Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium

Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients

Postoperative atrial fibrillation is associated with increased resource utilization after cardiac surgery: a regional analysis of the Southeastern United States

Aim: Postoperative atrial fibrillation (POAF) is a known risk factor for morbidity and mortality following cardiac surgery though contemporary resource utilization data is limited. We hypothesize that POAF increases the length of stay, hospital cost, and discharges to facilities, though this trend may be tempering over time.Methods: Records were extracted for all patients in a regional database who underwent coronary artery bypass grafting, aortic valve replacement, or both (2012-2020). Patients without a history of atrial fibrillation were stratified by POAF for univariate analysis. Patients were propensity-score matched to account for baseline, operative, and postoperative differences.Results: Of the 27,307 cardiac surgery patients, 23% developed POAF. Matching resulted in 5926 well-balanced pairs of patients with and without POAF. Every metric of resource utilization was higher for patients with POAF, including ICU length of stay (58 h vs. 49 h, P < 0.0001), postoperative length of stay (7 days vs. 5 days, P < 0.0001), discharge to a facility (27% vs. 23%, P < 0.0001), and readmission (11% vs. 8%). The mean additional total hospital cost attributable to POAF was $6705 by paired analysis. A sensitivity analysis of only patients without major complications demonstrated similarly increased resource utilization for patients with POAF.Conclusions: POAF was associated with an increased 9 additional ICU hours, 2 postoperative days, 18$6705 is associated with POAF. These conservative estimates demonstrate the broad impact of POAF on in and out of hospital resource utilization that warrants future efforts at containment and quality improvement

Outcomes of heparinized adult veno-arterial extracorporeal membrane oxygenation patients managed with low and high activated partial thromboplastin time targets: A systematic review and meta-analysis.

INTRODUCTION: There are no randomized controlled trials comparing low and high activated partial thromboplastin time (aPTT) targets in heparinized adult veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) patients. Our systematic review and meta-analysis summarized complication rates in adult VA ECMO patients treated with low and high aPTT targets. METHODS: Studies published from January 2000 to May 2022 were identified using Pubmed, Embase, Cochrane Library, and LILACS (Latin American and Caribbean Health Sciences Literature). Studies were included if aPTT was primarily used to guide heparin anticoagulation. For the low aPTT group, we included studies where aPTT goal was ≤60 seconds and for the high aPTT group, we included studies where aPTT goal was ≥60 seconds. Proportional meta-analysis with a random effects model was used to calculate pooled complication rates for patients in the two aPTT groups. RESULTS: Twelve studies met inclusion criteria (5 in the low aPTT group and 7 in the high aPTT group) CONCLUSIONS: Adult ECMO patients managed with low and high aPTT goals appeared to have similar bleeding and other complication rates further highlighting the need for a randomized controlled trial

Effect of Cardiopulmonary Bypass on SARS‐CoV‐2 Vaccination Antibody Levels

Background Adults undergoing heart surgery are particularly vulnerable to respiratory complications, including COVID‐19. Immunization can significantly reduce this risk; however, the effect of cardiopulmonary bypass (CPB) on immunization status is unknown. We sought to evaluate the effect of CPB on COVID‐19 vaccination antibody concentration after cardiac surgery. Methods and Results This prospective observational clinical trial evaluated adult participants undergoing cardiac surgery requiring CPB at a single institution. All participants received a full primary COVID‐19 vaccination series before CPB. SARS‐CoV‐2 spike protein‐specific antibody concentrations were measured before CPB (pre‐CPB measurement), 24 hours following CPB (postoperative day 1 measurement), and approximately 1 month following their procedure. Relationships between demographic or surgical variables and change in antibody concentration were assessed via linear regression. A total of 77 participants were enrolled in the study and underwent surgery. Among all participants, mean antibody concentration was significantly decreased on postoperative day 1, relative to pre‐CPB levels (−2091 AU/mL, P<0.001). Antibody concentration increased between postoperative day 1and 1 month post CPB measurement (2465 AU/mL, P=0.015). Importantly, no significant difference was observed between pre‐CPB and 1 month post CPB concentrations (P=0.983). Two participants (2.63%) developed symptomatic COVID‐19 pneumonia postoperatively; 1 case of postoperative COVID‐19 pneumonia resulted in mortality (1.3%). Conclusions COVID‐19 vaccine antibody concentrations were significantly reduced in the short‐term following CPB but returned to pre‐CPB levels within 1 month. One case of postoperative COVID 19 pneumonia‐specific mortality was observed. These findings suggest the need for heightened precautions in the perioperative period for cardiac surgery patients

Delirium is associated with failure to rescue after cardiac surgeryCentral MessagePerspective

Objective: Postoperative delirium after cardiac surgery is associated with long-term cognitive decline and mortality. We investigated whether increased ICU Confusion Assessment Method scores were associated with greater 30-day mortality and failure to rescue after cardiac surgery. Methods: We studied 4030 patients who underwent a Society of Thoracic Surgeons index operation at the University of Virginia Health System from 2011 to 2021. We obtained all ICU Confusion Assessment Method scores recorded during patients' admission and summarized scores for the first 7 postoperative days. Univariate and multivariable logistic regression analyzed the association between ICU Confusion Assessment Method score/delirium presence and postoperative complications, operative mortality, and failure to rescue. Results: Any episode of ICU Confusion Assessment Method screen-positive delirium and nearly all components of the score were associated with increased 30-day mortality on univariate analysis. We found that a single episode of delirium was associated with increased mortality. Feature 2 (inattention) had the strongest association with poorer outcomes, including failure to rescue in our analysis, as were patients with higher peak Richmond Agitation Sedation Scale scores. Patients with higher mean Richmond Agitation Sedation Scale scores had an association with decreased failure to rescue. Conclusions: A single episode of delirium, as measured using ICU Confusion Assessment Method scores, is associated with increased mortality. Inattention and higher peak Richmond Agitation Sedation Scale scores were associated with failure to rescue. Screening may clarify diagnosing delirium and assessing its implications on mortality and failure to rescue. Our findings suggest the importance of identifying and managing risk factors for delirium to improve patient outcomes and reduce mortality and failure to rescue rates

Victims’ perceptions of the police response as a predictor of victim cooperation in the Netherlands: a prospective analysis

The current study prospectively explores whether crime victims’ willingness to cooperate with the police is predicted by victims’ perceptions of police officers’ behaviour with regard to their case through their perceptions of police legitimacy. Structural equation modelling was used to examine the interrelationships between the study variables while controlling for baseline values among a sample of 201 crime victims in the Netherlands. Results indicate that victims’ perceptions of procedural justice and police performance were predictive of both indicators of perceived police legitimacy (i.e. obligation to obey the law and trust in the police). Moreover, victims’ willingness to cooperate with the police was indirectly predicted by victims’ perceptions of procedural justice and police performance, through their perceptions of obligation to obey the law. These findings suggest that police officers may play an important role in stimulating victims’ willingness to cooperate with the police by treating victims fairly and by taking investigative actions to solve the crime.Criminal Justice: Legitimacy, accountability, and effectivit