Early Determinants of Death Due to Multiple Organ Failure After Noncardiac Surgery in High-Risk Patients

POSTOPERATIVE OUTCOME OF PATIENTS ADMITTED TO THE INTENSIVE CARE UNIT AFTER ELECTIVE AND EMERGENCY LAPAROTOMY

BACKGROUND

Surgery is associated with a high risk for morbidity and mortality, particularly when performed in critical patients requiring intensive care unit (ICU) admission.

AIM

The aim of this study was to investigate risk factors associated with adverse outcomes in a large cohort of patients admitted to a single-center ICU after abdominal surgery.

METHODS

All patients admitted to a surgical ICU for postoperative care, from January 2016 to December 2022, were retrospectively evaluated. Data concerning demographics and clinical and perioperative variables were compared to in-hospital mortality.

RESULTS

A total of 1,717 patients (1,096 women, mean age: 61±17 years) were evaluated. Most of the patients underwent colorectal (n=499), pancreatic (n=148), biliary tract (n=147), and gastric surgeries (n=145); liver resection (n=131); and several gynecological or obstetric procedures (n=250). Only 52.3% of these surgical procedures were elective. The mean Charlson Comorbidity Index (CCI) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were 4.4±2.8 and 10.1±5.6, respectively. Mortality was observed in 158 (9.2%) patients. Age (70.4±14.3 vs. 60.6±17.1 years in survivors, p=0.002), CCI (6.1±2.5 vs. 4.3±2.8 in survivors, p=0.005), type of surgery (13.6% in emergent/urgent vs. 5.5% in elective surgeries, p<0.001), and APACHE II score (16.7±8.4 vs. 9.4±4.7 in survivors, p<0.0001) were associated with mortality on univariate analysis, but only CCI, type of surgery, and APACHE II score were independently correlated with a higher risk of death on multivariate analysis.

CONCLUSIONS

Mortality after abdominal surgery in patients requiring postoperative ICU support is less than 10% nowadays, and it is independently associated with urgent or emergent surgeries, disease severity, and comorbidity.

Impact of perioperative organ injury on morbidity and mortality in 28 million surgical patients

Perioperative organ injury contributes to morbidity and mortality of surgical patients. This cohort study included all elective and emergent surgeries in Germany over 4 years to address the impact of perioperative organ injuries on outcomes. We analyzed 28,350,953 cases. In-hospital mortality was 1.4% (n = 393,157), and 4.4% of cases (n = 1,245,898) experienced perioperative organ injury. Perioperative organ injury was associated with 9-fold higher odds of death and prolonged hospital stay by 11.2 days. Acute kidney injury had the highest incidence (2.0%) and was associated with 25.0% mortality. While delirium had the second highest incidence (1.5%), it was associated with the lowest mortality (10.8%). This was followed by acute myocardial infarction (incidence 0.6%, mortality 15.6%), stroke (incidence 0.6%, mortality 13.1%), pulmonary embolism (incidence 0.3%, mortality 20.0%), liver injury (incidence 0.1%, mortality 68.7%), and acute respiratory distress syndrome (incidence 0.1%, mortality 44.7%). These findings help prioritize interventions for preventing or treating individual types of perioperative organ injury.

Reliability of Bioreactance and Pulse-Power Analysis in Measuring Cardiac Index During Open Abdominal Aortic Surgery

OBJECTIVE

To investigate the accuracy, precision, and trending ability of noninvasive bioreactance-based Starling SV and the mini invasive pulse-power device LiDCOrapid as compared to thermodilution cardiac output (TDCO) as measured by pulmonary artery catheter when assessing cardiac index (CIx) in the setting of elective open abdominal aortic (AA) surgery.

DESIGN

A prospective method-comparison study.

SETTING

Oulu University Hospital, Finland.

PARTICIPANTS

Forty patients undergoing elective open abdominal aortic surgery.

INTERVENTIONS

Intraoperative CI measurements were obtained simultaneously with TDCO and the study monitors, resulting in 627 measurement pairs with Starling SV and 497 with LiDCOrapid.

MEASUREMENTS AND MAIN RESULTS

The Bland-Altman method was used to investigate the agreement among the devices, and four-quadrant plots with error grids were used to assess trending ability. The agreement between TDCO and Starling SV was associated with a bias of 0.18 L/min/m2 (95% confidence interval [CI] = 0.13 to 0.23), wide limits of agreement (LOA = -1.12 to 1.47 L/min/m2), and a percentage error (PE) of 63.7 (95% CI = 52.4-71.0). The agreement between TDCO and LiDCOrapid was associated with a bias of -0.15 L/min/m2 (95% CI = -0.21 to -0.09), wide LOA (-1.56 to 1.37), and a PE of 68.7 (95% CI = 54.9-79.6). The trending ability of neither device was sufficient.

CONCLUSION

The CI measurements achieved with Starling SV and LiDCOrapid were not interchangeable with TDCO, and the ability to track changes in CI was poor. These results do not support the use of either study device in monitoring CI during open AA surgery.

Chronic obstructive pulmonary disease affects outcome in surgical patients with perioperative organ injury: a retrospective cohort study in Germany

BACKGROUND

The impact of chronic obstructive pulmonary disease (COPD) on outcome in perioperative organ injury (POI) has not yet been investigated sufficiently.

METHODS

This retrospective cohort study analysed data of surgical patients with POI, namely delirium, stroke, acute myocardial infarction, acute respiratory distress syndrome, acute liver injury (ALI), or acute kidney injury (AKI), in Germany between 2015 and 2019. We compared in-hospital mortality, hospital length of stay (HLOS) and perioperative ventilation time (VT) in patients with and without COPD.

RESULTS

We analysed the data of 1,642,377 surgical cases with POI of which 10.8% suffered from COPD. In-hospital mortality was higher (20.6% vs. 15.8%, p < 0.001) and HLOS (21 days (IQR, 12-34) vs. 16 days (IQR, 10-28), p < 0.001) and VT (199 h (IQR, 43-547) vs. 125 h (IQR, 32-379), p < 0.001) were longer in COPD patients. Within the POI examined, AKI was the most common POI (57.8%), whereas ALI was associated with the highest mortality (54.2%). Regression analysis revealed that COPD was associated with a slightly higher risk of in-hospital mortality (OR, 1.19; 95% CI:1.18-1.21) in patients with any POI.

CONCLUSIONS

COPD in patients with POI is associated with higher mortality, longer HLOS and longer VT. Especially patients suffering from ALI are susceptible to the detrimental effects of COPD on adverse outcome.

Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study

BACKGROUND

The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death.

METHODS

Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death.

RESULTS

In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death.

CONCLUSION

Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.

Improving perioperative care in low-resource settings with goal-directed therapy: a narrative review

Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.

Regulated cell death and inflammasome activation in gut injury following traumatic surgery in vitro and in vivo: implication for postoperative death due to multiorgan dysfunction

Postoperative multi-organ dysfunction (MOD) is associated with significant mortality and morbidity. Necroptosis has been implicated in different types of solid organ injury; however, the mechanisms linking necroptosis to inflammation require further elucidation. The present study examines the involvement of necroptosis and NLR family pyrin domain containing 3 (NLRP3) inflammasome in small intestine injury following traumatic surgery. Kidney transplantation in rats and renal ischaemia-reperfusion (I/R) in mice were used as traumatic and laparotomic surgery models to study necroptosis and inflammasome activation in the small intestinal post-surgery; additional groups also received receptor-interacting protein kinase 1 (RIPK1) inhibitor necrostatin-1s (Nec-1s). To investigate whether necroptosis regulates inflammasome activity in vitro, necroptosis was induced in human colonic epithelial cancer cells (Caco-2) by a combination of tumour necrosis factor-alpha (TNFα), SMAC mimetic LCL-161 and pan-caspase inhibitor Q-VD-Oph (together, TLQ), and necroptosis was blocked by Nec-1s or mixed lineage kinase-domain like (MLKL) inhibitor necrosulfonamide (NSA). Renal transplantation and renal ischaemia-reperfusion (I/R) upregulated the expression of necroptosis mediators (RIPK1; RIPK3; phosphorylated-MLKL) and inflammasome components (P2X purinoceptor subfamily 7, P2X7R; NLRP3; caspase-1) in the small intestines at 24 h, and Nec-1s suppressed the expression of inflammasome components. TLQ treatment induced NLRP3 inflammasome, promoted cleavage of caspase-1 and interleukin-1 beta (IL-1β), and stimulated extracellular ATP release from Caco-2 cells, and MLKL inhibitor NSA prevented TLQ-induced inflammasome activity and ATP release from Caco-2 cells. Our work suggested that necroptosis and inflammasome interactively promote remote postoperative small intestinal injury, at least in part, through ATP purinergic signalling. Necroptosis-inflammasome axis may be considered as novel therapeutic target for tackling postoperative MOD in the critical care settings.

Usefulness of Preoperative Determination of Serum MR-ProAdrenomedullin Levels to Predict the Need for Postoperative Organ Support in Abdominal Oncological Surgery

The need for postoperative organic support is associated with patient outcomes. Biomarkers may be useful for detecting patients at risk. MR-ProADM is a novel biomarker with an interesting profile that can be used in this context. The main objective of this study was to verify whether there was an association between the preoperative serum levels of MR-ProADM and the need for organic support after elective abdominal cancer surgery, and to determine the preoperative MR-ProADM value that predicts the need for postoperative organic support. This was a multicenter prospective observational study conducted by four tertiary hospitals in Spain between 2017 and 2018. Plasma samples were collected for the quantification of MR-ProADM from adults who underwent major abdominal surgery during 2017-2018. The primary outcome was the need for organic support in the first seven postoperative days and its association with the preoperative levels of MR-ProADM, and the secondary outcome was the preoperative levels of MR-ProADM in the study population. This study included 370 patients with a mean age of 67.4 ± 12.9 years. Seventeen percent (63 patients) required some postoperative organic support measures in the first week. The mean preoperative value of MR-ProADM in patients who required organic support was 1.16 ± 1.15 nmol/L. The AUC-ROC of the preoperative MR-ProADM values associated with the need for organic support was 0.67 (95% CI: 0.59-0.75). The preoperative MR-ProADM value, which showed the best compromise in sensitivity and specificity for predicting the need for organic support, was 0.70 nmol/L. The negative predictive value was 91%. A multivariate analysis confirmed that a preoperative level of MR-ProADM ≥ 0.70 nmol/L is an independent factor associated with risk of postoperative organic support (OR 2, 6). Elevated preoperative MR-ProADM levels are associated with the need for postoperative organic support. Therefore, MR-ProADM may be a useful biomarker for perioperative risk assessment.

The magnitude, but not the duration of elevated central venous pressure is associated with mortality in sepsis patients: An analysis of the MIMIC-IV database

BACKGROUND

It is unclear whether the magnitude and duration of elevated central venous pressure (ECVP) greater than ten mmHg has the same impact on mortality in sepsis patients.

METHODS

Critically ill patients with sepsis were identified from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The duration and the magnitude of ECVP were calculated. Normalized ECVP load was defined as the ECVP load (the sum of ECVP value times its duration) divided by the total duration of ECVP. The primary endpoint was 28-day mortality. Kaplan-Meier survival analysis was used to compare survival between patients with high or low normalized ECVP load.

RESULTS

A total of 1071 sepsis patients were included. Higher normalized ECVP load was associated with higher mortality rate; in contrast, the duration of ECVP was not associated with mortality. A linear relationship between normalized ECVP load and mortality was identified. Patients with higher normalized ECVP load had less urine output and more positive fluid balance.

CONCLUSION

The magnitude, but not the duration of ECVP, is associated with mortality in sepsis patients. ECVP should be considered as a valuable and easily accessible safety parameter during fluid resuscitation.

[New aspects of perioperative organ protection]

BACKGROUND

Acutely occurring organ damage significantly contributes to morbidity and mortality in the perioperative context.

OBJECTIVE

This article highlights new clinical perspectives on how perioperative organ damage can be prevented and ameliorated by influencing the high mobility group box 1 protein (HMGB1) signaling.

MATERIAL AND METHODS

A MEDLINE search was performed in the fields of clinical and basic research. The presentation of basic mechanisms of perioperative organ damage and the discussion of the importance of HMGB1 in prevention and treatment by pharmaceutical and nonpharmaceutical interventions are the focus of the review.

RESULTS

The HMGB1 is a central element in the pathogenesis of septic and aseptic inflammation-induced organ damage. Remote ischemic preconditioning (RIPC) and dexmedetomidine are highly effective approaches to mitigate or prevent organ damage.

CONCLUSION

The RIPC and dexmedetomidine offer protective properties in ischemia-reperfusion injury as well as in inflammation-related organ damage, which are mediated by HMGB1, among others. This effectively protects the kidneys, heart, lungs, liver and brain. The application of these concepts should be considered in routine clinical practice.

High Central Venous Pressure Associated with Mortality in Intensive Care Unit

BACKGROUND: Central venous pressure (CVP) has been used as a measurement tool to assess hemodynamics, medication, and nutritional status in critically ill patients for decades. We frequently use the Acute Physiology and Chronic Health Evaluation or Sequential Organ Failure Assessment score to predict the mortality of intensive care unit (ICU) patients. Unfortunately, it requires a lot of time and procedures to measure these parameters. Moreover, not every single hospital can apply these scores. Since CVP is widely used in ICU, we can use the value of CVP to predict mortality. AIM: The aim of this study was to find the correlation between CVP and mortality rate. METHODS: This cross-sectional study was conducted in ICU of Haji Adam Malik General Hospital, Medan, in 2017. Basic demographic data, CVP measurements and mortality were recorded among all ICU patients. Patients with CVP >12 mmHg were considered high. The association between CVP and mortality was analyzed. RESULTS: One hundred patients were admitted during the study period with mortality rate of 38%. The most common cause of ICU admission was postoperative neurosurgical patients (28%). We found correlation between high CVP (>12 mmHg) and mortality among ICU patients (odds ratio: 3.372; 95% confidence interval: 1.349–8.428; p = 0.008) CONCLUSION: CVP level >12 mmHg associated with higher mortality rate in ICU patients.

Changes in the incidence and outcome of multiple organ failure in emergency non-cardiac surgical admissions: a 10-year retrospective observational study

BACKGROUND

During the past decades, epidemiologic data of independent predictors of multiple organ failure (MOF), incidence, and mortality have changed. The aim of the study was to assess the potential changes in the incidence and outcomes of MOF for one decade (2008-2017). In addition, resource utilization was considered.

METHODS

Patients were eligible for inclusion if they were adults, admitted to the ICU between January 1, 2008 and December 31, 2017, and had complete data sets regarding MOF. MOF was defined as organ failure separately with and without central nervous system (CNS) failure. The onset of MOF was defined as being early (≤48 h of ICU admission) and late (>48 h after ICU admission).

RESULTS

Of a total of 13,270 patients enclosed in this study, 44.6% of the patients developed MOF with and 31.4% without CNS failure. MOF-related mortality decreased in patients with (adjusted IRR 0.972 [95% CI 0.948 to 0.996], P=0.022) and without (adjusted IRR 0.957 [95% CI 0.931 to 0.983], P=0.0013) CNS failure. In addition, the incidence (adjusted IRR 0.970 [95% CI 0.950 to 0.991], P=0.006) and mortality (adjusted IRR 0.968 [95% CI 0.940 to 0.996], P=0.025) of early-onset MOF decreased, while the incidence and mortality of late-onset MOF remained constant. The length of ICU (P=0.024) and hospital (P=0.032) stays decreased while the length of mechanical ventilation remained constant (P=0.41).

CONCLUSIONS

Despite all improvements in intensive care during the last decades, the incidence of late-onset MOF remains a resource-intensive, morbid, and lethal condition. More research on etiologies, signs of organ failure, and where and when to start treatment is needed to improve the prognosis of late-onset MOF.

Postoperative hypotension in patients discharged to the intensive care unit after non-cardiac surgery is associated with adverse clinical outcomes

BACKGROUND

The postoperative period is critical for a patient's recovery, and postoperative hypotension, specifically, is associated with adverse clinical outcomes and significant harm to the patient. However, little is known about the association between postoperative hypotension in patients in the intensive care unit (ICU) after non-cardiac surgery, and morbidity and mortality, specifically among patients who did not experience intraoperative hypotension. The goal of this study was to assess the impact of postoperative hypotension at various absolute hemodynamic thresholds (≤ 75, ≤ 65 and ≤ 55 mmHg), in the absence of intraoperative hypotension (≤ 65 mmHg), on outcomes among patients in the ICU following non-cardiac surgery.

METHODS

This multi-center retrospective cohort study included specific patient procedures from Optum® healthcare database for patients without intraoperative hypotension (MAP ≤ 65 mmHg) discharged to the ICU for ≥ 48 h after non-cardiac surgery with valid mean arterial pressure (MAP) readings. A total of 3185 procedures were included in the final cohort, and the association between postoperative hypotension and the primary outcome, 30-day major adverse cardiac or cerebrovascular events, was assessed. Secondary outcomes examined included all-cause 30- and 90-day mortality, 30-day acute myocardial infarction, 30-day acute ischemic stroke, 7-day acute kidney injury stage II/III and 7-day continuous renal replacement therapy/dialysis.

RESULTS

Postoperative hypotension in the ICU was associated with an increased risk of 30-day major adverse cardiac or cerebrovascular events at MAP ≤ 65 mmHg (hazard ratio [HR] 1.52; 98.4% confidence interval [CI] 1.17-1.96) and ≤ 55 mmHg (HR 2.02, 98.4% CI 1.50-2.72). Mean arterial pressures of ≤ 65 mmHg and ≤ 55 mmHg were also associated with higher 30-day mortality (MAP ≤ 65 mmHg, [HR 1.56, 98.4% CI 1.22-2.00]; MAP ≤ 55 mmHg, [HR 1.97, 98.4% CI 1.48-2.60]) and 90-day mortality (MAP ≤ 65 mmHg, [HR 1.49, 98.4% CI 1.20-1.87]; MAP ≤ 55 mmHg, [HR 1.78, 98.4% CI 1.38-2.31]). Furthermore, we found an association between postoperative hypotension with MAP ≤ 55 mmHg and acute kidney injury stage II/III (HR 1.68, 98.4% CI 1.02-2.77). No associations were seen between postoperative hypotension and 30-day readmissions, 30-day acute myocardial infarction, 30-day acute ischemic stroke and 7-day continuous renal replacement therapy/dialysis for any MAP threshold.

CONCLUSIONS

Postoperative hypotension in critical care patients with MAP ≤ 65 mmHg is associated with adverse events even without experiencing intraoperative hypotension.

Transfusion in critical care: Past, present and future

Anaemia and coagulopathy are common in critically ill patients and are associated with poor outcomes, including increased risk of mortality, myocardial infarction, failure to be liberated from mechanical ventilation and poor physical recovery. Transfusion of blood and blood products remains the corner stone of anaemia and coagulopathy treatment in critical care. However, determining when the benefits of transfusion outweigh the risks of anaemia may be challenging in some critically ill patients. Therefore, the European Society of Intensive Care Medicine prioritised the development of a clinical practice guideline to address anaemia and coagulopathy in non-bleeding critically ill patients. The aims of this article are to: (1) review the evolution of transfusion practice in critical care and the direction for future developments in this important area of transfusion medicine and (2) to provide a brief synopsis of the guideline development process and recommendations in a format designed for busy clinicians and blood bank staff. These clinical practice guidelines provide recommendations to clinicians on how best to manage non-bleeding critically ill patients at the bedside. More research is needed on alternative transfusion targets, use of transfusions in special populations (e.g., acute neurological injury, acute coronary syndromes), use of anaemia prevention strategies and point-of-care interventions to guide transfusion strategies.

Wireless, non-invasive, wearable device for continuous remote monitoring of hemodynamic parameters in a swine model of controlled hemorrhagic shock

Accurate and continuous monitoring of critically ill patients is frequently achieved using invasive catheters, which is technically complex. Our purpose was to evaluate the validity and accuracy of a photoplethysmography (PPG)-based remote monitoring device compared to invasive methods of arterial line (AL) and Swan-Ganz (SG) catheters in a swine model of controlled hemorrhagic shock. Following a baseline phase, hemorrhagic shock was induced in 11 pigs by bleeding 35% of their blood volume, followed by a post-bleeding follow-up phase. Animals were monitored concomitantly by the PPG device, an AL and a SG catheter, for a median period of 447 min. Heart rate (HR), systolic and diastolic blood pressure (SBP and DBP, respectively), and cardiac output (CO) were recorded continuously. The complete data set consisted of 1312 paired observations. Correlations between the PPG-based technique and the invasive methods were significant (p < 0.001) during baseline, bleeding and follow-up phases for HR (r = 0.90–0.98), SBP (r = 0.90–0.94), DBP (r = 0.89–0.93), and CO (r = 0.76–0.90). Intraclass correlations for all phases combined were 0.96, 0.92, 0.93 and 0.87 for HR, SBP, DBP and CO, respectively. Correlations for changes in CO, SBP and DBP were significant (p < 0.001) and strong (r > 0.88), with concordance rates (determined by quadrant plots) of 86%, 66% and 68%, respectively. The novel PPG-based device was accurate and valid compared to existing invasive techniques and might be used for continuous monitoring in several clinical settings following further studies.

Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum

Multiorgan dysfunction syndrome (MODS) remains a major complication and challenge to treat patients with critical illness in different intensive care unit settings. The exact mechanism and pathophysiology of MODS is complex and remains unexplored. We reviewed the literature from January 2011 to August 2019 to analyze the underlying mechanisms, prognostic factors, MODS scoring systems, organ systems dysfunctions, and the management of MODS. We used the search engines PubMed, MEDLINE, Scopus, and Google Scholar with the keywords "multiple organ dysfunction syndrome," "intensive care units," "multiorgan failure," "MODS scoring system," and "MODS management." The initial search yielded 3550 abstracts, of which 91 articles were relevant to the scope of the present article. A better understanding of a disease course will help differentiate the signs of an intense inflammatory response from the early onset of sepsis and minimize the inappropriate use of medications. This, in turn, will promote organtargeted therapy and prevent occurrence and progression of MODS.

Strategies to Modulate MicroRNA Functions for the Treatment of Cancer or Organ Injury

Cancer and organ injury-such as that occurring in the perioperative period, including acute lung injury, myocardial infarction, and acute gut injury-are among the leading causes of death in the United States and impose a significant impact on quality of life. MicroRNAs (miRNAs) have been studied extensively during the last two decades for their role as regulators of gene expression, their translational application as diagnostic markers, and their potential as therapeutic targets for disease treatment. Despite promising preclinical outcomes implicating miRNA targets in disease treatment, only a few miRNAs have reached clinical trials. This likely relates to difficulties in the delivery of miRNA drugs to their targets to achieve efficient inhibition or overexpression. Therefore, understanding how to efficiently deliver miRNAs into diseased tissues and specific cell types in patients is critical. This review summarizes current knowledge on various approaches to deliver therapeutic miRNAs or miRNA inhibitors and highlights current progress in miRNA-based disease therapy that has reached clinical trials. Based on ongoing advances in miRNA delivery, we believe that additional therapeutic approaches to modulate miRNA function will soon enter routine medical treatment of human disease, particularly for cancer or perioperative organ injury. SIGNIFICANCE STATEMENT: MicroRNAs have been studied extensively during the last two decades in cancer and organ injury, including acute lung injury, myocardial infarction, and acute gut injury, for their regulation of gene expression, application as diagnostic markers, and therapeutic potentials. In this review, we specifically emphasize the pros and cons of different delivery approaches to modulate microRNAs, as well as the most recent exciting progress in the field of therapeutic targeting of microRNAs for disease treatment in patients.

Elevated central venous pressure is associated with increased mortality and acute kidney injury in critically ill patients: a meta-analysis

Background

The association of central venous pressure (CVP) and mortality and acute kidney injury (AKI) in critically ill adult patients remains unclear. We performed a meta-analysis to determine whether elevated CVP is associated with increased mortality and AKI in critically ill adult patients.

Methods

We searched PubMed and Embase through June 2019 to identify studies that investigated the association between CVP and mortality and/or AKI in critically ill adult patients admitted into the intensive care unit. We calculated the summary odds ratio (OR) and 95% CI using a random-effects model.

Results

Fifteen cohort studies with a broad spectrum of critically ill patients (mainly sepsis) were included. On a dichotomous scale, elevated CVP was associated with an increased risk of mortality (3 studies; 969 participants; OR, 1.65; 95% CI, 1.19–2.29) and AKI (2 studies; 689 participants; OR, 2.09; 95% CI, 1.39–3.14). On a continuous scale, higher CVP was associated with greater risk of mortality (5 studies; 7837 participants; OR, 1.10; 95% CI, 1.03–1.17) and AKI (6 studies; 5446 participants; OR, 1.14; 95% CI, 1.06–1.23). Furthermore, per 1 mmHg increase in CVP increased the odds of AKI by 6% (4 studies; 5150 participants; OR, 1.06; 95% CI, 1.01–1.12). Further analyses restricted to patients with sepsis showed consistent results.

Conclusions

Elevated CVP is associated with an increased risk of mortality and AKI in critically ill adult patients admitted into the intensive care unit.

Trial registration

PROSPERO, CRD42019126381

[Perioperative fluid management]

An appropriate perioperative infusion management is pivotal for the perioperative outcome of the patient. Optimization of the perioperative fluid treatment often results in enhanced postoperative outcome, reduced perioperative complications and shortened hospitalization. Hypovolemia as well as hypervolemia can lead to an increased rate of perioperative complications. The main goal is to maintain perioperative euvolemia by goal-directed therapy (GDT), a combination of fluid management and inotropic medication, to optimize perfusion conditions in the perioperative period; however, perioperative fluid management should also include the preoperative and postoperative periods. This encompasses the preoperative administration of carbohydrate-rich drinks up to 2 h before surgery. In the postoperative period, patients should be encouraged to start per os hydration early and excessive i.v. fluid administration should be avoided. Implementation of a comprehensive multimodal, goal-directed fluid management within an enhanced recovery after surgery (ERAS) protocol is efficient but the exact status of indovodual items remains unclear at present.

Epidemiology and outcome of high-surgical-risk patients admitted to an intensive care unit in Brazil

OBJECTIVE

To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil.

METHODS

This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28-day postoperative, intensive care unit and hospital mortality rates were evaluated.

RESULTS

Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051).

CONCLUSION

Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay.

Effects of antiplatelet therapy on the mortality rate of patients with sepsis: A meta-analysis

PURPOSE

Abnormal platelet activation plays an important role in the development of sepsis. The effect of antiplatelet drugs on the outcome of patients with sepsis remains unclear. This meta-analysis aimed to determine the effect of antiplatelet drugs on the prognosis of patients with sepsis.

MATERIALS AND METHODS

PubMed, Cochrane Library, CBM, and Embase were searched for all related articles published from inception to April 2018. The primary end point was mortality. Adjusted data were used and statistically analysed.

RESULTS

Ten cohort studies were included. The total number of patients with sepsis was 689,897. Data showed that the use of antiplatelet drugs could effectively reduce the mortality of patients with sepsis (odds ratio (OR) = 0.82, 95% CI: 0.81-0.83, p < 0.05). Seven studies used aspirin for antiplatelet therapy, and subgroup analysis showed that aspirin effectively reduced ICU or hospital mortality in patients with sepsis (OR = 0.60, 95% CI: 0.53-0.68, p < 0.05). A subgroup analysis on the timing of anti-platelet drug administration showed that antiplatelet drugs can reduce mortality when administered either before (OR = 0.78, 95% CI: 0.77-0.80) or after sepsis (OR = 0.59, 95% CI: 0.52-0.67).

CONCLUSIONS

Antiplatelet drugs, particularly aspirin, could be used to effectively reduce mortality in patients with sepsis.

Severity of disease scoring systems and mortality after non-cardiac surgery

Background

Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery.

Methods

Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann–Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI).

Results

4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR = 1.24); emergent surgery (OR = 4.10), serum sodium (OR = 1.06) and FiO₂ at admission (OR = 14.31). Serum bicarbonate at admission (OR = 0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR = 1.02), APACHE II (OR = 1.09), emergency surgery (OR = 1.82), high-risk surgery (OR = 1.61), FiO₂ at admission (OR = 1.02), postoperative acute renal failure (OR = 1.96), heart rate (OR = 1.01) and serum sodium (OR = 1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay.

Conclusion

Some factors influenced both surgical intensive care unit and hospital mortality.

[Severity of disease scoring systems and mortality after non-cardiac surgery]

BACKGROUND

Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery.

METHODS

Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann-Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI).

RESULTS

4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR=1.24); emergent surgery (OR=4.10), serum sodium (OR=1.06) and FiO₂ at admission (OR=14.31). Serum bicarbonate at admission (OR=0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR=1.02), APACHE II (OR=1.09), emergency surgery (OR=1.82), high-risk surgery (OR=1.61), FiO₂ at admission (OR=1.02), postoperative acute renal failure (OR=1.96), heart rate (OR=1.01) and serum sodium (OR=1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay.

CONCLUSION

Some factors influenced both surgical intensive care unit and hospital mortality.

Cervical Spinal Cord Injury Shows Markedly Lower than Predicted Mortality (>72 Hours After Multiple Trauma) From Sepsis and Multiple Organ Failure

BACKGROUND

Sepsis and multiple organ failure (MOF) remain one of the main causes of death after multiple trauma. Trauma- and infection-associated immune reactions play an important role in the pathomechanism of MOF, but the exact pathways remain unknown. Spinal cord injury (SCI) may lead to an altered immune response, and some studies suggest a prognostic advantage for such patients having sepsis or multiple trauma. Yet these findings need to be evaluated in larger cohorts of trauma patients.

METHODS

Retrospective, multicenter study, using the data of the TraumaRegister DGU. Patients with and without SCI surviving the initial first 72 hours after trauma were matched according to injury pattern and age. Comparative analysis considered morbidity (sepsis, MOF) and hospital mortality.

RESULTS

The study population included 800 matched pairs. As intended by the matching process, patients with cervical SCI had an otherwise comparable injury pattern but a higher severity of trauma (mean Injury Severity Score: 36 vs 29, mean number of diagnosis: 5.6 vs 4.4). They had a higher rate of sepsis (15.9% vs 10.9%, P = .005) and MOF (35.9% vs 24.1%, P < .001) while mortality revealed no significant difference (9.5% vs 9.9%, P = .866).

CONCLUSIONS

Cervical SCI leads to an increased rate of sepsis and MOF but appears to be favorable with respect to outcome of sepsis and MOF following multiple trauma. Further research should focus on the pathomechanisms and the possible arising therapeutic options.

Preload dependency determines the effects of phenylephrine on cardiac output in anaesthetised patients: A prospective observational study

BACKGROUND

Although phenylephrine is widely used in the operating room to control arterial pressure, its haemodynamic effects remain controversial.

OBJECTIVE

We hypothesised that the effect of phenylephrine on cardiac output is affected by preload dependency.

DESIGN

A prospective observational study.

SETTING

Single-centre, University Hospital of Caen, France.

PATIENTS

Fifty ventilated patients undergoing surgery were studied during hypotension before and after administration of phenylephrine.

MAIN OUTCOME MEASURES

Cardiac index (CI), stroke volume (SV), corrected flow time, mean arterial pressure, pulse pressure variations (PPV) and systemic vascular resistance index were used to assess effects of changes in preload dependency.

RESULTS

Twenty seven (54%) patients were included in the preload-dependent group (PPV ≥ 13%) and 23 (46%) in the preload-independent group (PPV < 13%) before administration of phenylephrine. For the whole cohort, phenylephrine increased mean arterial pressure [58 (±8) mmHg vs. 79 (±13) mmHg; P < 0.0001] and calculated systemic vascular resistance index [2010 (1338; 2481) dyn s cm m vs. 2989 (2155; 3870) dyn s cm m; P < 0.0001]. However, CI and SV decreased in the preload-independent group [2.3 (1.9; 3.7) l min m vs. 1.8 (1.5; 2.7) l min m; P < 0.0001 and 65 (44; 81) ml vs. 56 (39; 66) ml; P < 0.0001 for both] but not in the preload-dependent group [respectively 2.1 (1.8; 3.5) l min m vs. 2.1 (1.8; 3.3) l min m; P = 0.168 and 49 (41; 67) ml vs. 53 (41; 69) ml; P = 0.191]. Corrected flow time increased [294 (47) ms vs. 306 (56) ms; P = 0.031], and PPV decreased [17 (15; 19) % vs.12 (14; 16) %; P < 0.0003] only in the PPV at least 13% group.

CONCLUSION

The effects of phenylephrine on CI and SV depend on preload. CI and SV decreased in preload-independent patients through increase in afterload, but were unchanged in those preload-dependent through increased venous return.

A Brief Period of Hypothermia Induced by Total Liquid Ventilation Decreases End-Organ Damage and Multiorgan Failure Induced by Aortic Cross-Clamping

BACKGROUND

In animal models, whole-body cooling reduces end-organ injury after cardiac arrest and other hypoperfusion states. The benefits of cooling in humans, however, are uncertain, possibly because detrimental effects of prolonged cooling may offset any potential benefit. Total liquid ventilation (TLV) provides both ultrafast cooling and rewarming. In previous reports, ultrafast cooling with TLV potently reduced neurological injury after experimental cardiac arrest in animals. We hypothesized that a brief period of rapid cooling and rewarming via TLV could also mitigate multiorgan failure (MOF) after ischemia-reperfusion induced by aortic cross-clamping.

METHODS

Anesthetized rabbits were submitted to 30 minutes of supraceliac aortic cross-clamping followed by 300 minutes of reperfusion. They were allocated either to a normothermic procedure with conventional ventilation (control group) or to hypothermic TLV (33°C) before, during, and after cross-clamping (pre-clamp, per-clamp, and post-clamp groups, respectively). In all TLV groups, hypothermia was maintained for 75 minutes and switched to a rewarming mode before resumption to conventional mechanical ventilation. End points included cardiovascular, renal, liver, and inflammatory parameters measured 300 minutes after reperfusion.

RESULTS

In the normothermic (control) group, ischemia-reperfusion injury produced evidence of MOF including severe vasoplegia, low cardiac output, acute kidney injury, and liver failure. In the TLV group, we observed gradual improvements in cardiac output in post-clamp, per-clamp, and pre-clamp groups versus control (53 ± 8, 64 ± 12, and 90 ± 24 vs 36 ± 23 mL/min/kg after 300 minutes of reperfusion, respectively). Liver biomarker levels were also lower in pre-clamp and per-clamp groups versus control. However, acute kidney injury was prevented in pre-clamp, and to a limited extent in per-clamp groups, but not in the post-clamp group. For instance, creatinine clearance was 4.8 ± 3.1 and 0.5 ± 0.6 mL/kg/min at the end of the follow-up in pre-clamp versus control animals (P = .0004). Histological examinations of the heart, kidney, liver, and jejunum in TLV and control groups also demonstrated reduced injury with TLV.

CONCLUSIONS

A brief period of ultrafast cooling with TLV followed by rapid rewarming attenuated biochemical and histological markers of MOF after aortic cross-clamping. Cardiovascular and liver dysfunctions were limited by a brief period of hypothermic TLV, even when started after reperfusion. Conversely, acute kidney injury was limited only when hypothermia was started before reperfusion. Further work is needed to determine the clinical significance of our results and to identify the optimal duration and timing of TLV-induced hypothermia for end-organ protection in hypoperfusion states.

A pragmatic multi-center trial of goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery

Background

Intraoperative fluid therapy guided by mechanical ventilation-induced pulse-pressure variation (PPV) may improve outcomes after major surgery. We tested this hypothesis in a multi-center study.

Methods

The patients were included in two periods: a first control period (control group; n = 147) in which intraoperative fluids were given according to clinical judgment. After a training period, intraoperative fluid management was titrated to maintain PPV < 10% in 109 surgical patients (PPV group). We performed 1:1 propensity score matching to ensure the groups were comparable with regard to age, weight, duration of surgery, and type of operation. The primary endpoint was postoperative hospital length of stay.

Results

After matching, 84 patients remained in each group. Baseline characteristics, surgical procedure duration and physiological parameters evaluated at the start of surgery were similar between the groups. The volume of crystalloids (4500 mL [3200-6500 mL] versus 5000 mL [3750-8862 mL]; P = 0.01), the number of blood units infused during the surgery (1.7 U [0.9-2.0 U] versus 2.0 U [1.7-2.6 U]; P = 0.01), the fraction of patients transfused (13.1% versus 32.1%; P = 0.003) and the number of patients receiving mechanical ventilation at 24 h (3.2% versus 9.7%; P = 0.027) were smaller postoperatively in PPV group. Intraoperative PPV-based improved the composite outcome of postoperative complications OR 0.59 [95% CI 0.35-0.99] and reduced the postoperative hospital length of stay (8 days [6-14 days] versus 11 days [7-18 days]; P = 0.01).

Conclusions

In high-risk surgeries, PPV-directed volume loading improved postoperative outcomes and decreased the postoperative hospital length of stay.

Trial Registration

ClinicalTrials.gov Identifier; retrospectively registered- NCT03128190

Adrenomedullin Is Associated With Surgical Trauma and Impaired Renal Function in Vascular Surgery Patients

BACKGROUND:

Patients undergoing vascular surgery are prone to perioperative organ injury because of both higher prevalence of cardiovascular risk factors and the extent of surgery. Early detection of organ failure is essential to facilitate appropriate medical care. Midregional pro-adrenomedullin (MR-proADM) has been investigated in acute medical care settings to guide clinical decision-making regarding patient pathways and to identify patients prone to imminent cardiovascular or inflammatory complications. In this study, we evaluated the impact of perioperative MR-proADM levels as an early marker of perioperative cardiovascular and inflammatory stress reactions and kidney injury.

METHODS:

The study was conducted as a monocentric, prospective, noninterventional trial at Hannover Medical School, Germany. A total of 454 consecutive patients who underwent open vascular surgery were followed from the day prior to until 30 days after surgery. The composite primary end point was defined as the occurrence of major adverse cardiac events (MACEs), acute kidney injury (AKI), or systemic inflammatory response syndrome (SIRS). Measurements were correlated with both medical history and postoperative MACE, AKI, or SIRS using univariate and multivariate regression analysis.

RESULTS:

One hundred thirty-nine (31%) of the patients reached the primary end point within the study interval. Midregional pro-adrenomedullin change was associated with the combined primary end point and with the intensity of surgical trauma. Midregional pro-adrenomedullin change was increased in patients reaching the secondary end points, SIRS (optimal cutoff: 0.2 nmol/L) and AKI (optimal cutoff: 0.7 nmol/L), but not in patients with MACEs.

CONCLUSION:

Increased levels of MR-proADM within the perioperative setting (1) were linked to the invasiveness of surgery and (2) identified patients with ongoing loss of renal function. Increased MR-proADM levels may therefore identify a subgroup of patients prone to excessive cardiovascular stress but did not directly correlate with adverse cardiac events. Consistently low levels of MR-proADM may identify a subgroup of patients with acceptable low risk to guide discharge from high-density care units.

Outcome of Noncardiac Surgical Patients Admitted to a Multidisciplinary Intensive Care Unit

Context:

Surgical procedures carry significant morbidity and mortality depending on the type of surgery and patients. There is a dearth of evidence from India on the outcome of surgical patients admitted to an Intensive Care Unit (ICU).

Aims:

We aimed to describe the incidence and risk factors of postoperative complications and mortality in noncardiac surgical patients admitted to the ICU.

Settings and Design:

This was a prospective observational study on all perioperative patients admitted to a multidisciplinary ICU for 18 months.

Subjects and Methods:

Data on demography, admission Acute Physiology and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA) scores, perioperative course, type and duration of surgery, reason for ICU admission, ICU interventions, and perioperative complications were recorded. The primary outcomes analyzed were perioperative complications and mortality.

Results:

The study included 762 patients with a mean age of (mean ± standard deviation [SD]) 50.5 ± 18 years and a male (58.4%) preponderance. The mean (±SD) admission APACHE-II and SOFA scores were 15 (±5.0) and 4.26 (±2.6), respectively. The most common reason for ICU admission was elective mechanical ventilation 50%, followed by prolonged surgery 26.2% and hemodynamic instability 21.2%. Most (51.1%) patients belonged to American Society of Anaesthesiologists physical Status III or IV and Lee's surgical risk Category I and II (66.8%). The most common surgical procedures performed were gastro-intestinal (28.5%) followed by interventional Neuro-radiology (14.0%) and orthopedic (13.9%). Overall perioperative complications were observed in 51.4% (n = 392). Common complications observed were hemodynamic instability 24%, hypothermia 17.2%, sepsis 17.3%, poor glycemic control 11.2%, perioperative myocardial infarction 7.1%, cardiac arrest 0.13%, and acute kidney injury (AKI) 10.1%. The overall hospital mortality was 7.9%. Multivariate logistic regression analysis showed that admission APACHE-II score, sepsis, AKI, and ICU length of stay were independent predictors for mortality.

Conclusions:

High risk perioperative patients after noncardiac surgery have significant mortality and morbidity.

SAPS 3 score as a predictive factor for postoperative referral to intensive care unit

BACKGROUND

Patients undergoing intermediate-risk surgery are typically taken to the ward postoperatively. However, some may develop complications requiring intensive care later. We aimed to evaluate the characteristics of patients undergoing intermediate-risk surgery who required late postoperative admission to the intensive care unit (ICU) and determine the predictors for this.

METHODS

The study included patients undergoing intermediate-risk surgery with preoperative indication for ICU but who were taken to the ward postoperatively, because they appeared to be responding well. However, they required late ICU admission. ICU care and preoperative SAPS 3 score were evaluated. Palliative surgeries and patients readmitted to ICU were excluded.

RESULTS

The study included 100 patients, 27 % of whom had late postoperative admission to the ICU. The preoperative SAPS 3 score was higher (45.4 ± 7.8 vs. 35.9 ± 7.4, P < 0.001) in patients who required delayed admission to the ICU postoperatively. Furthermore, they had undergone longer surgery (4.2 ± 1.9 vs. 2.7 ± 1.5 h, P < 0.001), and a greater proportion were gastrointestinal surgeries (14.8 vs. 5.5 %, P = 0.03) and intraoperative transfusion (18.5 vs. 5.5 % P = 0.04). In multivariate analysis, preoperative SAPS 3 and surgery duration independently predicted postoperative ICU admission, respectively (OR 1.25; 95 % CI 1.1-1.4 and OR 3.33; 95 % CI 1.7-6.3).

CONCLUSION

The identification of high-risk surgical patients is essential for proper treatment; time of surgery and preoperative SAPS 3 seem to provide a useful indication of risk and may help better to characterize patients undergoing intermediate-risk surgery that demand ICU care.

Liberal or restrictive fluid management during elective surgery: a systematic review and meta-analysis

This article reviews if a restrictive fluid management policy reduces the complication rate if compared to liberal fluid management policy during elective surgery. The PubMed database was explored by 2 independent researchers. We used the following search terms: "Blood transfusion (MESH); transfusion need; fluid therapy (MESH); permissive hypotension; fluid management; resuscitation; restrictive fluid management; liberal fluid management; elective surgery; damage control resuscitation; surgical procedures, operative (MESH); wounds (MESH); injuries (MESH); surgery; trauma patients." A secondary search in the Medline, EMBASE, Web of Science, and Cochrane library revealed no additional results. We selected randomized controlled trials performed during elective surgeries. Patients were randomly assigned to a restrictive fluid management policy or to a liberal fluid management policy during elective surgery. The patient characteristics and the type of surgery varied. All but 3 studies reported American Society of Anaesthesiologists groups 1 to 3 as the inclusion criterion. The primary outcome of interest is total number of patients with a complication and the complication rate. Secondary outcome measures are infection rate, transfusion need, postoperative rebleeding, hospital stay, and renal function. In total, 1397 patients were analyzed (693 restrictive protocol, 704 liberal protocol). Meta-analysis showed that in the restrictive group as compared with the liberal group, fewer patients experienced a complication (relative risk [RR], 0.65; 95% confidence interval [CI], 0.55-0.78). The total complication rate (RR, 0.57; 95% CI, 0.52-0.64), risk of infection (RR, 0.62; 95% CI, 0.48-0.79), and transfusion rate (RR, 0.81; 95% CI, 0.66-0.99) were also lower. The postoperative rebleeding did not differ in both groups: RR, 0.76 (95% CI, 0.28-2.06). We conclude that compared with a liberal fluid policy, a restrictive fluid policy in elective surgery results in a 35% reduction in patients with a complication and should be advised as the preferred fluid management policy.

[Goal-directed hemodynamic therapy: Concepts, indications and risks]

Goal-directed hemodynamic therapy is becoming increasingly more interesting for anesthesiologists and intensive care physicians. Meta-analyses of studies evaluating perioperative therapy algorithms demonstrated a reduction of postoperative morbidity compared to the previous clinical practices. In this review article the basic concepts of goal-directed hemodynamic therapy and the principles of previously employed therapy algorithms are described and discussed. Furthermore, the questions of how these therapy strategies can be transferred into daily clinical practice and whether these therapeutic approaches might even bear risks for patients are elucidated.

Central venous-to-arterial carbon dioxide difference as a prognostic tool in high-risk surgical patients

Introduction

The purpose of this study was to evaluate the clinical relevance of high values of central venous-to-arterial carbon dioxide difference (PCO₂ gap) in high-risk surgical patients admitted to a postoperative ICU. We hypothesized that PCO₂ gap could serve as a useful tool to identify patients still requiring hemodynamic optimization at ICU admission.

Methods

One hundred and fifteen patients were included in this prospective single-center observational study during a 1-year period. High-risk surgical inclusion criteria were adapted from Schoemaker and colleagues. Demographic and biological data, PCO₂ gap, central venous oxygen saturation, lactate level and postoperative complications were recorded for all patients at ICU admission, and 6 hours and 12 hours after admission.

Results

A total of 78 (68%) patients developed postoperative complications, of whom 54 (47%) developed organ failure. From admission to 12 hours after admission, there was a significant difference in mean PCO₂ gap (8.7 ± 2.8 mmHg versus 5.1 ± 2.6 mmHg; P = 0.001) and median lactate values (1.54 (1.1-3.2) mmol/l versus 1.06 (0.8-1.8) mmol/l; P = 0.003) between patients who developed postoperative complications and those who did not. These differences were maximal at admission to the ICU. At ICU admission, the area under the receiver operating characteristic curve for occurrence of postoperative complications was 0.86 for the PCO₂ gap compared to Sequential Organ Failure Assessment score (0.82), Simplified Acute Physiology Score II score (0.67), and lactate level (0.67). The threshold value for PCO₂ gap was 5.8 mmHg. Multivariate analysis showed that only a high PCO₂ gap and a high Sequential Organ Failure Assessment score were independently associated with the occurrence of postoperative complications. A high PCO₂ gap (≥6 mmHg) was associated with more organ failure, an increase in duration of mechanical ventilation and length of hospital stay.

Conclusion

A high PCO₂ gap at admission in the postoperative ICU was significantly associated with increased postoperative complications in high-risk surgical patients. If the increase in PCO₂ gap is secondary to tissue hypoperfusion then the PCO₂ gap might be a useful tool complementary to central venous oxygen saturation as a therapeutic target.

A web-based Italian survey of current trends, habits and beliefs in hemodynamic monitoring and management

Significant evidence outlines that the management of the high-risk surgical patient with perioperative hemodynamic optimization leads to significant benefits. This study aimed at studying the current practice of hemodynamic monitoring and management of Italian anesthesiologists. An invitation to participate in a web-based survey was published on the web site of the Società Italiana di Anestesia Analgesia Rianimazione Terapia Intensiva. Overall, 478 questionnaires were completed. The most frequently used monitoring techniques was invasive blood pressure (94.1 %). Cardiac output was used in 41.3% of the cases mainly throughout less-invasive methods. When cardiac output was not monitored, the main reason given was that other surrogate techniques, mainly central venous oxygen saturation (40.5%). Written protocols concerning hemodynamic management in high-risk surgical patients were used by the 29.1% of the respondents. 6.3% of the respondents reported not to be aware if such document was available at their institution. 86.3% of the respondents reported that they usually optimize high risk patients but to use blood flow assessment rarely (39.7%). The most used parameter in clinical practice to assess the effects of volume loading were an increase in urine output and arterial blood pressure together with a decrease in heart rate and blood lactates. The 45.1% or the respondents outlined that hemodynamic optimization in the high risk patients is of major clinical value. Our study outlines an important gap between available evidence and clinical practice emphasizing the need for a better awareness, more information and knowledge on the specific topic.

Risk factors for perioperative complications in endoscopic surgery with irrigation

BACKGROUND AND OBJECTIVES

Currently, endoscopic medicine is being increasingly used, albeit not without risks. Therefore, this study evaluated the factors associated with perioperative complications in endoscopic surgery with intraoperative irrigation.

METHOD

A cohort study of six months duration. Patients aged ≥ 18 years undergoing endoscopic surgery with the use of irrigation fluids during the intraoperative period were included. Exclusion criteria were: use of diuretics, kidney failure, cognitive impairment, hyponatremia prior to surgery, pregnancy, and critically ill. The patients who presented with or without complications during the perioperative period were allocated into two groups. Complications evaluated were related to neurological, cardiovascular and renal changes, and perioperative bleeding.

RESULTS

In total, 181 patients were enrolled and 39 excluded; therefore, 142 patients met the study criteria. Patients with complications amounted to 21.8%, with higher prevalence in endoscopic prostate surgery, followed by hysteroscopy, bladder, knee, and shoulder arthroscopy (58.1%, 36.9%, 19.4%, 3.8%, 3.2% respectively). When comparing both groups, we found association with complications in univariate analysis: age, sex, smoking, heart disease, ASA, serum sodium at the end of surgery, total irrigation fluid administered, TURP, and hysteroscopy. However, in multiple regression analysis for complications, only age (OR = 1.048), serum sodium (OR = 0.962), and volume of irrigation fluid administered during surgery (OR = 1.001) were independent variables.

Nursing Activities Score and workload in the intensive care unit of a university hospital

OBJECTIVE

The nursing workload consists of the time spent by the nursing staff to perform the activities for which they are responsible, whether directly or indirectly related to patient care. The aim of this study was to evaluate the nursing workload in an adult intensive care unit at a university hospital using the Nursing Activities Score (NAS) instrument.

METHODS

A longitudinal, prospective study that involved the patients admitted to the intensive care unit of a university hospital between March and December 2008. The data were collected daily to calculate the NAS, the Acute Physiology and Chronic Health Evaluation (APACHE II), the Sequential Organ Failure Assessment (SOFA) and the Therapeutic Intervention Scoring System (TISS-28) of patients until they left the adult intensive care unit or after 90 days of hospitalization. The level of significance was set at 5%.

RESULTS

In total, 437 patients were evaluated, which resulted in an NAS of 74.4%. The type of admission, length of stay in the intensive care unit and the patients' condition when leaving the intensive care unit and hospital were variables associated with differences in the nursing workload. There was a moderate correlation between the mean NAS and APACHE II severity score (r=0.329), the mean organic dysfunction SOFA score (r=0.506) and the mean TISS-28 score (r=0.600).

CONCLUSION

We observed a high nursing workload in this study. These results can assist in planning the size of the staff required. The workload was influenced by clinical characteristics, including an increased workload required for emergency surgical patients and patients who died.

The Cost of Inappropriate Care at the End of life: Implications for an Aging Population

Elderly patients patients (older than 65 years) account for only 11% of the US population yet they account for 34% of health care expenditure. The disproportionate usage of health care costs by elderly patients is in striking contrast with that of other Western Nations. It is likely that these differences are largely due to variances in hospitalization and the use of high technology health care resources at the end of life. The United States has 8 times as many intensive care unit (ICU) beds per capita when compared to other Western Nations. In the United States, elderly patients currently account for 42% to 52% of ICU admissions and for almost 60% of all ICU days. A disproportionate number of these ICU days are spent by elderly patients before their death. In many instances, aggressive life supportive measures serve only to prolong the patient's death. Such treatment inflicts pain and suffering on the patient (with little prospects of gain) and incurs enormous financial costs to the health care system. We present the case of an 86-year-old female who spent almost 3 months in our ICU prior to her death. The fully allocated hospital costs for this patient were estimated to be US$254 945 (US$5100/d). With the increasing age of the population and the projected increased demand for ICU beds, we review the benefits and burdens of admitting elderly patients to the ICU.

Risk factors for perioperative complications in endoscopic surgery with irrigation

BACKGROUND AND OBJECTIVES

Currently, endoscopic medicine is being increasingly used, albeit not without risks. Therefore, this study evaluated the factors associated with perioperative complications in endoscopic surgery with intraoperative irrigation.

METHOD

A cohort study of six months duration. Patients aged ≥ 18 years undergoing endoscopic surgery with the use of irrigation fluids during the intraoperative period were included. Exclusion criteria were: use of diuretics, kidney failure, cognitive impairment, hyponatremia prior to surgery, pregnancy, and critically ill. The patients who presented with or without complications during the perioperative period were allocated into two groups. Complications evaluated were related to neurological, cardiovascular and renal changes, and perioperative bleeding.

RESULTS

In total, 181 patients were enrolled and 39 excluded; therefore, 142 patients met the study criteria. Patients with complications amounted to 21.8%, with higher prevalence in endoscopic prostate surgery, followed by hysteroscopy, bladder, knee, and shoulder arthroscopy (58.1%, 36.9%, 19.4%, 3.8%, 3.2% respectively). When comparing both groups, we found association with complications in univariate analysis: age, sex, smoking, heart disease, ASA, serum sodium at the end of surgery, total irrigation fluid administered, TURP, and hysteroscopy. However, in multiple regression analysis for complications, only age (OR = 1.048), serum sodium (OR = 0.962), and volume of irrigation fluid administered during surgery (OR = 1.001) were independent variables.

CONCLUSION

The incidence of serious complications in endoscopic surgeries is high. Serum sodium at the end of the operation, amount of irrigation fluid, and age were strong independent factors associated with the problem. Thus, these factors must be taken into account in these surgeries.