Improving Statewide Post-Operative Sepsis Performance Measurement Using Hospital Risk Adjustment Within a Surgical Collaborative

Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.

Description of Intensive Care and Intermediate Care resources managed by Anaesthesiology Departments in Spain and their adaptation capacity during the COVID-19 pandemic

INTRODUCTION

It is essential to understand the strategic importance of intensive care resources in the sustainable organisation of healthcare systems. Our objective has been to identify the intensive and intermediate care beds managed by Anaesthesiology and Resuscitation Services (A-ICU and A-IMCU) in Spain, their human and technical resources, and the changes made to these resources during the COVID-19 pandemic.

MATERIAL AND METHODS

Prospective observational study performed between December 2020 and July 2021 to register the number and characteristics of A-ICU and A-IMCU beds in hospitals listed in the catalogue published by the Spanish Ministry of Health.

RESULTS

Data were obtained from 313 hospitals (98% of all hospitals with more than 500 beds, 70% of all hospitals with more than 100 beds). One hundred and forty seven of these hospitals had an A-ICU with a total of 1702 beds. This capacity increased to 2107 (124%) during the COVID-19 pandemic. Three hundred and eight hospitals had an A-IMCU with a total of 3470 beds, 52.9% (2089) of which provided long-term care. The hospitals had 1900 ventilators, at a ratio of 1.07 respirators per A-ICU; 1559 anaesthesiologists dedicated more than 40% of their working time to intensive care. The nurse-to-bed ratio in A-ICUs was 2.8.

DISCUSSION

A large proportion of fully-equipped ICU and IMCU beds in Spanish hospitals are managed by the anaesthesiology service. A-ICU and A-IMCUs have shown an extraordinary capacity to adapt their resources to meet the increased demand for intensive care during the COVID-19 pandemic.

Defining Intensivists: A Retrospective Analysis of the Published Studies in the United States, 2010-2020

OBJECTIVES

The Society of Critical Care Medicine last published an intensivist definition in 1992. Subsequently, there have been many publications relating to intensivists. Our purpose is to assess how contemporary studies define intensivist physicians.

DESIGN

Systematic search of PubMed, Embase, and Web of Science (2010-2020) for publication titles with the terms intensivist, and critical care or intensive care physician, specialist, or consultant. We included studies focusing on adult U.S. intensivists and excluded non-data-driven reports, non-U.S. publications, and pediatric or neonatal ICU reports. We aggregated the study title intensivist nomenclatures and parsed Introduction and Method sections to discern the text used to define intensivists. Fourteen parameters were found and grouped into five definitional categories: A) No definition, B) Background training and certification, C) Works in ICU, D) Staffing, and E) Database related. Each study was re-evaluated against these parameters and grouped into three definitional classes (single, multiple, or no definition). The prevalence of each parameter is compared between groups using Fisher exact test.

SETTING

U.S. adult ICUs and databases.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 657 studies, 105 (16%) met inclusion criteria. Within the study titles, 17 phrases were used to describe an intensivist; these were categorized as intensivist in 61 titles (58%), specialty intensivist in 30 titles (29%), and ICU/critical care physician in 14 titles (13%). Thirty-one studies (30%) used a single parameter (B-E) as their definition, 63 studies (60%) used more than one parameter (B-E) as their definition, and 11 studies (10%) had no definition (A). The most common parameter "Works in ICU" (C) in 52 studies (50%) was more likely to be used in conjunction with other parameters rather than as a standalone parameter (multiple parameters vs single-parameter studies; 73% vs 17%; p < 0.0001).

CONCLUSIONS

There was no consistency of intensivist nomenclature or definitions in contemporary adult intensivist studies in the United States.

Effect of vitamin D on clinical outcomes in patients with thermal injury

Evaluating complications and mortality risks in burn patients is crucial for effective treatment planning and improving survival rates. This study investigated the relationship between the serum vitamin D level and the clinical outcomes of adult burns patients. This was a prospective cohort of adult patients hospitalized due to thermal burns at a burn centre in the north of Iran. Based on the level of 25 hydroxyvitamin D measured upon admission, patients were divided into two groups of patients with sufficient 25 hydroxyvitamin D level and insufficient 25 hydroxyvitamin D level. Descriptive statistics were used for baseline demographics. Univariate analysis was conducted using Mann-Whitney U, Chi-square, independent samples, and Fisher's exact tests. A multivariate logistic regression was performed to adjust for the effects of confounding variables. Statistical analyses were conducted using SPSS 28.0 software. A total of 220 patients were included in the study. The average total body surface area burned was 30.52 ± 9.34. Patients with insufficient vitamin D levels had longer hospital stays (12.53 vs. 11.45) and longer stays in the intensive care unit (ICU) (3.32 vs. 2.40) than those with appropriate vitamin D levels. Participants with insufficient vitamin D levels exhibited a numerically higher incidence of infections than those with adequate levels (p < 0.05). The multivariate regression found that vitamin D deficiency levels were associated with increased infection rates and prolonged hospital stay. This study suggests that vitamin D deficiency is a significant risk factor for adverse clinical outcomes in burn patients. Further research is needed to confirm these associations and to explore potential interventions to optimize vitamin D status in this patient population.

Hydrogel burn dressing effectiveness in burn pain

Severe burns are painful and dramatic injuries. Studies show that pain is underestimated and often not adequately treated. This study aims to evaluate the analgesic efficacy of hydrogel burn dressing and silver sulfadiazine, which are two agents commonly used in first-aid dressings for burn patients. This study, designed as a prospective, observational, and cross-sectional study. Study included 64 pediatric patients admitted to our burn center between 01.03.2020 and 01.09.2020 who were examined by our burn service after their first treatment in the emergency dressing room. Two groups of patients were included in the study. Pain level was assessed in the dressing room before and 10 min after the procedure using the Visual Analog Scale and FLACC (Face, Legs, Activity, Cry, Consolability) pain assessment scales.During the study period, Burnaid® was applied to 62.5% of patients (40 patients) and silver sulfadiazine to 37.5% (24 patients). In terms of pain scores, pre-dressing FLACC values were higher in Group B (p = 0.039); post-dressing VAS and FLACC values were significantly lower in group B (p 0.001; p 0.001). In terms of additional analgesia, we found more patients in Group S received analgesics (p 0.001).We believe that its effect on burn wound pain is superior to that of silver sulfadiazine.

Data Representation Structure to Support Clinical Decision-Making in the Pediatric Intensive Care Unit: Interview Study and Preliminary Decision Support Interface Design

BACKGROUND

Clinical decision-making is a complex cognitive process that relies on the interpretation of a large variety of data from different sources and involves the use of knowledge bases and scientific recommendations. The representation of clinical data plays a key role in the speed and efficiency of its interpretation. In addition, the increasing use of clinical decision support systems (CDSSs) provides assistance to clinicians in their practice, allowing them to improve patient outcomes. In the pediatric intensive care unit (PICU), clinicians must process high volumes of data and deal with ever-growing workloads. As they use multiple systems daily to assess patients' status and to adjust the health care plan, including electronic health records (EHR), clinical systems (eg, laboratory, imaging and pharmacy), and connected devices (eg, bedside monitors, mechanical ventilators, intravenous pumps, and syringes), clinicians rely mostly on their judgment and ability to trace relevant data for decision-making. In these circumstances, the lack of optimal data structure and adapted visual representation hinder clinician's cognitive processes and clinical decision-making skills.

OBJECTIVE

In this study, we designed a prototype to optimize the representation of clinical data collected from existing sources (eg, EHR, clinical systems, and devices) via a structure that supports the integration of a home-developed CDSS in the PICU. This study was based on analyzing end user needs and their clinical workflow.

METHODS

First, we observed clinical activities in a PICU to secure a better understanding of the workflow in terms of staff tasks and their use of EHR on a typical work shift. Second, we conducted interviews with 11 clinicians from different staff categories (eg, intensivists, fellows, nurses, and nurse practitioners) to compile their needs for decision support. Third, we structured the data to design a prototype that illustrates the proposed representation. We used a brain injury care scenario to validate the relevance of integrated data and the utility of main functionalities in a clinical context. Fourth, we held design meetings with 5 clinicians to present, revise, and adapt the prototype to meet their needs.

RESULTS

We created a structure with 3 levels of abstraction-unit level, patient level, and system level-to optimize clinical data representation and display for efficient patient assessment and to provide a flexible platform to host the internally developed CDSS. Subsequently, we designed a preliminary prototype based on this structure.

CONCLUSIONS

The data representation structure allows prioritizing patients via criticality indicators, assessing their conditions using a personalized dashboard, and monitoring their courses based on the evolution of clinical values. Further research is required to define and model the concepts of criticality, problem recognition, and evolution. Furthermore, feasibility tests will be conducted to ensure user satisfaction.

Oxidative stress and the role of redox signalling in chronic kidney disease

Chronic kidney disease (CKD) is a major public health concern, underscoring a need to identify pathogenic mechanisms and potential therapeutic targets. Reactive oxygen species (ROS) are derivatives of oxygen molecules that are generated during aerobic metabolism and are involved in a variety of cellular functions that are governed by redox conditions. Low levels of ROS are required for diverse processes, including intracellular signal transduction, metabolism, immune and hypoxic responses, and transcriptional regulation. However, excess ROS can be pathological, and contribute to the development and progression of chronic diseases. Despite evidence linking elevated levels of ROS to CKD development and progression, the use of low-molecular-weight antioxidants to remove ROS has not been successful in preventing or slowing disease progression. More recent advances have enabled evaluation of the molecular interactions between specific ROS and their targets in redox signalling pathways. Such studies may pave the way for the development of sophisticated treatments that allow the selective control of specific ROS-mediated signalling pathways.

Approach to burn treatment in the rural emergency department

OBJECTIVE

To outline an approach to the assessment and initial management of patients with burns in the rural emergency department setting. Three mnemonics are presented that can be used for both the assessment and the initial management of patients with burns in rural settings.

QUALITY OF EVIDENCE

Current and local guidelines compiled by a plastic surgeon were reviewed to develop a systematic approach to the treatment of patients with burns. PubMed and other databases were also searched for current literature on emergency care of patients with burns.

MAIN MESSAGE

Burn injuries are a common reason for presentation to the emergency department. However, the care of patients with these injuries can vary substantially depending on geographic location, provider training, and hospital resources. Classification of burns, fluid resuscitation guidelines, dressings and wound care, indications for referral, and pain management are discussed.

CONCLUSION

Using a systematic approach may help improve burn injury outcomes for patients and provide practitioners with a step-by-step framework for the management of patients with burns in rural settings.

Nutrition in chronic inflammatory conditions: Bypassing the mucosal block for micronutrients

Nutritional Immunity is one of the most ancient innate immune responses, during which the body can restrict nutrients availability to pathogens and restricts their uptake by the gut mucosa (mucosal block). Though this can be a beneficial strategy during infection, it also is associated with non-communicable diseases-where the pathogen is missing; leading to increased morbidity and mortality as micronutritional uptake and distribution in the body is hindered. Here, we discuss the acute immune response in respect to nutrients, the opposing nutritional demands of regulatory and inflammatory cells and particularly focus on some nutrients linked with inflammation such as iron, vitamins A, Bs, C, and other antioxidants. We propose that while the absorption of certain micronutrients is hindered during inflammation, the dietary lymph path remains available. As such, several clinical trials investigated the role of the lymphatic system during protein absorption, following a ketogenic diet and an increased intake of antioxidants, vitamins, and minerals, in reducing inflammation and ameliorating disease.

Rete ridges are decreased in dyschromic burn hypertrophic scar: A histological study

Dyschromic hypertrophic scar (HTS) is a common sequelae of burn injury, however, its mechanism has not been elucidated. This work is a histological study of these scars with a focus on rete ridges. Rete ridges are important for normal skin physiology, and their absence or presence may hold mechanistic significance in post-burn HTS dyschromia. It was posited that hyper-, and hypo-pigmented areas of scars have different numbers of rete ridges. Subjects with dyschromic burn hypertrophic scar were prospectively enrolled (n = 44). Punch biopsies of hyper-, hypo-, and normally pigmented scar and skin were collected. Biopsies were paraffin embedded, sectioned, stained with H&E, and imaged. The number of rete ridges were investigated. Burn hypertrophic scars that healed without autografts were first investigated. The number of rete ridges was higher in normal skin compared to HTS that was either hypo- (p < 0.01) or hyper-pigmented (p < 0.001). This difference was similar despite scar pigmentation phenotype (p = 0.8687). Autografted hyper-pigmented scars had higher rete ridge ratio compared to non-autografted hyper-pigmented HTS (p < 0.0001). Burn hypertrophihc scars have fewer rete ridges than normal skin. This finding may explain the decreased epidermal adherence to underlying dermis associated with hypertrophic scars. Though, contrary to our hypothesis, no direct link between the extent of dyschromia and rete ridge quantity was observed, the differences in normal skin and hypertrophic scar may lead to further understanding of dyschromic scars.

Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency

ABSTRACT

The complexity of improving health in the United States and the rising call for outcomes-based physician training present unique challenges and opportunities for both graduate medical education (GME) and health systems. GME programs have been particularly challenged to implement systems-based practice (SBP) as a core physician competency and educational outcome. Disparate definitions and educational approaches to SBP, as well as limited understanding of the complex interactions between GME trainees, programs, and their health system settings, contribute to current suboptimal educational outcomes elated to SBP. To advance SBP competence at individual, program, and institutional levels, the authors present the rationale for an integrated multilevel systems approach to assess and evaluate SBP, propose a conceptual multilevel data model that integrates health system and educational SBP performance, and explore the opportunities and challenges of using multilevel data to promote an empirically driven approach to residency education. The development, study, and adoption of multilevel analytic approaches to GME are imperative to the successful operationalization of SBP and thereby imperative to GME's social accountability in meeting societal needs for improved health. The authors call for the continued collaboration of national leaders toward producing integrated and multilevel datasets that link health systems and their GME-sponsoring institutions to evolve SBP.

Optimal positive-end expiratory pressure weaning in acute respiratory distress syndrome patients

PURPOSE OF REVIEW

Positive-end expiratory pressure (PEEP) is a tool in managing acute respiratory distress syndrome (ARDS). In this review, we discuss the various approaches to weaning PEEP after the acute phase of ARDS.

RECENT FINDINGS

There is a paucity of research specifically looking at the differences between PEEP weaning protocols. Data in some populations though, particularly those with elevated BMI, suggest that a physiologic approach to PEEP weaning may be helpful. Use of various tools to optimize PEEP prior to and during spontaneous breathing trials (SBTs) may allow for improved alveolar recruitment and respiratory outcomes.

SUMMARY

Although further prospective studies are warranted, we should consider using a physiologic approach to PEEP weaning in ARDS rather than a one size fits all model, which is currently the standard used in many clinical trials and throughout many ICUs.

Setting positive end-expiratory pressure: the use of esophageal pressure measurements

PURPOSE OF REVIEW

To summarize the key concepts, physiological rationale and clinical evidence for titrating positive end-expiratory pressure (PEEP) using transpulmonary pressure ( PL ) derived from esophageal manometry, and describe considerations to facilitate bedside implementation.

RECENT FINDINGS

The goal of an esophageal pressure-based PEEP setting is to have sufficient PL at end-expiration to keep (part of) the lung open at the end of expiration. Although randomized studies (EPVent-1 and EPVent-2) have not yet proven a clinical benefit of this approach, a recent posthoc analysis of EPVent-2 revealed a potential benefit in patients with lower APACHE II score and when PEEP setting resulted in end-expiratory PL values close to 0 ± 2 cmH 2 O instead of higher or more negative values. Technological advances have made esophageal pressure monitoring easier to implement at the bedside, but challenges regarding obtaining reliable measurements should be acknowledged.

SUMMARY

Esophageal pressure monitoring has the potential to individualize the PEEP settings. Future studies are needed to evaluate the clinical benefit of such approach.

Bedside Ultrasound: The Silent Guardian for Upper Airway Assessment and Management

Ultrasound evaluation of the upper airway has emerged as an essential instrument for clinicians, offering real-time assessment that can help to guide interventions and improve patient outcomes. This review aims to provide health care providers with a practical approach to performing ultrasound evaluation of the upper airway, covering basic physics relevant to upper airway ultrasound, the identification of key anatomical structures, and elucidating its various clinical applications, such as prediction of difficult airway, confirmation of endotracheal intubation, and guidance for surgical airway procedures and airway blocks. We also discuss evidence-based training programs, limitations, and future directions of ultrasound imaging of the upper airway.

Ultrasonography in the intensive care unit: a bibliometrics analysis

Background

Ultrasonography is widely used in critical care practice. The status of related studies remains unclear. The purpose of this study is to analyze current literature investigating the use of ultrasound in critical care units by using bibliometric analysis.

Methods

The Science Citation Index Expanded (SCI-E) database was used for data retrieval. The search formula for literature retrieval was "ultrasound" OR "ultrasonography" AND "intensive care unit" OR "critical care unit" OR "intensive care" OR "critical care". The bibliometric software package of R software was used to analyze the results. Information of related literatures were analyzed.

Results

Finally, 3,715 articles were included. The number of published articles and the number of references increased annually. The research fields included medical imaging, critical care medicine, cardiology, etc. The United States has published more documents in this field than other countries and has shown the highest rate of cooperation with other countries. Among the top 10 research institutions with the largest number of publications, 5 are from France and 3 are from the United States. There are many authors from China in the top 10 published studies. Among the top 10 journals with the largest number of published articles, 5 journals are top journals in the field of critical care medicine. Among the top 10 keywords, there are 5 of ultrasound specialty and 2 of critical care medicine.

Conclusions

Researches on the use of ultrasound in critical care units are mainly concentrated in several developed countries in Europe and the United States. Chinese research institutions should perform more studies in this field and increase cooperation with institutions from other countries.

Combination of a propofol emulsion with alpha-2 adrenergic receptor agonists used for multimodal analgesia or sedation in intensive care units: a physicochemical stability study

OBJECTIVES

To assess the physicochemical stability of the combination of a propofol emulsion with an alpha-2 (α2) adrenergic receptor agonist (α2A; clonidine or dexmedetomidine) under conditions mimicking routine practice in an intensive care unit or in multimodal analgesia procedures.

METHODS

We developed and validated three stability-indicating methods based on high-performance liquid chromatography with ultraviolet (HPLC-UV) detection. Eight different conditions per combination were evaluated in triplicate, with variations in the simulated, bodyweight-adjusted dose level and the drugs' flow rate. The drugs were mixed in clinically relevant concentrations and proportions and then stored unprotected from light, in clear glass vials at room temperature for 96 hours. At each sampling point, we assessed the chemical stability (the HPLC-UV drug level, pH, and osmolality) and physical compatibility (visual aspect, zeta potential (ZP), mean droplet diameter (MDD, Z-average) and polydispersity index (PDI)). We validated our stability findings in positive and negative control experiments.

RESULTS

Over the 96-hour test, the concentrations of propofol, clonidine and dexmedetomidine did not fall below 90% of the initial value, and the pH and osmolality were stable. The visual aspect of the mixed propofol emulsions did not change. The MDD remained below 500 nm (range 165-195 nm). The PDI was always below 0.4; 78.7% of the measurements were below 0.1 and 21.3% were between 0.1 and 0.4. The ZP measurements (-31.3 to -42.9 mV) suggested that the emulsion was stable. The MDD and PDI increased slightly at 96 hours under some conditions, which might indicate early destabilisation of the emulsion. Given that the MDD remained below 500 nm, these emulsions are compatible with intravenous administration.

CONCLUSIONS

Our results demonstrate the chemical and physical compatibility of propofol-α2 agonist mixtures at concentrations and in proportions representative of standard protocols when stored unprotected from light at room temperature for 96 hours.

The 50% effective dose of hydromorphone and morphine for epidural analgesia in the hemorrhoidectomy: a double-blind, sequential dose-finding study

BACKGROUND

Although previous studies have showed that epidural morphine can be used as a complement to local anesthetics for analgesia after postcesarean delivery under spinal anesthesia, there is little known about the analgesic dosage of epidural morphine and hydromorphone for hemorrhoidectomy. Therefore, we conducted this study to examine the potency ratio of hydromorphone to epidural morphine as well as effective analgesic dose for 50% patients (ED50) undergoing elective hemorrhoidectomy.

METHODS

80 patients under elective hemorrhoidectomy with combined spinal and epidural anesthesia(CSEA) in department of anesthesia, Dongguan Tungwah hospital. To assess the ED50, patients were treated with epidural morphine or epidural hydromorphone randomly using a biased coin method-determined dose with a sequential allocation procedure. Following surgery, standardized multimodal analgesia was administered to all patients. A pain response score of ≤ 3 (on a scale of 0-10) was determined to be the effective dose after 24 h following CSEA. The ED50 in both groups were determined using the probit regression and isotonic regression method. We also measured pain intensity by patient interview using a 10 point verbal numeric rating scale prospectively at 6, 12 and 24 h after CSEA, and adverse effects were also noted.

RESULTS

The ED50 was 0.350 mg (95% CI, 0.259-0.376 mg) in hydromorphone group and 1.129 mg (95% CI, 0.903-1.187 mg) in morphine group, respectively, estimated by isotonic regression method. Regression analysis with the probit, the ED50 of epidural hydromorphone was 0.366 mg (95% CI, 0.276-0.388 mg) and epidural morphine was 1.138 mg (95% CI, 0.910-1.201 mg). Exploratory findings showed that there was no difference between the most frequent dosages of epidural hydromorphone or epidural morphine in the occurrence of nausea, vomiting and pruritus. When administered with epidural opioids at ED50 doses or higher, 97.5% (39/40) of epidural morphine patients and 97.5% (39/40) epidural hydromorphone of patients were satisfied with their analgesia.

CONCLUSION

Effective hemorrhoidectomy analgesia requires a 3:1 ratio of epidural morphine to epidural hydromorphone. Both drugs provide excellent patient satisfaction.

Safety and effectiveness of neuromuscular electrical stimulation in cardiac surgery: A systematic review

BACKGROUND

Lack of mobilization and prolonged stay in the intensive care unit (ICU) are major factors resulting in the development of ICU-acquired muscle weakness (ICUAW). ICUAW is a type of skeletal muscle dysfunction and a common complication of patients after cardiac surgery, and may be a risk factor for prolonged duration of mechanical ventilation, associated with a higher risk of readmission and higher mortality. Early mobilization in the ICU after cardiac surgery has been found to be low with a significant trend to increase over ICU stay and is also associated with a reduced duration of mechanical ventilation and ICU length of stay. Neuromuscular electrical stimulation (NMES) is an alternative modality of exercise in patients with muscle weakness. A major advantage of NMES is that it can be applied even in sedated patients in the ICU, a fact that might enhance early mobilization in these patients.

AIM

To evaluate safety, feasibility and effectiveness of NMES on functional capacity and muscle strength in patients before and after cardiac surgery.

METHODS

We performed a search on Pubmed, Physiotherapy Evidence Database (PEDro), Embase and CINAHL databases, selecting papers published between December 2012 and April 2023 and identified published randomized controlled trials (RCTs) that included implementation of NMES in patients before after cardiac surgery. RCTs were assessed for methodological rigor and risk of bias via the PEDro. The primary outcomes were safety and functional capacity and the secondary outcomes were muscle strength and function.

RESULTS

Ten studies were included in our systematic review, resulting in 703 participants. Almost half of them performed NMES and the other half were included in the control group, treated with usual care. Nine studies investigated patients after cardiac surgery and 1 study before cardiac surgery. Functional capacity was assessed in 8 studies via 6MWT or other indices, and improved only in 1 study before and in 1 after cardiac surgery. Nine studies explored the effects of NMES on muscle strength and function and, most of them, found increase of muscle strength and improvement in muscle function after NMES. NMES was safe in all studies without any significant complication.

CONCLUSION

NMES is safe, feasible and has beneficial effects on muscle strength and function in patients after cardiac surgery, but has no significant effect on functional capacity.

Update on vitamin D role in severe infections and sepsis

Severe infections frequently require admission to the intensive care unit and cause life-threatening complications in critically ill patients. In this setting, severe infections are acknowledged as prerequisites for the development of sepsis, whose pathophysiology implies a dysregulated host response to pathogens, leading to disability and mortality worldwide.Vitamin D is a secosteroid hormone that plays a pivotal role to maintain immune system homeostasis, which is of paramount importance to resolve infection and modulate the burden of sepsis. Specifically, vitamin D deficiency has been widely reported in critically ill patients and represents a risk factor for the development of severe infections, sepsis and worse clinical outcomes. Several studies have demonstrated the feasibility, safety and effectiveness of vitamin D supplementation strategies to improve vitamin D body content, but conflictual results support its benefit in general populations of critically ill patients. In contrast, small randomised clinical trials reported that vitamin D supplementation may improve host-defence to pathogen invasion via the production of cathelicidin and specific cytokines. Nonetheless, no large scale investigations have been designed to specifically assess the impact of vitamin D supplementation on the outcome of critically ill septic patients admitted to the intensive care unit.

High PEEP extubation as guided by esophageal manometry

The ventilatory management of morbidly obese patients presents an ongoing challenge in the Intensive Care Unit (ICU) as multiple physiologic changes in the respiratory system complicate weaning efforts and make extubation more difficult, often leading to increased time on the ventilator. We report the case of a young adult male who presented to our ICU on two separate occasions with hypoxemic respiratory failure requiring intubation. Esophageal manometry (EM) guided positive end expiratory pressure (PEEP) titration was utilized during both ICU admissions to improve oxygenation and aid in extubation with spontaneous breathing trials performed on higher-than-normal PEEP settings and successful liberation on both occasions.

Unraveling the impact of nitric oxide, almitrine, and their combination in COVID-19 (at the edge of sepsis) patients: a systematic review

Introduction: During the coronavirus disease 2019 (COVID-19) pandemic, a large number of critically ill and severe COVID-19 patients meet the diagnostic criteria for sepsis and even septic shock. The treatments for COVID-19 patients with sepsis are still very limited. For sepsis, improving ventilation is one of the main treatments. Nitric oxide (NO) and almitrine have been reported to improve oxygenation in patients with "classical" sepsis. Here, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of NO, almitrine, and the combination of both for COVID-19 (at the edge of sepsis) patients. Method: A systematic search was performed on Embase, PubMed, the Cochrane Library, the Web of Science, Wanfang Data, and China National Knowledge Infrastructure. Randomized clinical trials, cohort studies, cross-sectional studies, case-control studies, case series, and case reports in COVID-19 patients with suspected or confirmed sepsis were performed. Study characteristics, patient demographics, interventions, and outcomes were extracted from eligible articles. Results: A total of 35 studies representing 1,701 patients met eligibility criteria. Inhaled NO did not affect the mortality (OR 0.96, 95% CI 0.33-2.8, I2 = 81%, very low certainty), hospital length of stay (SMD 0.62, 95% CI 0.04-1.17, I2 = 83%, very low certainty), and intubation needs (OR 0.82, 95% CI 0.34-1.93, I2 = 56%, very low certainty) of patients with COVID-19 (at the edge of sepsis). Meanwhile, almitrine did not affect the mortality (OR 0.44, 95% CI 0.17-1.13, low certainty), hospital length of stay (SMD 0.00, 95% CI -0.29-0.29, low certainty), intubation needs (OR 0.94, 95% CI 0.5-1.79, low certainty), and SAEs (OR 1.16, 95% CI 0.63-2.15, low certainty). Compared with pre-administration, the PaO2/FiO2 of patients with NO (SMD-0.87, 95% CI -1.08-0.66, I2 = 0%, very low certainty), almitrine (SMD-0.73, 95% CI-1.06-0.4, I2 = 1%, very low certainty), and the combination of both (SMD-0.94, 95% CI-1.71-0.16, I2 = 47%, very low certainty) increased significantly. Conclusion: Inhaled NO, almitrine, and the combination of the two drugs improved oxygenation significantly, but did not affect the patients' mortality, hospitalization duration, and intubation needs. Almitrine did not significantly increase the patients' SAEs. Well-designed high-quality studies are needed for establishing a stronger quality of evidence. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=367667, identifier CRD42022367667.

Raising patients hope in despair: The culture of nursing care of burn pain: An ethnographic study

BACKGROUND

Although many studies have been carried out to address burn patients' pain and suffering, pain relief still remains an immense unsolved challenge with individual, social, and cultural aspects.

MATERIAL AND METHODS

This study was conducted aiming to investigate and explain nursing care in burn patients. This was a semifocused ethnographic research conducted in burns units in a referral teaching hospital (Mazandaran, Iran). The data were collected through descriptive, focused, and selective participant observations and ethnographic interviews with burns unit nurses selected via a purposeful sampling method. The collected data were analyzed on the basis of James Spradley's approach.

RESULTS

Three main categories and nine subcategories were obtained from data analysis that are as follows: 1) Bending over backward (tenacity, altruism, dedication, and conscience and constancy), 2) Prevention is worth a pound of cure (unique clinical methods, enhanced frustration tolerance through self-motivation and self-efficacy, raise patient's hope in despair), and 3) undisputed dominance of nursing art (reduced unsettling experiences, burnt and ripped body rehabilitation, patient stress management, and avoidance of false hope).

CONCLUSIONS

Although burn nurses are under huge physical and mental pressure, they enhance patients' pain tolerance through their art of nursing, which is a collection of empirical knowledge, huge work conscience, unique clinical skills, and various therapeutic communication techniques.

Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol

BACKGROUND

Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain and analgesic medications may be risk factors for delirium. Delirium is associated with longer length of stay or cognitive impairment. Our systematic review and meta-analysis will examine the relationship between pain or analgesic medications with delirium occurrence, duration and severity among critically ill adults.

METHODS AND ANALYSIS

MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials and a review of recent conference abstracts will be searched without restriction from inception to 15 May 2023. Study inclusion criteria are: (1) age≥18 years admitted to intensive care; (2) report a measure of pain, analgesic medications and delirium; (3) study design-randomised controlled trial, quasiexperimental designs and observational cohort and case-control studies excluding case reports. Study exclusion criteria are: (1) alcohol withdrawal delirium or delirium tremens; or (2) general anaesthetic emergence delirium; or (3) lab or animal studies. Risk of bias will be assessed with the Risk of Bias V.2 and risk of bias in non-randomised studies tools. There is no language restriction. Occurrence estimates will be transformed using the Freeman-Tukey double arcsine. Point estimates will be pooled using Hartung-Knapp Sidik-Jonkman random effects meta-analysis to estimate a pooled risk ratio. Statistical heterogeneity will be estimated with the I2 statistic. Risk of small study effects will be assessed using funnel plots and Egger test. Studies will be analysed for time-varying and unmeasured confounding using E values.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is an analysis of published aggregated data. We will share our findings at conferences and in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

The finalised protocol was submitted to the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022367715).

The biological role and future therapeutic uses of nitric oxide in extracorporeal membrane oxygenation, a narrative review

BACKGROUND

Nitric oxide (NO) is a gas naturally produced by the human body that plays an important physiological role. Specifically, it binds guanylyl cyclase to induce smooth muscle relaxation. NO's other protective functions have been well documented, particularly its protective endothelial functions, effects on decreasing pulmonary vascular resistance, antiplatelet, and anticoagulation properties. The use of nitric oxide donors as vasodilators has been known since 1876. Inhaled nitric oxide has been used as a pulmonary vasodilator and to improve ventilation perfusion matching since the 1990s. It is currently approved by the United States Food and Drug Administration for neonates with hypoxic respiratory failure, however, it is used off-label for acute respiratory distress syndrome, acute bronchiolitis, and COVID-19.

PURPOSE

In this article we review the currently understood biological action and therapeutic uses of NO through nitric oxide donors such as inhaled nitric oxide. We will then explore recent studies describing use of NO in cardiopulmonary bypass and extracorporeal membrane oxygenation and speculate on NO's future uses.

Prone Positioning and Molecular Biomarkers in COVID and Non-COVID ARDS: A Narrative Review

Prone positioning (PP) represents a therapeutic intervention with the proven capacity of ameliorating gas exchanges and ventilatory mechanics indicated in acute respiratory distress syndrome (ARDS). When PP is selectively applied to moderate-severe cases of ARDS, it sensitively affects clinical outcomes, including mortality. After the COVID-19 outbreak, clinical application of PP peaked worldwide and was applied in 60% of treated cases, according to large reports. Research on this topic has revealed many physiological underpinnings of PP, focusing on regional ventilation redistribution and the reduction of parenchymal stress and strain. However, there is a lack of evidence on biomarkers behavior in different phases and phenotypes of ARDS. Patients response to PP are, to date, decided on PaO2/FiO2 ratio improvement, whereas scarce data exist on biomarker tracking during PP. The purpose of this review is to explore current evidence on the clinical relevance of biomarkers in the setting of moderate-severe ARDS of different etiologies (i.e., COVID and non-COVID-related ARDS). Moreover, this review focuses on how PP may modulate biomarkers and which biomarkers may have a role in outcome prediction in ARDS patients.

Rethinking Fluid Responsiveness during Septic Shock: Ameliorate Accuracy of Noninvasive Cardiac Output Measurements through Evaluation of Arterial Biomechanical Properties

Beat-to-beat estimates of cardiac output from the direct measure of peripheral arterial blood pressure rely on the assumption that changes in the waveform morphology are related to changes in blood flow and vasomotor tone. However, in septic shock patients, profound changes in vascular tone occur that are not uniform across the entire arterial bed. In such cases, cardiac output estimates might be inaccurate, leading to unreliable evaluation of fluid responsiveness. Pulse wave velocity is the gold-standard method for assessing different arterial biomechanical properties. Such methods might be able to guide, personalize and optimize the management of septic patients.

Upregulation of PTPN1 aggravates endotoxemia-induced cardiac dysfunction through inhibiting mitophagy

OBJECTIVES

To investigate the role of protein tyrosine phosphatase non-receptor type 1 (PTPN1) in mitophagy during sepsis and its underlying mechanisms and determine the therapeutic potential of PTPN1 inhibitors in endotoxemia-induced cardiac dysfunction.

METHODS

A mouse model of endotoxemia was established by administering an intraperitoneal injection of lipopolysaccharide (LPS). The therapeutic effect of targeting PTPN1 was evaluated using its inhibitor Claramine (CLA). Mitochondrial structure and function as well as the expression of mitophagy-related proteins were evaluated. Rat H9c2 cardiomyocytes were exposed to mouse RAW264.7 macrophage-derived conditioned medium. Cryptotanshinone, a specific p-STAT3 (Y705) inhibitor, was used to confirm the role of STAT3 in PTPN1-mediated mitophagy following LPS exposure. Electrophoretic mobility shift and dual luciferase reporter assays were performed to discern the mechanisms by which STAT3 regulated the expression of PINK1 and PRKN.

RESULTS

CLA alleviated LPS-induced myocardial damage, cardiac dysfunction, and mitochondrial injury and dysfunction in the mouse heart. PTPN1 upregulation exacerbated LPS-induced mitochondrial injury and dysfunction in H9c2 cardiomyocytes, but inhibited LPS-induced mitophagy. LPS promoted the interaction between PTPN1 and STAT3 and reduced STAT3 phosphorylation at Tyr705 (Y705), which was required to inhibit mitophagy by PTPN1. Upon LPS stimulation, PTPN1 negatively regulated the transcription of PINK1 and PRKN through dephosphorylation of STAT3 at Y705. STAT3 regulated the transcription of PINK1 and PRKN by binding to STAT3-responsive elements in their promoters.

CONCLUSION

PTPN1 upregulation aggravates endotoxemia-induced cardiac dysfunction by impeding mitophagy through dephosphorylation of STAT3 at Y705 and negative regulation of PINK1 and PRKN transcription.

Effect of sugammadex on postoperative complications in patients with severe burn who underwent surgery: a retrospective study

This retrospective study investigated the association of sugammadex with postoperative pulmonary complication risk between 2013 and 2021 in patients with severe burn of five hospitals. Postoperative pulmonary complications included atelectasis, pulmonary edema, pulmonary effusion, pneumothorax, pneumonia, pulmonary thromboembolism, respiratory failure and acute respiratory distress. To identify whether sugammadex reduced the risk of postoperative pulmonary complication in patients with severe burn who underwent surgery, Kaplan-Meier curve were used to check the difference of incidence according to surgical cases and time-varying Cox hazard regression were used to calculate the hazard ratio. The study included 1213 patients with severe burn who underwent 2259 surgeries. Postoperative pulmonary complications were occurred in 313 (25.8%) patients. Among 2259 surgeries, sugammadex was used in 649 (28.7%) surgeries. Cumulative postoperative pulmonary complication were 268 (16.6%) cases in surgeries without sugammadex, and 45 (6.9%) cases in surgeries with sugammadex, respectively (P < 0.005). The postoperative pulmonary complications risk was reduced significantly in patients who use sugammadex than those who did not use sugammadex. (Adjusted hazard ratio, 0.61; 95% confidence interval, 0.42-0.89; P = 0.011). In conclusion, sugammadex reduced risk of postoperative pulmonary complications compared with nonuse of sugammadex in patients with severe burn who underwent surgery.

Carotid blood flow changes following a simulated end-inspiratory occlusion maneuver measured by ultrasound can predict hypotension after the induction of general anesthesia: an observational study

BACKGROUND

The primary purpose of this study was to investigate the predictive value of alterations in cervical artery hemodynamic parameters induced by a simulated end-inspiratory occlusion test (sEIOT) measured by ultrasound for predicting postinduction hypotension (PIH) during general anesthesia.

METHODS

Patients undergoing gastrointestinal tumor resection under general anesthesia were selected for this study. Ultrasound has been utilized to assess hemodynamic parameters in carotid artery blood flow before induction, specifically focusing on variations in corrected flow time (ΔFTc) and peak blood flow velocity (ΔCDPV), both before and after sEIOT. Anesthesia was induced by midazolam, sufentanil, propofol, and rocuronium, and blood pressure (BP) and heart rate (HR) were recorded within the first 10 min following endotracheal intubation. PIH was defined as fall in systolic blood pressure (SBP) or mean arterial pressure (MAP) by > 30% of baseline or MAP to < 60 mm Hg.

RESULTS

The area under the receiver operating characteristic curves (AUC) for carotid artery ΔFTc was 0.88 (95%CI, 0.81 to 0.96; P < 0.001), and the optimal cutoff value was -16.57%, with a sensitivity of 91.4% and specificity of 77.60%. The gray zone for carotid artery ΔFTc was -16.34% to -15.36% and included 14% of the patients. The AUC for ΔCDPV was 0.54, with an optimal cutoff value of -1.47%. The sensitivity and specificity were calculated as 55.20% and 57.10%, respectively.

CONCLUSION

The corrected blood flow time changes in the carotid artery induced by sEIOT can predict hypotension following general anesthesia-induced hypotension, wherein ΔFTc less than 16.57% is the threshold.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( www.chictr.org.cn ; 20/06/2023; ChiCTR2300072632).

Effects of acupressure on sleep quality and anxiety of patients with second- or third-degree burns: a randomized sham-controlled trial

BACKGROUND

Although acupressure is proposed to boost sleep quality and alleviate anxiety in various disorders, no trials have yet documented these consequences in burn victims. Considering the high importance of managing sleep quality and anxiety among burn patients utilizing adjunctive non-pharmacological measures, this study sought to investigate the impacts of acupressure on sleep quality and anxiety among a population of Iranian patients with burn injuries.

METHODS

This trial was performed on 72 patients with second- or third-degree burns, who were divided into two equal arms to receive routine care plus 10-minute acupressure on either real acupoints (i.e., Yintang and Shen men) or sham points for three consecutive nights. Sleep quality and anxiety were investigated at baseline (T1) and on the fourth day (T2) by using St. Mary's Hospital Sleep Questionnaire (SMHSQ) and Spielberger's State-Trait Anxiety Inventory for State Anxiety (STAI-S), respectively.

RESULTS

The mean scores of SMHSQ and STAI-S were significantly lower in the real acupressure arm at T2 (P < 0.001 in two cases), implying better sleep quality improvement and higher anxiety alleviation. Also, the reduction in mean changes of SMHSQ and STAI-S scores from T1 to T2 was significantly more in the real acupressure arm (P < 0.001 in two cases).

CONCLUSION

Acupressure, as a low-cost complementary method, could be potentially helpful in enhancing sleep quality and decreasing the anxiety of burn patients. Additional long-term trials are required to identify the sustainability of the findings.

TRIAL REGISTRATION NO

IRCT20130424013110N13 (Registration date: 19/03/2021, https://www.irct.ir/trial/55076 ).

Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution

Importance

The opioid crisis has led to scrutiny of opioid exposures before and after surgical procedures. However, the extent of intraoperative opioid variation and the sources and contributing factors associated with it are unclear.

Objective

To analyze attributable variance of intraoperative opioid administration for patient-, clinician-, and hospital-level factors across surgical and analgesic categories.

Design, Setting, and Participants

This cohort study was conducted using electronic health record data collected from a national quality collaborative database. The cohort consisted of 1 011 268 surgical procedures at 46 hospitals across the US involving 2911 anesthesiologists, 2291 surgeons, and 8 surgical and 4 analgesic categories. Patients without ambulatory opioid prescriptions or use history undergoing an elective surgical procedure between January 1, 2014, and September 11, 2020, were included. Data were analyzed from January 2022 to July 2023.

Main Outcomes and Measures

The rate of intraoperative opioid administration as a continuous measure of oral morphine equivalents (OMEs) normalized to patient weight and case duration was assessed. Attributable variance was estimated in a hierarchical structure using patient, clinician, and hospital levels and adjusted intraclass correlations (ICCs).

Results

Among 1 011 268 surgical procedures (mean [SD] age of patients, 55.9 [16.2] years; 604 057 surgical procedures among females [59.7%]), the mean (SD) rate of intraoperative opioid administration was 0.3 [0.2] OME/kg/h. Together, clinician and hospital levels contributed to 20% or more of variability in intraoperative opioid administration across all analgesic and surgical categories (adjusting for surgical or analgesic category, ICCs ranged from 0.57-0.79 for the patient, 0.04-0.22 for the anesthesiologist, and 0.09-0.26 for the hospital, with the lowest ICC combination 0.21 for anesthesiologist and hosptial [0.12 for the anesthesiologist and 0.09 for the hospital for opioid only]). Comparing the 95th and fifth percentiles of opioid administration, variation was 3.3-fold among anesthesiologists (surgical category range, 2.7-fold to 7.7-fold), 4.3-fold among surgeons (surgical category range, 3.4-fold to 8.0-fold), and 2.2-fold among hospitals (surgical category range, 2.2-fold to 4.3-fold). When adjusted for patient and surgical characteristics, mean (square error mean) administration was highest for cardiac surgical procedures (0.54 [0.56-0.52 OME/kg/h]) and lowest for orthopedic knee surgical procedures (0.19 [0.17-0.21 OME/kg/h]). Peripheral and neuraxial analgesic techniques were associated with reduced administration in orthopedic hip (51.6% [95% CI, 51.4%-51.8%] and 60.7% [95% CI, 60.5%-60.9%] reductions, respectively) and knee (48.3% [95% CI, 48.0%-48.5%] and 60.9% [95% CI, 60.7%-61.1%] reductions, respectively) surgical procedures, but reduction was less substantial in other surgical categories (mean [SD] reduction, 13.3% [8.8%] for peripheral and 17.6% [9.9%] for neuraxial techniques).

Conclusions and Relevance

In this cohort study, clinician-, hospital-, and patient-level factors had important contributions to substantial variation of opioid administrations during surgical procedures. These findings suggest the need for a broadened focus across multiple factors when developing and implementing opioid-reducing strategies in collaborative quality-improvement programs.

Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain.

METHODS

We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I2 statistics. All outcomes were submitted to random-effect models.

RESULTS

Our meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04-1.20; p < 0.01; I2 = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24-0.80; p < 0.01; I2 = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41-0.96; p = 0.03; I2 = 0%) compared to DL.

CONCLUSION

VL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients. Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685 . Registered 6 July 2023.

Evaluating a Pediatric Palliative Care Elective Rotation Through Prompted Reflective Writing and Aligning With Competencies

Background: Hospice and palliative medicine is important in the education of pediatric residents. Little is known about if and how residents' learnings during a pediatric palliative care elective fulfill core competencies and Pediatrics subcompetencies as set forth by the Accreditation Council for Graduate Medical Education (ACGME) and published subspecialty competencies for residents in pediatric hospice and palliative medicine (pHPM). Objectives: To evaluate what residents are learning on a four-week pediatric palliative care elective rotation at a single institution and how these learnings fulfill ACGME and pHPM competencies. Setting/Subjects: Prompted, written reflections were collected from residents completing a pediatric palliative care rotation at a large, urban academic center in the United States between academic years 2016-2017 and 2020-2021. Measurements: A qualitative, inductive reasoning approach was used to analyze reflections for emergent themes and codes. A deductive approach was used to map resulting codes to ACGME core competencies, Pediatric subcompetencies, and pHPM competencies. Results: Twenty-five resident reflections were collected. Inductive analysis revealed three primary themes and 102 codes. These codes were mapped to all six ACGME core competencies and mapped to most Pediatric subcompetencies with the exception of performing a physical examination, organizing and prioritizing patients, diagnostic evaluation, and community and population health. Codes mapped to most pHPM competencies with the exception of two symptom-based competencies, malignant bowel obstruction and severe fatigue. Conclusions: Residents' written reflections following a pediatric palliative care elective rotation demonstrated robust learnings that fulfill many core, specialty, and subspecialty competencies, particularly those that relate to patient- and family-centered care, communication, professionalism, and systems-based practice.

Obesity and Extracorporeal Membrane Oxygenation (ECMO): Analysis of Outcomes

Traditionally, patients with obesity have been deemed ineligible for extracorporeal life support (ELS) therapies such as extracorporeal membrane oxygenation (ECMO), given the association of obesity with chronic health conditions that contribute to increased morbidity and mortality. Nevertheless, a growing body of literature suggests the feasibility, efficacy, and safety of ECMO in the obese population. This review provides an in-depth analysis of the current literature assessing the effects of obesity on outcomes among patients supported with ECMO (venovenous [VV] ECMO in noncoronavirus disease 2019 and coronavirus disease 2019 acute respiratory distress syndrome, venoarterial [VA] ECMO, and combined VV and VA ECMO), offer a possible explanation of the current findings on the basis of the obesity paradox phenomenon, provides a framework for future studies addressing the use of ELS therapies in the obese patient population, and provides guidance from the literature for many of the challenges related to initiating, maintaining, and weaning ELS therapy in patients with obesity.

Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know

ABSTRACT

Pain, agitation, and delirium (PAD) are primary drivers of outcome in the ICU, and expertise in managing these entities successfully is crucial to the intensivist's toolbox. In addition, there are unique aspects of surgical patients that impact assessment and management of PAD. In this review, we address the continuous spectrum of assessment, and management of critically ill surgical patients, with a focus on limiting PAD, particularly incorporating mobility as an anchor to ICU liberation. Finally, we touch on the impact of PAD in specific populations, including opioid use disorder, traumatic brain injury, pregnancy, obesity, alcohol withdrawal, and geriatric patients. The goal of the review is to provide rapid access to information regarding PAD and tools to assess and manage these important elements of critical care of surgical patients.

Fluid Resuscitation and Sepsis Management in Patients with Chronic Kidney Disease or End-Stage Renal Disease: Scoping Review

Managing sepsis and fluid resuscitation in patients with chronic kidney disease or end-stage renal disease is challenging for health care providers. Nurses are essential for early identification and treatment of these patients. Nurse education on assessing perfusion and implementing 3-hour bundled care can improve mortality rates in patients with sepsis. In this scoping review, initial screening identified 1176 articles published from 2015 through 2023 in the National Library of Medicine database; 29 articles were included in the literature summary and evidence synthesis. A systematic review meta-analysis was not possible because of data heterogeneity. The review revealed that most patients with chronic kidney disease or end-stage renal disease received more conservative resuscitation than did the general population, most likely because of concerns about volume overload. However, patients with chronic kidney disease or end-stage renal disease could tolerate the standard initial fluid resuscitation bolus of 30 mL/kg for sepsis. Outcomes in patients with chronic kidney disease or end-stage renal disease were similar to outcomes in patients without those conditions, whether they received standard or conservative fluid resuscitation. Patients who received the standard (higher) fluid resuscitation volume did not have increased rates of complications such as longer duration of mechanical ventilation, increased mortality, or prolonged length of stay. Using fluid responsiveness to guide resuscitation was associated with improved outcomes. The standard initial fluid resuscitation bolus of 30 mL/kg may be safe for patients with chronic kidney disease or end-stage renal disease and sepsis. Fluid responsiveness could be a valuable resuscitation criterion, promoting better decision-making by multidisciplinary teams. Further research is required.

Droxidopa or Atomoxetine for Refractory Hypotension in Critically Ill Cardiothoracic Surgery Patients

OBJECTIVE

To evaluate the effects of droxidopa or atomoxetine on intravenous (IV) vasoactive agent discontinuation in cardiothoracic intensive care unit (ICU) patients with hypotension refractory to midodrine.

DESIGN

Single-center, retrospective cohort study.

SETTING

Tertiary- and quaternary-care university teaching hospital.

PARTICIPANTS

Included patients who received at least 4 consecutive doses of droxidopa or atomoxetine and remained on concurrent midodrine. Patients were excluded if they received study medication before admission, had clinical deterioration after study medication initiation requiring additional vasoactives/escalation of IV vasoactive dosage for at least 12 hours, had a diagnosis of hepatorenal syndrome, were prisoners, or were pregnant.

INTERVENTIONS

Droxidopa, atomoxetine, or both.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was time to discontinuation of IV vasoactive agents after initiation of study medication, analyzed using a Kaplan-Meier estimate with the Wilcoxon method, censoring death within 24 hours of the last dose of study medication. No adjustment for repetitive analyses was made, as the analysis was hypothesis-generating. Of the 72 charts reviewed, 45 patients met inclusion criteria (18 atomoxetine, 17 droxidopa, and 10 both). There were no differences in median time to discontinuation of IV vasoactive agents (21.9 days v 8.0 days v 13.9 days, respectively; p = 0.259) or ICU or hospital length of stay between groups. A higher percentage of patients who survived to hospital discharge received both study medications or droxidopa alone (90% v 76.5%) than atomoxetine alone (44.4%, p = 0.028).

CONCLUSIONS

Droxidopa and atomoxetine are oral vasoactive agents with potential mechanisms to facilitate IV vasopressor weaning for patients in the ICU with hypotension refractory to midodrine, but further prospective research is needed.

Perioperative use of low dose haloperidol safely reduces episodes of postoperative nausea/vomiting and length of stay following elective minimally invasive bariatric surgery

INTRODUCTION

While total intravenous anesthesia (TIVA) protocols include Dexamethasone and Ondansetron prophylaxis, bariatric patients continue to be considered at particularly high risk for postoperative nausea/vomiting (PONV). A multimodal approach for prophylaxis is recommended by the Bariatric Enhanced Recovery After Surgery (ERAS) Society however, there remains a lack of consensus on the optimal strategy to manage PONV in these patients. Haloperidol has been shown at low doses to have a therapeutic effect in treatment of refractory nausea and in PONV prophylaxis in other high risk surgical populations. We sought to investigate its efficacy as a prophylactic medication for PONV in the bariatric population and to identify which perioperative strategies were most effective at reducing episodes of PONV.

METHODS

An institutional bariatric database was created by retrospectively reviewing patients undergoing elective minimally invasive bariatric procedures from 2018 to 2022. Demographic data reviewed included age, gender, preoperative body mass index (BMI), ethnicity, and primary language. Primary endpoints included patient reported episodes of PONV, total doses of Ondansetron administered, need for a second antiemetic (rescue medication), complication rate (most commonly readmission within 30 days), and length of stay. Fisher's exact test, Mann-Whitney test, and ANOVA were used to evaluate the effect of perioperative management on various endpoints.

RESULTS

A total of 475 patients were analyzed with Haloperidol being utilized in 15.8% of all patients. Patients receiving Haloperidol were less likely to require Ondansetron outside of the immediate perioperative period (34.7% vs. 49.8%, p = 0.02), experienced less PONV (41.3% vs. 64.3%, p = 0.01) and also had a decreased median length of stay (27.3 vs. 35.8 h, p < 0.0001).

CONCLUSIONS

Addition of low dose Haloperidol to Bariatric ERAS protocols decreases incidence of PONV and the need for additional antiemetic coverage resulting in a significantly shorter length of stay, increasing the likelihood of safe discharge on postoperative day 1.

Codon Pattern and Context Analysis in Genes Triggering Alzheimer's Disease and Latent Tau Protein Aggregation Post-Anesthesia Exhibited Unique Molecular Patterns Associated with Functional Aspects

Background

Previous reports have demonstrated post-operative dementia and Alzheimer's disease (AD), and increased amyloid-β levels and tau hyperphosphorylation have been observed in animal models post-anesthesia.

Objective

After surgical interventions, loss in memory has been observed that has been found linked with genes modulated after anesthesia. Present study aimed to study molecular pattern present in genes modulated post anesthesia and involved in characters progressing towards AD.

Methods

In the present study, 17 transcript variants belonging to eight genes, which have been found to modulate post-anesthesia and contribute to AD progression, were envisaged for their compositional features, molecular patterns, and codon and codon context-associated studies.

Results

The sequences' composition was G/C rich, influencing dinucleotide preference, codon preference, codon usage, and codon context. The G/C nucleotides being highly occurring nucleotides, CpGdinucleotides were also preferred; however, CpG was highly disfavored at p3-1 at the codon junction. The nucleotide composition of Cytosine exhibited a unique feature, and unlike other nucleotides, it did not correlate with codon bias. Contrarily, it correlated with the sequence lengths. The sequences were leucine-rich, and multiple leucine repeats were present, exhibiting the functional role of neuroprotection from neuroinflammation post-anesthesia.

Conclusions

The analysis pave the way to elucidate unique molecular patterns in genes modulated during anesthetic treatment and might help ameliorate the ill effects of anesthetics in the future.

[Guideline-conform treatment of sepsis]

The time to administration of broad-spectrum antibiotics and (secondarily) to the initiation of hemodynamic stabilization are the most important factors influencing survival of patients with sepsis and septic shock; however, the basic prerequisite for the initiation of an adequate treatment is that a suspected diagnosis of sepsis is made first. Therefore, the treatment of sepsis, even before it has begun, is an interdisciplinary and interprofessional task. This article provides an overview of the current state of the art in sepsis treatment and points towards new evidence that has the potential to change guideline recommendations in the coming years. In summary, the following points are critical: (1) sepsis must be diagnosed as soon as possible and the implementation of a source control intervention (in case of a controllable source) has to be implemented as soon as (logistically) possible. (2) In general, intravenous broad-spectrum antibiotics should be given within the first hour after diagnosis if sepsis or septic shock is suspected. In organ dysfunction without shock, where sepsis is a possible but unlikely cause, the results of focused advanced diagnostics should be awaited before a decision to give broad-spectrum antibiotics is made. If it is not clear within 3 h whether sepsis is the cause, broad-spectrum antibiotics should be given when in doubt. Administer beta-lactam antibiotics as a prolonged (or if therapeutic drug monitoring is available, continuous) infusion after an initial loading dose. (3) Combination treatment with two agents for one pathogen group should remain the exception (e.g. multidrug-resistant gram-negative pathogens). (4) In the case of doubt, the duration of anti-infective treatment should rather be shorter than longer. Procalcitonin can support the clinical decision to stop (not to start!) antibiotic treatment! (5) For fluid treatment, if hypoperfusion is present, the first (approximately) 2L (30 ml/kg BW) of crystalloid solution is usually safe and indicated. After that, the rule is: less is more! Any further fluid administration should be carefully weighed up with the help of dynamic parameters, the patient's clinical condition and echo(cardio)graphy.

Physiotherapy Approach in Transradial Amputation Following the Sequelae of Electric Burn: A Case Report

A considerable amount of mortality and morbidity has been attributed to burn injuries. Because of expanding industrial development, greater consumption of electricity, and electric appliances at home, the number of burns caused by electricity is expanding. When it pertains to addressing burn injuries, therapeutic pursuits are necessary. The 18-year-old female patient in this case reported a history of burns due to electrical shock to her left upper and lower limbs along with her right foot. She came to the hospital, and after necessary investigations and examination, she was suggested for below elbow amputation or transradial amputation with debridement of the wound over the left axilla, foot, and right foot. Following the surgical procedure, the patient had pain, reduced muscle strength, limited joint mobility, and edema. For further rehabilitation, community health physiotherapy was advised. Routine physiotherapy treatment was provided to the patient for fifteen days. We report that after surgery, the effects of physical therapy showed decreased pain intensity, enhanced range of motion (ROM) of the affected and peripheral joints, and improved strength in adjacent muscles.

Right and left ventricular cardiac magnetic resonance imaging derived peak systolic strain is abnormal in children with myocarditis

PURPOSE

Cardiac Magnetic resonance (CMR) derived left ventricular longitudinal and circumferential strain is known to be abnormal in myocarditis. CMR strain is a useful additional tool that can identify subclinical myocardial involvement and may help with longitudinal follow-up. Right ventricular strain derived by CMR in children has not been studied. We sought to evaluate CMR derived biventricular strain in children with acute myocarditis.

METHODS

Children with acute myocarditis who underwent CMR between 2016-2022 at our center were reviewed, this group included subjects with COVID-19 myocarditis. Children with no evidence of myocarditis served as controls Those with congenital heart disease and technically limited images for CMR strain analysis were excluded from final analysis. Biventricular longitudinal, circumferential, and radial peak systolic strains were derived using circle cvi42®. Data between cases and controls were compared using an independent sample t-test. One-way ANOVA with post hoc analysis was used to compare COVID-19, non-COVID myocarditis and controls.

RESULTS

38 myocarditis and 14 controls met inclusion criteria (mean age 14.4 ± 3 years). All CMR derived peak strain values except for RV longitudinal strain were abnormal in myocarditis group. One-way ANOVA revealed that there was a statistically significant difference with abnormal RV and LV strain in COVID-19 myocarditis when compared to non-COVID-19 myocarditis and controls.

CONCLUSION

CMR derived right and left ventricular peak systolic strain using traditionally acquired cine images were abnormal in children with acute myocarditis. All strain measurements were significantly abnormal in children with COVID-19 even when compared to non-COVID myocarditis.

Trends and cardiovascular outcomes of Takotsubo syndrome with cardiogenic shock vs. mixed cardiogenic and septic shock: a nationwide propensity matched analysis

INTRODUCTION

Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, can be complicated by shock. The outcomes of patients with TTS complicated with cardiogenic shock (CS) versus mixed cardiogenic and septic shock (MS) is not known.

METHODS

We queried Nationwide Inpatient Sample (NIS) from 2009-2020 to compare TTS patients with CS and MS using International Classification of Disease, Ninth & Tenth Edition, Clinical Modification (ICD- 9 & 10-CM) coding. In-hospital outcomes were compared using one: one propensity score matched (PSM) analysis. The primary outcome was in-hospital mortality.

RESULTS

Of 23,126 patients with TTS 17,132 (74%) had CS, and 6,269 (26%) had MS. The mean age was 67 years in CS and 66 years in MS, and majority of patients were female (n = 17,775, 77%). On adjusted multivariate analysis, MS patients had higher odds of in-hospital mortality (aOR 1.44, 95% CI 1.36-1.52), AKI (aOR 1.53, 95% CI 1.48-1.58), pressor requirement (aOR 1.37, 95% CI 1.25-1.50). However, had lower odds of MCS use (aOR 0.44, 95% CI 0.40-0.48) and cardiac arrest (aOR: 0.81, 95% CI 0.73-0.90) (p-value <0.0001). Mean LOS and inflation-adjusted hospital charges were higher in MS.

CONCLUSION

MS in the setting of TTS have higher rates of in-hospital mortality, AKI, and pressor requirements.

Postoperative thrombotic events following major surgery in patients with a history of COVID-19: a retrospective cohort analysis of commercially insured beneficiaries in the USA

PURPOSE

We sought to evaluate the synergistic risk of postoperative thrombosis in patients with a history of COVID-19 who undergo major surgery. Major surgery and SARS-CoV-2 infection are independently associated with an increased risk of thrombosis, but the magnitude of additional risk beyond surgery conferred by a COVID-19 history on the development of perioperative thrombotic events has not been clearly elucidated in the literature.

METHODS

We conducted a retrospective cohort study among commercially insured adults in the USA from March 2020 to June 2021 using the Optum Labs Data Warehouse (OLDW), a longitudinal, real-world data asset containing deidentified administrative claims and electronic health records. We compared patients with prior COVID-19 who underwent surgery with control individuals who underwent surgery without a COVID-19 history and with control individuals who did not undergo surgery with and without a COVID-19 history. We assessed the interaction of surgery and previous COVID-19 on perioperative thrombotic events (venous thromboembolism and major adverse cardiovascular events) within 90 days using multivariable logistic regression and interaction analysis.

RESULTS

Two million and two-hundred thousand eligible patients were identified from the OLDW. Patients in the surgical cohorts were older and more medically complex than nonsurgical population controls. After adjusting for confounders, only surgical exposure-not COVID-19 history-remained associated with perioperative thrombotic events (adjusted odds ratio [aOR], 4.07; 95% confidence interval [CI], 3.81 to 4.36). The multiplicative interaction term (aOR, 1.25; 95% CI, 0.96 to 1.61) and the synergy index (0.76; 95% CI, 0.56 to 1.04) suggest minimal effect modification of prior COVID-19 on surgery with regards to overall thrombotic risk.

CONCLUSIONS

We found no evidence of synergistic thrombotic risk from previous COVID-19 in patients who underwent selected major surgery relative to the baseline thrombotic risk from surgery alone.