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Author(s): Shannon M. Fernando [sup.1] [sup.2], Graeme MacLaren [sup.3] [sup.4], Ryan P. Barbaro [sup.5] [sup.6], Rebecca Mathew [sup.7], Laveena Munshi [sup.8] [sup.9], Purnema Madahar [sup.10] [sup.11], Justin A. Fried [sup.12], [...], Purpose Venoarterial extracorporeal membrane oxygenation (V-A ECMO) can be used to support severely ill patients with cardiogenic shock. While age is commonly used in patient selection, little is known regarding its association with outcomes in this population. We sought to evaluate the association between increasing age and outcomes following V-A ECMO. Methods We used individual-level patient data from 440 centers in the international Extracorporeal Life Support Organization registry. We included all adult patients receiving V-A ECMO from 2017 to 2019. The primary outcome was hospital mortality. Secondary outcomes included a composite of complications following initiation of V-A ECMO. We conducted Bayesian analyses of the relationship between increasing age and outcomes of interest. Results We included 15,172 patients receiving V-A ECMO. Of these, 8172 (53.9%) died in hospital. For the analysis conducted using weakly informed priors, and as compared to the reference category of age 18-29, the age bracket of 30-39 (odds ratio [OR] 0.94, 95% credible interval [CrI] 0.79-1.10) was not associated with hospital mortality, but age brackets 40-49 (odds ratio [OR] 1.26, 95% CrI: 1.08-1.47), 50-59 (OR 1.78, 95% CrI: 1.55-2.06), 60-69 (OR 2.24, 95% CrI: 1.94-2.59), 70-79 (OR 2.90, 95% CrI: 2.49-3.39) and [greater than or equal to] 80 (OR 4.02, 95% CrI: 3.13-5.20) were independently associated with increasing hospital mortality. Similar results were found in the analysis conducted with an informative prior, as well as between increasing age and post-ECMO complications. Conclusions Among patients receiving V-A ECMO for cardiogenic shock, increasing age is strongly associated with increasing odds of death and complications, and this association emerges as early as 40 years of age.

Author(s): Catarina Aragon Pinto [sup.1], Vivek Iyer [sup.1], Yahya A. Almodallal [sup.1], Hasan Albitar [sup.1], Hilary Dubrock [sup.1], Hector Cajigas [sup.1], Julie K. Heimbach [sup.2], Charles B. Rosen [sup.2], Kimberly [...], Purpose There are limited data regarding hospital and intensive care unit (ICU) outcomes in patients with hepatopulmonary syndrome (HPS) following liver transplantation (LT). Methods Data were retrospectively collected from consecutive HPS adult patients who underwent LT and were immediately admitted to the ICU at three transplant centers with shared management protocols, from 2002 to 2018. Demographic, clinical, surgical, laboratory, and outcome data were extracted. Results We identified 137 patients (74 male, 54%), with a median age at LT of 58 years (IQR: 52-63). One hundred and 31 (95.6%) patients were admitted to the ICU on invasive mechanical ventilation (MV). The median time on invasive MV in the ICU was 12 hours (IQR: 5-28) and 97 patients (74%) were extubated within 24 hours of ICU admission. The median highest positive end expiratory pressure and fraction of inspired oxygen (FiO.sub.2) were 7 (IQR: 5-8) and 0.6 (IQR: 0.5-0.7), respectively. 7 patients (5%) developed severe post-transplant hypoxemia. Of all patients, 42 (30.4%) required vasopressors and the median ICU and hospital length of stay (LOS) were 3 (IQR: 1-5) and 10 (IQR: 7-20) days, respectively. The in-hospital mortality rate was 3.6% (5/137). HPS severity was not associated with hospital mortality. Conclusion Most HPS patients have short durations of MV, ICU, and hospital LOS post-LT. HPS severity does not impact hospital mortality.

Author(s): Claudio Sandroni [sup.1] [sup.2], Tobias Cronberg [sup.3], Mypinder Sekhon [sup.4] Author Affiliations: (1) grid.8142.f, 0000 0001 0941 3192, Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro [...], Post-cardiac arrest brain injury (PCABI) is caused by initial ischaemia and subsequent reperfusion of the brain following resuscitation. In those who are admitted to intensive care unit after cardiac arrest, PCABI manifests as coma, and is the main cause of mortality and long-term disability. This review describes the mechanisms of PCABI, its treatment options, its outcomes, and the suggested strategies for outcome prediction.

Author(s): Colin J. Adams [sup.1], Karan Chohan [sup.2], Dmitry Rozenberg [sup.1] [sup.3], John Kavanagh [sup.4], Gerhard Greyling [sup.4], Shane Shapera [sup.1], Jolene H. Fisher [sup.1] [sup.5] Author Affiliations: (1) grid.17063.33, [...], Background and Objective Despite the high mortality of acute exacerbations of interstitial lung disease (AE-ILD), there is minimal evidence to guide management decisions. We aimed to assess the feasibility and outcomes of a standardized management protocol for AE-ILD. Methods We performed a retrospective cohort study of patients with AE-ILD admitted to hospital between January 2015 and August 2019. Patients were managed with a standardized protocol including chest computed tomography (CT) at diagnosis, pulse corticosteroid treatment, and a follow-up CT 7 days after corticosteroid pulse. The association between idiopathic pulmonary fibrosis (IPF) versus non-IPF diagnosis and transplant-free survival within 1-year of AE-ILD was assessed using adjusted Cox proportional hazards regression survival analysis. Associations with CT chest improvement 7 days after corticosteroid pulse were secondarily assessed. Results 89 patients with AE-ILD were identified. 1-year transplant-free and overall survival were 20.2 and 51.7%, respectively. Protocol adherence to pulse corticosteroids was high (95.5%). A diagnosis of IPF was associated with higher risk of death or transplant at 1-year versus a non-IPF diagnosis [hazard ratio (HR) 2.23, 95% CI 1.19-4.17, p = 0.012]. There were no significant associations with 7-day CT improvement; however, CT improvement was associated with higher transplant-free survival (p = 0.02) and a lower risk of in-hospital mortality ([chi].sup.2 = 7.06, p = 0.01) on unadjusted analysis. Conclusions IPF is associated with a higher risk of death or transplant at 1-year as compared to a non-IPF diagnosis in patients with AE-ILD managed using a standardized protocol. Improvement on CT chest 7 days after corticosteroid pulse is associated with better survival.

Approximately 26 000 Canadians experience hip fractures each year, (1) with just under 4500 cases per year requiring hemiarthroplasty. (2) We know from multiple studies that hip fractures carry a [...], Background: Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in elective orthopedic surgery. The safety of intravenous TXA in nonelective hip fracture surgery is uncertain. The purpose of this study was to evaluate the efficacy and safety of topical TXA in hip fracture surgery. Methods: Adult patients presenting to a community hospital with a hip fracture requiring surgery were randomly assigned to receive topical TXA or placebo. Hemoglobin and troponin I levels were measured preoperatively and on postoperative days 1, 2 and 3. All postoperative blood transfusions were recorded. Complications, including acute coronary syndrome (ACS), venous thromboembolism (VTE), cerebrovascular accidents (CVA), surgical site infections (SSI) and 90-day mortality, were recorded. Results: Data were analyzed for 65 patients (31 in the TXA group, 34 in the control group). Hemogloblin level was significantly higher on postoperative days 1 and 2 in the TXA group than in the control group. The difference in hemoglobin level between the groups was not statistically significant by postoperative day 3. Significantly fewer units of packed red blood cells were transfused in the TXA group (2 units v. 8 units); however, 2 of the units in the control group were given intraoperatively, and when these were excluded the difference was not significant. The incidence of ACS, CVA, VTE, SSI, transfusion and all-cause mortality at 90 days did not differ significantly between the groups. Conclusion: Topical TXA reduces early postoperative blood loss after hip fracture surgery without increased patient risk. Trial registration: Clinicaltrials.gov, no. NCT02993341. Contexte: L'acide tranexamique (TXA) a permis de reduire les pertes sanguines perioperatoires lors de chirurgies orthopediques non urgentes. On ne connait pas pre-cisement l'innocuite du TXA lors de chirurgies urgentes pour fracture de la hanche. Cette etude avait pour but d'evaluer l'efficacite et l'innocuite du TXA topique lors de chirurgies pour fracture de la hanche. Methodes: Des patients adultes ayant consulte dans un hopital communautaire pour une fracture de la hanche necessitant une chirurgie ont ete assignes aleatoirement soit au TXA topique, soit a un placebo. Les taux d'hemoglobine et de troponine I ont ete mesures avant, puis 1, 2 et 3 jours apres l'intervention. Toutes les transfusions sanguines ont ete consignees, ainsi que les complications, telles que le syndrome corona-rien aigu (SCA), la thromboembolie veineuse (TEV), l'accident vasculaire cerebral (AVC), l'infection de la plaie operatoire et la mortalite a 90 jours. Resultats: Les donnees ont ete analysees pour 65 patients (31 dans le groupe sous TXA et 34 dans le groupe temoin). Le taux d'hemoglobine etait significativement plus eleve aux jours postoperatoires 1 et 2 dans le groupe sous TXA que dans le groupe temoin. La difference de taux d'hemoglobine entre les groupes n'etait plus statistique-ment significative au 3 (e) jour postoperatoire. Un nombre significativement moindre d'unites de culots globulaires ont ete administrees dans le groupe TXA (2 unites c. 8 unites); par contre, 2 des unites dans le groupe temoin ont ete administre pendant l'intervention, et lorsqu'elles ont ete exclues, la difference n'etait plus significative. L'incidence des SCA, des AVC, des TEV, des infections de plaies, des transfusions et de la mortalite de toute cause a 90 jours n'a pas ete significativement differente entre les 2 groupes. Conclusion: Le TXA topique reduit les pertes sanguines durant la periode post-operatoire immediate apres la chirurgie pour fracture de la hanche, sans exposer les patients a un risque accru. Numero d'enregistrement de la recherche: ClinicalTrials.gov, no. NCT02993341.

Author(s): Kumait Al Lawati [sup.1] [sup.2] [sup.3], Sameer Sharif [sup.1] [sup.2], Said Al Maqbali [sup.1] [sup.3], Hussein Al Rimawi [sup.1], Andrew Petrosoniak [sup.4], Emilie P. Belley-Cote [sup.2] [sup.5], Sunjay V. [...], Purpose With the publication of a large randomized-controlled trial (RCT) suggesting that tranexamic acid (TXA) may improve head-injury-related deaths, we aimed to determine the safety and efficacy of TXA in acute traumatic brain injury (TBI). Methods In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents ([greater than or equal to] 15 years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO (CRD42020164232). Results Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88-1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, - 0.18 points; 95% CI - 0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58-1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA. Conclusions In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.

Author(s): Ying Wang [sup.1], Long Ge [sup.2], Zhikang Ye [sup.1], Reed A. Siemieniuk [sup.1] [sup.3], Annika Reintam Blaser [sup.4] [sup.5], Xin Wang [sup.6], Anders Perner [sup.7], Morten H. Møller [sup.7], [...], Purpose Motivated by a new randomized trial (the PEPTIC trial) that raised the issue of an increase in mortality with proton pump inhibitors (PPIs) relative to histamine-2 receptor antagonists (H2RAs), we updated our prior systematic review and network meta-analysis (NMA) addressing the impact of pharmacological gastrointestinal bleeding prophylaxis in critically ill patients. Methods We searched for randomized controlled trials that examined the efficacy and safety of gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. We performed Bayesian random-effects NMA and conducted analyses using all PEPTIC data as well as a restricted analysis using only PEPTIC data from high compliance centers. We used the GRADE approach to quantify absolute effects and assess the certainty of evidence. Results Seventy-four trials enrolling 39 569 patients proved eligible. Both PPIs (risk ratio (RR) 1.03, 95% credible interval 0.93 to 1.14, moderate certainty) and H2RAs (RR 0.98, 0.89 to 1.08, moderate certainty) probably have little or no impact on mortality compared with no prophylaxis. There may be no important difference between PPIs and H2RAs on mortality (RR 1.05, 0.97 to 1.14, low certainty), the 95% credible interval of the complete analysis has not excluded an important increase in mortality with PPIs. Both PPIs (RR 0.46, 0.29 to 0.66) and H2RAs (RR 0.67, 0.48 to 0.94) probably reduce clinically important gastrointestinal bleeding; the magnitude of reduction is probably greater in PPIs than H2RAs (RR 0.69, 0.45 to 0.93), and the difference may be important in higher, but not lower bleeding risk patients. PPIs (RR 1.08, 0.88 to 1.45, low certainty) and H2RAs (RR 1.07, 0.85 to 1.37, low certainty) may have no important impact on pneumonia compared with no prophylaxis. Conclusion This updated NMA confirmed that PPIs and H2RAs are most likely to have a similar effect on mortality compared to each other and compared to no prophylaxis; however, the possibility that PPIs may slightly increase mortality cannot be excluded (low certainty evidence). PPIs and H2RAs probably achieve important reductions in clinically important gastrointestinal bleeding; for higher bleeding risk patients, the greater benefit of PPIs over H2RAs may be important. PPIs or H2RAs may not result in important increases in pneumonia but the certainty of evidence is low.

Enhanced Recovery After Surgery (ERAS) guidelines are best practice guidelines that direct the perioperative pathway, (1) and they have been shown to improve patient outcomes after major surgery. (2) Records [...], Background: In March 2016, an Enhanced Recovery After Surgery (ERAS) initiative was implemented for all elective colorectal resections at an urban hospital in St. John's, Newfoundland and Labrador, Canada. An ERAS coordinator supervised and enforced guideline compliance for 6 months. The aim of this study was to evaluate the sustainability of the ERAS program after supervision of guideline compliance was eliminated. Methods: Patient outcomes and guideline compliance were compared between surgeries performed under standard practice (April 2014 to March 2015) and those performed during and after the implementation of the ERAS initiative (March 2016 to August 2016 was the implementation phase and September 2016 to February 2017 was the sustainability phase). Results: Hospital length of stay decreased from 7.26 days at baseline to 5.44 days during the implementation phase of the ERAS program (p < 0.001). There was no significant difference between length of stay at baseline and during the 6-month sustainability phase of the ERAS program (7.10 d). There were no significant differences in rates of readmission or mortality during and after implementation. Rate of ileus decreased significantly from 13.8% during the implementation phase to 4.6% during the sustainability phase (p = 0.036). Total guideline compliance increased from 52.2% at baseline to 80.7% during the implementation phase (p < 0.001), and decreased to 74.7% during the sustainability phase (p < 0.001). Adherence to postoperative guidelines regressed: 79.2% in the implementation phase and 68.6% in the sustainability phase (p < 0.001). Conclusion: Hospital length of stay decreased when the ERAS program was implemented and the ERAS coordinator was present on the surgical ward. Methods for sustaining guideline implementation are vital to the success of similar programs in the future. Contexte : En mars 2016, une initiative de recuperation amelioree apres la chirurgie (RAAC) a ete mise en place pour toutes les resections colorectales electives effectuees dans un h[delta]pital urbain de St. John's, a Terre-Neuve-et-Labrador, au Canada. Un coordonnateur du projet de RAAC a supervise l'application des directives pendant 6 mois. Cette etude visait a evaluer la viabilite du programme une fois que l'application des directives n'etait plus surveillee. Methodes : Nous avons compare les issues pour les patients et le respect des directives pour les chirurgies realisees selon les pratiques habituelles (avril 2014 a mars 2015) et pour celles realisees pendant et apres l'adoption du programme de RAAC (mars 2016 a aout 2016--mise en ceuvre--et septembre 2016 a fevrier 2017--evaluation de la viabilite). Resultats : La duree du sejour a l'h[delta]pital est passee de 7,26 jours a 5,44 jours pendant la phase de mise en ceuvre du programme (p < 0,001). Il n'y avait pas de difference significative entre la duree du sejour au debut du programme et pendant les 6 mois de la phase d'evaluation de la viabilite (7,10 jours). Les taux de readmission et de mortalite avant et apres la mise en place du programme n'ont pas change de maniere significative. Le taux d'ileus a connu une baisse significative, passant de 13,8 % pendant la phase de mise en ceuvre a 4,6 % pendant l'evaluation de la viabilite (p = 0,036). Le respect des directives est passe de 52,2 % au debut de la mise en ceuvre a 80,7 % pendant cette meme phase (p < 0,001), pour ensuite descendre a 74,7 % pendant la phase suivante (p < 0,001). Le respect de lignes directrices postoperatoires a regresse : il etait de 79,2 % pendant la phase de mise en ceuvre et de 68,6 % pendant la phase d'evaluation de la viabilite (p < 0,001). Conclusion : La duree des sejours a l'hopital a augmente apres l'adoption du programme de RAAC, lorsque le coordonnateur du programme etait present. Les methodes de maintien des lignes directrices apres leur adoption seront cruciales au succes de programmes similaires a l'avenir.

It is clear to every surgeon working in acute care surgery (ACS) and emergency general surgery (EGS) that timely and complex surgical care is required to achieve optimal outcomes for [...], Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown. Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed. Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively. Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada. Contexte : Les services de chirurgie dans les unites de soins actifs (CSA) et de chirurgie generale dans les services d'urgence (CGSU) doivent fournir rapidement des soins et des interventions a des patients dont les besoins sont parmi les plus complexes. En effet, les patients pris en charge par les services de CSA sont souvent gravement malades et presentent des comorbidites sur fond de faible reserve physiologique. Meme si les services de CSA/CGSU se sont repandus en Amerique du Nord, les taux reels de morbidite postoperatoire demeurent pour une bonne part inconnus. Methodes : Dans cette etude prospective, on a suivi pendant 30 jours ou jusqu'a leur conge, les patients hospitalises pour des interventions chirurgicales dans 8 centres de CSA/CGSU achalandes de divers endroits au Canada. On a egalement tenu compte des readmissions dans les 30 jours. Les parametres pre-, per- et postoperatoires ont ete enregis tres. Une methodologie statistique standard a ete appliquee. Resultats : En tout, 601 patients de CSA/CGSU ont ainsi ete suivis pendant une duree allant jusqu'a 30 jours d'hospitalisation ou de readmission apres leur intervention urgente initiale. Cinquante et un pour cent etaient de sexe feminin et l'age moyen etait de 51 ans. Ces patients etaient nombreux a presenter des comorbidites de nature medicale substantielles (42 %) et une obesite morbide (15 %). La majorite des interventions ont ete minimalement effractives (66 % laparoscopiques). La duree mediane des sejours a ete de 3,3 jours et le taux de readmission precoce (< 30 j) a ete de 6 %. Six pour cent des patients ont ete admis aux soins intensifs. Les taux globaux de complications et de mortalite ont ete respectivement de 34 % et de 2 %. Cholecystite (31 %), appendicite (21 %), obstruction intestinale (18 %), hernie incarceree (12 %), hemorragie digestive (7 %) et infections des tissus mous (7 %) comptent parmi les diagnostics les plus frequents. Les taux de morbidite et de mortalite dans les cas de chirurgies ouvertes ont ete respectivement de 73 % et 5 %. Conclusion : Les interventions de CSA/CGSU non liees a la traumatologie sont associees a un taux de morbidite postoperatoire eleve. Cette etude fournira un ensemble de valeurs de references pour l'etude prospective des complications chez les patients pris en charge par les services de CSA/CGSU et l'amelioration subsequente des soins partout au Canada.

Author(s): Adriana D. Oprea [sup.1], Xiaoxiao Wang [sup.1], Robert Sickeler [sup.2], Miklos D. Kertai [sup.3] Author Affiliations: (1) grid.47100.32, 0000000419368710, Department of Anesthesiology, Yale School of Medicine, , New Haven, [...], Beta-adrenergic blockers ([beta]-blockers) are clearly indicated for the long-term treatment of patients with systolic heart failure and post-acute myocardial infarction. Early small-scale studies reported their potential benefits for perioperative use; subsequent randomized controlled trials, however, failed to reproduce earlier findings. Furthermore, their role in reducing major postoperative cardiac events following noncardiac and cardiac surgery remains controversial. This case-based review presents an overview of contemporary literature on perioperative [beta]-blocker use with a focus on data available since 2008 when the PreOperative ISchemic Evaluation (POISE) trial was published. Our review suggests that studies should determine the effects of situational-based guidelines on perioperative [beta]-blocker use on the risk of cardiac adverse events and mortality in the perioperative period.

Author(s): Stewart J. H. McCann [sup.1] Author Affiliations: (1) grid.253649.f, 0000 0001 2151 8595, Department of Psychology, Cape Breton University, , 1250 Grand Lake Road, B1P 6L2, Sydney, NS, Canada [...], The present research was conducted to determine state-level relations of resident neuroticism to age-adjusted cancer incidence, overall health status, the prevalence of four other major illnesses, the incidence of 25 invasive cancer sites, all-cause mortality, and 10 main cause-of-death categories. Responses of 619,397 residents to the Big Five Inventory between 1999 and 2005 produced state neuroticism scores for each of the 50 states. State socioeconomic status, White population percent, urban population percent, heavy drinking, smoking, obesity, exercise, and consumption of fruits and vegetables served as control variables. For each of the 44 criteria, statistical control was attained in sequential multiple regression equations by entering the eight variables first as block, and then first stepwise, followed by the forced entry of neuroticism. For the 2000-2010 period, Study 1 established that state resident neuroticism accounted for an additional 11.2 to 31.7% of the variance in total, male, and female cancer incidence. With the same analytic procedures, Study 2 provided evidence for convergent and discriminant validity. Neuroticism accounted for significant variance in the incidence of a majority of the top 25 invasive cancer sites between 2000 and 2010, and cancer as a cause of death in 2011. In contrast, neuroticism was not a significant positive predictor of overall health in 2011, all-cause mortality in 2011, the prevalence of diabetes, COPD, and kidney disease in 2011, or, death in 2011 from digestive, nervous system, endocrine, nutritional, and metabolic diseases, as well as from mental and behavioral disorders and certain infectious and parasitic diseases.

Author(s): Michael E. Wilson [sup.1] [sup.2] [sup.3], Aniket Mittal [sup.1], Bibek Karki [sup.1], Claudia C. Dobler [sup.2] [sup.4] [sup.5], Abdul Wahab [sup.1], J. Randall Curtis [sup.6] [sup.7], Patricia J. Erwin [...], Purpose To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure. Methods We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019. Results Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate. Conclusions One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.

Author(s): Markos G. Kashiouris [sup.1] [sup.2], Curtis N. Sessler [sup.1] [sup.2], Rehan Qayyum [sup.3], Venu Velagapudi [sup.4], Christos Stefanou [sup.5], Rahul Kashyap [sup.6], Niall Crowley [sup.1], Craig Daniels [sup.7], Kianoush [...], Purpose Prior studies have reported the adverse effects of strain on patient outcomes. There is a paucity of literature about a type of strain that may be caused by near-simultaneous intensive care unit (ICU) admissions. We hypothesized that when multiple admissions arrive nearly at the same time, the ICU teams are excessively strained, and this leads to unfavorable patient outcomes. Methods This is a retrospective cohort study of consecutive adult patients admitted to an academic medical ICU of a tertiary referral center over five consecutive years. Primary outcomes were the all-cause hospital and ICU mortality. Results We enrolled 13,234 consecutive ICU admissions during the study period. One-fourth of the admissions had an elapsed time since the last admission (ETLA) of < 55 min. Near-simultaneous admissions (NSA) had on average, a higher unadjusted odds ratio (OR) of ICU death of 1.16 (95% CI 1-1.35, P = 0.05), adjusted 1.23 (95% CI 1.04-1.44, P = 0.01), unadjusted hospital death of 1.11 (95% CI 0.99-1.24, P = 0.06), adjusted 1.20 (95% 1.05-1.35, P = 0.004), and a lower adjusted OR of home discharge of 0.91 (95% CI 0.84-0.99, P = 0.04). NSA was associated with 0.16 (95% CI 0.04-0.29, P = 0.01) added days in the ICU. For each incremental unit increase of the logarithmic transformation of ETLA [log (ETLA in minutes)], the average adjusted hospital mortality OR incrementally decreased by an added average OR of 0.93 (95% CI 0.89â0.97, P = 0.001). Conclusion Our results suggest that near-simultaneous ICU admissions (NSA) are frequent and are associated with a dose-dependent effect on mortality, length of stay, and odds of home versus nursing facility discharge.

Author(s): Gerald Chi [sup.1], C. Michael Gibson [sup.2], Arzu Kalayci [sup.1], Alexander T. Cohen [sup.3], Adrian F. Hernandez [sup.4], Russell D. Hull [sup.5], Farima Kahe [sup.1], Mehrian Jafarizade [sup.1], Sadaf [...], Purpose To assess the efficacy and safety of betrixaban for venous thromboembolism (VTE) prophylaxis among critically ill patients. Methods The APEX trial randomized 7513 acutely ill hospitalized patients to betrixaban for 35-42 days or enoxaparin for 10 ± 4 days. Among those, 703 critically ill patients admitted to the intensive care unit were included in the analysis, and 547 patients who had no severe renal insufficiency or P-glycoprotein inhibitor use were included in the full-dose stratum. The risk of VTE, bleeding, net clinical benefit (composite of VTE and major bleeding), and mortality was compared at 35-42 days and at 77 days. Results At 35-42 days, extended betrixaban reduced the risk of VTE (4.27% vs 7.95%, P = 0.042) without causing excess major bleeding (1.14% vs 3.13%, P = 0.07). Both VTE (3.32% vs 8.33%, P = 0.013) and major bleeding (0.00% vs 3.26%, P = 0.003) were decreased in the full-dose stratum. Patients who received betrixaban had more non-major bleeding than enoxaparin (overall population: 2.56% vs 0.28%, P = 0.011; full-dose stratum: 3.32% vs 0.36%, P = 0.010). Mortality was similar at the end of study (overall population: 13.39% vs 16.19%, P = 0.30; full-dose stratum: 13.65% vs 16.30%, P = 0.39). Conclusions Compared with shorter-duration enoxaparin, critically ill medical patients who received extended-duration betrixaban had fewer VTE without more major bleeding events. The benefit of betrixaban was driven by preventing asymptomatic thrombosis and offset by an elevated risk of non-major bleeding. The APEX trial did not stratify by intensive care unit admission and the present study included a highly selected population of critically ill patients. These hypothesis-generating findings need to be validated in future studies. Clinical trial registration http://www.clinicaltrials.gov. Unique identifier: NCT01583218.

Author(s): Marie O. Collet [sup.1] [sup.2], Jesús Caballero [sup.3], Romain Sonneville [sup.4] [sup.5], Fernando A. Bozza [sup.6], Peter Nydahl [sup.7] [sup.8], Anna Schandl [sup.9], Hilden Wøien [sup.10], Giuseppe Citerio [sup.11], [...], Purpose We assessed the prevalence and variables associated with haloperidol use for delirium in ICU patients and explored any associations of haloperidol use with 90-day mortality. Methods All acutely admitted, adult ICU patients were screened during a 2-week inception period. We followed the patient throughout their ICU stay and assessed 90-day mortality. We assessed patients and their variables in the first 24 and 72 h in ICU and studied their association together with that of ICU characteristics with haloperidol use. Results We included 1260 patients from 99 ICUs in 13 countries. Delirium occurred in 314/1260 patients [25% (95% confidence interval 23-27)] of whom 145 received haloperidol [46% (41-52)]. Other interventions for delirium were benzodiazepines in 36% (31-42), dexmedetomidine in 21% (17-26), quetiapine in 19% (14-23) and olanzapine in 9% (6-12) of the patients with delirium. In the first 24 h in the ICU, all subtypes of delirium [hyperactive, adjusted odds ratio (aOR) 29.7 (12.9-74.5); mixed 10.0 (5.0-20.2); hypoactive 3.0 (1.2-6.7)] and circulatory support 2.7 (1.7-4.3) were associated with haloperidol use. At 72 h after ICU admission, circulatory support remained associated with subsequent use of haloperidol, aOR 2.6 (1.1-6.9). Haloperidol use within 0-24 h and within 0-72 h of ICU admission was not associated with 90-day mortality [aOR 1.2 (0.5-2.5); p = 0.66] and [aOR 1.9 (1.0-3.9); p = 0.07], respectively. Conclusions In our study, haloperidol was the main pharmacological agent used for delirium in adult patients regardless of delirium subtype. Benzodiazepines, other anti-psychotics and dexmedetomidine were other frequently used agents. Haloperidol use was not statistically significantly associated with increased 90-day mortality.