Adult congenital heart disease: intensive care management and outcome prediction

Objective Improved patient survival and increasingly complex surgery have expanded the requirement for specialist care for patients with adult congenital heart disease (ACHD). Despite the recent publications of management guidelines for ACHD, data concerning optimal patterns of care in the peri-operative/critical care period of this challenging population are sparse. The aims of the current study were to therefore to determine the pattern of intensive care unit (ICU) management, resource utilisation and predictors of mortality in critically ill ACHD patients. Design, setting and patients Data were collected prospectively for patients with ACHD stratified for complexity of disease admitted to the ICU of a tertiary cardiothoracic centre (1997–2002). Multivariate analysis of pre-operative indices as predictors of mortality was performed. Of 342 ACHD admissions (total mortality 4.4%, simple 0%, moderate/complex 10.6%), the requirement for specialist investigations and interventions was high, reflected in ICU admission costs per patient (simple $5391 ± 130, moderate $13218 ± 261, complex $30074 ± 689). Standard severity of illness scoring systems did not accurately predict mortality; however, abnormal pre-operative thyroid function (p = 0.0048), creatinine (p = 0.0032) and bilirubin (p = 0.0021) were highly predictive of mortality. Conclusions Peri-operative mortality in patients with ACHD is low overall but varies with disease complexity. Such patients have a high requirement for specialist ICU investigation/intervention. Although standard severity of illness scoring is unhelpful, simple pre-operative parameters may predict peri-operative mortality. These findings reflect the requirement for specialist care, and have implications for planning service provision, training and operative consent in ACHD patients.     

Clinical review: Goal-directed therapy in high risk surgical patients

A small group of patients account for the majority of peri-operative morbidity and mortality. These 'high-risk' patients have a poor outcome due to their inability to meet the oxygen transport demands imposed on them by the nature of the surgical response during the peri-operative period. It has been shown that by targeting specific haemodynamic and oxygen transport goals at any point during the peri-operative period, the outcomes of these patients can be improved. This goal directed therapy includes the use of fluid loading and inotropes, in order to optimize the preload, contractility and afterload of the heart whilst maintaining an adequate coronary perfusion pressure. Despite the benefits seen, it remains a challenge to implement this management due to difficulties in identifying these patients, scepticism and lack of critical care resources.     

The veterinary nurse’s role in nursing an equine surgical colic patient

Abstract

The nurse’s role is critical in the pre-operative, peri-operative and post-operative period in surgical colic patients, due to colic being a major cause of morbidity and mortality in horses. The nurse’s role can vary hugely when nursing a surgical colic patient as their role could include laboratory work, placing catheters and administering medication, theatre nursing, intravenous fluid therapy and general TLC.     

The prevalence of pre-operative anaemia and an examination of its effect on transfusion practice between sexes: A multicentre retrospective study

Pre-operative anaemia affects one third of patients presenting for surgery and is associated with increased peri-operative morbidity and mortality. Most studies on this subject make a distinction in acceptable haemoglobin level between sexes. We analysed data for patients undergoing major elective surgery, with pre-operative anaemia defined as haemoglobin <13 g/dL. Data was collected for 1074 patients, of whom 411 (38.3%) had pre-operative anaemia. The odds of red cell transfusion were significantly higher in patients with pre-operative anaemia, OR = 4.35 [95%CI OR: 3.0- 6.2]. Additional binary logistic regression results identified haemoglobin level, male gender and increasing age as independent predictors for red cell transfusion. The length of post-operative stay was also significantly higher in anaemic patients, those with lower haemoglobin, males and older patients. Women were twice as likely to have a haemoglobin < 13 g/dl as men. Women were also 3.55 times more likely not to be transfused despite being anaemic. This suggests differences in clinician's attitudes to transfusion limits in women, despite Blaudszun et al. 2018 showing that women with borderline anaemia (Hb 12–12.9 g/dL) are: more likely to be transfused; to be transfused more units of red cells; and to have longer lengths of hospital stay than non- anaemic women. A change in attitude to acceptable haemoglobin in women is needed. Increased clinician awareness of the associated morbidity of even a mild reduction in haemoglobin in women is required to result in more pro-active anaemia management pre-operatively and less allogenic red cell transfusion, shorter lengths of hospital stay and overall decreased morbidity.     

Hepatocellular carcinoma in the United States

In the United States, the majority of patients with hepatocellular carcinoma have underlying cirrhosis; overall, their prognosis is very poor. Although the surgical morbidity and mortality rates are high and the chance for cure is low, resection may be curative in a few carefully selected patients. Invasive diagnostic interventions should be avoided in those who are not likely to survive the surgery or in whom the disease is too advanced.     

Prospective analysis of mortality,morbidity, and risk factors in elderly diabetic subjects: Nagano study

OBJECTIVE: To clarify mortality and morbidity of intensively managed elderly diabetic individuals and to explore factors predicting mortality and diabetes-related end points. RESEARCH DESIGN AND METHODS: A total of 390 elderly (>or=65 years of age) outpatients with type 2 diabetes ( 173 men and 217 women, mean age 73.0 years) were analyzed. The mean HbA(1c) upon entry was 6.8% (332 receiving oral hypoglycemics and/or insulin) and blood pressure upon entry was 136/74 mmHg (219 receiving antihypertensive drugs). The patients have been followed-up for 3 years with HbA(1c) <7.0% and blood pressure <145/80 mmHg as targets, with mortality and an aggregate of fatal and nonfatal diabetes-related events as end points. Mortality rate and causes of mortality, as well as risk factors for mortality and morbidity, were determined. RESULTS: The mortality rate, 2.9% per year, was comparable to that of the age- and sex-matched general population. Stroke was a leading cause of mortality after malignancy. By the univariate Cox proportional hazards model, only high serum creatinine and prior stroke were highly significant and strong risks for both end points. In those without prior stroke and receiving antihypertensive agents, the incidence of the diabetes-related end point based on their systolic blood pressure (SBP) quartile was U-shaped, with the nadir at the 3rd (SBP, 137-147 mmHg) and the peak at the 1st (SBP 相似文献   

Another “double bubble” sign or “double bladder” sign: fetal intra-abdominal umbilical vein varix

Fetal intra-abdominal umbilical vein varix increases the incidence of fetal/neonatal morbidity and mortality. Its early diagnosis may be clinically important. For a case of this disorder, we have proposed the new name of “double bladder” sign; “another double bubble” sign may also illustrate this disorder.     

Optimal management of the high risk surgical patient: beta stimulation or beta blockade?

Several groups of investigators have shown that peri-operative goal directed therapy (GDT) may reduce mortality in high-risk surgical patients. GDT usually requires the use of beta-adrenergic agents, however, and these may also carry the risk of cardiac ischemia, especially in patients with ischemic diseases. In this commentary, we will discuss the apparent contradiction between studies showing beneficial effects of GDT in high-risk surgical patients and studies showing the benefit of beta-blockade in high-risk surgery. One of the key differences between both types of studies is that GDT is applied in patients with high risk of postoperative death, excluding patients with cardiac ischemic disease, while studies reporting beneficial effects of beta-blockade have investigated patients with high risk of cardiac ischemia but moderate risk of death related to the surgical procedure itself. It is likely that beta-blockade should be proposed in patients with moderate risk of death, whereas GDT using fluids and inotropic agents should be applied in patients with high risk of peri-operative death. Monitoring central venous oxygen saturation may be useful to individualize therapy, but further studies are required to validate this option.     

Liver cirrhosis and biliary surgery: assessment of risk

Operations on the biliary tract in cirrhotic patients are reported to have a higher than normal risk of operative morbidity and mortality. We reviewed 39 cases from two university-based hospitals over a five-year period. Each patient had biliary tract surgery and biopsy-proven cirrhosis. Eight patients died (21%), and major complications were found in 12 surviving patients (35%). Local and systemic sepsis was the major contributor, accounting for all of the deaths and 17 of the 22 (77%) complications among survivors. Choledochotomy was done in ten patients; three of them died (30%) and nine major complications occurred in the remaining five. Preoperative risk factors found to be predictive of this high morbidity and mortality were ascites (50% mortality, 50% morbidity), prolonged prothrombin time (29% mortality, 38% morbidity), and a serum albumin level of less than 3.5 mg/dl (33% mortality, 40% morbidity). The presence of other major systemic disease was not significantly different between survivors and nonsurvivors. In 12 patients with no ascites and normal preoperative serum chemistry values, no deaths and only one minor complication occurred. We conclude that although biliary surgery in cirrhotic patients carries a high mortality, this risk can be assessed preoperatively. There appears to be a small subgroup of patients with cirrhosis and cholelithiasis who can have a favorable outcome. Operative therapy in these patients should be reserved for the complications of the biliary tract.     

脑出血的遗传因素

脑卒中是人类三大死因之一,具有发病率高、致残率高、死亡率高等特点。脑卒中分为出血性脑卒中和梗塞性脑卒中,出血性脑卒中又称脑出血,其死亡率及致残率更高。脑出血具有一定的家族遗传倾向,许多研究表明其与高血压、高脂血症、代谢综合征、凝血功能异常、动脉炎症等疾病有相关性。本文综述了近年来这些基础疾病研究中所发现与脑出血有关的遗传基因的研究进展。     

Adrenal-exhaustion syndrome in patients with liver disease

Objective Adrenal failure is emerging as an important cause of excess morbidity and mortality in critically ill patients. We have recently reported the high incidence of adrenal failure in patients with liver disease, the so called “hepato-adrenal syndrome.” It has been noted that patients who on initial testing may have “normal” adrenal function subsequently progress to overt adrenal failure, the adrenal-exhaustion syndrome. The goal of this study was to further characterize this syndrome. Design Retrospective review of the “Hepatic Cortisol Research and Adrenal Pathophysiology Study” database. Setting Liver transplant ICU of a tertiary care university hospital. Patients and methods Patients who on initial testing had “normal” adrenal function were followed, and adrenal function testing was repeated in those who failed to improve. The patients were grouped as follows: (1) patients who developed adrenal failure on follow-up testing; and (2) patients who had normal adrenal function during their ICU stay. The incidence and risk factors for the development of adrenal-exhaustion syndrome were determined. Measurements and results The study cohort consisted of 221 patients, of whom 120 (54%) were diagnosed with adrenal insufficiency on initial diagnostic testing and were excluded from further analysis. The remaining 101 patients comprised those who made up the group of interest. On follow-up, 16 (16%) of these developed adrenal failure a mean of 3 days after initial testing. The only factor that predicted the development of adrenal-exhaustion syndrome was a low HDL level (p < 0.001). Conclusion This study demonstrates that adrenal failure is a dynamic process and that repeat adrenal function testing is indicated in patients who remain hemodynamically unstable or fail to improve with aggressive supportive treatment. Low HDL levels may be pathogenetically linked to the development of adrenal failure. The author has no financial interest in any of the products mentioned in this paper.     

Pre-operative tonometry is predictive for mortality and morbidity in high-risk surgical patients

OBJECTIVE: To determine whether a) pre-operative measurement of gastric intramucosal pHi is predictive for mortality and morbidity in high-risk surgical patients and b) peri-operative improvement of global oxygen delivery (DO2) with fluids and dopexamine leads to increased gastric pHi and c) either improved global perfusion or improved splanchnic perfusion is related to the prevention of multiple organ failure (MOF). DESIGN: Retrospective analysis of a double-blind, placebo-controlled, randomised study. SETTING: General intensive care units from 14 hospitals. PATIENTS: Two hundred eighty-six high-risk surgical patients. INTERVENTIONS: Swan-Ganz and tonometer catheter placement; patients were stabilised pre-operatively using fluids, blood and/or oxygen to preset goals before receiving placebo or two doses of dopexamine (0.5 or 2.0 microg.kg.min) peri-operatively. MEASUREMENTS AND RESULTS: Haemodynamic assessment (including DO2 and oxygen consumption (VO2)) was performed together with measurement of gastric mucosal pHi pre-operatively and directly, 2, 6, 12, 24 and 36 h post-operatively. Retrospectively, patients were divided pre-operatively into two sub-groups based on the optimal cut-off value for mortality of the first pHi measurement after induction of anaesthesia as calculated by a receiver operator characteristic (ROC) curve analysis --low pHi group (< 7.35) and normal pHi (> or =7.35). Mortality in the low pHi, was higher than in the normal pHi, group (16.8 vs 2.3%; p = 0.0001). In the normal pHi group dopexamine, which was given prior to the first pHi measurement, had no effect on pHi, while DO2 increased significantly. In this group MOF score and number of patients with MOF remained similar for the treatment sub-groups. In the low pHi group gastric pHi increased significantly during dopexamine infusion (p = 0.008), despite the lack of an increase in DO2 and VO2. In this group the MOF score and the number of patients developing MOF decreased significantly with the use of dopexamine (p = 0.04). In both groups bicarbonate levels remained similar for the treatment subgroups. CONCLUSIONS: In high-risk surgical patients pre-operative measurement of pHi was predictive for mortality. The peri-operative response of pHi to dopexamine seemed to be dependent on pre-operative gastric pHi.     

Mortality and hospital morbidity from cirrhosis of the liver in relation to per capita consumption of absolute alcohol, education and native status, Ontario; 1978 to 1982

Correlation and regression analyses have been carried out to test the hypothesis that areas experiencing high per capita consumption of absolute alcohol will also experience correspondingly higher annual rates of cirrhosis, in Ontario from 1978 to 1982. Adjustment was made for the influence of socio-demographic variables upon hospital morbidity and mortality rates. Areas experiencing higher per capita consumption of absolute alcohol were found to have higher hospital morbidity. The relationship between hospital morbidity and general mortality from cirrhosis, and per capita consumption of absolute alcohol appears to be growing weaker; no relationship could be demonstrated, however, between cirrhosis mortality and hospital morbidity and proportionate native population and education status.     

The diagnostic value of serum leptin monitoring and its correlation with tumor necrosis factor-α in critically ill patients: a prospective observational study

Introduction  

Severe infection and sepsis are common causes of morbidity and mortality. Early diagnosis in critically ill patients is important to reduce these complications. The present study was conducted to determine the role of serum leptin at early diagnosis and differentiation between patients with manifestations of systemic inflammatory response syndrome (SIRS) and those with sepsis in patients suffering from a broad range of diseases in the intensive care unit (ICU) and its correlation with other biomarkers, such as C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α).     

Determinants of mortality in non-neutropenic ICU patients with candidaemia

Introduction  

Candidaemia in critically-ill intensive care unit (ICU) patients is associated with high crude mortality. Determinants of mortality – particularly those amenable to potential modification – are incompletely defined.     

Light and darkness fail to regulate melatonin release in critically ill humans

Objective Pineal dysfunction has been associated with morbidity and mortality in various animal models of severe illness, and low melatonin plasma concentrations have recently been reported in patients on the ICU. However, it is not known whether the physiological response of the pineal gland to light and darkness is preserved in critical illness. Design and patients We examined the nocturnal release of melatonin in response to 1 h of darkness followed by 1 h of bright light (> 10,000 lux) in 20 severely ill patients on a medical ICU. Eleven elderly (median age 73 years) and 9 young patients (38 years) were recruited. Melatonin plasma concentrations were measured at 30-min intervals. Results In 15 patients melatonin plasma concentration was low and responded to neither darkness nor light. In three elderly and two young patients melatonin plasma concentrations were elevated irrespective of illumination. Conclusions The physiological regulation of melatonin secretion by darkness and light is abolished in severely ill patients.     

High burden and low awareness of toxoplasmosis in the United States

Toxoplasmosis, a disease with diverse clinical manifestations, caused by infection with the Apicomplexan parasite, Toxoplasma gondii (T. gondii), is a major source of morbidity and mortality in the United States. Although toxoplasmosis prevalence and mortality have declined over the past two decades, the CDC considers this disease a neglected parasitic infection requiring public health action. Here, we overview the literature to bring attention to the prevalence of the disease in the United States, and high economic burden associated with the disease. The conclusions to be drawn are clear: there is low awareness and underestimation of the disease burden amongst healthcare professionals; a high economic burden associated with the disease; relapse rates to treatment represent additional mortality and morbidity and further costs for the healthcare system; and better treatments are necessary to combat this public health threat.     

Psychiatric Morbidity after Myocardial Infarction

Using a standardized interview, psychiatric morbidity was diagnosedin 35 out of 100 consecutive male patients one week after admissionto hospital following a first acute myocardial infarction. Sixteenof these patients had been psychiatrically ill before the infarctionand their psychiatric symptoms and social difficulties persistedthroughout the 12 month period of observation. In contrast,patients whose psychiatric morbidity had been precipitated bythe infarction tended to have transient symptoms and fewer problemsof social adjustment. Measures of psychiatric morbidity oneweek after the attack did not predict subsequent mortality ordifficulty in returning to work. Only a history of heavy smokingwas significantly associated with mortality during the ensuing12 months. Patients who regarded their illness as a loss ora threat had greater psychiatric morbidity than those who regardedit as an insignificant event.     

Insufficient nitric oxide bioavailability: a hypothesis to explain adverse effects of red blood cell transfusion

While transfusion of red blood cells (RBCs) is effective at preventing morbidity and mortality in anemic patients, studies have indicated that some RBC components have functional defects ("RBC storage lesions") that may actually cause adverse events when transfused. For example, in some studies patients transfused with RBCs stored more than 14 days have had statistically worse outcomes than those receiving "fresher" RBC units. Recipient-specific factors may also contribute to the occurrence of these adverse events. Unfortunately, these events have been difficult to investigate because up to now they have existed primarily as "statistical occurrences" of increased morbidity and mortality in large data sets. There are currently no clinical or laboratory methods to detect or study them in individual transfusion recipients. We propose a unifying hypothesis, centered on insufficient nitric oxide bioavailability (INOBA), to explain the increased morbidity and mortality observed in some patients after RBC transfusion. In this model, variables associated with RBC units (storage time; 2,3-diphosphoglycerate acid concentration) and transfusion recipients (endothelial dysfunction) collectively lead to changes in nitric oxide (NO) levels in vascular beds. Under certain circumstances, these variables are "aligned" such that NO concentrations are markedly reduced, leading to vasoconstriction, decreased local blood flow, and insufficient O(2) delivery to end organs. Under these circumstances, the likelihood of morbidity and mortality escalates. If the key tenets of the INOBA hypothesis are confirmed, it may lead to improved transfusion methods including altered RBC storage and/or processing conditions, novel transfusion recipient screening methods, and improved RBC-recipient matching.