ABSTRACT
Introduction: Early noninvasive respiratory support (NIRS) is correlated with a success rate of 60-75% in patients experiencing SARS-CoV-2 ARDS. We conducted a prospective case-control study to assess differences in outcomes between Helmet c-PAP (H-c-PAP) and noninvasive positive pressure ventilation (NIPPV). Methods: All patients with SARS-CoV-2 ARDS, treated with H-c-PAP or NIPPV between October 2021 and April 2022 were sampled. We recorded: demographics, comorbidities, clinical, respiratory, sepsis, NIRS parameters, and outcomes. A "NIRS team" followed the patients in respiratory support supplying them with early and timely intensive physiotherapy i-PKT as well. The Cox's proportional hazard model was applied for multivariate analyses. Results: 368 patients were admitted to our hospital medical ward. 85 patients were treated with H-c-PAP and 145 underwent NIPPV. 138 patients needing oxygen supplementation alone were excluded. The two groups were homogeneously distributed and ICU admission rates were lower in the H-c-PAP one (9.4 vs 11% P = .001) while mortality was higher in the NIPPV group (22.7 vs 9.4%, P = .001). The two multivariate models, that had overall mortality as primary outcome, identified age, H-c-PAP daily, i-PKT and ICU admission as independent variables impacting on the outcome. Age was no longer a significant independent predictor after the inclusion of elderly patients (age >80). The third model showed daily i-PKT could prevent ICU admission whereas the length of NIRS was inversely proportional to outcome. Conclusions: A "NIRS multidisciplinary team" made it possible to adopt an early and timely combination of NIRS and i-PKT resulting in the saving of both patient lives and ICU resources.
ABSTRACT
New-onset systolic heart failure (HF) after liver transplantation (LT) is a significant cause of morbidity and mortality; however, its characteristics are still insufficiently delineated. HF may involve the left ventricle (LV), right ventricle (RV), or both ventricles. We explored the incidence, characteristics, etiologies, risks, involved cardiac chambers, and outcomes of HF after LT. Methods: This study included 528 adult patients with preoperative LV ejection fraction ≥ 55% who underwent LT between 2016 and 2020. The primary outcome was new-onset systolic HF, defined by the presence of clinical signs, symptoms, and echocardiographic evidence of reduced LVejection fraction <50% and RV dysfunction within the first year after LT. Results: Thirty-one patients (6%) developed systolic HF within a median of 9 d (1-364). Of those, 23% of patients had ischemic HF, whereas 77% had nonischemic HF. Nonischemic HF was caused by stress (11), sepsis (8), or other factors (5). Nonischemic HF was secondary to isolated LV failure in 58% of patients or RV ± LV failure in 42% of patients. Recursive partitioning identified subgroups with varying risks and uncovered interaction between variables. HF risk increased from 4.2% to 13% when epinephrine and/or norepinephrine drips were used intraoperatively (P < 0.01). When no epinephrine and/or norepinephrine were used, HF risk increased from 3.1% to 38.5% if baseline hemoglobin was <7.2 g/dL (P < 0.01). When baseline hemoglobin was ≥7.2 g/dL, HF risk increased from 0% to 5.2% when ≥3500 mL crystalloid was used intraoperatively (P < 0.01). Posttransplant first-year survival and reversibility of HF depended on the etiology (stress, sepsis, ischemia, etc) and cardiac chamber involvement (isolated LV or RV ± LV). RV dysfunction was associated with inferior recovery of cardiac function and poorer survival than nonischemic isolated LV dysfunction (50% versus 70%, respectively). Conclusions: Posttransplant new-onset HF is mostly nonischemic in nature and is associated with increased morbidity and mortality.
