Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Management of labour and delivery in congenitally corrected transposition of great arteries

A descriptive case report of the labour and delivery management of a 28-year-old woman who presented with congenitally corrected transposition of great arteries, dextrocardia, systemic ventricular dysfunction and junctional tachycardia. Patients with congenitally corrected transposition have a thin-walled morphological right ventricle as the systemic circulatory pump. The stress of increased cardiac output can lead to congestive heart failure, systemic atrioventricular valve regurgitation and arrhythmias. We used minimally invasive continuous cardiac output monitoring, fluid balance optimization and good maternal pain control to prevent decompensation and achieve vaginal delivery with a good maternal and neonatal outcome.

Stability study of a constant-volume thin film flow

We study the stability of a constant volume of fluid spreading down an incline. In contrast to the commonly considered flow characterized by constant fluid flux, in the present problem the base flow is time dependent. We present a method to carry out consistently linear stability analysis, based on simultaneously solving the time evolution of the base flow and of the perturbations. The analysis is performed numerically by using a finite-difference method supplemented with an integral method developed here. The computations show that, after a short transient stage, imposed perturbations travel with the same velocity as the leading contact line. The spectral analysis of the modes evolution shows that their growth rates are, in general, time dependent. The wavelength of maximum amplitude, lambda_{max} , decreases with time until it reaches an asymptotic value which is in good agreement with experimental results. We also explore the dependence of lambda_{max} on the cross sectional fluid area A , and on the inclination angle alpha of the substrate. For considered small A 's, corresponding to small Bond numbers, we find that the dependence of lambda_{max} on A is in good agreement with experimental data. This dependence differs significantly from the one observed for the films characterized by much larger A 's and Bond numbers. We also predict the dependence of lambda_{max} on the inclination angle alpha .

Spreading of a micrometric fluid strip down a plane under controlled initial conditions

We experimentally study the spreading of a small volume of silicon oil down a vertical plane with small Bond number. The initial condition is characterized by a horizontal long fluid strip with cross sectional area A and width w(0). We find that the experiments are characterized by a unique nondimensional parameter, R proportional w4(0)/(a2A), where a is the capillary length. An empirical criterium to estimate the onset of the contact line instability is established. The later rivulet formation at the contact line leads to a pattern which is characterized by a dominant wavelength. We find that this wavelength is approximately proportional to R(-1/4).

Spreading of a thin two-dimensional strip of fluid on a vertical plane: experiments and modeling

We study the thin-film flow of a constant volume of silicon oil (polydymethilsiloxane) spreading down a vertical glass plate. The initial condition is generated from a horizontal fluid filament of typical diameter 0.4 mm. Two optical diagnostic methods are used: One based on an anamorphic system, and the other on the Schlieren method. The first one allows for a detailed characterization of the early stable stage of the spreading which is used to estimate the thickness of the precursor film needed to model the flow. The second one captures the bidimensional pattern of the transversal film instability. We use these techniques to determine the film thickness profiles, and the evolution of the moving contact line, including its shape and Fourier spectra. The numerical simulations of the stable stage of spreading are in good quantitative agreement with the experimental results. We develop a model based on linear stability theory that predicts the evolution of the modes present in the linear stage of the instability.

Felodipine use in pregnancy. Report of three cases

BACKGROUND

Calcium channel blockers are effective agents for the management of chronic hypertension and are being used with increasing frequency. If their safety and efficacy during pregnancy can be documented, women can be counseled to continue their antihypertensive agent during pregnancy. To our knowledge, the use of felodipine, a calcium channel blocker of the dihydropyridine group, during pregnancy has not been described.

CASES

We report three cases of felodipine use in pregnancy by women with chronic hypertension.

CONCLUSION

In women with severe hypertension (diastolic blood pressure > 100 mm Hg) who require pharmacologic treatment of it during pregnancy, felodipine appears to be an acceptable option.

Profilometry of a liquid-free surface with large slope variations

We describe and test a refractive method for determining the height profile of an unsteady liquid-free surface, which is adequate for regions where the slope of the surface changes strongly, as for example the head of a spreading current. The method is developed for situations in which the height depends on a single Cartesian coordinate (plane flows); however, the underlying idea could be applied to more general cases. As a test, we obtained the profiles of a transparent solid object (a cylindrical lens) and of an actual liquid flow. These profiles are determined with high accuracy even if the direction of the normal to the free surface changes approximately 150 degrees within the probed region.

Carotid arterial blood flow in the ovine fetus as a continuous measure of cerebral blood flow

OBJECTIVE

The purpose of this study was to establish a continuous measure of cerebral blood flow in the ovine fetus with a transit time flow probe.

METHODS

Seven chronically catheterized fetal sheep were studied near term with placement of a 3R Transonic flow probe on the external carotid artery, just proximal to the internal maxillary artery. Blood flow changes were induced by altering maternal inspired oxygen and carbon dioxide concentrations, with cerebral and extracerebral blood flows also determined by the microsphere technique.

RESULTS

Although absolute carotid and cerebral blood flow values were only modestly related under the present study conditions (r = 0.60, P < .05), both the percent change and the actual change in carotid arterial blood flow showed a strong linear correlation with that for cerebral blood flow (r = 0.84, P < .01, and r = 0.72, P < .02) but less so with that for extracerebral blood flow (r = 0.44 and r = 0.28).

CONCLUSION

Measurements of carotid blood flow as studied with a transit time flow probe and induced blood gas changes can provide for a continuous assessment of changes in blood flow to the ovine fetal brain.

Capillarity Effects on Viscous Gravity Spreadings of Wetting Liquids

Highly viscous silicone oils within a wide range of volumes were left to spread on smooth horizontal substrates to investigate the effects of capillarity on viscous gravity spreadings under the condition of complete wetting. The study was centered on the intermediate asymptotic behavior, where the details of the initial liquid distribution are irrelevant. We detected small but appreciable departures from the well-known solution without surface tension forces (viscous gravity self similar solution, or base solution). Two stages are clearly identified in the spreadings. During the first, which is usually rather brief, capillarity does not play an appreciable role on the dynamics of the spreading, i.e., the base solution is a very good approximation. The head of the current displays a wheel-like profile progressively decreasing in size; when the size becomes on the order of the capillary length, this stage ends. The wheel-like configuration cannot be associated either with the rheological behavior of the fluid used or with the initial conditions. To observe this first stage without the influences due to peculiarities of the initial conditions, a proper release of the spreading is needed. The second stage is characterized by a spreading rate below the base solution; the slowing is associated with a change of the current head shape, which takes the form of a wedge as a consequence of capillarity. The rate of advance of the front may still be well approximated by the same power law as given by the base solution, but with a smaller prefactor. In this work we measure the parameters that characterize the flow during both stages; besides, for the second stage, we develop a heuristic calculation which shows that the wedge-like shape of the current head gives place to a higher viscous dissipation rate, thus explaining the observed slowing of the spreading.

Droplet profiles obtained from the intensity distribution of refraction patterns

A noninterferometric method for obtaining profiles of axially symmetric transparent liquid droplets is described. The drops are illuminated along the symmetry axis by a uniform parallel beam whose intensity distribution is recorded at the focal plane of a lens placed behind the drop. In some conditions and within the geometrical optics approach, it is possible to reconstruct the profile of the drop from this intensity distribution except for the length scale factor, which, if necessary, may be provided by an additional simple measurement. Because of CCD cameras and digital image processing, this method is an interesting alternative technique for measuring drop profile shapes with considerable accuracy when interferometry is unwieldy. We also analyze the diffraction features of the intensity distribution to clarify the extent that they affect the approach that we used and to establish additional information that they may provide.

Measurements of free-surface profile in transient flow with a simple light-slicing method

A simple light-slicing technique for the direct measurement of the free-surface shape h(x) in onedirectional transient liquid flows is studied. The method is used to determine h(x) with a precision of the order of 10(-2) mm along a line several centimeters long, allowing for height differences of some millimeters. It is useful for transient flows in rectangular channels in which capillarity and liquid adhesion at walls perturb lateral observations; the method can also be used for nondiffusive fluids in cases in which it is not advisable to add diffusive particles.

Fluorescence properties of polyene antibiotics in phospholipid bilayer membranes

The fluorescence characteristics of the polyene antibiotic Nystatin have been studied by measurements of quantum yields, lifetimes, and anisotropies in a model bilayer membrane. These measurements have been performed as a function of temperature and fluorophore-to-phospholipid molar ratio. Comparisons with data available for the parinaric acids demonstrate that the photophysics of the two polyene chromophores is similar. The quantum yield decreases at increasing Nystatin densities while the lifetimes are constant. These observations combined with quantitative comparisons with calculations of the density dependence of dynamic quenching in two-dimensional systems show that Nystatin fluorescence is quenched in bilayer membranes by a static process. This is likely due to the formation of complexes within the bilayer. The quenching is equally efficient in both the gel and liquid crystalline phases of the bilayer which suggests that the formation of the complexes occurs at all temperatures. At high Nystatin densities, there is also a quenching of the polarization, but the mechanism whereby this occurs is not clear. The limiting anisotropy at low concentrations is between 0.33 and 0.35 at all temperatures, suggesting that the Nystatin monomer is highly restricted in its reorientational motion in both gel and liquid crystalline phases.