Maximum and minimum lactate levels within 24 hours after veno-arterial extracorporeal membrane oxygenation induction are risk factors for intensive care unit mortality: a retrospective observational study

Introduction: Lactate level and clearance were hypothesized to be potential prognostic factors for mortality in patients withrefractory cardiogenic shock who underwent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). This study aimed to determine the prognosis of VA-ECMO patients and whether the lactate level at intensive care unit (ICU) admission(La) and at 24 h after VA-ECMO induction (L24), minimum (L24min) or maximum (L24max) lactate level within 24 h after VAECMO induction, and/or maximum lactate level after ICU admission (Lmax) could predict ICU mortality in VA-ECMO patients.Materials and Methods: This retrospective observational study included consecutive patients who underwent VA-ECMO for severe cardiogenic shock and admitted to the ICU in a hospital from April 2009 to March 2017. Risk factors for ICU mortalitywith respect to lactate levels after VA-ECMO induction were determined through multiple logistic regression analysis.Results: VA-ECMO induction was performed in 67 adult patients, of whom 23 (34.3%) survived to ICU discharge. La, L24min,L24max, and Lmax were risk factors for ICU mortality in VA-ECMO patients after adjustment for the Acute Physiology and Chronic Health Evaluation II score and use of continuous renal replacement therapy and refractory ventricular arrhythmia after VA-ECMO induction, which were confounding factors in univariate analysis (La: odds ratio [OR], 1.44; 95% confidence interval[CI], 1.13-2.05; L24min: OR, 1.20; 95% CI, 1.01-2.56; L24max: OR, 1.44; 95% CI, 1.11-2.02; Lmax: OR, 1.52; 95% CI, 1.14-2.21).Conclusion: Lactate levels can be a therapeutic target and indicator of the need for improved patient management after VAECMO induction

Association between enterocyte injury and fluid balance in patients with septic shock: a post hoc exploratory analysis of a prospective observational study

Background: The required fluid volume differs among patients with septic shock. Enterocyte injury caused by shock may increase the need for fluid by triggering a systematic inflammatory response or an ischemia-reperfusion injury in the presence of intestinal ischemia/necrosis. This study aimed to evaluate the association between enterocyte injury and positive fluid balance in patients with septic shock.Methods: This study was a post hoc exploratory analysis of a prospective observational study that assessed the association between serum intestinal fatty acid-binding protein, a biomarker of enterocyte injury, and mortality in patients with septic shock. Intestinal fatty acid-binding protein levels were recorded on intensive care unit admission, and fluid balance was monitored from intensive care unit admission to Day 7. The association between intestinal fatty acid-binding protein levels at admission and the infusion balance during the early period after intensive care unit admission was evaluated. Multiple linear regression analysis, with adjustments for severity score and renal function, was performed.Results: Overall, data of 57 patients were analyzed. Logarithmically transformed intestinal fatty acid-binding protein levels were significantly associated with cumulative fluid balance per body weight at 24 and 72 h post-intensive care unit admission both before (Pearson’s r = 0.490 [95% confidence interval: 0.263–0.666]; P < 0.001 and r = 0.479 [95% confidence interval: 0.240–0.664]; P < 0.001, respectively) and after (estimate, 14.4 [95% confidence interval: 4.1–24.7]; P = 0.007 and estimate, 26.9 [95% confidence interval: 11.0–42.7]; P = 0.001, respectively) adjusting for severity score and renal function.Conclusions: Enterocyte injury was significantly associated with cumulative fluid balance at 24 and 72 h post-intensive care unit admission. Enterocyte injury in patients with septic shock may be related to excessive fluid accumulation during the early period after intensive care unit admissio

Ice Cliff Dynamics of Debris-Covered Trakarding Glacier in the Rolwaling Region, Nepal Himalaya

Ice cliffs can act as “hot spots” for melt on debris-covered glaciers and promote local glacier mass loss. Repeat high-resolution remote-sensing data are therefore required to monitor the role of ice cliff dynamics in glacier mass loss. Here we analyze high-resolution aerial photogrammetry data acquired during the 2007, 2018, and 2019 post-monsoon seasons to delineate and monitor the morphology, distribution, and temporal changes of the ice cliffs across the debris-covered Trakarding Glacier in the eastern Nepal Himalaya. We generate an ice cliff inventory from the 2018 and 2019 precise terrain data, with ice cliffs accounting for 4.7 and 6.1% of the debris-covered area, respectively. We observe large surface lowering (&gt;2.0 m a−1) where there is a denser distribution of ice cliffs. We also track the survival, formation, and disappearance of ice cliffs from 2018 to 2019, and find that ∼15% of the total ice cliff area is replaced by new ice cliffs. Furthermore, we observe the overall predominance of northwest-facing ice cliffs, although we do observe spatial heterogeneities in the aspect variance of the ice cliffs (ice cliffs face in similar/various directions). Many new ice cliffs formed across the stagnant middle sections of the glacier, coincident with surface water drainage and englacial conduit intake observations. This spatial relationship between ice cliffs and the glacier hydrological system suggests that these englacial and supraglacial hydrological systems play a significant role in ice cliff formation

Removal of a catheter mount and heat-and-moisture exchanger improves hypercapnia in patients with acute respiratory distress syndrome

To avoid ventilator-associated lung injury in acute respiratory distress syndrome (ARDS) treatment, respiratory management should be performed at a low tidal volume of 6 to 8 mL/kg and plateau pressure of ≤30 cmH2O. However, such lung-protective ventilation often results in hypercapnia, which is a risk factor for poor outcomes. The purpose of this study was to retrospectively evaluate the effectiveness and safety of the removal of a catheter mount (CM) and using heated humidifiers (HH) instead of a heat-and-moisture exchanger (HME) for reducing the mechanical dead space created by the CM and HME, which may improve hypercapnia in patients with ARDS.This retrospective observational study included adult patients with ARDS, who developed hypercapnia (PaCO2 > 45 mm Hg) during mechanical ventilation, with target tidal volumes between 6 and 8 mL/kg and a plateau pressure of ≤30 cmH2O, and underwent stepwise removal of CM and HME (replaced with HH). The PaCO2 values were measured at 3 points: ventilator circuit with CM and HME (CM + HME) use, with HME (HME), and with HH (HH), and the overall number of accidental extubations was evaluated. Ventilator values (tidal volume, respiratory rate, minutes volume) were evaluated at the same points.A total of 21 patients with mild-to-moderate ARDS who were treated under deep sedation were included. The values of PaCO2 at HME (52.7 ± 7.4 mm Hg, P < .0001) and HH (46.3 ± 6.8 mm Hg, P < .0001) were significantly lower than those at CM + HME (55.9 ± 7.9 mm Hg). Measured ventilator values were similar at CM + HME, HME, and HH. There were no cases of reintubation due to accidental extubation after the removal of CM.The removal of CM and HME reduced PaCO2 values without changing the ventilator settings in deeply sedated patients with mild-to-moderate ARDS on lung-protective ventilation. Caution should be exercised, as the removal of a CM may result in circuit disconnection or accidental extubation. Nevertheless, this intervention may improve hypercapnia and promote lung-protective ventilation

Wide Effect of Maxillomandibular Advancement

Objectives: Maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) is considered the useful treatment; however, its wide effectiveness is unclear. Thus, this study aimed to explore factors affecting the efficacy of MMA for OSA using a 3-D morphological and computed fluid dynamics (CFD) analysis of the upper airway (UA). Design: Retrospective study Settings and participants: Twenty consecutive patients (six women, mean age 34.2 ± 12.4 years) who underwent MMA because of persistent OSA at our center. Main outcome measures: Cone-beam computed tomography images were captured before and after MMA. We assessed the maxilla and mandibular positions, cross-sectional areas of the nasal airway (NA) and pharyngeal airway (PA), and PA space (PAS). The negative pressure of the PA, NA, and UA were measured at inspiration using CFD. We performed paired t-tests and Wilcoxon signed-rank test to compare values before and after MMA. The relationship between the airway size and pressure was evaluated using Spearman correlation coefficients and a non-linear regression analysis. Results: PAS significantly expanded from 6.5 ± 3.4 mm to 12.2 ± 3.8 mm. NA obstruction significantly improved from -312.6 ± 265.0 Pa to -76.2 ± 129.0 Pa. Moreover, the patients were divided into four types according to the PAS size and presence of NA obstruction, namely narrow PAS with NA obstruction, narrow PAS, NA obstruction, and wide PAS and without NA obstruction. Conclusions: We identified variations in the OSA types. However, MMA substantially improved NA obstruction and PA expansion. Thus, we considered that MMA for OSA was effective for various types

Maximum and minimum lactate levels within 24 hours after veno-arterial extracorporeal membrane oxygenation induction are risk factors for intensive care unit mortality: a retrospective observational study

Introduction: Lactate level and clearance were hypothesized to be potential prognostic factors for mortality in patients with refractory cardiogenic shock who underwent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). This study aimed to determine the prognosis of VA-ECMO patients and whether the lactate level at intensive care unit (ICU) admission(La) and at 24 h after VA-ECMO induction (L24), minimum (L24min) or maximum (L24max) lactate level within 24 h after VAECMO induction, and/or maximum lactate level after ICU admission (Lmax) could predict ICU mortality in VA-ECMO patients.Materials and Methods: This retrospective observational study included consecutive patients who underwent VA-ECMO for severe cardiogenic shock and admitted to the ICU in a hospital from April 2009 to March 2017. Risk factors for ICU mortality with respect to lactate levels after VA-ECMO induction were determined through multiple logistic regression analysis.Results: VA-ECMO induction was performed in 67 adult patients, of whom 23 (34.3%) survived to ICU discharge. La, L24min,L24max, and Lmax were risk factors for ICU mortality in VA-ECMO patients after adjustment for the Acute Physiology and Chronic Health Evaluation II score and use of continuous renal replacement therapy and refractory ventricular arrhythmia after VA-ECMO induction, which were confounding factors in univariate analysis (La: odds ratio [OR], 1.44; 95% confidence interval[CI], 1.13-2.05; L24min: OR, 1.20; 95% CI, 1.01-2.56; L24max: OR, 1.44; 95% CI, 1.11-2.02; Lmax: OR, 1.52; 95% CI, 1.14-2.21).Conclusion: Lactate levels can be a therapeutic target and indicator of the need for improved patient management after VAECMO induction