Differences in early, intermediate, and long-term mortality among elderly patients admitted to the ICU: results of a retrospective observational study.

BACKGROUND: Few studies have investigated both short- and long-term prognostic factors, and the differences between chronic and acute conditions in the very old critically ill patient. Our study aims to shed light in this field and to provide useful prognostic factors that may support clinical decisions in the management of the elderly. METHODS: Six ICUs collected data concerning 80-year-old (or more) patients admitted in 2015 and 2016 and followed-up until May 2018. Three prognostic models were developed: an in-hospital mortality model, a model for patients discharged from the hospital and entering follow-up, and an intermediate model for those alive after three days from ICU admission. RESULTS: Our centers admitted 1189 patients, 1071 (90.1%) had survived after three days from admission, 889 (74.8%) were discharged from the hospital, 701 (59.0%) survived six months after hospital discharge, 539 (45.3%) survived at the end of follow-up. Among survivors the median follow-up time was 810 days. Acute organ failures were the main causes of death in the hospital mortality multivariable model. These factors are modifiable and potentially a target for intervention to improve outcome. The model focused on mortality six months after hospital in patients that survived a three-day time-limited trial, showed a clear shift toward chronic diseases, unmodifiable factors crucial for prognostic assessment. This trend was even more evident at the end of follow-up. CONCLUSIONS: Among very old ICU patients, prognostic factors shift from acute to chronic conditions in passing from in-hospital to posthospital outcomes.

Clinical and predictive value of blood lactate levels during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): a comparative analysis.

Postoperative outcome after cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is strongly related to surgical and anesthesiologic expertise. This study aims to evaluate the clinical significance and prognostic value of lactate levels (LL) measured during CRS-HIPEC on postoperative outcome compared to similar major surgical procedures. Patients who were treated between January and September 2019 at our Institute and met the inclusion criteria were selected. Patients were divided into three groups: group 1: patients who underwent major surgical procedures; group 2: patients who underwent CRS without HIPEC; group 3: patients who underwent CRS with HIPEC. Intraoperative LL were analyzed and correlated with surgical procedure and postoperative outcome. We observed a significant increase of LL during surgical/CRS phase (group 1: p = 0.0001; group 2: p = 0.001; group 3: p = 0.057), rather than during the HIPEC phase in group 3 (p = ns). In patients undergoing CRS and peritonectomies, the mean LL were significantly higher compared to group 1 (p = 0.05). Although not statistically significant, the complication rate was higher in patients with end-CRS lactate values > 2 mMol/l, especially in the group undergoing CRS plus HIPEC. Our pilot study shows that higher LL during peritoneal cancer surgery are expected compared to major surgical procedures. Cytoreductive phase, rather than HIPEC, is related to an increase of LL. The role of LL as an early marker of postoperative complications after CRS-HIPEC should be further verified in properly designed studies.

Biology of immunoglobulins.

Intravenous Immunoglobulins (IvIg) are often administered to critically ill patients more as an act of faith than on the basis of relevant clinical studies. This particularly applies to the treatment of sepsis in adult patients, in whom the current guidelines even recommend against their use, despite that many studies demonstrated either their beneficial effects in different subsets of patients and that some preparations of IvIg are more effective than other. The biology of Ig are reviewed, aiming to a more in-depth understanding of their properties in order to clarify their possible indications in different clinical settings.

End-tidal versus manually-controlled low-flow anaesthesia.

During low-flow manually-controlled anaesthesia (MCA) the anaesthetist needs constantly adjust end-tidal oxygen (EtO2) and anaesthetic concentrations (EtAA) to assure an adequate and safe anaesthesia. Recently introduced anaesthetic machines can automatically maintain those variables at target values, avoiding the burden on the anaesthetist. End-tidal-controlled anaesthesia (EtCA) and MCA provided by the same anaesthetic machine under the same fresh gas flow were compared. Eighty patients were prospectively observed: in MCA group (n = 40) target end-tidal sevoflurane (1%) and EtO2 concentrations (≥ 35%) were manually controlled by the anaesthetist. In EtCA group (n = 40) the same anaesthetic machine with an additional end-tidal control feature was used to reach the same targets, rendering automatic the achievement and maintenance of those targets. Anaesthetic machine characteristics, amount of consumed gases, oxygen and sevoflurane efficiencies, and the amount of interventions by the anaesthetist were recorded. In EtCA group EtAA was achieved later (145 s) than in MCA (71 s) and remained controlled thereafter. Even though the target expired gas fractions were achieved faster in MCA, manual adjustments were required throughout anaesthesia for both oxygen and sevoflurane. In MCA patients the number of manual adjustments to stabilize EtAA and EtO2 were 137 and 107, respectively; no adjustment was required in EtCA. Low-flow anaesthesia delivered with an anaesthetic machine able to automatically control EtAA and EtO2 provided the same clinical stability and avoided the continuous manual adjustment of delivered sevoflurane and oxygen concentrations. Hence, the anaesthetist could dedicate more time to the patient and operating room activities.