The routine use of preoperative non-contrast chest computerized tomography and carotid arteries Doppler prior to cardiac surgery.

INTRODUCTION: There is no consensus as to which patients should undergo Non-Contrast Chest Computerized Tomography (NCCCT) and carotid arteries Doppler (CD) prior to cardiac surgery. The objective of this study was to examine whether preoperative imaging modalities provide clinical benefits and a change in surgical strategy. METHODS: We routinely performed NCCCT and CD in all non-urgent cardiac surgery patients. Major NCCCT/CD findings related to cardiovascular findings (aortic calcification/atherosclerosis, carotid artery plaque/stenosis), or other incidental findings (lung kidney, thyroid, adrenal, gastrointestinal sites etc.) were documented. The results were divided into 3 categories: (A) findings requiring both changes in surgical strategy and post-operative evaluation/treatment; (B) findings requiring changes in surgical strategy, but not requiring a specific post-operative evaluation/treatment; (C) findings not requiring changes in surgical strategy but requiring post-operative evaluation/treatment. RESULTS: In this cohort, 93 (18.6%) out of 500 patients had significant cardiac and extra-cardiac findings on NCCCT and/or CD. Among the 93 patients with significant findings, 33.33% (31 patients, 6.2% of all patients) were in group A, 7.5% (7 patients, 1.4% of all patients) were in group B, and 59.14% (55 patients, 11% of all patients) were in group C. Change in surgical strategies included, for example, switching from planned on-pump Coronary Artery Bypass Graft surgery (CABG) to off-pump CABG and performing additional procedures to the originally planned heart surgery. CONCLUSION: Routine preoperative NCCCT and CD evaluation in all non-urgent cardiac surgical patients is an effective measure for uncovering cardiac and extra-cardiac findings prior to surgery.

Emergency Physician-Administered Sedation for Thoracostomy in Children With Pleuropneumonia.

BACKGROUND: Thoracostomy drainage is sometimes required in children with pleuropneumonia who have large parapneumonic effusion. This procedure is usually performed under sedation. The aim was to report sedation adverse events (SAEs) in pneumonia patients sedated for thoracostomy by pediatric emergency physicians. METHODS: A retrospective cohort study was conducted. The medical records of all emergency department patients who underwent thoracostomy between January 1, 2012, and December 31, 2018, were extracted. Study outcomes were SAEs that required intervention. RESULTS: Pigtail catheters were placed by chest surgeons in 28 children with a median age of 2 years (interquartile range [IQR], 1-5 years). All the thoracostomies were successfully performed under sedation performed by 11 pediatric emergency physicians. The median amount of fluid drained after catheter insertion was 200 mL (IQR, 100-500 mL). The median pleural fluid PH was 7.0 (IQR, 6.9-7.3), and the median white blood cell count was 34,600 per mm3 (IQR, 11,800-109,000 per mm3). Thirteen patients (46.4%) were sedated with a total median dose of 3 mg/kg of ketamine (IQR, 2-4 mg/kg) and 0.2 mg/kg of midazolam (IQR, 0.2-0.3 mg/kg); 11 patients (39.3%) were treated with 1 mg/kg of ketamine (IQR, 0.5-2 mg/kg) and 3 mg/kg of propofol (IQR, 2-4 mg/kg). Four patients (14.3%) were treated exclusively with 4 mg/kg of ketamine (IQR, 3-5 mg/kg). Nine oxygen desaturations required intervention; 1 was associated with laryngospasm and 1 with apnea. All the SAEs were successfully managed. No cases of hypotension, bradycardia, airway obstruction, or pulmonary aspiration were recorded. CONCLUSIONS: The first series of pneumonia patients sedated for thoracostomy by pediatric emergency physicians is reported. Sedation was safely performed in this cohort.

Noninvasivepositive pressure ventilation vsinvasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure in cancer patients.

PURPOSE: The objective was to describe the characteristics and outcomes of critically ill cancer patients who received noninvasive positive pressure ventilation (NIPPV) vs invasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure. MATERIAL AND METHODS: A retrospective cohort study of consecutive adult intensive care unit (ICU) cancer patients who received either conventional invasive mechanical ventilation or NIPPV as first-line therapy for hypoxemic respiratory failure. RESULTS: Of the 1614 patients included, the NIPPV failure group had the greatest hospital length of stay, ICU length of stay, ICU mortality (71.3%), and hospital mortality (79.5%) as compared with the other 2 groups (P < .0001). The variables independently associated with NIPPV failure included younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99; P=.031), non-Caucasian race (OR, 1.61; 95% CI, 1.14-2.26; P=.006), presence of a hematologic malignancy (OR, 1.87; 95% CI, 1.33-2.64; P=.0003), and a higher Sequential Organ Failure Assessment score (OR, 1.12; 95% CI, 1.08-1.17; P < .0001). There was no difference in mortality when comparing early vs late intubation (less than or greater than 24 or 48 hours) for the NIPPV failure group. CONCLUSION: Noninvasive positive pressure ventilation failure is an independent risk factor for ICU mortality, but NIPPV patients who avoided intubation had the best outcomes compared with the other groups. Early vs late intubation did not have a significant impact on outcomes.