Advances in critical care management of patients undergoing cardiac surgery

Trends in the Utilization of Multiorgan Support Among Adults Undergoing High-risk Cardiac Surgery in the United States

OBJECTIVES

To examine trends in the prevalence of multiorgan dysfunction (MODS), utilization of multi-organ support (MOS), and mortality among patients undergoing cardiac surgery with MODS who received MOS in the United States.

DESIGN

Retrospective cohort study.

SETTING

183 hospitals in the Premier Healthcare Database.

PARTICIPANTS

Adults ≥18 years old undergoing high-risk elective or non-elective cardiac surgery.

INTERVENTIONS

none.

MEASUREMENTS AND MAIN RESULTS

The exposure was time (consecutive calendar quarters) January 2008 and June 2018. We analyzed hospital data using day-stamped hospital billing codes and diagnosis and procedure codes to assess MODS prevalence, MOS utilization, and mortality. Among 129,102 elective and 136,190 non-elective high-risk cardiac surgical cases across 183 hospitals, 10,001 (7.7%) and 21,556 (15.8%) of patients developed MODS, respectively. Among patients who experienced MODS, 2,181 (22%) of elective and 5,425 (25%) of non-elective cardiac surgical cases utilized MOS. From 2008-2018, MODS increased in both high-risk elective and non-elective cardiac surgical cases. Similarly, MOS increased in both high-risk elective and non-elective cardiac surgical cases. As a component of MOS, mechanical circulatory support (MCS) increased over time. Over the study period, risk-adjusted mortality, in patients who developed MODS receiving MOS, increased in high-risk non-elective cardiac surgery and decreased in high-risk elective cardiac surgery, despite increasing MODS prevalence and MOS utilization (p<0.001).

CONCLUSIONS

Among patients undergoing high-risk cardiac surgery in the United States, MODS prevalence and MOS utilization (including MCS) increased over time. Risk-adjusted mortality trends differed in elective and non-elective cardiac surgery. Further research is necessary to optimize outcomes among patients undergoing high-risk cardiac surgery.

Linking preoperative and early intensive care unit data for prolonged intubation prediction

Objectives

Prolonged intubation (PI) is a frequently encountered severe complication among patients following cardiac surgery (CS). Solely concentrating on preoperative data, devoid of sufficient consideration for the ongoing impact of surgical, anesthetic, and cardiopulmonary bypass procedures on subsequent respiratory system function, could potentially compromise the predictive accuracy of disease prognosis. In response to this challenge, we formulated and externally validated an intelligible prediction model tailored for CS patients, leveraging both preoperative information and early intensive care unit (ICU) data to facilitate early prophylaxis for PI.

Methods

We conducted a retrospective cohort study, analyzing adult patients who underwent CS and utilizing data from two publicly available ICU databases, namely, the Medical Information Mart for Intensive Care and the eICU Collaborative Research Database. PI was defined as necessitating intubation for over 24 h. The predictive model was constructed using multivariable logistic regression. External validation of the model's predictive performance was conducted, and the findings were elucidated through visualization techniques.

Results

The incidence rates of PI in the training, testing, and external validation cohorts were 11.8%, 12.1%, and 17.5%, respectively. We identified 11 predictive factors associated with PI following CS: plateau pressure [odds ratio (OR), 1.133; 95% confidence interval (CI), 1.111-1.157], lactate level (OR, 1.131; 95% CI, 1.067-1.2), Charlson Comorbidity Index (OR, 1.166; 95% CI, 1.115-1.219), Sequential Organ Failure Assessment score (OR, 1.096; 95% CI, 1.061-1.132), central venous pressure (OR, 1.052; 95% CI, 1.033-1.073), anion gap (OR, 1.075; 95% CI, 1.043-1.107), positive end-expiratory pressure (OR, 1.087; 95% CI, 1.047-1.129), vasopressor usage (OR, 1.521; 95% CI, 1.23-1.879), Visual Analog Scale score (OR, 0.928; 95% CI, 0.893-0.964), pH value (OR, 0.757; 95% CI, 0.629-0.913), and blood urea nitrogen level (OR, 1.011; 95% CI, 1.003-1.02). The model exhibited an area under the receiver operating characteristic curve (AUROC) of 0.853 (95% CI, 0.840-0.865) in the training cohort, 0.867 (95% CI, 0.853-0.882) in the testing cohort, and 0.704 (95% CI, 0.679-0.727) in the external validation cohort.

Conclusions

Through multicenter internal and external validation, our model, which integrates early ICU data and preoperative information, exhibited outstanding discriminative capability. This integration allows for the accurate assessment of PI risk in the initial phases following CS, facilitating timely interventions to mitigate adverse outcomes.

Regional Citrate Anticoagulation versus No Anticoagulation for CKRT in Patients with Liver Failure with Increased Bleeding Risk

BACKGROUND

The opinions on the efficacy and safety of no anticoagulation versus regional citrate anticoagulation for continuous KRT (CKRT) were controversial in patients with severe liver failure with a higher bleeding risk. We performed a randomized controlled trial to assess no anticoagulation versus regional citrate anticoagulation for CKRT in these patients.

METHODS

Adult patients with liver failure with a higher bleeding risk who required CKRT were considered candidates. The included participants were randomized to receive regional citrate anticoagulation or no-anticoagulation CKRT. The primary end point was filter failure.

RESULTS

Of the included participants, 44 and 45 were randomized to receive regional citrate anticoagulation and no-anticoagulation CKRT, respectively. The no-anticoagulation group had a significantly higher filter failure rate (25 [56%] versus 12 [27%], P = 0.003), which was confirmed by cumulative incidence function analysis and sensitive analysis including only the first CKRT sessions. In the cumulative incidence function analysis, the cumulative filter failure rates at 24, 48, and 72 hours of the no-anticoagulation and regional citrate anticoagulation groups were 31%, 58%, and 76% and 11%, 23%, and 35%, respectively. Participants in the regional citrate anticoagulation group had significantly higher incidences of Ca 2+tot /Ca 2+ion >2.5 (7% versus 57%, P < 0.001), hypocalcemia (51% versus 82%, P = 0.002), and severe hypocalcemia (13% versus 77%, P < 0.001). However, most (73%) of the increased Ca 2+tot /Ca 2+ion ratios were normalized after the upregulation of the calcium substitution rate. In the regional citrate anticoagulation group, there was no significant additional increase in the systemic citrate concentration after 6 hours.

CONCLUSIONS

For patients with liver failure with a higher bleeding risk who required CKRT, regional citrate anticoagulation resulted in significantly longer filter lifespan than no anticoagulation. However, regional citrate anticoagulation in patients with liver failure was associated with a significantly higher risk of hypocalcemia, severe hypocalcemia, and Ca 2+tot /Ca 2+ion >2.5.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

RCA for CRRT in Liver Failure and High Risk Bleeding Patients, NCT03791190 .

State of the art: Proceedings of the American Association for Thoracic Surgery Enhanced Recovery After Cardiac Surgery Summit

Despite the benefits established for multiple surgical specialties, enhanced recovery after surgery has been underused in cardiac surgery. A cardiac enhanced recovery after surgery summit was convened at the 102nd American Association for Thoracic Surgery annual meeting in May 2022 for experts to convey key enhanced recovery after surgery concepts, best practices, and applicable results for cardiac surgery. Topics included implementation of enhanced recovery after surgery, prehabilitation and nutrition, rigid sternal fixation, goal-directed therapy, and multimodal pain management.

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.

Epidemiologic Study of Intensive Care Unit Admission in South Korea: A Nationwide Population-Based Cohort Study from 2010 to 2019

We aimed to investigate the trends of intensive care unit (ICU) admissions in South Korea from 2010 to 2019. We included all adult patients (≥20 years old) who were admitted to the ICU during hospitalization from 2010 to 2019 in South Korea. There were 3,517,423 ICU admissions of 2,461,848 adult patients. Of the ICU admission cases, 66.8% (2,347,976/3,517,423) were surgery-associated admissions, and the rate of in-hospital mortality after ICU admission was 12.0% (422,155 patients). The most common diagnoses were diseases of the circulatory system (36.8%) and pneumonia (4%). The 30-day, 90-day, and 1-year mortality rates were 16.0%, 23.6%, and 33.3% in 2010, and these values slightly decreased by 2019 to 14.7%, 22.1%, and 31.7%, respectively. The proportions of continuous renal replacement therapy (CRRT) use and extracorporeal membrane oxygenation (ECMO) support were 2.0% and 0.3% in 2010, and these values gradually increased by 2019 to 4.7% and 0.8%, respectively. Although the age and cost of hospitalization among critically ill patients who were admitted to the ICU increased from 2010 to 2019, the mortality rate decreased slightly. Moreover, the proportions of ECMO support and CRRT use had increased in our South Korean cohort.

The value of bioactive adrenomedullin and dipeptidyl peptidase 3 to predict short-term unfavourable outcomes after cardiac surgery: A prospective cohort study

BACKGROUND

Adrenomedullin (ADM) is a key regulator of endothelial barrier function and vascular tone. Dipeptidyl peptidase 3 (DPP3) is a protease involved in the degradation of several cardiovascular mediators. Increased levels of bioactive ADM (bio-ADM) and circulating DPP3 (cDPP3) were found to predict short-term outcome in cardiogenic shock patients.

OBJECTIVES

To investigate the unknown temporal profiles of bio-ADM and cDPP3 and their association with short-term outcome following cardiac surgery.

DESIGN

Prospective observational study of 203 adult cardiac surgery patients admitted to the intensive care unit (ICU) postoperatively. Plasma bio-ADM and cDPP3 levels were measured at ICU admission (day 1) and on days 2 and 3.

MAIN OUTCOME MEASURES

Biomarker prediction of prolonged vasopressor dependency (>3 days), acute kidney injury (AKI) and prolonged ICU length of stay (ICU-LOS) (>3 days).

RESULTS

bio-ADM and cDPP3 levels displayed distinct temporal profiles following cardiac surgery. cDPP3 levels were highest on day 1 and strongly correlated with surgical complexity and duration but subsequently normalised on day 2 in most patients. In contrast, bio-ADM levels on day 1 were within the normal range but subsequently increased. Day 2 bio-ADM levels were strongly associated with study outcomes: the area under the receiver-operating curves (AUROC) were 0.82 (95% CI, 0.72 to 0.92) for prolonged vasopressor dependency, 0.87 (0.81 to 0.92) for AKI and 0.82 (0.75 to 0.90) for prolonged ICU-LOS (all P < 0.0001). cDPP3 levels on day 2 also predicted these outcomes, albeit to a lesser extent, with AUROCs of 0.73 (95% CI, 0.64 to 0.81) for prolonged vasopressor dependency, 0.69 (0.61 to 0.77) for AKI and 0.70 (0.62 to 0.79) for prolonged ICU-LOS (all P < 0.0001).

CONCLUSION

Following cardiac surgery, increased bio-ADM levels are strongly associated with unfavourable short-term outcomes, whereas cDPP3 levels are mainly related to surgery complexity and duration. On the basis of these findings, ADM-modulating therapies may have beneficial effects in cardiac surgery patients whereas DPP3-targeted therapies should be reserved for patient categories with higher baseline disease severity.

Mortality Trends after Extracorporeal Membrane Oxygenation Support: A Korean Nationwide Cohort

BACKGROUND

This study aimed to investigate the prevalence of 7-, 30-, 60-, and 365-day overall and cause-specific mortality following extracorporeal membrane oxygenation (ECMO) support.

METHODS

The National Health Insurance claims database in South Korea was the data source for this population-based cohort study. We enrolled all adult patients aged ≥18 years receiving intensive care unit ECMO support from January 1, 2005 to December 31, 2018. The study population was divided into three groups based on the main diagnoses during ECMO support: 1) cardiovascular, 2) respiratory, and 3) other diagnoses group (all other main diagnoses rather than cardiovascular or respiratory diseases).

RESULTS

A total of 18,697 patients were included in the final analysis (64.5%, 10.9%, and 24.6% in the cardiovascular, respiratory, and other groups, respectively). The corresponding 7-, 30-, 60-, and 365-day mortality rates in these groups were 33.1%, 56.1%, 62.4%, and 67.7%. Kaplan-Meier curves demonstrated that the median survival time was shortest in the cardiovascular group (12.0 days, 95% confidence interval [CI]: 11.3-12.7), with 31.0 (95% CI: 28.5-33.6) and 49.0 (95% CI: 44.4-57.6) day survival in the respiratory and other diagnoses groups (p<0.001).

CONCLUSIONS

Approximately one-third of patients died within 7 days, half of the patients died within 30 days, and two-thirds died within 365 days of ECMO support. Overall survival time was shortest in the cardiovascular group, followed by that of the respiratory group.

S100B in cardiac surgery brain monitoring: friend or foe?

Recent advances in perioperative management of adult and pediatric patients requiring open heart surgery (OHS) and cardiopulmonary bypass (CPB) for cardiac and/or congenital heart diseases repair allowed a significant reduction in the mortality rate. Conversely morbidity rate pattern has a flat trend. Perioperative period is crucial since OHS and CPB are widely accepted as a deliberate hypoxic-ischemic reperfusion damage representing the cost to pay at a time when standard of care monitoring procedures can be silent or unavailable. In this respect, the measurement of neuro-biomarkers (NB), able to detect at early stage perioperative brain damage could be especially useful. In the last decade, among a series of NB, S100B protein has been investigated. After the first promising results, supporting the usefulness of the protein as predictor of short/long term adverse neurological outcome, the protein has been progressively abandoned due to a series of limitations. In the present review we offer an up-dated overview of the main S100B pros and cons in the peri-operative monitoring of adult and pediatric patients.

Limb Amputation Following Extracorporeal Membrane Oxygenation Therapy Among Survivors: A Nationwide Cohort Study from South Korea

We aimed to investigate the incidence of limb amputation due to vascular complications related to extracorporeal membrane oxygenation (ECMO) therapy among survivors and examine its association with long-term mortality in these cases. Data from the National Health Insurance Service database in South Korea were extracted for this population-based cohort study. Adult people who underwent ECMO therapy between 2005 and 2018 were included. ECMO survivors were defined as those who survived for at least 365 days after the initiation of ECMO therapy. A total of 6,968 ECMO survivors were included in the study. Among them, 114 (1.6%) underwent limb amputation within 365 days of starting ECMO therapy. On multivariable Cox regression analysis, the risk of 3-year all-cause mortality was not significantly associated with limb amputation compared with those without limb amputation (hazard ratio: 1.53; 95% CI: 0.89-2.63; P = 0.072). In South Korea, 1.6% of ECMO survivors underwent limb amputation within 365 days after initiating ECMO therapy; however, it was not significantly associated with the 3-year all-cause mortality. Our findings warrant future studies on the impact on the quality of life and morbidity-related implications among patients who undergo limb amputation due to ECMO therapy.

Development and Validation of a Diagnostic Model to Predict the Risk of Ischemic Liver Injury After Stanford A Aortic Dissection Surgery

Objective: To define the risk factors of ischemic liver injury (ILI) following Stanford A aortic dissection surgery and to propose a diagnostic model for individual risk prediction. Methods: We reviewed the clinical parameters of ILI patients who underwent cardiac surgery from Beijing Anzhen Hospital, Capital Medical University between January 1, 2015 and October 30, 2020. The data was analyzed by the use of univariable and multivariable logistic regression analysis. A risk prediction model was established and validated, which showed a favorable discriminating ability and might contribute to clinical decision-making for ILI after Stanford A aortic dissection (AAD) surgery. The discriminative ability and calibration of the diagnostic model to predict ILI were tested using C statistics, calibration plots, and clinical usefulness. Results: In total, 1,343 patients who underwent AAD surgery were included in the study. After univariable and multivariable logistic regression analysis, the following variables were incorporated in the prediction of ILI: pre-operative serum creatinine, pre-operative RBC count <3.31 T/L, aortic cross-clamp time >140 min, intraoperative lactic acid level, the transfusion of WRBC, atrial fibrillation within post-operative 24 h. The risk model was validated by internal sets. The model showed a robust discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.718. The calibration plots for the probability of perioperative ischemic liver injury showed coherence between the predictive probability and the actual probability (Hosmer-Lemeshow test, P = 0.637). In the validation cohort, the nomogram still revealed good discrimination (C statistic = 0.727) and good calibration (Hosmer-Lemeshow test, P = 0.872). The 10-fold cross-validation of the nomogram showed that the average misdiagnosis rate was 9.95% and the lowest misdiagnosis rate was 9.81%. Conclusion: Our risk model can be used to predict the probability of ILI after AAD surgery and have the potential to assist clinicians in making treatment recommendations.

Delirium and Long-Term Outcomes among Survivors of Extracorporeal Membrane Oxygenation Therapy: A Nationwide Cohort Study in South Korea

Background: The prevalence of delirium and its association with long-term outcomes of extracorporeal membrane oxygenation (ECMO) therapy have not yet been identified. We aimed to investigate the prevalence of delirium and its associated factors during hospitalization among ECMO survivors. We also examined whether the occurrence of delirium was associated with 1-year all-cause mortality among ECMO survivors. Methods: As a population-based cohort study, data were obtained from the National Health Insurance Service database in South Korea. Adults older than 18 years who received ECMO therapy between 2005 and 2018 were included in this study. ECMO survivors were defined as patients who were discharged from the hospital. Results: The analysis included a total of 8153 ECMO survivors, of whom 551 (6.8%) experienced delirium during hospitalization. Older age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: 1.00-1.02; P = 0.004), male sex (OR: 1.38, 95% CI: 1.13-1.68; P = 0.002), underlying depression (OR: 1.90, 95% CI: 1.49-2.41; P < 0.001), and longer length of hospital stay (OR: 1.02, 95% CI: 1.02-1.03; P < 0.001) were associated with a higher incidence of delirium. In multivariable Cox regression modeling, the occurrence of delirium was not significantly associated with the risk of 1-year all-cause mortality (hazard ratio: 0.90, 95% CI: 0.76-1.07; P = 0.229). Conclusion: The prevalence of delirium among ECMO survivors during hospitalization was 6.8% in South Korea, and old age, male sex, longer duration of hospital stay, and underlying depression were associated with it. However, there was no significant association between delirium and 1-year all-cause mortality among ECMO survivors.

Prior Antiplatelet Therapy and Stroke Risk in Critically Ill Patients Undergoing Extracorporeal Membrane Oxygenation

We aimed to investigate whether prior exposure to antiplatelet therapy (anti-PLT) was associated with stroke incidence after the initiation of extracorporeal membrane oxygenation (ECMO) therapy. We conducted a population-based cohort study based on health records obtained from the National Health Insurance Service database in South Korea. Adult patients (aged ≥ 18 years) who underwent ECMO therapy in the intensive care unit during 2009-2018 were enrolled. In total, 17,237 patients who underwent ECMO therapy were included; stroke occurred in 779 (4.5%) of 17,237 patients within 7 days of initiating the ECMO therapy. The number of patients in the anti-PLT and control groups was 3909 (22.7%) and 13,328 (77.3%), respectively. In the multivariable logistic regression analysis, the anti-PLT group showed 33% lower incidence of stroke than the control group (odds ratio (OR): 0.67, 95% confidence interval (CI): 0.55-0.82; p < 0.001). The cardiovascular group showed 35% lower incidence of stroke than the control group (OR: 0.65, 95% CI: 0.52-0.78; p < 0.001), whereas the respiratory group (p = 0.821) and the other group (p = 0.705) did not show any significant association. Prior anti-PLT therapy was associated with a lower incidence of stroke within 7 days of initiating ECMO therapy, which was more evident in the cardiovascular group.

Insomnia disorder and long-term mortality in adult patients treated with extracorporeal membrane oxygenation in South Korea

We investigated the prevalence of insomnia in extracorporeal membrane oxygenation (ECMO)-treated patients and examined the association between post-ECMO insomnia disorder and long-term mortality. In the present population-based cohort study, we used data from the National Health Insurance Claims database in South Korea. All adult patients who underwent ECMO between 2006 and 2014 were included, and ECMO-treated patients were defined as those who survived >365 days after ECMO. Insomnia disorder was identified using the International Classification of Diseases 10th Revision codes G47.0 and F51.0. Overall, 3,055 ECMO-treated patients were included in the final analysis: 431 (14.1%) had pre-ECMO insomnia disorder, while 148 (4.8%) were newly diagnosed with insomnia disorder up to 1 year after ECMO. In multivariable Cox regression model, patients with post-ECMO insomnia disorder had higher 5-year all-cause mortality (ACM) than controls (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.21-2.42; p = 0.003); however, those with pre-ECMO insomnia disorder did not (p = 0.655). In sensitivity analysis, post-ECMO insomnia disorder with underlying psychiatric illness was associated with a 2.39-fold higher 5-year ACM in ECMO-treated patients (HR 2.39, 95% CI 1.52-3.75; p < 0.001). In conclusion, at 1-year after ECMO, 4.8% of ECMO-treated patients were newly diagnosed with insomnia disorder, and post-ECMO insomnia disorder was associated with higher 5-year ACM, especially in those with underlying psychiatric illness. Our present results suggest that the development of insomnia disorder might be related to poorer long-term survival in ECMO-treated patients, especially in case of underlying psychiatric illness.

Chronic respiratory disease and survival outcomes after extracorporeal membrane oxygenation

Background

Quality of life following extracorporeal membrane oxygenation (ECMO) therapy is an important health issue. We aimed to describe the characteristics of patients who developed chronic respiratory disease (CRD) following ECMO therapy, and investigate the association between newly diagnosed post-ECMO CRDs and 5-year all-cause mortality among ECMO survivors.

Methods

We analyzed data from the National Health Insurance Service in South Korea. All adult patients who underwent ECMO therapy in the intensive care unit between 2006 and 2014 were included. ECMO survivors were defined as those who survived for 365 days after ECMO therapy. Chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease, lung cancer, lung disease due to external agents, obstructive sleep apnea, and lung tuberculosis were considered as CRDs.

Results

A total of 3055 ECMO survivors were included, and 345 (11.3%) were newly diagnosed with CRDs 365 days after ECMO therapy. The prevalence of asthma was the highest at 6.1% (185). In the multivariate logistic regression, ECMO survivors who underwent ECMO therapy for acute respiratory distress syndrome (ARDS) or respiratory failure had a 2.00-fold increase in post-ECMO CRD (95% confidence interval [CI]: 1.39 to 2.89; P < 0.001). In the multivariate Cox regression, newly diagnosed post-ECMO CRD was associated with a 1.47-fold (95% CI: 1.17 to 1.86; P = 0.001) higher 5-year all-cause mortality.

Conclusions

At 12 months after ECMO therapy, 11.3% of ECMO survivors were newly diagnosed with CRDs. Patients who underwent ECMO therapy for ARDS or respiratory failure were associated with a higher incidence of newly diagnosed post-ECMO CRD compared to those who underwent ECMO for other causes. Additionally, post-ECMO CRDs were associated with a higher 5-year all-cause mortality. Our results suggest that ECMO survivors with newly diagnosed post-ECMO CRD might be a high-risk group requiring dedicated interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01796-8.

Long-term mortality associated with depression among South Korean survivors of extracorporeal membrane oxygenation

INTRODUCTION

Depression is an important sequela in critically ill patients. However, its prevalence after extracorporeal membrane oxygenation (ECMO) therapy and its association with long-term mortality remain controversial.

METHODS

Data were extracted from the South Korean National Health Insurance Service database in this population-based cohort study. Adults who received ECMO therapy from 2006 to 2014 were included. Survivors of ECMO were defined as patients who underwent ECMO and survived over 365 days after the initiation of ECMO therapy.

RESULTS

A total of 3,055 survivors of ECMO were included in the final analysis. They were classified into the pre-ECMO depression group (n = 275 [9.0%]), post-ECMO depression group (n = 331 [10.8%]), and other ECMO survivor group. In the multivariable Cox regression model, a 1.52-fold higher mortality was observed in the post-ECMO depression group than in the other groups (hazard ratio, 1.52; 95% confidence interval, 1.17-1.96; p = .002). However, there was no statistically significant difference between the pre-ECMO depression group and the other groups (p = .075).

CONCLUSIONS

The prevalence of pre- and post-ECMO depression was 9.0% and 10.8%, respectively. Additionally, post-ECMO depression was associated with an increased 5 year all-cause mortality; however, pre-ECMO depression was not.

Trends in extracorporeal membrane oxygenation treatment from 2005 to 2018 in South Korea

INTRODUCTION

This study aimed to investigate trends in extracorporeal membrane oxygenation (ECMO) treatment during 2005-2018 and examine factors associated with in-hospital mortality.

METHODS

We conducted a population-based cohort study based on health records obtained from the National Health Insurance Service database in South Korea. All adult patients (⩾18 years old) who received ECMO treatment in the intensive care unit after hospitalization from 2005 to 2018 were enrolled.

RESULTS

We analyzed data for 21,129 adult ECMO patients from 128 hospitals. The prevalence of ECMO treatment gradually and continuously increased from 4 per 100,000 individuals (95% confidence interval [CI]: 3-4) in 2005 to 67.4 per 100,000 individuals (95% CI: 65-68) in 2018. There was a significant increase in ECMO treatment for acute respiratory distress syndrome (ARDS) or respiratory failure (from 2.5% during 2005-2008 to 14.5% during 2016-2018). The overall in-hospital and 30-day mortality rates of the patients were 48.4% and 53.5%, respectively. The in-hospital mortality rate was highest among patients with shock (62.1%) and lowest among ECMO patients with liver failure (21.6%). On multivariable logistic regression, a higher hospital case volume was associated with improvement in in-hospital mortality (p < 0.001).

CONCLUSIONS

In South Korea, the prevalence of ECMO treatment has increased gradually and continuously between 2005 and 2018. There was a significant increase in the prevalence of ECMO treatment for ARDS or respiratory failure. Our results support that ECMO treatment indications have been expanding, and ECMO will become vital for treating critically ill patients in the future.

Weekend effect in extracorporeal membrane oxygenation therapy initiation: a nationwide cohort study in South Korea

Background

Extracorporeal membrane oxygenation (ECMO) therapy requires close monitoring and optimal management after initiation. However, it remains unclear whether the day of the week of ECMO initiation affects patient outcomes. We aimed to investigate whether the initiation of ECMO therapy during a weekend was associated with increased mortality risk.

Methods

We performed a population-level cohort study, based on health records obtained from the National Health Insurance Service database in South Korea. All critically ill adult patients who received ECMO therapy in the intensive care unit during 2005-2018 were enrolled. The primary endpoint was the 60-day mortality rate following ECMO therapy. Multivariable Cox regression was used for the analysis.

Results

Data from a total of 21,129 ECMO patients were included in the analysis, of whom 12,825 (60.7%) died within 60 days. There were 4,647 (22.0%) patients who received ECMO therapy during a weekend (weekend group). Multivariable Cox regression revealed that the weekend group was at increased risk of 60-day mortality compared to the weekday group (hazard ratio: 1.05, 95% confidence interval: 1.01 to 1.09; P=0.025). In the sensitivity analysis, ECMO patients whose therapy started on a Saturday were at higher risk of 60-day mortality (hazard ratio relative to those whose therapy started on a Wednesday: 1.11, 95% confidence interval: 1.04-1.19; P=0.003). However, starting ECMO therapy on other weekdays (Thursday, Friday, Sunday, Monday, or Tuesday) did not affect mortality outcomes (P>0.05).

Conclusions

ECMO therapy initiated during a weekend was associated with a slightly increased risk of 60-day mortality compared to that associated with ECMO therapy initiated on a weekday. This association was more evident in patients who received ECMO therapy that started on a Saturday. Further studies are needed to confirm these findings.

Quality of Life and Long-Term Mortality Among Survivors of Extracorporeal Membrane Oxygenation: A Nationwide Cohort Study in South Korea

OBJECTIVES

The quality of life after extracorporeal membrane oxygenation therapy has emerged as an important issue for extracorporeal membrane oxygenation survival; however, its association with long-term prognosis has not been identified. We investigated the changes in the quality of life after extracorporeal membrane oxygenation among the survivors and examine the association between a worse quality of life and 3-year all-cause mortality.

DESIGN

This was a population-based cohort study.

SETTING

Data were obtained from the National Health Insurance Service database in South Korea.

PATIENTS

Adult individuals (≥ 18 yr old) who received extracorporeal membrane oxygenation therapy from 2006 to 2017 were included. Extracorporeal membrane oxygenation survivors were defined as patients who had survived for 1-year after the initiation of extracorporeal membrane oxygenation therapy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The income level, employment status, and registered disability were examined before and 1-year after extracorporeal membrane oxygenation therapy. The decreased income level, job loss, and newly acquired disability were considered as change in the quality of life among extracorporeal membrane oxygenation survivors. A total of 5,821 adult extracorporeal membrane oxygenation survivors were included in the final analysis, and 2,959 patients (50.8%) experienced quality of life change. Specifically, 1,782 patients (30.6%) experienced a decrease in income, 682 (11.7%) lost their jobs, and 1,540 (26.5%) had a new disability within 1-year after extracorporeal membrane oxygenation therapy. In the multivariable Cox regression model, newly acquired disability was associated with 2.31-fold higher 3-year all-cause mortality among extracorporeal membrane oxygenation survivors (hazard ratio, 2.31; 95% CI, 1.79-2.97; p < 0.001), while job loss (p = 0.180) and decreased income (p = 0.993) were not associated with the 3-year all-cause mortality.

CONCLUSIONS

At 12 months after extracorporeal membrane oxygenation therapy, nearly half survivors experienced quality of life worsening such as unemployment, decreased income, and new disability. Additionally, among the three factors, acquiring a new disability might significantly increase the 3-year mortality. This is the first study to report the association between changes in the quality of life and long-term prognosis in extracorporeal membrane oxygenation survivors.

Scoring Systems for Risk Stratification in Patients Undergoing Cardiac Surgery

Cardiac surgery is associated with significant mortality rates. Careful selection of surgical candidates is, therefore, vital to optimize morbidity and mortality outcomes. Risk scores can be used to inform this decision-making process. The European System for Cardiac Operative Risk Evaluation Score and the Society of Thoracic Surgeons score are among the most commonly used risk scores. There are many other scoring systems in existence; however, no perfect scoring system exists, therefore, additional research is needed as clinicians strive toward a more idealized risk stratification model. The purpose of this review is to discuss the advantages and limitations of some of the most commonly used risk stratification systems and use this to determine what an ideal scoring system might look like. This includes not only the generalizability of available scores but also their ease of use and predictive power.

Prior Statin Therapy and Mortality After Extracorporeal Membrane Oxygenation Therapy: A Retrospective, Population-Based, Cohort Study

OBJECTIVE

To investigate whether prior statin therapy is associated with an improvement in mortality among patients who undergo extracorporeal membrane oxygenation (ECMO) therapy.

DESIGN

Retrospective, population-based, cohort study.

SETTING

Health records were obtained from the National Health Insurance Service database in South Korea.

PATIENTS

All adult patients (≥18 y) who underwent ECMO therapy in the intensive care unit between 2005 and 2018 were enrolled.

EXPOSURES

Statin users were defined as patients who were prescribed continuous oral statins ≥90 days before ECMO.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint of this study was 90-day mortality. A total of 21,129 adult patients from 128 hospitals were included (4,737 [22.4%] statin users and 16,392 [77.6%] nonusers). After propensity score matching, 9,474 ECMO patients (4,737 in each group) were included in the final analysis. In the propensity-score-matched cohort, statin users exhibited lower 90-day mortality than did nonusers (58.6% [2,774/4,737] in statin users v 65.6% [3,106/4,737] in nonusers). In addition, on Cox regression, 90-day mortality in statin users was 14% less than that in nonusers (hazard ratio 0.86, 95% confidence interval 0.81-0.90; p < 0.001).

CONCLUSION

Among patients who underwent ECMO in South Korea, prior statin therapy was found to be associated with lower 90-day mortality rates after ECMO therapy. However, because this study had a retrospective design, future prospective trials are needed to confirm the findings.

Post-operative renal failure management in mechanical circulatory support patients

Acute kidney injury (AKI) occurs commonly in patients requiring mechanical circulatory support (MCS) after cardiothoracic surgery. The prognostic implications of AKI in this patient group relate closely to the pathophysiology and risk factors associated with the underlying disease; pre-operative, intra-operative, and post-operative variables; hemodynamic factors; and type of support device used. General approaches to AKI management, including prevention strategies, medical management, and hemodynamic support, are also applicable in patients requiring MCS. Approaches to renal replacement therapy vary depend on patient factors, device-specific factors, and local preferences and experience. In this invited narrative review, we discuss the pathophysiology, risk factors, and prognostic implications of AKI in post-operative adult patients following institution of MCS. Management strategies for AKI are presented with a focus on those supported with either extracorporeal membrane oxygenation or a ventricular assist device.

Managing Vasoactive Medications Following Cardiothoracic Surgery

This article reviews the use of vasoactive medications prescribed in the postoperative management of patients who have undergone cardiac surgery. With a focus on the influence these medications have on the physiologic contributors to cardiac output and blood pressure, insight into decision making related to use, titration, and discontinuation of these medications is provided. Case studies offer vignettes to demonstrate the application of knowledge gleaned from the article.

Die traumatische Aortenruptur

Verkehrsunfälle sind für den größten Teil der traumatischen Aortenrupturen verantwortlich, meist zusammen mit weiteren schweren Begleitverletzungen. Die prähospitale Sterblichkeit ist hoch. Bei Verdacht auf eine beteiligte Aortenverletzung, aufgrund eines hohen traumatic aortic injury scores, ist eine Computertomographie durchzuführen. Es erfolgt eine Triage der Verletzungen, und die Versorgungspriorität der Aorta richtet sich nach dem Schweregrad der Aorten- und Begleitverletzungen sowie dem Zustand des Patienten. Bis zur definitiven Versorgung der aortalen Läsion muss der Blutdruck konsequent gesenkt werden. Grad I und II können in Einzelfällen unter enger Kontrolle inital konservativ gemanagt werden. Grad III (gedeckte Ruptur) und Grad IV (freie Ruptur) benötigen eine raschestmögliche Versorgung (interventionell, chirurgisch). In ausgesuchten Fällen kann auch eine verzögerte Versorgung günstig sein.

Als bevorzugte Versorgungsform hat sich die interventionelle Stentgrafttherapie etabliert.

Near-Infrared-Based Cerebral Oximetry for Prediction of Severe Acute Kidney Injury in Critically Ill Children After Cardiac Surgery

Supplemental Digital Content is available in the text.

Cerebral oximetry by near-infrared spectroscopy is used frequently in critically ill children but guidelines on its use for decision making in the PICU are lacking. We investigated cerebral near-infrared spectroscopy oximetry in its ability to predict severe acute kidney injury after pediatric cardiac surgery and assessed its additional predictive value to routinely collected data.