Early Enteral Nutrition Prevents Intra-abdominal Hypertension and Reduces the Severity of Severe Acute Pancreatitis Compared with Delayed Enteral Nutrition: A Prospective Pilot Study

Background

To investigate the effects of early enteral nutrition (EEN) on intra-abdominal pressure (IAP) and disease severity in patients with severe acute pancreatitis (SAP).

Methods

Enteral nutrition (EN) was started within 48 h after admission in the EEN group and from the 8th day in the delayed enteral nutrition (DEN) group. The IAP and intra-abdominal hypertension (IAH) incidence were recorded for 2 weeks. The caloric intake and feeding intolerance (FI) incidence were recorded daily after EN was started. The severity markers and clinical outcome variables were also recorded.

Results

Sixty patients were enrolled to this study. No difference about IAP was found. The IAH incidence of the EEN group was significantly lower than that of the DEN group from the 9th day (8/30 versus 18/30; P = 0.009) after admission. The FI incidence of the EEN group was higher than that of the DEN group during the initial 3 days of feeding (25/30 versus 12/30; P = 0.001; 22/30 versus 9/30; P = 0.001; 15/30 versus 4/30; P = 0.002). Patients with an IAP <15 mmHg had lower FI incidence than those with an IAP ≥15 mmHg on the 1st day (20/22 versus 17/38; P < 0.001), the 3rd day (11/13 versus 8/47; P < 0.001), and the 7th day (3/5 versus 3/55; P = 0.005) of feeding. The severity markers and clinical outcome variables of the EEN group were significantly improved.

Conclusions

Early enteral nutrition did not increase IAP. In contrast, it might prevent the development of IAH. In addition, EEN might be not appropriate during the initial 3–4 days of SAP onset. Moreover, EN might be of benefit to patients with an IAP <15 mmHg. Early enteral nutrition could improve disease severity and clinical outcome, but did not decrease mortality of SAP.     

The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk

BackgroundThe optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion.MethodsA retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression.Results102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48–39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20–85) vs. those who did not (median 9 mg/dL, IQR 7–13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737).ConclusionWe demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO.Level of evidenceLevel III cohort study.     

Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice

IntroductionGastro-esophageal reflux disease (GERD) is the most frequent long-term morbidity of congenital diaphragmatic hernia (CDH) survivors. Performing a preventive fundoplication during CDH repair remains controversial. This study aimed to: (1) Analyze the variability in practices regarding preventive fundoplication; (2) Identify predictive factors for fundoplication.(3) Evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair;MethodsThis prospective multi-institutional cohort study (French CDH Registry) included CDH neonates born in France between January 1st, 2010-December 31st, 2018. Patch CDH was defined as need for synthetic patch or muscle flap repair. Main outcome measures included need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion.ResultsOf 762 CDH neonates included, 81 underwent fundoplication (10.6%), either preventive or curative. Median follow-up was 3.0 years (IQR: 1.0–5.0).(1) Preventive fundoplication is considered in only 31% of centers. The rates of both curative fundoplication (9% vs 3%, p = 0.01) and overall fundoplication (20% vs 3%, p < 0.0001) are higher in centers that perform preventive fundoplication compared to those that do not.(2) Predictive factors for preventive fundoplication were: prenatal diagnosis (p = 0.006), intra-thoracic liver (p = 0.005), fetal tracheal occlusion (p = 0.002), CDH-grade C-D (p < 0.0001), patch repair (p < 0.0001). After CDH repair, 8% (n = 51) required curative fundoplication (median age: 101 days), for which a patch repair was the only independent predictive factors identified upon multivariate analysis.(3) In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p = 0.53), and was associated with higher rates of failure to thrive (discharge: 81% vs 51%, p = 0.03; 6-months: 81% vs 45%, p = 0.008), tube feeds (6-months: 50% vs 21%, p = 0.02; 2-years: 65% vs 26%, p = 0.004), and oral aversion (6-months: 67% vs 37%, p = 0.02; 1-year: 71% vs 40%, p = 0.03).ConclusionsChildren undergoing a CDH patch repair are at high risk of requiring a curative fundoplication. However, preventive fundoplication during a patch repair does not decrease the need for curative fundoplication and is associated with worse gastro-intestinal outcomes in children.Level of evidenceII – Prospective Study.     

Intra-Abdominal Pressure and Abdominal Compartment Syndrome in Acute General Surgery

Background  Intra-abdominal pressure (IAP) is a harbinger of intra-abdominal mischief, and its measurement is cheap, simple to perform, and reproducible. Intra-abdominal hypertension (IAH), especially grades 3 and 4 (IAP > 18 mmHg), occurs in over a third of patients and is associated with an increase in intra-abdominal sepsis, bleeding, renal failure, and death. Patients and methods  Increased IAP reading may provide an objective bedside stimulus for surgeons to expedite diagnostic and therapeutic work-up of critically ill patients. One of the greatest challenges surgeons and intensivists face worldwide is lack of recognition of the known association between IAH, ACS, and intra-abdominal sepsis. This lack of awareness of IAH and its progression to ACS may delay timely intervention and contribute to excessive patient resuscitation. Conclusions  All patients entering the intensive care unit (ICU) after emergency general surgery or massive fluid resuscitation should have an IAP measurement performed every 6 h. Each ICU should have guidelines relating to techniques of IAP measurement and an algorithm for management of IAH.     

Requirement and Duration of Tube Feed Supplementation among Congenital Diaphragmatic Hernia Patients

PurposeOral feeds pose a challenge for congenital diaphragmatic hernia (CDH) infants. Tube feed (TF) supplementation may be required to support the achievement of normal growth. The aim of this study was to determine the duration and factors associated with TF use in CDH infants at our institution.MethodsA single centre retrospective chart review was performed for CDH-born infants who underwent repair between 2000 to 2013 (REB #1000053124). Patient demographics, perinatal management, and feeding status of infants with at least 1-year follow-up were reviewed.ResultsOf 160 CDH infants, 32 (20%) were discharged on partial or complete TF, and an additional 5 (3.1%) patients started TF post discharge. CDH infants with TF were more likely to have initial arterial blood pH < 7.25, patch repair, ECMO support, and prolonged ICU stay (p < 0.05). Time to TF discontinuation did not differ significantly between those partially or fully TF at discharge. Twelve patients (33.3%) remained TF at their last known follow-up.ConclusionHigh risk CDH patients are likely to require TF to support their nutritional intake. Parents and caregivers need to be informed and properly supported. Long-term monitoring of CDH patient oral intake, growth, and development will be required.Level of Evidence/Type of StudyLevel III Retrospective Study.     

Intra-Abdominal Hypertension and Abdominal Compartment Syndrome Following Surgery for Ruptured Abdominal Aortic Aneurysm

OBJECTIVES: To investigate the importance of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), based on the December 2004 consensus definition, on outcome after surgery for ruptured abdominal aortic aneurysm (rAAA). METHODS: Twenty-seven patients underwent open surgery for rAAA after the introduction of intra-abdominal pressure (IAP) measurements among patients at risk of IAH. Case-records were reviewed retrospectively. Seventeen patients underwent IAP-monitoring. RESULTS: Of eight patients with IAP <21 mmHg none developed colonic ischaemia or ACS. Of four patients with IAP 21-25 mmHg (IAH grade III), two underwent colonic resection. One patient treated with open abdomen died from cardiac arrhythmia. Five patients had IAP >25 mmHg (IAH grade IV). All developed ACS. Two were not decompressed and both developed pulmonary complications, one died. Two underwent colonic resection and one was treated with open abdomen, all three survived. Of 10 patients not monitored for IAP, one died of cardiac complications, but no patient developed signs of colonic ischaemia or ACS. Mortality at 30 days and 1 year was 3/27 (11%). CONCLUSION: IAH and ACS were common among patients undergoing surgery for rAAA. The ACS consensus definition seems appropriate in this clinical context. Monitoring IAP, and timely decompression of patients with IAH might improve outcome after surgery for rAAA.     

Intraabdominal hypertension/abdominal compartment syndrome after pelvic fractures: How they occur and what can be done?

BackgroundLimited data exist regarding intraabdominal hypertension/abdominal compartment syndrome (IAH/ACS) after pelvic fractures. We aimed to explore risk factors for IAH/ACS in pelvic fracture patients, assess the physiological effects of decompressive laparotomy (DL) on IAH/ACS, and generate an algorithm to manage IAH/ACS after pelvic fracture.Materials and methodsPelvic fracture patients were included based on the presence of IAH/ACS. Intraabdominal pressure (IAP) was measured through a Foley catheter. DL was performed in patients with refractory IAH or ACS. Multivariable linear regression was applied to assess associations between IAP levels (≥12 mmHg) and age, sex, injury severity score (ISS), pelvic fracture, volume of resuscitation fluids over 24 h and hemoglobin values. The Wilcoxon signed-rank test for paired samples was used to compare variables before and after DL.ResultsAmong 455 pelvic fracture patients, 44 (9.7%) and 5 (1.1%) were diagnosed with IAH and ACS, respectively. The volume of resuscitation fluids over 24 h exhibited a significant positive correlation with IAP levels (≥12 mmHg) (p = 0.002). The main findings during DL were edematous bowel (11/20) and retroperitoneal hematoma (7/20). DL caused a significant decrease in the mean IAP from 24.4 ± 8.5 mmHg to 13.4 ± 4.0 mmHg (p < 0.0001). Physiological parameters (APP, PaO2/FIO2 ratio, PIP, arterial lactate and UOP) were significantly improved after DL. The mortality rate was 15% in patients who underwent DL and 40% in ACS patients.ConclusionsIAH/ACS is common in pelvic fracture patients. The most effective method to decrease IAP in pelvic fracture patients is DL. Prophylactic DL is important for decreasing mortality as it prevents IAH from progressing to ACS. Massive fluid resuscitation is a significant risk factor for IAH/ACS. A pathway incorporating prophylactic/therapeutic DL and optimized fluid resuscitation to prevent and manage IAH/ACS after pelvic fractures may reduce morbidity and mortality.     

The relationship of abdominal perfusion pressure with mortality in critically ill pediatric patients

PurposeTo the best of our knowledge, in the literature, there is no data regarding clinical utility of the abdominal perfusion pressure (APP) in critically ill children. Thus, in the present study, we aimed to investigate the clinical utility of APP in predicting of survival in critically ill children with IAH.DesignA prospective cohort study of patients between 1 month to 18 years who had risk for intra-abdominal hypertension from June 2013 to January 2014.SettingPediatric intensive care unit (PICU) at a tertiary university hospital.PatientsThirty-five (16 female) PICU patients who had risk for the development of IAH were included. Serial intraabdominal pressure (IAP) and mean arterial pressure (MAP) measurements were performed. Abdominal perfusion pressure was calculated using the formula (MAP-IAP).Measurements and Main ResultsOverall mortality rate was 49% (n = 17). The mortality rate in patients with IAP mean ≥ 10 mmHg (n = 27, 77%) was 55% (n = 15), while 53% (n = 16) in patients with IAP max ≥ 10 mmHg (n = 30, 86%) and 47% (n = 7) in patients with IAP min ≥ 10 mmHg (n = 15, 43%). Overall mean APP was 58 ± 20 mmHg. Logistic regression analysis revealed that decrease in minAPP was associated with increased risk for mortality (Odds ratio for each 1 mmHg decrease in APP was 1.052 [CI 95%, 1.006–1.100], p < 0.05). ROC curve analysis revealed that, in predicting mortality, area under curve for minAPP was 0.765. The optimal cut-off point for APP was obtained as 53 mmHg with the 77.8% sensitivity and 70.6% specificity using the IU method.ConclusionsOur findings showed that APP seems to be a useful tool in predicting mortality. Interventions to improve APP may be associated with better outcomes in critically ill PICU patients.Level of evidenceLevel II.Type of studyDiagnostic.     

Early Results after Treatment of Open Abdomen after Aortic Surgery with Mesh Traction and Vacuum-Assisted Wound Closure

ObjectivesThis study aimed to describe the use of vacuum-assisted wound closure (VAWC) and mesh traction to repair an open abdomen after aortic surgery.DesignProspective clinical study.Material and methodsFrom October 2006 to April 2009, nine consecutive patients were treated; seven of the patients received laparostomy following abdominal compartment syndrome (ACS), while two wounds were left open initially. The indication for laparostomy was intra-abdominal pressure (IAP) > 20 mmHg or abdominal perfusion pressure (APP) < 60 mmHg and development of organ failure. V.A.C. therapy (KCI, San Antonio, TX, USA) was initiated with the laparostomy, and supplemented with a fascial mesh after 2 days. The wound was then closed stepwise with mesh traction and VAWC.ResultsAll wounds could be closed following a median interval of 10.5 (range: 6–19) days after laparostomy. A median of four (range: 2–7) dressing changes were performed. One patient died on the seventh postoperative day. Two other patients died 38 and 50 days after final closure, respectively. Left colonic necrosis was seen in two patients while incisional hernia was observed in two patients. Mean follow-up duration was 17 (range: 2–36) months.ConclusionVAWC with mesh traction was successful in terms of early delayed primary closure and is a useful tool in the treatment of open abdomen after aortic surgery.     

Increased serum adenosine and interleukin 10 levels as new laboratory markers of increased intra-abdominal pressure

Background  

Increased intra-abdominal pressure (IAP), intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are severe complications of surgical interventions with a high rate of mortality. The technique of IAP measurement is accurate, precise, reproducible and cost-effective. However, laboratory measures for monitoring of IAH have not been defined. We investigated the linkage between the serum levels of adenosine and interleukin 10 (IL-10) with IAP.     

Surgeon level variation in outcome of repair of congenital diaphragmatic hernia with particular reference to the management of recurrence

IntroductionThe aim of this study is to investigate firstly, the rate of recurrence following primary repair of a congenital diaphragmatic hernia (CDH) and secondly, the rate of recurrence following revisional surgical repair. The primary outcome is rate of recurrence. Secondary outcomes are to establish whether recurrence is related to surgeon, surgeon volume, side of defect, the use of a patch, or a thoracopscopic approachMethodsAll repairs performed in an English regional center over 22 years were recorded. Possible explanatory variables were whether the repair was itself of a recurrence, the surgeon's identity, the surgeon's volume of prior repairs, the side of the defect, the use of a patch.Results198 repairs were performed; 170 primary repairs and 28 of recurrences. Failure occurred significantly more commonly among recurrences (32%) than primary repairs (11%), p = 0.005. Failure of the primary repair was significantly more common where a patch was used 8/34 (23%) rather than a sutured repair 10/136 (7%), p = 0.006, or where a thoracoscopic technique was used 4/13 (31%) rather than laparotomy 14/157 (9%) p = 0.01. Failure of the primary repair was unrelated to the identity of the surgeon (Χ² = 5, p = 0.9) or the volume of prior repairs (t = 0.3, p = 0.6). However, failure of repair of a recurrence was significantly related to the surgeon's volume of prior repairs (t = 2.3, p = 0.01) and the identity of the surgeon (Χ² = 17, p = 0.014), but not the use of a patch (Χ² = 1.6, p = 0.2).ConclusionsRepair of a recurrence of a CDH has a higher probability of failure than the original repair and is related to both the identity of the surgeon and the prior volume of experience. There is a volume outcome relationship for the repair of recurrence, but not the primary repair of CDH. Our study suggests the repair of recurrence of CDH should be restricted to surgeons with proven outcomes for this procedure.     

Impact of a standardized management guideline for infants with CDH: A single-center experience

BackgroundInfants with congenital diaphragmatic hernia (CDH) are at high risk of death, even despite extracorporeal membrane oxygenation (ECMO) support. In January 2012 we implemented a standardized clinical practice guideline (CPG) to manage infants with CDH. We hypothesized that infants with CDH managed with CPG had better clinical outcomes, less ECMO utilization, and increased survival to discharge.MethodsWe conducted a retrospective pre-post study of infants with CDH admitted between January 2007 and July 2021 (n = 133). Patients were divided into Cohort 1, pre-CPG (January 2007 to December 2011, n = 54), and Cohort 2, post-CPG (January 2012 to July 2021, n = 79).ResultsMore patients in Cohort 1 were small for gestational age than in Cohort 2. No other patient demographics were different between cohorts. Cohort 2 had significantly lower ECMO utilization as compared to Cohort 1 (18% vs 50%, p<0.001). Cohort 2 had significantly higher survival to discharge compared to Cohort 1 (85% vs 57%, p<0.001). Survival for ECMO-treated patients in Cohort 2 was significantly higher than in Cohort 1 (71% vs 26%, p = 0.005). In Cohort 1, 70% of the non-survivors were repaired, of which 81% were repaired on ECMO. In Cohort 2, 8% of the non-survivors were repaired, none on ECMO. Only 3% in Cohort 2 were discharged with pulmonary hypertension medication.ConclusionsA standardized CPG to manage patients with CDH decreased ECMO utilization and improved clinical outcomes including survival to discharge. Refinement of management strategies, implementation of new interventions, and meticulous care can improve outcomes in patients with CDH.     

Does creating a dome reduce recurrence in congenital diaphragmatic hernia following patch repair?

PurposeTo develop a quantifiable approach to identify a dome shape of the repaired diaphragm using post-operative chest radiograph and to determine if a dome-shaped prosthetic patch repair is associated with a decreased rate of CDH recurrence.MethodsWe conducted a retrospective review of all neonates evaluated at our institution from January 2004 to August 2017 with left- and right-sided CDH with at least 6 months of follow-up after CDH repair. Patch use, post-operative imaging and postnatal outcomes were analyzed. Neonates with patch repair were divided into two groups based on the presence of a dome. Using postoperative chest radiographs, the presence of a dome was classified as having a vertical-horizontal diaphragm ratio (VHDR) greater than 20%. Primary outcome was CDH recurrence after repair.ResultsWe identified 192 neonates who met our inclusion criteria. Cohort survival was 96%, recurrence rate was 15%, 78% had a left-sided CDH; 54% received a patch repair, of which 58% had a type C defect. Of the 104 infants with patch repairs, the CDH recurrence rate was 22% (n = 23) at a median age of 8.5 months (3.8, 20.1). Although neonates with a dome repair had more ECMO use and longer hospital stay, their recurrence rate was about half of those with a non-dome repair (14% vs 28%, p = 0.07).ConclusionsA dome-shaped repair may reduce recurrence following prosthetic patch repair of congenital diaphragmatic hernia. A larger, multi-institutional study is needed to statistically validate this clinically significant observation.Type of StudyRetrospective review.Level of EvidenceIII.     

Intra-abdominal pressure and intra-abdominal hypertension in critically ill obstetric patients: a prospective cohort study

BackgroundCritically ill obstetric patients may have risk factors for intra-abdominal hypertension. This study evaluated the intra-abdominal pressure and its effect on organ function and the epidemiology of intra-abdominal hypertension.MethodsObstetric patients admitted to an Intensive Care Unit, with an anticipated stay greater than 24 hours, were included. Intra-abdominal pressure was measured daily via a Foley catheter, based on intravesical pressure.ResultsOne-hundred-and-one patients were enrolled. The intra-abdominal pressure was 5–7 mmHg in 34%; 7–12 mmHg in 60%; and ≥12 mmHg (intra-abdominal hypertension) in 6%. All six patients with intra-abdominal hypertension were pregnant at the time of admission. The intra-abdominal pressure in four patients normalized to <12 mmHg following delivery, but in the remaining two it persisted ≥12 mmHg and both these patients died. Correlation between intra-abdominal pressure and organ dysfunction was weak (r=0.211). Statistical comparison between patients with and without intra-abdominal hypertension for risk factors, daily intra-abdominal pressures, and Sequential Organ Failure Assessment score could not be done due to the disproportionately small number of patients with intra-abdominal hypertension as opposed to those without (6 versus 95). Intra-abdominal pressure did not significantly differ between survivors and non-survivors (8.5 ± 1.1 vs 7.9 ± 1.7 mmHg, P=0.079).ConclusionsThe incidence of intra-abdominal hypertension in critically ill obstetric patients was lower than previously defined for mixed Intensive Care Unit populations, with an association with the pregnant state. Normalization of intra-abdominal pressure after delivery was associated with better survival. There was no correlation between intra-abdominal pressure and organ function or mortality.     

Biological versus synthetic patch for the repair of congenital diaphragmatic hernia: 8-year experience at a tertiary center

PurposeThe aim of this study is to compare outcome between small intestinal submucosal (SIS) and polytetrafluoroethylene (PTFE) patches in patients with congenital diaphragmatic hernia (CDH) with large muscular defects.Material and methodsWe performed a retrospective review of prospectively collected data of patients who underwent CDH repair from January 2011 to June 2019, with a minimum follow-up of 1 year. Data were collected regarding length of stay (LOS), mortality and recurrence. Kaplan-Meier analyses was used.ResultsIn the study period, 195 patients with CDH were admitted, 176 underwent surgical repair and 19 died before surgery. Sixty-two (35%) required a patch. Over the last 5 years, our institution transitioned from the use of all SIS to all PTFE. SIS was used in 18 cases and PTFE in 25. Overall survival rate was 89% (174/195). There was no significant difference regarding LOS and mortality. Nine patients (50%) of SIS and 1 (4%) of PTFE repairs recurred (P < 0.01; log-rank test P <  0.01), with a time course of recurrence of 18 (SD = 13) and 8 months, respectively. Median follow-up was 60 months (SD: 23) for the SIS group and 26 (SD: 10) for the PTFE group.ConclusionA significant lower recurrence was found using PTFE patches instead of SIS for the repair of large CDH.Level of evidenceLevel 3. Retrospective comparative study.     

Early tracheostomy and active exercise programmes in adult intensive care patients with severe burns

BackgroundTracheostomy is a strategy often employed in patients requiring prolonged intubation in ICU settings. Evidence suggests that earlier tracheostomy and early active exercise are associated with better patient centered outcomes. Severe burn patients often require prolonged ventilatory support due to their critical condition, complex sedation management and multiple operating room visits. It is still unclear the optimal timing for tracheostomy in this population.MethodsWe conducted a service evaluation where we compared Early Tracheostomy (≤10 days) with Late Tracheostomy (>10 days) in 41 severely burned patients that required prolonged respiratory support.ResultsEarly Tracheostomy cohort was associated with fewer days of mechanical ventilation (16 vs 33, p = 0.001), shorter hospital length of stay (65 vs 88 days, p = 0.018), earlier first day of active exercise (day 8 vs day 25, p < 0.0001) and higher Functional Assessment for Burns scores upon discharge (32 vs 28, p = 0.016).ConclusionEarly tracheostomy in patients with severe burns is associated with earlier active exercise, fewer days of ventilation, shorter length of hospital stay and better physical functional independence upon discharge from hospital.     

Cornelia de Lange syndrome and congenital diaphragmatic hernia

PurposeThere is a known association between Cornelia de Lange syndrome (CdLS) and congenital diaphragmatic hernia (CDH), with CDH being the cause of death in 5%–20% of CdLS cases. We aimed to identify and describe patients with CDLS and CDH. We hypothesized that CdLS would be associated with high-risk CDH and poor outcomes.MethodsCDH Study Group patients from 1995 to 2019 were included. Those with CdLS were reviewed retrospectively. Rates of repair and outcomes were compared between patients with and without CdLS.ResultsWe identified 9,251 CDH patients. Of those, 21 had confirmed CdLS. CdLS patients had a lower birth weight (2.2 ± 0.57 kg) than non-CdLS patients (2.9 ± 0.64 kg) (p < 0.001). 5-min Apgar scores were lower in CdLS patients (6, 4–7) than non-CdLS patients (7, 5–8) (p = 0.014). Only 33% of CdLS patients underwent diaphragmatic repair compared to 84.2% of non-CdLS patients (p < 0.001). Mortality was 76% for CdLS patients compared with 29% for non-CdLS patients (p < 0.001). Of the 7 CdLS patients who underwent repair, 5 survived to hospital discharge.ConclusionsInfants with CdLS and CDH have a poor prognosis. However, CdLS patients who undergo repair can survive to discharge; therefore, the concomitant diagnosis of CdLS and CDH is not necessarily a contraindication to repair. Early recognition of these anomalies can assist with counseling and prognostication.Type of studyRetrospective comparative studyLevel of evidenceIII     

Current insights in intra-abdominal hypertension and abdominal compartment syndrome: open the abdomen and keep it open!

Background and aims  The abdominal compartment syndrome (ACS) is associated with organ dysfunction and mortality in critically ill patients. Furthermore, the deleterious effects of increased IAP have been shown to occur at levels of intra-abdominal pressure (IAP) previously deemed to be safe. The aim of this article is to provide an overview of all aspects of this underrecognized pathological syndrome for surgeons. Methods and contents  This review article will focus primarily on the recent literature on ACS as well as the definitions and recommendations published by the World Society for the Abdominal Compartment Syndrome. The definitions regarding increased IAP will be listed, followed by a brief but comprehensive overview of the different mechanisms of organ dysfunction associated with intra-abdominal hypertension (IAH). Measurement techniques for IAP will be discussed, as well as recommendations for organ function support in patients with IAH. Finally, surgical treatment and management of the open abdomen are briefly discussed, as well as some minimally invasive techniques to decrease IAP. Conclusions  The ACS was first described in surgical patients with abdominal trauma, bleeding, or infection, but in recent years ACS has also been described in patients with other pathologies such as burn injury and sepsis. Some of these so-called nonsurgical patients will require surgery to treat their ACS. This review article is intended to provide surgeons with a clear insight into the current state of knowledge regarding IAH, ACS, and the impact of IAP on the critically ill patient.     

A long duration of intraoperative hypotension is associated with postoperative delirium occurrence following thoracic and orthopedic surgery in elderly

BackgroundPostoperative delirium (POD) is a common surgical complication associated with increased morbidity and mortality in elderly. Although the underlying mechanisms remain elusive, perioperative risk factors were reported to be closely related to its development. This study was designed to investigate the association between the duration of intraoperative hypotension and POD incidence following thoracic and orthopedic surgery in elderly.MethodThe perioperative data from 605 elderly undergoing thoracic and orthopedic surgery from January 2021 to July 2022 were analyzed. The primary exposure was a cumulative duration of mean arterial pressure (MAP) ≤ 65 mmHg. The primary end-point was the POD incidence assessed with confusion assessment method (CAM) or CAM-ICU for three days after surgery. Restricted cubic spline (RCS) was conducted to examine the continuous relationship between the duration of intraoperative hypotension and POD incidence adjusted with patients' demographics and surgery related factors. Then the duration of intraoperative hypotension was categorized into three groups: no hypotension, short (< 5 mins) or long duration (≥ 5 mins) of hypotension for further analysis.ResultThe incidence of POD was 14.7% (89 cases out of 605) within three days after surgery. The duration of hypotension presented a non-linear and “inverted L-shaped” effect on POD development. Compared to no hypotension, long duration (adjusted OR 3.93; 95% CI: 2.07–7.45; P < 0.001) rather than short duration of MAP ≤65 mmHg (adjusted OR 1.18; 95% CI: 0.56–2.50; P = 0.671) was closely related to the POD incidence.ConclusionIntraoperative hypotension (MAP ≤65 mmHg) for ≥5 mins was associated with an increased incidence of POD after thoracic and orthopedic surgery in elderly.     

Extracorporeal membrane oxygenation in patients with hepatopulmonary syndrome undergoing liver transplantation: A systematic review of the literature

BackgroundIsolated cases of extracorporeal membrane oxygenation (ECMO) in patients with hepatopulmonary syndrome (HPS) undergoing liver transplantation (LT) have been reported with increasing frequency. We aimed to systemically review and synthesize the available literature on ECMO use in this population.MethodsA systematic literature review of the PubMed, Web of Science, Cochrane Library, and Embase databases (end-of-search date: November 14, 2021) was conducted in accordance with the PRISMA statement. Eligible studies presented clinical parameters and outcomes of adult or pediatric patients with HPS receiving ECMO support at the time of, or following, LT.ResultsSixteen studies from 4 continents reporting on 17 patients who were initiated on ECMO prior to (n = 2), during (n = 1) or after LT (n = 14) were included. Nine of the 16 studies were published between 2019 and 2021. The median pre-LT PaO₂ was 38.0 mmHg (IQR 35.0–52.0). The median time from LT to ECMO initiation was 7 days (IQR, 3–12). Six patients (50%, n = 6 of 12) were extubated post-LT, before deterioration, development of refractory hypoxemia, and initiation of ECMO. Most patients were cannulated with a venovenous configuration (75%, n = 12 of 16). Most patients cannulated with a venoarterial or veno-arterial-venous strategy (75%, n = 3 of 4) had concurrent hemodynamic instability. The median total time on ECMO was 13 days (IQR 10–29). Using linear regression, for patients cannulated postoperatively, each day between LT and ECMO initiation was associated with a 3.5-day increase in total ECMO duration (95%CI: 2.23–4.73, p < 0.001, R² = 73.7%). The median postoperative intensive care unit length of stay was 40 days (IQR, 37–61) and hospital length of stay was 59.5 days (IQR 42–77). 82.4% of patients (14 of 17) survived to discharge.ConclusionsECMO is feasible in patients with HPS undergoing LT and appears to be associated with better outcomes compared to other causes of cardiopulmonary failure in LT patients. As the volume of experience grows, ECMO may become a central part of perioperative support in LT patients with severe HPS.