A systematic review and meta-analysis of the entire COVID-19 Tracheostomy cohort was conducted to determine the cumulative incidence of complications, mortality, time to decannulation and ventilatory ...weaning. Outcomes of surgical versus percutaneous and outcomes relative to tracheostomy timing were also analysed. Studies reporting outcome data on patients with COVID-19 undergoing tracheostomy were identified and screened by 2 independent reviewers. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Outcome data were analysed using a random-effects model. From 1016 unique studies, 39 articles reporting outcomes for a total of 3929 patients were included for meta-analysis. Weighted mean follow-up time was 42.03±26 days post-tracheostomy. Meta-analysis showed that 61.2% of patients were weaned from mechanical ventilation 95%CI 52.6%–69.5%, 44.2% of patients were decannulated 95%CI 33.96%–54.67%, and cumulative mortality was found to be 19.23% 95%CI 15.2%–23.6% across the entire tracheostomy cohort. The cumulative incidence of complications was 14.24% 95%CI 9.6%–19.6%, with bleeding accounting for 52% of all complications. No difference was found in incidence of mortality (RR1.96; p=0.34), decannulation (RR1.35, p=0.27), complications (RR0.75, p=0.09) and time to decannulation (SMD 0.46, p=0.68) between percutaneous and surgical tracheostomy. Moreover, no difference was found in mortality (RR1.57, p=0.43) between early and late tracheostomy, and timing of tracheostomy did not predict time to decannulation. Ten confirmed nosocomial staff infections were reported from 1398 tracheostomies. This study provides an overview of outcomes of tracheostomy in COVID-19 patients, and contributes to our understanding of tracheostomy decisions in this patient cohort.
The rapid global spread of SARS-CoV-2, the causative agent of COVID-19, has dominated healthcare services, with exponential numbers requiring mechanical ventilation in the intensive care unit (ICU). ...Tracheostomy facilitates respiratory and sedative weaning but risks potential viral transmission. This study reviewed the tracheostomy provision, techniques, and outcomes for a single-centre prospective cohort during the resource-pressured COVID-19 period. Seventy-two of 176 patients underwent tracheostomy at a median 17 days: 44 surgical (open), 28 percutaneous. Their median age was 58 years, the male to female ratio was 2.4:1, 75.1% were of BAME backgrounds, 76% had a BMI≥25kg/m2, and 65% had ≥2 major co-morbidities. Seventy-nine percent of patients were weaned from sedation at a median 2 days, 61% were weaned from mechanical ventilation at a median 10 days, 39% were discharged from the ICU at a median 11.5 days, and 19.4% were discharged home at a median 24 days. All patients survived the procedure. The mortality rate was 9.7% at a median 12 days. No clinician reported COVID-19 symptoms within 14 days of the procedure. The role of tracheostomy in COVID-19 is currently unclear. Delivery of tracheostomy by maxillofacial surgeons relieved the workload pressure from ICU clinicians. The choice of technique was influenced by the patient and resource factors, resulting in a mixed cohort of open and percutaneous tracheostomy in COVID-19 patients. Preliminary data suggest that open tracheostomy is as favourable as percutaneous tracheostomy for COVID-19 patients, and is safe for clinicians.
Background & Aims Patients with cirrhosis are prone to infection which is a frequent precipitant of hepatic encephalopathy (HE). Clinical studies have examined the importance of inflammation and ...infection in modulating the manifestation of symptoms of HE in acute liver failure and patients with cirrhosis and minimal/low grade HE. It would be logical to presume that this relationship persists in patients who develop severe HE in cirrhosis although this has not been examined to date. Methods We report the findings of a prospective audit of 100 consecutive patients with cirrhosis admitted between Jan 2000 and March 2008 to a liver Intensive Care Unit (ICU) where HE was the primary indication for admission (59% Grade 3; 41% Grade 4). Haematological and microbiological data were collected at ICU admission, and organ scores and outcomes were recorded. Results 46% of patients had positive cultures taken within ±48 h from admission to ICU 25% blood and a further 22% were culture negative but had evidence of systemic inflammation (SIRS). SIRS score ( p = 0.03) and SOFA score ( p = 0.006) were significantly higher in those patients with Grade 4 HE, who were also less likely to survive ( p <0.001). HE grade/coma score did not correlate with ammonia, biochemistry or MELD score. Fifty-two percent of patients survived their ICU stay while the remainder developed progressive multiorgan failure and died; 38% survived to discharge, and 16% were transplanted. Conclusions These data support an association between infection/SIRS and not ammonia, in patients with cirrhosis that develop severe HE. The presence or absence of infection/SIRS did not determine survival.
Severe liver disease in pregnancy is generally considered to have a favorable prognosis. The limited data available have not yielded disease‐specific prognostic criteria or guidance on who should ...undergo liver transplantation (LT). We retrospectively evaluated 54 admissions with pregnancy‐related liver disease to (1) evaluate if any admission parameters were associated with death and/or transplantation and (2) identify maternal complications. Eighteen had acute fatty liver of pregnancy and 32 had hypertension/eclampsia related disease. Seven patients (13%) died and four (7%) underwent LT. Survival rates were 43/48 if not listed for LT and 4/6 if listed. Of the four transplanted, three survived. Patients who died and/or underwent LT were more likely to have encephalopathy (p = 0.04) and hyperlactaemia (p = 0.03). Serum lactate was the best discriminant (ROC AUC 0.84). An admission lactate greater than 2.8mg/dL had 73% sensitivity and 75% specificity for predicting death or LT. The addition of encephalopathy to this parameter increased sensitivity and specificity to 90% and 86%, respectively. The King's College criteria were not effective in predicting outcome. This study confirms the overall favorable prognosis in pregnancy‐related liver failure but indicates that elevated lactate levels in the presence of encephalopathy best identify patients at greatest risk of death or LT.
In this retrospective study, an elevated serum lactate and the presence of encephalopathy were the best discriminators for predicting either death or liver transplantation in patients admitted to intensive care with pregnancy induced liver failure.
Summary
Background
The timely diagnosis of acute kidney injury (AKI) in liver cirrhosis is challenging.
Aim
To evaluate whether quantification of glomerular filtration rate (GFR), proteinuria and ...kidney injury biomarkers can accurately predict the development of AKI.
Methods
A prospective cohort analysis of patients with cirrhosis was performed. Measures of baseline kidney function included serum creatinine, iohexol clearance and urine protein:creatinine ratio. Blood and urine samples were collected daily. A retrospective analysis of cystatin C GFR and neutrophil gelatinase‐associated lipocalin (NGAL) measured 48 h prior to the diagnosis of AKI was undertaken to evaluate their ability to predict the development of AKI.
Results
Eighteen of the 34 cirrhosis patients studied developed AKI. A GFR <60 mL/min/1.73 m2 was identified in 56% with Iohexol clearance compared to 8% using the four‐variable modified diet in renal disease formula (P < 0.0001). Prediction of AKI, 48 h prior to the development of AKI with cystatin C GFR and serum NGAL concentration were similar; area under the receiver operating curve (AUROC) values 0.74 (0.51–0.97), P = 0.04 and 0.72 (0.52–0.92), P = 0.02 respectively. The development of AKI was strongly predicted by urine protein:creatinine ratio above the cut‐off of >30 (equivalent to 300 mg/day of proteinuria) sensitivity 82% (57–96) and specificity 80% (52–96), AUROC 0.86 (0.73–0.98), P ≤ 0.0001. OR 21 (3–133), P ≤ 0.002.
Conclusions
In patients with liver cirrhosis a urine protein:creatinine ratio >30 predicts AKI. Iohexol clearance and cystatin C formulae identify a greater proportion of patients with a GFR <60 mL/min/1.73 m2, which also predicts the development of AKI.
Current diagnostic criteria for primary nonfunction (PNF) of liver grafts are based on clinical experience rather than statistical methods. A retrospective, single‐center study was conducted of all ...adults (n = 1286) who underwent primary liver transplant (LT) 2000–2008 in our center. Laboratory variables during the first post LT week were analyzed. Forty‐two patients (3.7%) had 2‐week graft failure. Transplant albumin, day‐1 aspartate aminotransferase (AST), day‐1 lactate, day‐3 bilirubin, day‐3 international normalized ratio (INR), and day‐7 AST were independently associated with PNF on multivariate logistic regression. PNF score =(0.000280*D1AST)+ (0.361*D1 Lactate)+(0.00884*D3 Bilirubin)+(0.940*D3 INR)+(0.00153*D7 AST)‐(0.0972*TxAlbumin)‐4.5503. Receiver operating curve analysis showed the model area under receiver operating curve (AUROC) of 0.912 (0.889–0.932) was superior to the current United Kingdom (UK) PNF criteria of 0.669 (0.634–0.704, p < 0.0001). When applied to a validation cohort (n = 386, 34.4% patients), the model had AUROC of 0.831 (0.789–0.867) compared to the UK early graft dysfunction criteria of 0.674 (0.624–0.721). The new model performed well after exclusion of patients with marginal grafts and when modified to include variables from the first three post‐LT days only (AUROC of 0.818, 0.776–0.856, p = 0.001). This model is superior to the current UK PNF criteria and is based on statistical methods. The model is also applicable to recipients of all types of grafts (marginal and nonmarginal).
A large single‐center study redefining primary nonfunction following liver transplantation develops and validates a novel method to predict death or graft failure in the first two weeks following transplantation. See the editorial from Sung on page 1158.
Strong reduction of multiple scattering for channeled particles has been observed in an experiment on the deflection of a 180 GeV/c π+-meson beam by bent silicon crystals. The RMS deflections due to ...multiple scattering for the channeled particles were about six times smaller than for non-channeled ones. It was shown that the approach suggested recently for the description of multiple scattering for channeled particles using the experimental data for random crystal orientations gives fair agreement with the experiment.
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