Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study.

PURPOSE: There is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre. MATERIALS AND METHODS: A single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017. RESULTS: The prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHE II scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required. CONCLUSION: Survival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service's collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.

Acceptance and transfer to a regional severe respiratory failure and veno-venous extracorporeal membrane oxygenation (ECMO) service: predictors and outcomes.

The use of extracorporeal membrane oxygenation for respiratory failure is high risk and resource intensive. In England, five centres provide this service and patients who are referred have four possible outcomes: declined transfer due to perceived futility; accepted in principle but remain at the referring centre with ongoing surveillance; retrieved using conventional ventilation; or retrieved on extracorporeal support. The decision-making process leading to these outcomes has not previously been examined. We evaluated referrals to one centre and identified factors associated with each decision outcome. Five hundred and sixty-four patients were analysed from January 2012 to October 2015. One hundred and fifty-seven patients were declined; multivariate analysis demonstrated associated factors to be: age (odds ratio (95% confidence interval) 1.05 (1.04-1.07)); immunocompromise (4.95 (2.58-9.67)); lactate (1.11 (1.01-1.22)); duration of ventilation (1.08 (1.04-1.14)); and cardiac failure (3.22 (1.04-10.51)). Factors associated with the decision to retrieve an accepted patient were: plateau pressure (1.05 (1.01-1.10)); ratio of arterial oxygen partial pressure to fractional inspired oxygen (0.89 (0.85-0.93)); partial pressure of carbon dioxide in arterial blood (1.13 (1.03-1.25)); and the absence of non-pulmonary infection (0.31 (0.15-0.61)). Only pH was independently associated with the decision to transfer on extracorporeal support (0.020 (0.002-0.017)). Six-month survival in the declined, non-retrieved, conventionally retrieved and extracorporeal-retrieved groups was 16.6%, 71.1%, 76.7% and 72.1%, respectively, substantially supporting the decision-making model. Survival in the accepted group exceeds that reported previously. However, a proportion of those declined do survive and some remotely managed patients die. This suggests the approach does not account for some important survival-determining factors.

Hypotension and anaemia--a blinding combination.

We present a case of complete blindness following severe dengue haemorrhagic fever complicated by anaemia and a dialysis-related episode of profound hypotension. The clinical and radiological features indicated an optic neuropathy, most likely ischaemic in aetiology. The features of posterior ischaemic optic neuropathy and differential diagnosis are discussed.

Acute respiratory distress syndrome.

Outcome in acute respiratory distress syndrome (ARDS) is influenced by a number of factors, including the nature of the precipitating condition and the extent to which multiorgan failure ensues. Most studies of potential therapeutic interventions have been unsuccessful due to the enrollment of limited numbers of patients with a wide variety of pathologies of varying severity. Moreover, the value of initiating single-agent interventions at varying time points in what is an evolving and complex inflammatory process must be questioned. Mortality may therefore represent an inappropriate end-point for clinical trials, which are increasingly focusing on ventilator-free days. Despite these uncertainties, survival appears to be improving, possibly due to the application of supportive techniques in a protocol-driven fashion to patients in whom the underlying condition has been rigorously treated.

The management of severe acute necrotising pancreatitis: an evidence-based review of the literature.

Clearly the main determinant of outcome in severe acute pancreatitis is the extent of pancreatic necrosis and the subsequent risk for the development of infected necrosis. A thorough assessment using appropriate scoring systems and the early use of dynamic contrast-enhanced CT will highlight those patients likely to benefit from higher dependency or intensive care. Despite numerous suggested specific therapies there is still no Grade A evidence that any confers a significant mortality benefit. However, general supportive measures should include vigorous replacement of fluid losses to correct the circulating volume, correction of electrolyte and glucose abnormalities, and respiratory, cardiovascular and renal support as necessary. Those patients with infected pancreatic necrosis or deteriorating organ systems should undergo surgery. Patients with sterile necrosis should receive a broad-spectrum prophylactic antibiotic which adequately penetrates pancreatic tissue. Due attention should also be paid to nutritional support, for which a jejunal feeding tube with EN is recommended as early as is achievable.

ICU protocol may affect the outcome of non-elective abdominal aortic aneurysm repair.

OBJECTIVES: To compare the outcome of patients undergoing non-elective abdominal aortic aneurysm repair at two hospitals under the care of a single vascular surgeon. DESIGN: Prospective and retrospective audit of 6 years of emergency and urgent infrarenal abdominal aortic aneurysm surgery. SETTING: Lewisham and North Southwark Health Authority. SUBJECTS: One hundred and forty-five patients who underwent emergency (46) or urgent (99) repair of an abdominal aortic aneurysm. PRIMARY OUTCOME MEASURE: Hospital mortality. SECONDARY OUTCOME MEASURES: Acute renal failure, intensive care and hospital length of stay distal ischaemia and return to theatre. RESULTS: Mortality was higher at hospital 2 than hospital 1 (28% vs. 9%, p = 0.0068). There was no significant difference in age, sex, cardiac history, hypertension, diabetes, smoking, renal impairment (all p > 0.05). There was no difference in operation time, blood loss and base excess at the end of surgery between the two groups (all p > 0.05). APACHE II scores on admission to ICU were similar in hospital 1 and hospital 2 (median 16 vs. 14, p > 0.03). Pulmonary artery catheters were placed in 18% of patients at hospital 1 compared with 96% at hospital 2. Patients at hospital 2 received more crystalloid (median 2990 vs. 2300 ml+, more colloid (median 4775 vs. 1500 ml), and more inotropes (median 1 vs. 0) than those at hospital 1 in their first 24 h on ICU (all p < 0.001). The volume of urine passed in the first 24 h was similar (median 2410 vs. 2000 ml, p = 0.12) yet the incidence of acute renal failure was higher at hospital 2 compared with hospital 1 (30% vs. 6%, p = 0.001). ICU length of stay of survivors was longer at hospital 2 (median 3 vs. 2 days, p = 0.0018) as was hospital length of stay (median 17.5 vs. 12 days, p = 0.0002). CONCLUSIONS: The outcome at both hospitals is at least as good as other reported series, but it is interesting to note that the hospital which used less pulmonary artery catheters and less intervention (in the form of colloid and inotropes) showed a reduced mortality. These data may be important in assessing the different therapeutic strategies employed postoperatively in the ICU.