31, 2020. Follow-up duration was 30 days. Patients 50 years or older undergoing noncardiac surgery who received CPR on postoperative day 0 were included; patients were excluded if data required to determine frailty, establish outcome, or perform multivariable analyses were missing. Data were analyzed from September 1, 2022, through January 30, 2023. Exposures: Frailty defined as Risk Analysis Index (RAI) of 40 or greater vs less than 40. Outcomes and Measures: Thirty-day mortality and nonhome discharge. Results: Among the 3149 patients included in the analysis, the median age was 71 (IQR, 63-79) years, 1709 (55.9%) were men, and 2117 (69.2%) were White. Mean (SD) RAI was 37.73 (6.18), and 792 patients (25.9%) had an RAI of 40 or greater, of whom 534 (67.4%) died within 30 days of surgery. Multivariable logistic regression adjusting for race, American Society of Anesthesiologists physical status, sepsis, and emergency surgery demonstrated a positive association between frailty and mortality (adjusted odds ratio [AOR], 1.35 [95% CI, 1.11-1.65]; P = .003). Spline regression analysis demonstrated steadily increasing probability of mortality and nonhome discharge with increasing RAI above 37 and 36, respectively. Association between frailty and mortality following CPR varied by procedure urgency (AOR for nonemergent procedures, 1.55 [95% CI, 1.23-1.97]; AOR for emergent procedures, 0.97 [95% CI, 0.68-1.37]; P = .03 for interaction). An RAI of 40 or greater was associated with increased odds of nonhome discharge compared with an RAI of less than 40 (AOR, 1.85 [95% CI, 1.31-2.62]; P < .001). Conclusions and Relevance: The findings of this cohort study suggest that although roughly 1 in 3 patients with an RAI of 40 or greater survived at least 30 days following perioperative CPR, higher frailty burden was associated with increased mortality and greater risk of nonhome discharge among survivors. Identifying patients who are undergoing surgery and have frailty may inform primary prevention strategies, guide shared decision-making regarding perioperative CPR, and promote goal-concordant surgical care.

Angiopoietin-2 is associated with capillary leak and predicts complications after cardiac surgery.

BACKGROUND: Patients undergoing cardiac surgery are prone to numerous complications. Increased vascular permeability may be associated with morbidity and mortality due to hemodynamic instability, fluid overload, and edema formation. We hypothesized that markers of endothelial injury and inflammation are associated with capillary leak, ultimately increasing the risk of postoperative complications. METHODS: In this prospective, observational, multidisciplinary cohort study at our tertiary academic medical center, we recruited 405 cardiac surgery patients. Patients were assessed daily using body impedance electrical analysis, ultrasound, sublingual intravital microscopy, and analysis of serum biomarkers. Multivariable models, as well as machine learning, were used to study the association of angiopoietin-2 with extracellular water as well as common complications after cardiac surgery. RESULTS: The majority of patients underwent coronary artery bypass grafting, valvular, or aortic surgeries. Across the groups, extracellular water increased postoperatively (20 ± 6 preoperatively to 29 ± 7L on postoperative day 2; P < 0.001). Concomitantly, the levels of the biomarker angiopoietin-2 rose, showing a strong correlation based on the time points of measurements (r = 0.959, P = 0.041). Inflammatory (IL-6, IL-8, CRP) and endothelial biomarkers (VE-Cadherin, syndecan-1, ICAM-1) suggestive of capillary leak were increased. After controlling for common risk factors of edema formation, we found that an increase of 1 ng/mL in angiopoietin-2 was associated with a 0.24L increase in extracellular water (P < 0.001). Angiopoietin-2 showed increased odds for the development of acute kidney injury (OR 1.095 [95% CI 1.032, 1.169]; P = 0.004) and was furthermore associated with delayed extubation, longer time in the ICU, and a higher chance of prolonged dependence on vasoactive medication. Machine learning predicted postoperative complications when capillary leak was added to standard risk factors. CONCLUSIONS: Capillary leak and subsequent edema formation are relevant problems after cardiac surgery. Levels of angiopoietin-2 in combination with extracellular water show promising potential to predict postoperative complications after cardiac surgery. TRIAL REGISTRATION NUMBER: German Clinical Trials Registry (DRKS No. 00017057), Date of registration 05/04/2019, www.drks.de.

Estimating the Attributable Disease Burden and Effects of Interhospital Patient Sharing on Clostridium difficile Infections.

OBJECTIVE: To estimate the burden of Clostridium difficile infections (CDIs) due to interfacility patient sharing at regional and hospital levels. DESIGN: Retrospective observational study. METHODS: We used data from the Healthcare Cost and Utilization Project California State Inpatient Database (2005-2011) to identify 26,878,498 admissions and 532,925 patient transfers. We constructed a weighted, directed network among the hospitals by defining an edge between 2 hospitals to be the monthly average number of patients discharged from one hospital and admitted to another on the same day. We then used a network autocorrelation model to study the effect of the patient sharing network on the monthly average number of CDI cases per hospital, and we estimated the proportion of CDI cases attributable to the network. RESULTS: We found that 13% (95% confidence interval [CI], 7.6%-18%) of CDI cases were due to diffusion through the patient-sharing network. The network autocorrelation parameter was estimated at 5.0 (95% CI, 3.0-6.9). An increase in the number of patients transferred into and/or an increased CDI rate at the hospitals from which those patients originated led to an increase in the number of CDIs in the receiving hospital. CONCLUSIONS: A minority but substantial burden of CDI infections are attributable to hospital transfers. A hospital's infection control may thus be nontrivially influenced by its neighboring hospitals. This work adds to the growing body of evidence that intervention strategies designed to minimize HAIs should be done at the regional rather than local level.