Search

Purpose: To evaluate the accuracy of ProAQT® sensor in patients who underwent cardiac surgery. Less-invasive monitoring, such as arterial pulse contour analysis (ProAQT® sensor), represents an alternative when hemodynamic monitoring is necessary for guiding postoperative resuscitation but invasive monitoring is not technically possible. Methods: Prospective observational study in a Surgical Intensive Care Unit of a tertiary university hospital. Ten patients who underwent cardiac surgery were included. We compared cardiac index (CI) measured simultaneously by ProAQT® sensor (i.e., radial arterial pressure waveform) with pulmonary arterial catheter (PAC). Parameters were assessed at predefined time points during early postoperative courses (6h, 12h, 24h, 48h and 72h). The degree of agreement with CI between PAC and ProAQT® sensors across time points was measured by the concordance correlation coefficient, Bland-Altman and four-quadrant plot analyses.Results: Sixty-three pairs of measurements were analyzed. We showed that measurements of CI were slightly higher with PAC (β ̂=-0.146, p-value=0.094). The concordance correlation coefficient for the additive model of CI was 0.64 (95% Confidence Interval: 0.36, 0.82), indicating a high concordance between both sensors. Bland-Altmann analysis showed a mean bias of 0.45 L·min-1·m-2, limits of agreement from -1.65 to 2.3 L·min-1·m-2, and percentage of error was 82.5%. Four-quadrant plot of changes in CI showed a good concordance rate (75%), which increases after applying the exclusion zone (87%).Conclusion: In patients undergoing cardiac surgery, the ProAQT® sensor may be useful to monitor CI and it may provide a reliable estimate of its absolute value during postoperative period.

Background The prospective identification of patients at high risk for hospital-acquired/ventilator-associated bacterial pneumonia may improve clinical trial feasibility and foster antibacterial development. In a prior study conducted in the United States, clinical criteria were used to prospectively identify these patients; however, these criteria have not been applied in a European population. Methods Adults considered high risk for pneumonia (treatment with ventilation or high levels of supplemental oxygen) in the intensive care units of 7 European hospitals were prospectively enrolled from June 12 to December 27, 2017. We estimated the proportion of high-risk patients developing pneumonia according to US Food and Drug Administration guidance and a subset potentially eligible for antibacterial trial enrollment. We compared patient characteristics, treatment exposures, and pneumonia incidence in a European cohort and a previously described US cohort. Results Of 888 high-risk patients, 211/888 (24%) were treated for possible pneumonia, and 150/888 (17%) met the Food and Drug Administration definition for hospital-acquired/ventilator-associated bacterial pneumonia. A higher proportion of European patients treated for possible pneumonia met the pneumonia definition (150/211 [71%] vs 537/1464 [37%]; P Conclusions Clinical criteria prospectively identified high-risk patients with high rates of pneumonia in the European cohort. Despite higher rates of established risk factors and incident pneumonia, European patients were significantly less likely to receive antibiotics for possible pneumonia than US patients. Different treatment practices may contribute to lower rates of antibacterial trial enrollment in the United States.

Background: The importance of artificial nutritional therapy is underrecognized, typically being considered an adjunctive rather than a primary therapy. We aimed to evaluate the influence of nutritional therapy on mortality in critically ill patients.Methods: This multicenter prospective observational study included adult patients needing artificial nutritional therapy for >48 h if they stayed in one of 38 participating intensive care units for ≥72 h between April and July 2018. Demographic data, comorbidities, diagnoses, nutritional status and therapy (type and details for ≤14 days), and outcomes were registered in a database. Confounders such as disease severity, patient type (e.g., medical, surgical or trauma), and type and duration of nutritional therapy were also included in a multivariate analysis, and hazard ratios (HRs) and 95% confidence intervals (95%CIs) were reported.Results: We included 639 patients among whom 448(70.1%) and 191(29.9%) received enteral and parenteral nutrition, respectively. Mortality was 25.6%, with non-survivors having the following characteristics: older age; more comorbidities; higher Sequential Organ Failure Assessment (SOFA) scores (6.6±3.3 vs 8.4±3.7; P); greater nutritional risk (Nutrition Risk in the Critically Ill [NUTRIC] score: 3.8±2.1 vs 5.2±1.7; P); more vasopressor requirements (70.4% vs 83.5%; P=0.001); and more renal replacement therapy (12.2% vs 23.2%; P=0.001). Multivariate analysis showed that older age (HR: 1.023; 95% CI: 1.008–1.038; P=0.003), higher SOFA score (HR: 1.096; 95% CI: 1.036–1.160; P=0.001), higher NUTRIC score (HR: 1.136; 95% CI: 1.025–1.259; P=0.015), requiring parenteral nutrition after starting enteral nutrition (HR: 2.368; 95% CI: 1.168–4.798; P=0.017), and a higher mean Kcal/Kg/day intake (HR: 1.057; 95% CI: 1.015–1.101; P=0.008) were associated with mortality. By contrast, a higher mean protein intake protected against mortality (HR: 0.507; 95% CI: 0.263–0.977; P=0.042).Conclusions: Old age, higher organ failure scores, and greater nutritional risk appear to be associated with higher mortality. Patients who need parenteral nutrition after starting enteral nutrition may represent a high-risk subgroup for mortality due to illness severity and problems receiving appropriate nutritional therapy. Mean calorie and protein delivery also appeared to influence outcomes.Trial Registration: ClinicaTrials.gov NCT: 03634943.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Sepsis and septic shock are severe inflammatory conditions related to high morbidity and mortality. We performed a systematic review with meta-analysis of randomized trials to assess whether extracorporeal blood purification reduces mortality in this setting. Methods Electronic databases were searched for pertinent studies up to January 2019. We included randomized controlled trials on the use of hemoperfusion, hemofiltration without a renal replacement purpose, and plasmapheresis as a blood purification technique in comparison to conventional therapy in adult patients with sepsis and septic shock. The primary outcome was mortality at the longest follow-up available. We calculated relative risks and 95% CIs. The grading of recommendations assessment, development and evaluation methodology for the certainty of evidence was used. Results Thirty-seven trials with 2,499 patients were included in the meta-analysis. Hemoperfusion was associated with lower mortality compared to conventional therapy (relative risk = 0.88 [95% CI, 0.78 to 0.98], P = 0.02, very low certainty evidence). Low risk of bias trials on polymyxin B immobilized filter hemoperfusion showed no mortality difference versus control (relative risk = 1.14 [95% CI, 0.96 to 1.36], P = 0.12, moderate certainty evidence), while recent trials found an increased mortality (relative risk = 1.22 [95% CI, 1.03 to 1.45], P = 0.02, low certainty evidence); trials performed in the United States and Europe had no significant difference in mortality (relative risk = 1.13 [95% CI, 0.96 to 1.34], P = 0.15), while trials performed in Asia had a positive treatment effect (relative risk = 0.57 [95% CI, 0.47 to 0.69], P < 0.001). Hemofiltration (relative risk = 0.79 [95% CI, 0.63 to 1.00], P = 0.05, very low certainty evidence) and plasmapheresis (relative risk = 0.63 [95% CI, 0.42 to 0.96], P = 0.03, very low certainty evidence) were associated with a lower mortality. Conclusions Very low-quality randomized evidence demonstrates that the use of hemoperfusion, hemofiltration, or plasmapheresis may reduce mortality in sepsis or septic shock. Existing evidence of moderate quality and certainty does not provide any support for a difference in mortality using polymyxin B hemoperfusion. Further high-quality randomized trials are needed before systematic implementation of these therapies in clinical practice.

Objectives:The effects of vitamin C administration on clinical outcome in critically ill patients remain controversial.Data Sources:Online databases were searched up to October 1, 2018.Study Selection:We included randomized controlled trials on the use of vitamin C (any regimen) in adult critically

Background: Prospective identification of patients at high risk of nosocomial pneumonia may improve clinical trial feasibility and foster antibacterial development. Clinical criteria prospectively identified patients at highest risk of hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP) in the United States (US). Whether these findings are applicable in a European population is unknown. Methods: Adults considered high risk for pneumonia (treatment with ventilation or high levels of supplemental oxygen) in the intensive care units of seven European hospitals were prospectively enrolled. We estimated the proportion of high-risk patients developing HABP/VABP, defined according to US Food and Drug Administration (FDA) guidance, and the subset potentially eligible for antibacterial trial enrollment. We compared patient characteristics, exposures, and HABP/VABP incidence in European and US cohorts. Findings: Of 888 high-risk patients enrolled between June 12 and December 27, 2017, 211/888 (24%) were treated for possible pneumonia and 150/888 (17%) met the FDA definition for HABP/VABP. A higher proportion of European high-risk patients treated for possible pneumonia met the HABP/VABP definition (150/211 [71%] versus 537/1464 [37%] in US, p

Objectives The postoperative period of cardiac surgery (CS) is associated with the development of major adverse cardiovascular events (MACEs). However, the evaluation of MACE after CS by means of biomarkers is poorly developed. We aimed to evaluate postoperative biomarkers that could be associated with MACE. Methods Two Hundred and ten patients who underwent CS were enrolled during the study period. The diagnosis of MACE was defined as the presence of at least one of the following complications: acute myocardial infarction, heart failure, stroke presented during intensive care unit (ICU) stay, and 30-day mortality after CS. High-sensitive troponin T (hs-TnT), C-reactive protein, procalcitonin, interleukin-6, and immature platelet fraction (IPF) were measured on ICU admission and after 24 h. The difference between both measurements (Δ) was calculated to assess their association with MACE. Early infected patients (n=13) after CS were excluded from final analysis. Results The most frequent surgery was single-valve surgery (n=83; 38%), followed by coronary artery bypass graft (n=72; 34%). Postoperative MACE was diagnosed in 31 (14.8%) patients. Biomarker dynamics showed elevated values at 24 h compared with those at ICU admission in patients with MACE versus no-MACE. Multivariate analysis showed that ΔIPF (OR: 1.47; 95% CI: 1.110–1.960; p=0.008) and Δhs-TnT (OR: 1.001; 95% CI: 1.0002–1.001; p=0.008) were independently associated with MACE. Conclusions These findings suggest that postoperative ΔIPF and Δhs-TnT may be useful biomarkers for the identification of patients at risk of MACE development.

Background The prognostic role of low postoperative serum albumin levels (SAL) after cardiac surgery (CS) remains unclear in patients with normal preoperative SAL. Our aim was to evaluate the influence of SAL on the outcome of CS. Methods Prospective observational study. Patients undergoing CS with normal preoperative SAL and nutritional status were included and classified into different subgroups based on SAL at 24 h after CS. We assessed outcomes (i.e., in-hospital mortality, postoperative complications and long-term survival) and results were analyzed among the different subgroups of SAL. Results We included 2818 patients. Mean age was 64.5 ± 11.6 years and body mass index 28.0 ± 4.3Kg·m− 2. 5.8%(n = 162) of the patients had normal SAL levels(≥35 g·L− 1), 32.8%(n = 924) low deficit (30–34.9 g·L− 1), 44.3%(n = 1249) moderate deficit (25–29.9 g·L− 1), and 17.1%(n = 483) severe deficit(− 1). Higher SAL after CS was associated with reduced in-hospital (OR:0.84;95% CI:0.80–0.84; P = 0.007) and long-term mortality (HR:0.85;95% CI:0.82–0.87;P P Conclusions The presence of postoperative hypoalbuminemia after CS is frequent and the degree of hypoalbuminemia may be associated with worst outcomes, even in the long-term scenario.

Halogenated anesthetic agents (desflurane, isoflurane and sevoflurane) may have cardioprotective properties at therapeutic doses against myocardial intraoperative ischemia-reperfusion injury. Cardioprotection mechanisms are related to mitochondrial and anti-apoptotic signaling pathways. Experimentals and human studies have proven that their use may reduce morbidity and mortality in the setting of cardiac surgery, including a reduction in myocardial infarct size and mechanical ventilation needs. In contrast, total intra-venous propofol based anesthesia may be detrimental. In the present review, we show the rationale for the perioperative use of halogenated anesthetics based on mechanisms of action, experimental research and human studies. Considerations and major concerns regarding their use, the present evidence for their use in other areas, such as major non-cardiac surgery and intensive care unit patients, and future perspectives are also discussed.

Background: Critically ill surgical patients remain at a high risk of adverse outcomes as a result of secondary peritonitis (SP). The risk is even higher if tertiary peritonitis (TP) develops. Factors related to the development of TP, however, are scarce in the literature. The main aim of our study was to identify factors associated with the development of TP in patients with SP in the intensive care unit (ICU), and also to report differences in microbiologic patterns and antibiotic therapy in patients with the two conditions. Patients and Methods: A prospective, observational study was conducted at our institution from 2010 to 2014. Baseline characteristics on admission, outcomes, microbiologic results, and antibiotic therapy were recorded for analysis. Results: We included 343 patients with SP, of whom TP developed in 185 (53.9%). Almost two-thirds (64.4%) were male; mean age was 63.7 +/- 14.3 years, and mean APACHE was 19.4 +/- 7.8. In-hospital death was 42.6% (146). Multivariable analysis showed that longer ICU stay (odds ratio [OR]: 1.019; 95% confidence interval [CI]: 1.004-1.034; p = 0.010), urgent operation on hospital admission (OR: 3.247; 95% CI: 1.392-7.575; p = 0.006), total parenteral nutrition (TPN) (OR: 3.079; 95% CI: 1.535-6.177; p = 0.002) and stomachduodenum as primary infection site (OR: 4.818; 95% CI: 1.429-16.247; p = 0.011) were factors associated with the development of TP, whereas patients with localized peritonitis were less prone to have TP develop (OR: 0.308; 95% CI: 0.152-0.624; p = 0.001). Higher incidences of Candida spp. (OR: 1.275; 95% CI: 1.096-1.789; p = 0.016), Enterococcus faecium (OR: 1.085; 95% CI: 1.018-1.400; p = 0.002), and Enterococcus spp. (OR: 1.370; 95% CI: 1.139-1.989; p = 0.047) were found in TP, and higher rates of cephalosporin use in SP (OR: 3.51; 95% CI: 1.139-10.817; p = 0.035). Conclusions: Complicated peritonitis remains a cause of a high numbers of deaths in the ICU. The need for TPN, urgent operation on hospital admission, and particularly surgical procedures in the proximal gastrointestinal tract were factors associated with development of TP and may potentially help to identify patients with SP at risk for development of TP. Physicians should be aware concerning multi-drug-resistant germs when treating these patients.

Postoperative pulmonary complications are frequent and entail worst outcomes when they occur after cardiothoracic and thoracic surgery. Non-invasive mechanical ventilation (NIV) may potentially help to reduce the impact of such complications, or even prevent the progression towards severe acute respiratory failure. In this chapter, we examine the current use of NIV and the potential recommendations for its use in this setting.

AimsCardiac surgery (CS) can induce an inflammatory response (IR) that is associated with poorer outcomes. Immature platelets are among the factors that may be associated with IR development. We aimed to evaluate whether immature platelet fraction (IPF) could be a predictive biomarker for IR and whether IPF could improve the prognosis assessment of IR for Acute Physiologic and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) following CS.MethodsThree-hundred and twenty-seven (327) patients who underwent CS were enrolled during the study period. IR was defined according to the need for vasopressor support (>48 hours). Perioperative variables and outcomes were registered in our database. IPF was measured immediately following CS and at 24 hours by Sysmex XN analyzer and the difference between both measurements (ΔIPF) was calculated. To assess the relationship between ΔIPF and IR, univariate and multivariate logistic regression were performed. To analyse the additive value of ΔIPF in APACHE II and SOFA scores in predicting IR, an area under the receiver operating characteristic (AUROC) curve was calculated.ResultsAmong 327 patients included, 60 patients (18.3%) developed IR. Multivariate analysis showed ΔIPF was significantly associated with IR (OR: 1.26; 95% CI: 1.01 to 1.56; p=0.038). The combination of ΔIPF with scores improved the AUROC for IR prediction: 0.629 vs 0.728 (p=0.010) for APACHE II and 0.676 vs 0.715 (p=0.106) for SOFA.ConclusionThese findings suggested that ΔIPF may be a useful and low-cost biomarker for the early identification of patients at risk of IR development.

Sepsis and septic shock are severe inflammatory conditions related to high morbidity and mortality. We performed a systematic review with meta-analysis of randomized trials to assess whether extracorporeal blood purification reduces mortality in this setting.Electronic databases were searched for pertinent studies up to January 2019. We included randomized controlled trials on the use of hemoperfusion, hemofiltration without a renal replacement purpose, and plasmapheresis as a blood purification technique in comparison to conventional therapy in adult patients with sepsis and septic shock. The primary outcome was mortality at the longest follow-up available. We calculated relative risks and 95% CIs. The grading of recommendations assessment, development and evaluation methodology for the certainty of evidence was used.Thirty-seven trials with 2,499 patients were included in the meta-analysis. Hemoperfusion was associated with lower mortality compared to conventional therapy (relative risk = 0.88 [95% CI, 0.78 to 0.98], P = 0.02, very low certainty evidence). Low risk of bias trials on polymyxin B immobilized filter hemoperfusion showed no mortality difference versus control (relative risk = 1.14 [95% CI, 0.96 to 1.36], P = 0.12, moderate certainty evidence), while recent trials found an increased mortality (relative risk = 1.22 [95% CI, 1.03 to 1.45], P = 0.02, low certainty evidence); trials performed in the United States and Europe had no significant difference in mortality (relative risk = 1.13 [95% CI, 0.96 to 1.34], P = 0.15), while trials performed in Asia had a positive treatment effect (relative risk = 0.57 [95% CI, 0.47 to 0.69], P0.001). Hemofiltration (relative risk = 0.79 [95% CI, 0.63 to 1.00], P = 0.05, very low certainty evidence) and plasmapheresis (relative risk = 0.63 [95% CI, 0.42 to 0.96], P = 0.03, very low certainty evidence) were associated with a lower mortality.Very low-quality randomized evidence demonstrates that the use of hemoperfusion, hemofiltration, or plasmapheresis may reduce mortality in sepsis or septic shock. Existing evidence of moderate quality and certainty does not provide any support for a difference in mortality using polymyxin B hemoperfusion. Further high-quality randomized trials are needed before systematic implementation of these therapies in clinical practice.

Objective: Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings. Design: A systematic review of the literature followed by a consensus-based voting process. Setting: A web-based international consensus conference. Participants: Two hundred fifty-one physicians from 46 countries. Interventions: The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines. Measurements and main results: The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma- derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. Conclusion: The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.

The authors aimed to identify interventions documented by randomized controlled trials (RCTs) that reduce mortality in adult critically ill and perioperative patients, followed by a survey of clinicians' opinions and routine practices to understand the clinicians' response to such evidence. The authors performed a comprehensive literature review to identify all topics reported to reduce mortality in perioperative and critical care settings according to at least 2 RCTs or to a multicenter RCT or to a single-center RCT plus guidelines. The authors generated position statements that were voted on online by physicians worldwide for agreement, use, and willingness to include in international guidelines. From 262 RCT manuscripts reporting mortality differences in the perioperative and critically ill settings, the authors selected 27 drugs, techniques, and strategies (66 RCTs, most frequently published by the New England Journal of Medicine [13 papers], Lancet [7], and Journal of the American Medical Association [5]) with an agreement ≥67% from over 250 physicians (46 countries). Noninvasive ventilation was the intervention supported by the largest number of RCTs (n = 13). The concordance between agreement and use (a positive answer both to "do you agree" and "do you use") showed differences between Western and other countries and between anesthesiologists and intensive care unit physicians. The authors identified 27 clinical interventions with randomized evidence of survival benefit and strong clinician support in support of their potential life-saving properties in perioperative and critically ill patients with noninvasive ventilation having the highest level of support. However, clinician views appear affected by specialty and geographical location.

The perioperative nutritional status of patients undergoing cardiac surgery influences outcomes; therefore nutritional support is essential for these patients. Owing to the lack of solid evidence, no protocols have been established for the nutritional management of this specific population, and most of the recommendations are based on other critically ill populations. In this review of the main studies performed in this population, the importance of preoperative evaluation of nutritional status, the management of nutritional support immediately after cardiac surgery, the influence of nutrition on outcomes, and the importance of nutrition after hospital discharge are discussed. In addition, the possible influence of glycemic control and pharmaconutrition in the outcomes of these patients are described briefly.

Introduction The Sysmex XN-series haematology analyser has newly adopted a fluorescent channel to measure immature platelet fraction (IPF). To promote the clinical utility of this promising parameter, establishing a reliable reference interval is mandatory. According to previous studies, IPF values may be affected by the employed analyser and the ethnic background of the individual, but no differences seem to be found between individuals' genders. Therefore, this study aimed to define the reference interval for IPF in a Spanish population following Clinical and Laboratory Standard Institute (CLSI) guidelines. Materials and methods A total of 153 healthy Caucasian adults from Spain met the inclusion criteria. IPF measurement was performed by means of a Sysmex XN-2000 haematology analyser. A non-parametric percentile method was used to calculate the reference intervals in accordance with CLSI guidelines. Results The obtained reference interval for IPF on the Sysmex XN-2000 was 1.6-9.6% (90% confidence intervals (CIs) were 1.5-1.8 and 9.3-11.5, respectively). No significant gender difference in IPF reference intervals was observed (P = 0.101). Conclusions This study provides, for the first time, a reference interval for IPF using a Sysmex XN-2000 in a Spanish population, ranging from 1.6 to 9.6%. These data are needed to evaluate platelet production in several conditions such as thrombocytopenia, inflammatory states and cardiovascular diseases, as well as for future research.

Although hyperlactatemia is common after cardiac surgery, its value as a prognostic marker is unclear. The aim of the present study was to determine whether postoperative serial arterial lactate (AL) measurements after cardiac surgery could predict outcome.Prospective, observational study.Surgical intensive care unit in a tertiary-level university hospital.Participants included 2,935 consecutive patients.AL was measured on admission to the intensive care unit and 6, 12, and 24 hours after surgery, and evaluated together with clinical data and outcomes including in-hospital and long-term mortality.In-hospital and long-term mortality (mean follow-up 6.3±1.7 years) were 5.9% and 8.7%, respectively. Compared with survivors, nonsurvivors showed higher mean AL values in all measurements (p0.001). Hyperlactatemia (AL3.0 mmol/L) was a predictor for in-hospital mortality (odds ratio = 1.468; 95% confidence interval = 1.239-1.739; p0.001) and long-term mortality (hazard ratio = 1.511; 95% confidence interval = 1.251-1.825; p0.001). Recent myocardial infarction and longer cardiopulmonary bypass time were predictors of hyperlactatemia. The pattern of AL dynamics was similar in both groups, but nonsurvivors showed higher AL values, as confirmed by repeated measures analysis of variance (p0.001). The area under the curve also showed higher levels of AL in nonsurvivors (80.9±68.2 v 49.71±25.8 mmol/L/h; p = 0.038). Patients with hyperlactatemia were divided according to their timing of peak AL, with higher mortality and worse survival in patients in whom AL peaked at 24 hours compared with other groups (79.1% v 86.7%-89.2%; p = 0.03).The dynamics of the postoperative AL curve in patients undergoing cardiac surgery suggests a similar mechanism of hyperlactatemia in survivors and nonsurvivors, albeit with a higher production or lower clearance of AL in nonsurvivors. The presence of a peak of hyperlactatemia at 24 hours is associated with higher in-hospital and long-term mortality.

Although hyperlactatemia is common after cardiac surgery (CS), its value and utility as a prognostic marker is controversial.

Critically ill surgical patients remain at high risk of adverse outcomes as a result of intra-abdominal infection and its related prolonged length ICU of stay.

PurposeObesity influences risk stratification in cardiac surgery in everyday practice. However, some studies have reported better outcomes in patients with a high body mass index (BMI): this is known as the obesity paradox. The aim of this study was to quantify the effect of diverse degrees of high BMI on clinical outcomes after cardiac surgery, and to assess the existence of an obesity paradox in our patients.MethodsA total of 2,499 consecutive patients requiring all types of cardiac surgery with cardiopulmonary bypass between January 2004 and February 2009 were prospectively studied at our institution. Patients were divided into four groups based on BMI: normal weight (18.5-24.9 kg∙m-2; n = 523; 21.4%), overweight (25-29.9 kg∙m-2; n = 1150; 47%), obese (≥ 30-≤ 34.9 kg∙m-2; n = 624; 25.5%) and morbidly obese (≥ 35kg∙m-2; n = 152; 6.2%). Follow-up was performed in 2,379 patients during the first year.ResultsAfter adjusting for confounding factors, patients with higher BMI presented worse oxygenation and better nutritional status, reflected by lower PaO2/FiO2 at 24h and higher albumin levels 48 h after admission respectively. Obese patients showed a higher risk for Perioperative Myocardial Infarction (OR: 1.768; 95% CI: 1.035-3.022; p = 0.037) and septicaemia (OR: 1.489; 95% CI: 1.282-1.997; p = 0.005). In-hospital mortality was 4.8% (n = 118) and 1-year mortality was 10.1% (n = 252). No differences were found regarding in-hospital mortality between BMI groups. The overweight group showed better 1-year survival than normal weight patients (91.2% vs. 87.6%; Log Rank: p = 0.029. HR: 1.496; 95% CI: 1.062-2.108; p = 0.021).ConclusionsIn our population, obesity increases Perioperative Myocardial Infarction and septicaemia after cardiac surgery, but does not influence in-hospital mortality. Although we found better 1-year survival in overweight patients, our results do not support any protective effect of obesity in patients undergoing cardiac surgery.

Background: the arterial partial pressure of O2 and the fraction of inspired oxygen (PaO2/FiO2) ratio is widely used in ICUs as an indicator of oxygenation status. Although cardiac surgery and ICU scores can predict mortality, during the first hours after cardiac surgery few instruments are available to assess outcome. The aim of this study was to evaluate the usefulness of PaO2/FIO2 ratio to predict mortality in patients immediately after cardiac surgery. Methods: we prospectively studied 2725 consecutive cardiac surgery patients between 2004 and 2009. PaO2/FiO2 ratio was measured on admission and at 3 h, 6 h, 12 h and 24 h after ICU admission, together with clinical data and outcomes. Results: all PaO2/FIO2 ratio measurements differed between survivors and non-survivors (p 242; Group 2, with PaO2/FIO2 from 202 to 242; and Group 3, with PaO2/FIO2

Summary BACKGROUND: A small proportion of patients with influenza H1N1 rapidly develop acute respiratory failure and are a problem for intensive care units (ICUs). Although certain clinical risk factors have been identified, few measurable biochemical/haematological markers able to predict poor outcome have been reported. The aims of the present report are to show which variables on and during admission are associated with increased in-hospital mortality in patients admitted to the ICU with acute respiratory failure due to H1N1 influenza. METHODS: A prospective observational study at two ICUs was carried out between August 2009 and March 2011. The study period covered two waves of pandemic influenza A H1N1 in Spain. Clinical and laboratory data on and during ICU admission were recorded for the purpose of analysis. RESULTS: Sixty patients with acute respiratory failure due to H1N1 influenza were admitted during the period described above; 63.3% (n = 38) were male and the mean age was 49.2 ± 14 years. Regarding comorbidities, 46.7% (n = 28) were smokers, 38% (n = 23) had hypertension, 30% (n = 18) had a body mass index (BMI) >30 kg/m 2 , 30% (n = 18) had chronic obstructive pulmonary disease and 26% (n = 16) had cardiac insufficiency; 16.6% (n = 10) had bacterial co-infection, 70% (n = 42) required invasive mechanical ventilation and 48.3% (n = 29) non-invasive mechanical ventilation. Mortality was 20% (n = 12). Comparing survivors with non-survivors, univariate analysis revealed significant differences in BMI, creatinine, haemoglobin, platelets, arterial pH, pCO2, and the rate of bacterial co-infection. In the multivariate analysis, only the presence of lower platelet count was statistically significant (214 ± 101 vs 113 ± 82 ×10 9 /L; p = 0.009). Patients with thrombocytopenia showed a lower in-hospital survival rate (55%vs92.5%; Log Rank = 0.008). CONCLUSIONS: Thrombocytopenia could be valuable marker of in-hospital mortality in patients with respiratory failure due to H1N1 influenza in the ICU scenario.

OBJECTIVES: Cirrhosis represents a serious risk in patients undergoing cardiac surgery. Several preoperative factors identify cirrhotic patients as high risk for cardiac surgery; however, a patient’s preoperative status may be modified by surgical intervention and, as yet, no independent postoperative mortality risk factors have been identified in this setting. The objective of this study was to identify preoperative and postoperative mortality risk factors and the scores that are the best predictors of short-term risk. METHODS: Fifty-eight consecutive cirrhotic patients requiring cardiac surgery between January 2004 and January 2009 were prospectively studied at our institution. Forty-two (72%) patients were operated on for valve replacement, 9 (16%) for a CABG and 7 (12%) for both (CABG and valve replacement). Thirty-four (58%) patients were classified as Child-Turcotte-Pugh class A, 21 (36%) as class B and 3 (5%) as class C. We evaluated the variables that are usually measured on admission and during the first 24 h of the postoperative period together with potential operative predictors of outcome, such as cardiac surgery scores (Parsonnet, EuroSCORE), liver scores (Child-Turcotte-Pugh, model for end-stage liver disease, United Kingdom end-stage liver disease score) and ICU scores (acute physiology and chronic health evaluation II and III, simplified acute physiology score II and III, sequential organ failure assessment). RESULTS: Seven patients (12%) died in-hospital, of whom 5 were Child-Turcotte-Pugh class B and 2 class C. Comparing survivors vs non-survivors, univariate analysis revealed that variables associated with short-term outcome were international normalized ratio (1.5 ± 0.24 vs 2.2 ± 0.11, P < 0.0001), presurgery platelet count (171 ± 87 vs 113 ± 52 l nl −1 , P = 0.031), presurgery haemoglobin count (11.8 ± 1.8 vs 10.2 ± 1.4 g dl −1 , P = 0.021), total need for erythrocyte concentrates (2 ± 3.4 vs 8.5 ± 8 units, P < 0.0001), PaO2/FiO2 at 12 h after ICU admission (327 ± 84 vs 257 ± 78, P = 0.04), initial central venous pressure (11 ± 3 vs 16 ± 4 mmHg, P = 0.02) and arterial blood lactate concentration 24 h after admission (1.8 ± 0.5 vs 2.5 ± 1.3 mmol l −1 , P = 0.019). Multivariate analysis identified initial central venous pressure as the only independent factor associated with short-term outcome (P = 0.027). The receiver operating characteristic curve showed that the model for end-stage Liver disease score had a better predictive value for short-term outcome than other scores (AUC: 90.5 ± 4.4%; sensitivity: 85.7%; specificity: 83.7%), although simplified acute physiology score III was acceptable. CONCLUSIONS: We conclude that central venous pressure could be a valuable predictor of short-term outcome in patients with cirrhosis undergoing cardiac surgery. The model for end-stage liver disease score is the best predictor of cirrhotic patients who are at high risk for cardiac surgery. Sequential organ failure assessment and simplified acute physiology score III are also valuable predictors.

Liver cirrhosis has evolved an important risk factor for cardiac surgery due to the higher morbidity and mortality that these patients may suffer compared with general cardiac surgery population. The presence of contributing factors for a poor outcome, such as coagulopathy, a poor nutritional status, an adaptive immune dysfunction, a degree of cirrhotic cardiomyopathy, and a degree of renal and pulmonary dysfunction, have to be taken into account for surgical evaluation when cardiac surgery is needed, together with the degree of liver disease and its primary complications. The associated pathophysiological characteristics that liver cirrhosis represents have a great influence in the development of complications during cardiac surgery and the postoperative course. Despite the population of cirrhotic patients who are referred for cardiac surgery is small and recommendations come from small series, since liver cirrhotic patients have increased their chance of survival in the last 20 years due to the advances in their medical care, which includes liver transplantation, they have been increasingly considered for cardiac surgery. Indeed, there is an expected rise of cirrhotic patients within the cardiac surgical population due to the increasing rates of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, especially in western countries. In consequence, a more specific approach is needed in the assessment of care of these patients if we want to improve their management. In this article, we review the pathophysiology and outcome prediction of cirrhotic patients who underwent cardiac surgery.

Introduction: The development of acute kidney injury (AKI) is associated with poor outcome. The modified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification for AKI, which classifies patients with renal replacement therapy needs according to RIFLE failure class, improves the predictive value of AKI in patients undergoing cardiac surgery. Our aim was to assess risk factors for post-operative AKI and the impact of renal function on short- and long-term survival among all AKI subgroups using the modified RIFLE classification. Methods: We prospectively studied 2,940 consecutive cardiosurgical patients between January 2004 and July 2009. AKI was defined according to the modified RIFLE system. Pre-operative, operative and post-operative variables usually measured on and during admission, which included main outcomes, were recorded together with cardiac surgery scores and ICU scores. These data were evaluated for association with AKI and staging in the different RIFLE groups by means of multivariable analyses. Survival was analyzed via Kaplan-Meier and a risk-adjusted Cox proportional hazards regression model. A complete follow-up (mean 6.9 ± 4.3 years) was performed in 2,840 patients up to April 2013. Results: Of those patients studied, 14% (n = 409) were diagnosed with AKI. We identified one intra-operative (higher cardiopulmonary bypass time) and two post-operative (a longer need for vasoactive drugs and higher arterial lactate 24 hours after admission) predictors of AKI. The worst outcomes, including in-hospital mortality, were associated with the worst RIFLE class. Kaplan-Meier analysis showed survival of 74.9% in the RIFLE risk group, 42.9% in the RIFLE injury group and 22.3% in the RIFLE failure group (P

Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.