EP.WE.490Influence of age on post-operative outcomes from adrenalectomy for phaeochromocytoma

Methods A retrospective search of institutional databases for histologically and biochemically confirmed cases of phaeochromocytoma, at a single tertiary care institution, from 2012 to 2020. Clinical parameters, adrenal function, intra and postoperative data were obtained. Patients > 60 years were classified as elderly and outcome data within 30 days of operation compared to < 60 years. Results Patients > 60 years constituted 31% (n = 17) of the cohort, mean age 70 ± 6 versus 43 ± 13 years for < 60 years (n = 38). There was no difference in tumour size, 4 ± 2.5 cm and 4.6 ± 2.6, p = 0.3. Frequency of laparoscopic resection was similar at 65% in both groups. Intra-operatively 5% of < 60 years required blood transfusion compared to none in > 60 years group with 12% in older group undergoing en-bloc resection and nephrectomy and 6% experiencing cardiac dysrhythmias. Postoperatively all patients were managed in level two care except 7% of < 60 years requiring level 3 care reflecting extent and complexity of resection. There was no difference in requirement and duration of vasoactive medication or length of stay in level 2, 1.6 ±1.2, 1.6 ±1.0 days. Proportion of patients graded ASA 3 in > 60 years was 53% compared with 41% in < 60 years. Postoperative complications in > 60 were 29% vs 13%, p = 0.003, with HAP being commonest. Length of hospital stay was also significantly longer at 5.8 ± 2.4 versus 4.5 ± 2.2, p = 0.02. There was no mortality. Conclusions Age of the patient alone does not influence post-operative outcomes from adrenalectomy in phaeochromocytoma.

A PROSPECTIVE RANDOMISED STUDY TO ASSESS WHETHER PROPHYLACTIC ATROPINE ADMINISTRATION ATTENUATES THE NEGATIVE HAEMODYNAMIC EFFECTS OF INDUCTION OF ANAESTHESIA WITH PROPOFOL AND FENTANYL

INTRODUCTION: To provide optimal surgical conditions safely and to avoid particular complications, balanced general anaesthesia by administering a combination of propofol and fentanyl as analgesics. This type of balanced anaesthesia often induces unwanted bradycardia and hypotension, raising concerns regarding haemodynamic stability and tissue oxygenation. It is possible that atropine could replace the common clinical practice of administering vasoactive medication such as phenylephrine or norepinephrine to maintain mean arterial pressure (MAP) levels. AIM OF THE STUDY: To study the effect of atropine in suppressing the negative haemodynamic effects of induction agents- propofol and fentanyl in patients receiving general anaesthesia. MATERIALS AND METHODS: This is a prospective randomised interventional study carried out in Department of Anaesthesiology in Kanyakumari Government Medical College from January 2018 to June 2019. Patients were allocated into two groups (25 patients each) by randomization. After preoxygenation Group A: Patient receives Atropine. Patient in Group S: Receives Saline. BMI, Height, weight, Heart rate, Noninvasive blood pressure, Mean arterial pressure were recorded for every minute for 15 minutes. RESULTS: The demographic parameters like age, height, weight and BMI were similar in both groups. Comparing the SBP of both group, at base and 1 minute the difference of SBP was small. After that, the SBP was increasing trend in Atropine subjects and SBP was decreasing trend in saline subjects (P<0.001). Comparing the DBP between the two groups, Base and 1 minutes, the DBP of both groups were not differed signicantly (P>0.05),after that the DBP of Atropine group DBP was increasing trend and the DBP of saline group was decreasing trend (P<0.001). The HR of the both groups were increasing and decreasing accordingly (P<0.001). Comparing the MAP of both groups at base through 15 minutes,MAP of both group at 1minute was not differed signicantly (P>0.05),after that the MAP of Atropine subjects were increasing and Saline subjects were decreasing trend P<0.001). Percentage of fall of parameters (SBP, DBP, HR, and MAP) was more signicant at 5 and 15 mins compared to 10 mins in both th group. This may be due to the intubation response after the 5 minute of induction. All values were signicant with P<0.001. CONCLUSION: Administration of atropine before Propofol and Fentanyl induction during general anaesthesia can signicantly attenuate the fall in Systolic Blood Pressure, Diastolic Blood Pressure, Heart Rate and Mean Arterial Pressure.

Changing trends in dialysis modalities utilization and mortality in children, adolescents and young adults with acute kidney injury, 2010–2017

The aim of the study was to assess trends in the relative use of dialysis modalities in the hospital-based pediatric cohort and to determine risk factors associated with in-hospital morality among pediatric patients receiving dialysis for acute kidney injury (AKI). Patients aged < 20 years who received dialysis between 2010 and 2017 were identified from electronic health records databases of a Taiwan’s healthcare delivery system. The annual uses of intermittent hemodialysis (HD), continuous and automated peritoneal dialysis (PD) and continuous kidney replacement therapy (CKRT) were assessed using Cochran-Armitage Tests for trend. Among patients who received their first dialysis as inpatients for AKI, a multivariate logistic regression model was employed to assess mortality risks associated with dialysis modalities, patient demographics, complexity of baseline chronic disease, and healthcare service use during their hospital stays. Kidney dialysis was performed 37.9 per patient per year over the study period. Intermittent hemodialysis (HD) (73.3%) was the most frequently used dialysis modality. In the inpatient setting, the relative annual use of CKRT increased over the study period, while HD use concomitantly declined (P < 0.0001). The overall in-hospital mortality rate after dialysis for AKI was 33.6%, which remained steady over time (P = 0.2411). Patients aged < 2 years [adjusted odds ratio: (aOR) 3.36; 95% confidence interval (CI) 1.34–8.93] and greater vasoactive regimen use (aOR: 17.1; 95% CI: 5.3–55.21) were significantly associated with dialysis-related mortality. Overall treatment modality used for dialysis in pediatric patients increased slowly in the study period, and HD and CRKT modality uses largely evolved in the inpatient setting. Younger ages and use of more vasoactive medication regimens were independently associated with increased early mortality in patients on AKI-dialysis.

Predictors of Mortality among Inter-Hospital Transferred Patients in a Middle-Income Country: a Retrospective Cohort Study

Objective: To identify predictors for hospital mortality among inter-hospital transferred patients in low-resource settings of rural hospitals in Thailand.Methods: We conducted a retrospective cohort study of patients transferred from emergency room(ER) of a community hospital to its designated tertiary care hospital in a western province of Thailand. During March 2018 and February 2019, medical records of 412 patients were reviewed and extracted for potential predictor variables and outcomes. We defined deaths within 72 hrs after a transfer as primary outcome and overall hospital mortality as secondary outcome. Multivariate logistic regression analysis was performed to identify predictors of the outcomes adjusted for potential confounders.Results: Out of 412 patients, a total of 37 patients (9.0%) died during the stay in receiving hospital and 18 (4.4%) of them died within 72 hrs after transfer. Top ten primary diagnostic categories included road traffic injuries (19.7%), acute appendicitis (9.7%), and acute myocardial infarction (5.1%). Univariate analysis revealed early mortality (<72 hrs) was associated with NEWS2, Emergency Severity Index (ESI), cardiac arrest prior to transfer, use of vasoactive agents, endotracheal intubation and admitting service. Using multiple logistic regression model adjusted for the predictors identified by univariate analysis, we found early mortality was independently associated with NEWS2 ≥ 9 (compared to NEWS2 0-6) with OR= 17.51(95%CI 3.16-97.00) and vasoactive medication use (OR= 5.46, 95%CI 1.39-21.46). Similarly, overall mortality was also independently associated with NEWS2 ≥ 9(OR= 4.76, 95%CI 1.31–17.36) and vasoactive medication use (OR= 7.51,95%CI 2.76–20.45).Conclusion: This study identified predictors of early (<72 hrs) hospital mortality and overall hospital mortality among ER patients transferred from a rural community hospital to its designated tertiary care hospital in Thailand, a middle-income country with universal healthcare coverage. The findings might be helpful to inform decision-making dealing with the inter-hospital transfer of ER patients in resource-poor rural settings with similar case-mix.

Deep immune profiling of MIS-C demonstrates marked but transient immune activation compared to adult and pediatric COVID-19

Pediatric COVID-19 following SARS-CoV-2 infection is associated with fewer hospitalizations and often milder disease than in adults. A subset of children, however, present with Multisystem Inflammatory Syndrome in Children (MIS-C) that can lead to vascular complications and shock, but rarely death. The immune features of MIS-C compared to pediatric COVID-19 or adult disease remain poorly understood. We analyzed peripheral blood immune responses in hospitalized SARS-CoV-2 infected pediatric patients (pediatric COVID-19) and patients with MIS-C. MIS-C patients had patterns of T cell-biased lymphopenia and T cell activation similar to severely ill adults, and all patients with MIS-C had SARS-CoV-2 spike-specific antibodies at admission. A distinct feature of MIS-C patients was robust activation of vascular patrolling CX3CR1+ CD8+ T cells that correlated with the use of vasoactive medication. Finally, whereas pediatric COVID-19 patients with acute respiratory distress syndrome (ARDS) had sustained immune activation, MIS-C patients displayed clinical improvement over time, concomitant with decreasing immune activation. Thus, non-MIS-C versus MIS-C SARS-CoV-2 associated illnesses are characterized by divergent immune signatures that are temporally distinct from one another and implicate CD8+ T cells in the clinical presentation and trajectory of MIS-C.

Abstract 16450: Early Identification of High Risk Cardiac Decompensation Phenotypes via Real-time Electronic Health Record Data

Introduction: Early identification of cardiac decompensation remains critical for improved patient outcomes. Digital phenotypes using real-time electronic health record (EHR) data offer an unbiased method to detect decompensation in at-risk individuals. Methods: Phenotypes designed to detect cardiac decompensation and its sequelae were retrospectively evaluated in 108,697 adult patient hospitalizations at a single center from October 2015-August 2018. The 6 phenotypes included hypotension, end organ dysfunction (EOD), hypoperfusion (concomitant hypotension and EOD), escalating vasoactive medication use (vasoactive meds), respiratory decline, and respiratory intervention. Median time from admission to phenotype development was measured in hours. In-hospital mortality and unanticipated ICU transfers were determined across all phenotypes and phenotype combinations. Results: Prevalence and time to detection varied across all six phenotypes (Table 1), with EOD found most frequently (35.7%) and detected earliest (3.4h, IQR 0.9-26.2h). Among individual phenotypes, patients with hypoperfusion had the highest rates of unanticipated ICU transfer (20.62%) and in-hospital mortality (20.99%). Patients meeting at least one phenotype had a 5.90% ICU transfer rate and 5.04% in-hospital mortality rate, compared to 0.62% mortality and 2.19% ICU transfer rates for patients meeting zero phenotypes. Among the 41 measured phenotype combinations, patients meeting all 6 phenotypes had the highest rates of unanticipated ICU transfer (28.75%) and in-hospital mortality (36.45%). Conclusions: Digital phenotypes of decompensation using real-world EHR data identify patients at higher risk of unexpected ICU transfer and in-hospital mortality at early times points in the hospitalization. Further studies will evaluate if implementation of a digital phenotype detection tool can improve care pathways and outcomes.

Usefulness of the society for cardiovascular angiography and intervention classification for predicting in-hospital mortality in patients with acute decompensated heart failure

Introduction Recently a multidisciplinary group of the Society for Cardiovascular Angiography and Interventions (SCAI) derived a new classification schema for cardiogenic shock (CS), simple, clinically based and suitable for rapid assessment at the bedside but also arbitrary. Validation in different clinical datasets, specifically in patients with acute decompensated heart failure (ADHF), is necessary to establish the utility of this proposed classification schema. Purpose We aimed to evaluate the ability of a new SCAI CS staging classification to predict in-hospital mortality in patients with ADHF. Methods We conducted a single-center cohort study, performing a retrospective analysis of prospectively collected data of consecutive patients admitted with ADHF as a primary diagnosis between January 2015 and January 2019. We excluded patients who were hospitalized for an acute coronary syndrome. Patients were assigned to the modified SCAI Classification for CS: Stage A is “at risk” for CS, stage B is “beginning” shock, stage C is “classic”, stage D is “deteriorating”, and E is “extremis”, and in-hospital mortality was evaluated for each group. All-cause mortality was compared across SCAI stages using Kaplan-Meier analysis and log-rank test. Cox proportional hazards models were used to determine the association between SCAI stages and in-hospital mortality after adjusting for age, gender, left ventricular ejection fraction, use of vasoactive medication, mechanical circulatory assist devices, mechanical ventilation, percutaneous coronary intervention and cardiac surgery. Results Among 668 patients with a mean age of 74.9±12 years, 63.9% were male. In-hospital mortality was 11.2%. According to SCAI classification, the proportion of patients in stages A through E was 51.7%, 26.7%, 14.4%, 4.6% and 2.5%. The unadjusted mortality in each stages was: A 0.6%, B 4.5%, C 32.3%, D 61.3%, and E 88.2% (Log Rank P&lt;0.0001). After multivariable adjustment, each SCAI shock stage remained associated with increased in-hospital mortality (all P&lt;0.001 compared to stage A). Compared with SCAI shock stage A, adjusted hazard ratio (HR) values in SCAI shock stages B through E were 5.2, 31, 107, and 185, respectively (Figure). Conclusion In this large clinical cohort of patients with ADHF exclusively, the new SCAI CS staging classification was associated with in-hospital mortality. This finding supports the rationale of the classification in this setting, further prospective trials are needed to validate these findings. Adjusted in-hospital Mortality as a Func Funding Acknowledgement Type of funding source: None

Deep Immune Profiling of MIS-C demonstrates marked but transient immune activation compared to adult and pediatric COVID-19

ABSTRACTPediatric COVID-19 following SARS-CoV-2 infection is associated with fewer hospitalizations and often milder disease than in adults. A subset of children, however, present with Multisystem Inflammatory Syndrome in Children (MIS-C) that can lead to vascular complications and shock, but rarely death. The immune features of MIS-C compared to pediatric COVID-19 or adult disease remain poorly understood. We analyzed peripheral blood immune responses in hospitalized SARS-CoV-2 infected pediatric patients (pediatric COVID-19) and patients with MIS-C. MIS-C patients had patterns of T cell-biased lymphopenia and T cell activation similar to severely ill adults, and all patients with MIS-C had SARS-CoV-2 spike-specific antibodies at admission. A distinct feature of MIS-C patients was robust activation of vascular patrolling CX3CR1+ CD8 T cells that correlated with use of vasoactive medication. Finally, whereas pediatric COVID-19 patients with acute respiratory distress syndrome (ARDS) had sustained immune activation, MIS-C patients displayed clinical improvement over time, concomitant with decreasing immune activation. Thus, non-MIS-C versus MIS-C SARS-CoV-2 associated illnesses are characterized by divergent immune signatures that are temporally distinct and implicate CD8 T cells in clinical presentation and trajectory of MIS-C.One Sentence SummaryMIS-C is defined by generalized lymphocyte activation that corrects during hospitalization, including elevated plasmablast frequencies and marked activation of vascular patrolling CX3CR1+ CD8 T cells.

A Comparison of Non-Invasive Blood Pressure Measurement Strategies with Intra-Arterial Measurement

Introduction:It is difficult to obtain an accurate blood pressure (BP) measurement, especially in the prehospital environment. It is not known fully how various BP measurement techniques differ from one another.Study Objective:The study hypothesized that there are differences in the accuracy of various non-invasive blood pressure (NIBP) measurement strategies as compared to the gold standard of intra-arterial (IA) measurement.Methods:The study enrolled adult intensive care unit (ICU) patients with radial IA catheters placed to measure radial intra-arterial blood pressure (RIBP) as a part of their standard care at a large, urban, tertiary-care Level I trauma center. Systolic blood pressure (SBP) was taken by three different NIBP techniques (oscillometric, auscultated, and palpated) and compared to RIBP measurements. Data were analyzed using the paired t-test with dependent samples to detect differences between RIBP measurements and each NIBP method. The primary outcome was the difference in RIBP and NIBP measurement. There was also a predetermined subgroup analysis based on gender, body mass index (BMI), primary diagnosis requiring IA line placement, and current vasoactive medication use.Results:Forty-four patients were enrolled to detect a predetermined clinically significant difference of 5mmHg in SBP. The patient population was 63.6% male and 36.4% female with an average age of 58.4 years old. The most common primary diagnoses were septic shock (47.7%), stroke (13.6%), and increased intracranial pressure (ICP; 13.6%). Most patients were receiving some form of sedation (63.4%), while 50.0% were receiving vasopressor medication and 31.8% were receiving anti-hypertensive medication. When compared to RIBP values, only the palpated SBP values had a clinically significant difference (9.88mmHg less than RIBP; P < .001). When compared to RIBP, the oscillometric and auscultated SBP readings showed statistically but not clinically significant lower values. The palpated method also showed a clinically significant lower SBP reading than the oscillometric method (5.48mmHg; P < .001) and the auscultated method (5.06mmHg; P < .001). There was no significant difference between the oscillometric and auscultated methods (0.42mmHg; P = .73).Conclusion:Overall, NIBPs significantly under-estimated RIBP measurements. Palpated BP measurements were consistently lower than RIBP, which was statistically and clinically significant. These results raise concern about the accuracy of palpated BP and its pervasive use in prehospital care. The data also suggested that auscultated and oscillometric BP may provide similar measurements.