Comparison of the Initiation Time of Enteral Nutrition for Critically Ill Patients: At Admission vs. 24 to 48 Hours after Admission

Objective. To investigate the better time of initiation of enteral nutrition for critically ill patients, such as at admission or 24 to 48 hours after admission. Methods. This was a prospective, randomized, parallel-controlled, single-blind, interventional clinical trial. A total of 100 patients admitted to the intensive care unit (ICU) of our hospital between January 2017 and December 2018 were recruited in this study. These patients had been divided into the control group or intervention group by a computer-generated random number table, and each group had 50 patients. For the control group, a gastric tube was inserted to start enteral nutrition at 24 to 48 hours after admission. For the intervention group, a nasojejunal tube was placed to start enteral nutrition at admission. The main endpoints included serum albumin and prealbumin at admission and on days 3, 7, and 14 after admission, length of ICU stay, ventilator time, and complications such as diarrhea, gastric retention, esophageal reflux, and pulmonary infection. Results. The results showed that serum albumin and prealbumin were significantly higher in the intervention group than in the control group ( P < 0.05). The length of ICU stay ( P < 0.05) and ventilator time ( P < 0.05) were both significantly shorter in the intervention group than in the control group. The incidences of gastric retention, esophageal reflux, and pulmonary infection were significantly lower in the intervention group than those in the control group ( P < 0.05). Conclusion. In the absence of contraindications, enteral nutrition can be initiated immediately after admission to the ICU (within 6 hours), and feeding nasojejunal tube is recommended. It can improve the nutritional status and prognosis of critical patients, improve the feeding effect, shorten the length of stay in the ICU and the use of the ventilator, and reduce the incidence of complications.

Mortality Risk Factors in Tetralogy of Fallot Patients Undergoing Total Correction

A total correction is a preferred treatment for Tetralogy of Fallot patients in every part of the world. However, the mortality in developing countries was as high as 6.9% to 15.3%. This was a retrospective analytic study that analyzed pre and post-operative risk factors that affected mortality on TOF patients that were performed total correction in Indonesia. A total of 47 TOF patients that were performed total correction from January 2016 to September 2019 were enrolled in this study based on the inclusion criteria. Preoperative and post-operative data were obtained from medical records. In this research, the majority of mortality was found in male patients (39.3%), while the female’s rate was lower (36.8%). Overall mortality was 38.3% and one operative death was found. The average age of patients was 84.12 months (12-210 months), whereas the average height (85.56 ± 36.17cm vs. 112.93 ± 21.73) and weight (17.22kg vs. 28.21kg) were lower for mortality patients. Some significant preoperative variables were identified as mortality risk factors such as: age below 60 months (p=0.047), smaller weight and height (p=0.008; p=0.002), abnormal hematocrit (p=0.002), and oxygen saturation below 75% (p=0.018). Significant post-operative risk factors included: temperature above 38.5⁰C (p=0.000), and ventilator time of more than 48 hours (p=0.033). In conclusion, the mortality of TOF patients undergoing a total correction in developing countries was quite high. It was associated with some risk factors, such as younger age, lower weight and height, low oxygen saturation, post-operative fever, and prolonged ventilator time.

Minimally Invasive Myxoma Resection: A Single-center 5 Years’ Experience

BackgroundIncreasing demand for minimally invasive myxoma resection. This study aimed to investigate the safety and feasibility of minimally invasive myxoma resection. MethodsThis is a retrospective study, we collected information on 95 patients who underwent myxoma resection from January 2016 to December 2020. According to the operative approach, they were divided into a minimally invasive myxoma resection(Mini-MR) group (n=30) and a sternotomy myxoma resection(SMR) group (n=65), we compared the intraoperative and postoperative data between the two groups. ResultsPostoperative ventilator assisted time, CSICU time and postoperative hospital stay of Mini-AVR were shorter than SAVR [(13.05 ± 4.98) VS (17.07 ± 9.52)h ;(1.73 ± 0.29) VS (2.27 ± 1.53)d; (6.20 ± 1.50) VS (9.48 ± 3.37)d], the difference was statistically significant (P <0.05). Mini-AVR has lower postoperative drainage and blood transfusion rate of the first 24 h compared with SAVR [(38.93 ± 69.62) VS (178.25 ± 153.06)ml; 26.6% VS 63.1%], the differences were statistically significant (P <0.05). ConclusionMini-MR has the advantages of less CSICU stay time, less ventilator time, less postoperative drainage the first 24h, less blood transfusion, fewer postoperative hospital stays, and faster recovery. Mini-MR is a safe and feasible surgical procedure for the resection of myxoma.

Accurate measurement of ventilator length of stay and ventilator days for use in assessing patient safety and ventilator associated events.

Objective: Accurate measurements of ventilator length of stay are important for quality measures and mandated by Centers of Disease Control for reporting ventilator associated events. However, it is unknown which method of such a calculation gives the more accurate results. Design: We collected data using three different methods of calculating ventilator length of stay in a community hospital ICU. The first method is the walk-through method for collection of data at 6 am, the second is a data base collection system we created where data was collected by respiratory therapists in a daily ventilator patient log then entered into the database, and finally from query of medical charges for ventilator days from financial department Results: There was statistically significant disagreement between the three methods. The walk though method and data base were not statistically different, but the data from financial charges overestimated the ventilator length of stay. Additionally, there was not statistically significant differences between the time of the walk-through data collection. Conclusion: Ventilator days and hours should be measured by a precise database rather than indirect methods of estimation like walk-through or financial charges. Patient exposure to risk, and reporting of ventilator time, whether days or hours should be measured directly, not estimated. A larger study needs to be performed to examine this variation in a broader medical setting. Keywords: ventilator length of stay, ventilator associated events, ventilator associated pneumonia

Dexmedetomidine as add-on sedation to reduce continuous infusion sedative in mechanically ventilated patients

Purpose To characterize the impact of add-on dexmedetomidine therapy on baseline continuous infusion sedative use. Methods A retrospective, single-center, chart review–based study was conducted to assess outcomes of and potential predictors of response to add-on dexmedetomidine therapy in mechanically ventilated intensive care unit (ICU) patients who were already receiving continuous infusions of sedatives. Patients were defined as complete, partial, or nonresponders to add-on dexmedetomidine therapy if initial sedative infusion rates were reduced by 100%, by 50% to 99%, and by less than 50%, respectively, at 6 and 24 hours after initiation of dexmedetomidine. Results Among the 100 patients included in the study sample, there were 54 complete responders, 21 partial responders, and 25 nonresponders to dexmedetomidine add-on therapy at 6 hours after dexmedetomidine initiation; at 24 hours, there were 65 complete and 12 partial responders and 23 nonresponders. Of the variables tested (ie, baseline characteristics, opioid and antipsychotic use, hemodynamic parameters), none differentiated between complete or partial responders and nonresponders. Ventilator time, ICU length of stay (LOS), and hospital LOS after add-on dexmedetomidine therapy initiation were shorter among both partial responders and complete responders vs nonresponders (median, 1.1 days vs 4.1 days [P = 0.01], 7.0 days vs 14.1 days [P = 0.20], and 11.0 vs 17.0 days [P = 0.58], respectively), with only ventilator time being significantly different. Conclusion Add-on dexmedetomidine therapy can obviate or reduce the need for alternate sedation in as many as 75% of mechanically ventilated ICU patients. However, the addition of dexmedetomidine does not allow the reduction of alternate sedation in a substantial minority of patients, and failure to respond to dexmedetomidine can be identified as early at 6 hours after add-on therapy initiation. In the absence of clear predictors of response to dexmedetomidine, these data suggest empiric trials of dexmedetomidine can be considered but should be time-limited.

Improved Outcomes With Integrated Intensivist Consultation for Cardiac Surgery Patients

This study examined the impact of integrated intensivist consultation in the immediate postoperative period on outcomes for cardiac surgery patients. A retrospective cohort study was conducted in 1711 adult cardiac surgery patients from a single quaternary care center in Minnesota. Outcomes were compared across 2 consecutive 2-year time periods reflecting an elective intensivist model (n = 801) and an integrated intensivist model (n = 910). Patients under the 2 models were comparable with respect to demographics, comorbidities, procedure types, and Society for Thoracic Surgery predicted risk of mortality score; however, patients in the earlier cohort were slightly older and more likely to have chronic kidney disease ( P = .003). Integrated intensivist involvement was associated with reduced postoperative ventilator time, length of stay (LOS), stroke, encephalopathy, and reoperations for bleeding (all P < .01) but was not associated with mortality. Intensivist integration into the postoperative care of cardiac surgery patients may reduce ventilator time, LOS, and complications but may not improve survival.

Topical and low-dose intravenous tranexamic acid in cyanotic cardiac surgery

Background Coagulopathy is a major problem in surgery for cyanotic congenital heart disease. Tranexamic acid has been used both topically and systemically and plays a vital role in pediatric cardiac surgery by reducing blood loss and blood product requirement. We aimed to determine the anti-fibrinolytic effectiveness of low-dose systemic or topical tranexamic acid or a combination of both. Methods Seventy-five patients were divided in 3 groups of 25. Group A patients were given tranexamic acid 20 mg kg−1 intravenously after sternotomy and 20 mg kg−1 after heparin reversal. Group B patients were given tranexamic acid 50 mg kg−1 in 20 mL of saline intrapericardially before sternal closure, with the drain clamped for 20 min. Group C patients were given tranexamic acid 20 mg kg−1 intravenously after sternotomy and 50 mg kg−1 intrapericardially before sternal closure. A number of clinical variables were recorded in the first 3 postoperative days. Ventilator time, intensive care unit stay, and outcome were also recorded. Results Chest tube drainage and blood product requirements were lowest in group C. Blood urea and serum creatinine levels were higher in groups A and C ( p < 0.05). Intensive care unit stay and ventilator time were similar in all 3 groups. No patient died and none had a seizure or other neurological event or thromboembolic complication postoperatively. Conclusion The combination of low-dose intravenous and topical tranexamic acid reduces postoperative blood loss and blood product requirement without incurring neurological, renal or thromboembolic complications. We recommend the routine use of topical and low-dose systemic tranexamic acid in cyanotic pediatric cardiac surgery.