Are frailty scales better than anesthesia or surgical scales to determine risk in cardiac surgery?

BACKGROUND: In the last year there has been an increasing interest for using frailty scales for risk stratification of elderly patients undergoing major surgery. We planned to compare two frailty scales with risk scales already used in cardiac surgery, to study which of these scores have better prognostic value predicting postoperative outcome in open heart surgery. METHODS: We conducted a prospective clinical trial, including 57 patients over 65 years. We calculated Cardiac Anesthesia Risk Evaluation score, EuroScore II, Clinical Frailty Scale, Edmonton Frail Scale for each patient and followed the postoperative complications, length of mechanical ventilation, length of stay in the intensive care unit and hospital, and in-hospital death related to these risk and frailty scores. RESULTS: Postoperative complications occurred in 25 patients (43.9%), while four patients (7%) died with multiple organ failure. All scales had low predictability for postoperative complications, but for length of mechanical ventilation we obtained positive correlations with EuroScore II, Edmonton Frail Scale and Clinical Frailty Scale. EuroScore II can also predict the length of stay in the intensive care unit. For postoperative deaths, the highest sensitivity had EuroScore II, followed by Clinical Frailty Scale and Edmonton Frail Scale. CONCLUSIONS: EuroScore II and the frailty scales have an increased prognostic value regarding the postoperative outcome of patients (length of mechanical ventilation and in-hospital mortality), the EuroScore II can predict the length of stay in the intensive care unit as well.

Caspase 3 expression and plasma level of Fas ligand as apoptosis biomarkers in inflammatory endotoxemic lung injury.

OBJECTIVE: The objective of this study is to evaluate if the immunohistochemical expression of a pulmonary apoptosis marker and plasma level of Fas ligand (FasL) correlates with the dose- and time-dependent severity of lung injury, induced by the administration of lipo-polysaccharide (LPS) in an endotoxemic rat model. MATERIALS AND METHODS: Our study included 30 male Wistar rats, randomly divided into three groups: one control group (n=6) and two experimental groups (n=12÷group), in whom we induced endotoxemia by intraperitoneal injection of progressively increasing doses of LPS (5, 10 mg÷kg). We measured FasL plasma levels of the rats at different time points and analyzed the relationships with markers of lung injury. To investigate the level of caspase 3-protein expression, the immunohistochemistry of the lung tissue was assessed. RESULTS: The median percentage of caspase 3-stained cells for the 5 mg÷kg LPS dose was 0.36%, for the 10 mg÷kg LPS dose was 0.4% and for the control group was 0.03% (p<0.0001). The elevated expression levels of caspase 3 were consistent with the altered lung morphologies observed (rs=0.88). LPS administration in rats resulted in a significant dose-dependent increase in the levels of plasma FasL (p<0.0001). These levels correlated with markers of lung injury: degree of hypoxemia (rs=-0.42), histological measured lung injury score (rs=0.72), the density of the caspase 3 staining cells in the immunohistochemistry assessment of apoptosis (rs=0.81) and with the plasma RAGE (receptor for advanced glycated end-products) values (rs=0.70). CONCLUSIONS: Apoptosis is increased in edotoxemia induced lung injury and is likely to contribute to alveolar injury.

Factors Favouring the Development of Clostridium Difficile Infection in Critically Ill Patients.

Clostridium difficile, an anaerobic, spore-forming, toxin-forming, gram-positive bacillus present in the bacterial flora of the colon is the principal cause of nosocomial diarrhoea in adults. AIM: Assessment of favouring factors of Clostridium difficile infections as well as the interactions between them, in critically ill hospitalized patients undergoing complex medical and surgical treatments. MATERIAL AND METHODS: A retrospective case-control study involving eighty patients admitted in the Intensive Care Unit (ICU) of the County Clinical Emergency Hospital Tîrgu-Mures was conducted between January and October 2014. Patients aged eighteen years and over, who had undergone complex medical and surgical treatment, were divided into two subgroups. Group 1 included patients who developed diarrhoea but were not diagnosed as having a Clostridium difficile infection (CDI). Group 2 included patients who developed diarrhoea due to CDI as indicated by a positive culture and the expression of exotoxin. The assessed parameters were age, length of stay (LOS), antibiotic spectrum, association with proton pump inhibitors (PPI) or H2-receptor antagonists, immunological status, the presence or lack of gastrointestinal tract surgery. RESULTS: The mean age was 64.6 years with an average LOS of 10 days. Fifty-six percent of patients came to the ICU from internal medicine wards and forty-three percent from surgical wards. 20.5% of them were immunosuppressed. Co-association of ceftriaxone and pantoprazole significantly increased the risk of CDI compared to co-administration of any other antibiotic or pantoprazole (p=0.01). The odds ratio for Pantoprazole together with any antibiotic versus antibiotic therapy alone was significantly higher (p=0.018) with a sevenfold increase in the risk of positive exotoxin increase. CONCLUSIONS: Antibiotic use is associated with "no risk to develop CDI" in the first five days of administration. PPIs associated therapy increased the risk of CDI in first seventy-two hours regardless of the antibiotic type, and contributes to an active expression of CD exotoxin.

Evaluation of O-POSSUM vs ASA and APACHE II scores in patients undergoing oesophageal surgery.

BACKGROUND AND AIMS: Risk and prognostic scores quantify the patient's risk of death or complication according to the severity of his illness. The aim of this study was to evaluate the predictive accuracy of O-POSSUM vs ASA and APACHE II models on patients undergoing oesophageal surgery. MATERIAL AND METHOD: In this observational retrospective study 55 patients were enrolled who had undergone surgical interventions of excision and reconstruction of the oesophagus for neoplastic oesophageal stenosis, in the Surgical Clinics (I and II) of the Clinical County Emergency Hospital Mures, between January 2011 and January 2014. By using patients file records after extracting the data we calculated the predictive mortality, according to the prognostic scores O-POSSUM, ASA and APACHE II and we analyzed its correlations with the postoperative evolution. We evaluated the discriminatory power of the three scores using the ROC (receiver-operating characteristic) curves. According to the cut-off value corresponding to each score, we compared the Kaplan Meier survival curves during the hospitalization period. RESULTS: ROC curves analysis revealed that O-POSSUM had a better discriminatory power for mortality compared to the other two scores: AUC = 0.73 for O-POSSUM, AUC = 0.57 for APACHE II and AUC = 0.64 for ASA (p < 0.001). The cut-off value was statistically significant only in case of O-POSSUM, as it derives from the statistical analysis of the survival curves (p = 0.035). CONCLUSION: O-POSSUM predicts mortality more accurately compared to ASA or APACHE II in patients undergoing oesophageal surgery.

Blood sampling as a cause of anemia in a general ICU - a pilot study.

OBJECTIVE: The objective of our pilot study was to evaluate the influence of daily phlebotomy on patients' haemoglobin levels from our general intensive care unit. METHODS: We prospectively enrolled 35 patients who did not present with acute haemorrhage or developed it during the study period. For each patient we recorded: the diagnosis, age, sex, haemoglobin, hematocrit, SOFA and APACHE II score, blood volume drawn in standardized vials, number of blood tests ordered per day, fluid balance per day, number of ICU days. The collected data were analyzed using the linear regression model, paired t-test, receiver operating characteristic curves, and descriptive analysis. Statistical analysis was performed with SPSS v.17 trial version (IBM, NY, USA). RESULTS: The mean volume of blood drawn per day was 18.1 (SD ± 14.4) ml and the number of blood tests was 3.8 (SD ± 1.75) per day. On univariate linear regression analysis both the blood volume drawn daily (p = 0.04) and the number of blood tests per day (p = 0.009) correlated with a drop in mean haemoglobin concentration. The difference in the mean value of haemoglobin at admission and discharge correlated with overall mortality (p = 0.03). The sensitivity of admission haemoglobin equal to 10.6 g/dL in predicting mortality was 82.4% with a specificity of 50%, (p = 0.019, AUC = 0.732). CONCLUSIONS: We evidenced the predictive power of blood sampling and number of blood tests done on haemoglobin concentration. Besides the main objective of the study we noticed that the difference in the mean value of haemoglobin at admission and discharge correlated with overall mortality. Considering that blood sampling contributes to anemia among ICU patients, we should limit the daily tests undertaken, to the tests absolutely necessary for guiding our therapy.

Plasma Neutrophil Gelatinase Associated Lipocalin (NGAL) - Early Biomarker for Acute Kidney Injury in Critically Ill Patients.

INTRODUCTION: NGAL (Neutrophil Gelatinase Associated Lipocalin) is a biomarker recently introduced into clinical practice for the early diagnosis of acute kidney injury (AKI). The aim of this study was to correlate the plasmatic NGAL value determined at admission with clinical progression and severity of AKI in critically ill patients. MATERIAL AND METHOD: Thirty two consecutive critically ill adult patients at risk of developing AKI (trauma, sepsis), admitted in Intensive Care Unit of the Clinical County Emergency Hospital Mures, between January to March 2015 were enrolled in the study. For each patient included in the study plasma NGAL levels were determined on admission, and these were correlated with the degree of AKI development (according to AKIN criteria) at 48 hours and 5 days post admission. The discriminatory power of NGAL, creatinine, creatinine clearance and corrected creatinine (depending on water balance) were determined using the ROC (receiver-operating characteristic) and likelihood ratios. RESULTS: ROC curve analysis showed a better discriminatory capacity in terms of early diagnosis of AKI for NGAL (AUC=0.81 for NGAL, AUC=0.59 for creatinine, AUC=0.62 for corrected creatinine, AUC=0.29 for creatinine clearance). The value of likelihood ratio was also significantly higher for NGAL (3.01±2.73 for NGAL, 1.27±1.14 for creatinine, 1.78±1.81 for corrected creatinine, and 0.48±0.33 for creatinine clearance). CONCLUSIONS: NGAL biomarker has a better discrimination capacity for early prediction of acute kidney injury compared to previously used markers.

Ischemic preconditioning and inflammatory response syndrome after reperfusion injury: an experimental model in diabetic rats.

Quantification of local ischemia and inflammatory response syndrome correlated with histological changes associated with ischemia-reperfusion injury (IRI) after revascularization techniques. We included 12 adult male Wistar rats, aged eight weeks that were randomly divided into two groups. The first group acted as the control and at the second group, we induced diabetes by intraperitoneal streptozotocin administration (60 mg/kg). After eight weeks, the rats were subject to ischemic preconditioning for 10 minutes at three regular intervals. Twenty-four hours post-preconditioning, both groups were subject to ischemia for 20 minutes, followed by 30 minutes of reperfusion. Oxygen extraction was higher in Group 1, the arterio-venous CO2 gradient was higher in the control group, but not significant. The lactate production was higher in Group 1. The second group had a higher Na+ and also a significant difference in K+ values. Receptor for Advanced Glycation End (RAGE) values were higher in the second group but with no significant difference (RAGE1=0.32 ng/mL versus RAGE2=0.40 ng/mL). The muscle samples from the control group displayed significant rhabdomyolysis, damage to the nucleus, while the preconditioned group showed almost normal morphological characteristics. The lungs and kidneys were most damaged in the control group, with damage expressed as thickened alveolar septa, neutrophil infiltrates, eosinophilic precipitates in the proximal convolute tubule. Ischemic preconditioning significantly attenuates the ischemic reperfusion injury.

Time- and dose-dependent severity of lung injury in a rat model of sepsis.

Different animal models of experimental lung injury have been used to investigate mechanisms of lung injury. Lipopolysaccharide (LPS) administration is the most often used approach to model the consequences of bacterial sepsis. We created an endotoxemia rat model, simulating sepsis-related lung injury, in order to quantify the time and dose dependent severity lesions induced by the administration of lipopolysaccharide. Our study included 42 male Wistar rats, randomly divided into four groups: one control group (n=6) and three experimental groups (n=12/group) in whom we induced sepsis by intraperitoneal injection of progressively increasing doses of LPS (3, 5, 10 mg/kg). At six hours, the animals included in the groups with higher doses of LPS developed thrombocytopenia, elevated lactate levels, and liver and renal injury in a dose and time dependent manner. The severity of hypoxemia at six hours correlated with the increasing doses of LPS, with a slight improvement at 24 hours. Lung injury scores became more severe with increased dose and time of exposure to LPS without reaching the level of hyaline membranes formation. We also demonstrated translocation of a protein from the airspaces into plasma (RAGE - receptor for advanced glycation end products). Induction of sepsis using LPS is a known experimental model, but LPS treatment in rats does not cause the severe endothelial and epithelial injury that occurs in humans with acute respiratory distress syndrome (ARDS). In our study, the clinical, laboratory and histopathological findings confirmed sepsis and the damage of the alveolar-capillary membrane in a dose-dependent manner.