A novel approach to delivery of extracorporeal support using a modified continuous flow ventricular assist device in a mid‐volume congenital heart program

Extracorporeal life support (ECLS) is an essential component of a modern congenital cardiac surgery program. The circuit components and bedside management team may, however, vary among institutions. Here, we evaluate our initial experience with a modified ventricular assist device—based ECLS circuit primarily managed by the bedside nurse. We hypothesize that our outcomes are comparable to Extracorporeal Life Support Organization (ELSO) registry data. All patients who received ECLS from January 1, 2016 to December 31, 2019 at a single institution were included. Primary outcomes were survival to ECLS decannulation and discharge or transfer. Secondary outcomes included complications from ECLS. Data were compared to available ELSO registry data. Thirty‐seven patients underwent 44 ECLS runs during the study period. Forty percent of patients had single ventricle physiology. Nearly 46% of patients received ECLS as part of extracorporeal cardiopulmonary resuscitation (eCPR). Survival to ECLS decannulation (68.2%) and survival to discharge or transfer (61.4%) did not differ from overall ELSO outcomes (69.7%, P = .870 and 50.7%, P = .136), as well as survival to discharge or transfer in a comparable cohort of ELSO centers (53.1%, P = .081). Patients with complications had a lower rate of survival to discharge or transfer but this did not reach statistical significance (47.7% vs. 75.0%, P = .455). Neurologic (50.0%), hemorrhagic (45.5%), and renal complications (31.8%) were most common in this cohort. A modified ventricular assist device‐based ECLS circuit with primary management by the bedside nurse can provide comparable support in a neonatal and pediatric cardiac surgery population. Cost analyses and further delineation of the complication profile are necessary for a complete characterization of this system.     

Validation of the modified NUTrition Risk Score (mNUTRIC) in mechanically ventilated,severe burn patients: A prospective multinational cohort study

BackgroundWhether nutrition therapy benefits all burn victims equally is unknown. To identify patients who will benefit the most from optimal nutrition, the modified Nutrition Risk in Critically Ill (mNUTRIC) Score has been validated in the Intensive Care Unit. However, the utility of mNUTRIC in severe burn victims is unknown. We hypothesized that a higher mNUTRIC (≥5) will be associated with worse clinical outcomes, but that greater nutritional adequacy will be associated with better clinical outcomes in patients with higher mNUTRIC score.MethodsThis prospective study included data from mechanically ventilated, severe burn patients (n = 359) from 51 Burn Units worldwide included in a randomized trial. Our primary and secondary outcomes were hospital mortality and the time to discharge alive (TTDA) from hospital. We described the association between nutrition performance and clinical outcomes.ResultsCompared to low mNUTRIC (n = 313), the high mNUTRIC group (n = 46) had higher mortality (61% vs. 19%, p = 0.001), and longer TTDA (>90 [87–>90] vs. 64 [38–90] days, p = <0.0001). Only in the high mNUTRIC group, increased calorie intake (per 20% increase) was associated with lower mortality and a faster TTDA.ConclusionsThe mNUTRIC score identifies those with poor clinical outcomes and may identifies those mechanically ventilated, severe burn patients in whom optimal nutrition therapy may be more advantageous.     

Racism,stress and health in Asian Americans: A structural equation analysis of mediation and social support group differences

The buffering effect of social support on the negative effects of racism exposure on health outcomes has been mixed in prior studies regarding Asian Americans. Based on the stress-coping framework and using structural equation modelling (SEM) methods, we tested a theoretical model portraying simultaneous mediational paths from racism exposure to general physical and mental health through racism-related stress. Bootstrap analysis was used to test the indirect effects present in the model. Additionally, multi-group SEM analysis was conducted to investigate the moderation effect of social support from family and friends on the paths in the model. The sample consisted of 310 Asian American adults who completed an online survey. The results from the two-step SEM analysis and bootstrap analysis supported the theoretical model—racism exposure can simultaneously have a negative indirect effect on Asian Americans' physical and mental health via racism-related stress. Multi-group SEM analysis showed that there were no differences in model path coefficients based on having varying levels of social support from friends or family.     

Supportive and Negative Responses in the Partner Relationship: Their Association with Psychological Adjustment Among Individuals with Cancer

This study examined the association between positive and negative aspects of spouse responses and psychological adjustment among 15S individuals with cancer. Two contextual variables, gender and disease-related functional impairment, were taken into account when examining the association between spouse responses and patient psychological distress and well-being. Results indicated that negative aspects of close relationships played a comparatively stronger role than positive aspects in their associations with both psychological distress and well-being. For negative spouse responses, patient gender did not moderate the effects of these responses upon psychological outcomes. For positive aspects of spouse support, both gender and functional disability moderated the association between spouse support and psychological outcomes. These findings are integrated with the general literature on positive and negative aspects of close relationships. Implications for clinical interventions are also discussed.     

P0.1 is a useful parameter in setting the level of pressure support ventilation

Objective The purpose of this study was to investigate whether changes in breathing pattern, neuromuscular drive (P0.1), and the work involved in breathing might help to set the individual appropriate level of pressure support ventilation (PSV) in patients with acute respiratory failure (ARF) requiring ventilatory assistance.Design: A prospective, interventional study.Setting An 8-bed multidisciplinary intensive care unit (ICU).Patients Ten patients with ARF due to adult respiratory distress syndrome (ARDS), sepsis or airway infection were included in the study. Chronic obstructive pulmonary disease (COPD) patients with acute exacerbation were excluded. None of these patients was in the weaning process.Interventions We found a level of pressure support able to generate a condition of near-relaxation in each patient, as evidenced by work of breathing (WOB) values close to 0 J/l. This level was called PS 100 and baseline physiological measurements, namely, breathing pattern, P 0.1 and WOB were obtained. Pressure support was then reduced to 85%, 70% and 50% of the initial value and the same set of measurements was obtained.Measurements and results Flow ( ) was measured by a flow sensor (Varflex) positioned between the Y-piece of the breathing circuit and the endotracheal tube. Tidal volume was obtained by numerical integration of the flow signal. Airway pressure (P_aw) was sampled through a catheter attached to the flow sensor. Esophageal pressure (P_es) was measured with a nasogastric tube incorporating an esophageal balloon. The esophageal balloon and flow and pressure sensors were connected to a portable monitor (CP 100 Bicore) that provided realtime display of flow, volume, P_aw and P_es tracings and loops of P_es/V, P_aw/V and /V relationships. The breathing pattern was analyzed from the flow signal. Patient work of breathing (WOB) was calculated by integration of the area of the P_es/V loop. Respiratory drive (P 0.1) was measured at the esophageal pressure change during the first 100 ms of a breath, by the quasiocclusion technique. When pressure support was reduced, we found that the respiration rate significantly increased from PS 100 to PS85, but varied negligibly with lower pressure support levels. Tidal volume behaved in a similar way, decreasing significantly from PS 100 to PS85, but hardly changing at PS 70 and PS 50. In contrast, WOB and P 0.1 increased progressively with decreasing pressure support levels. The changes in WOB were significant at each stage in the trial, whereas P 0.1 increased significantly from PS 100 at other stages. Linear regression analysis revealed a highly positive, significant correlation between WOB and P 0.1 at decreasing PSV levels (r=0.87), whereas the correlation between WOB and ventilatory frequency was less significant (r=0.53). No other correlation was found.Conclusions During pressure support ventilation, P 0.1 may be a more sensitive parameter than the assessment of breathing pattern in setting the optimal level of pressure support in individual patients. Although P 0.1 was measured with an esophageal balloon in the present study, non-invasive techniques can also be used.