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Weaning Pattern Characteristics, Based on Simplified Acute Physiology Score 3, of Critically Ill Patients Requiring Ventilator Care-Juniper Publishers
Background: The Simplified Acute Physiology Score 3 (SAPS 3) scoring system was developed through a worldwide prospective study to predict hospital mortality in critically ill patients. The present study focuses on how outcomes, according to SAPS 3 score, differ in patients receiving or not receiving mechanical ventilation.
Methods: We retrospectively reviewed electronic medical records of patients admitted to the surgical or medical ICU from October to December 2014. The SAPS 3 model scores were evaluated for all patients, and for subgroups of patients receiving mechanical ventilation (MV group) or not (Non-MV group). The MV group was further subdivided into two groups, based on the ventilator weaning (simple [MV-SW] and others [MV-Others]), to compare patient characteristics and mortality, based on SAPS 3 scores.
Results: The SAPS 3 score and mortality were significantly higher, and the length of ICU stay was significantly longer in the mechanical ventilation group (p = 0.004, p < 0.001, and p = 0.007, respectively) compared to the non-mechanical ventilation group. The MV-SW group included patients requiring significantly more postoperative care, while the MV-Others group had more patients intubated due to hypoxemia (p < 0.001). The AUC value, indicating discrimination, was 0.871.
Conclusion: The present study, conducted using the SAPS 3 score, showed good discrimination. It is believed that this method will be useful in predicting weaning difficulties and mortalities of patients requiring mechanical ventilation.
Keywords: Intensive care unit; Mechanical ventilation; Mortality; SAPS 3; Ventilator weaning
1,2]. The Acute Physiology and Chronic Health Evaluation (APACHE) and the Simplified Acute Physiology Score (SAPS) are the most widely used scoring systems in ICUs. Recently, the SAPS 3 was developed through a worldwide prospective study to predict hospital mortality in critically ill patients. It is based on 20 different variables, that are easily measured at patient admission, and dissociating patient status from the quality of care in the ICU [3-7]. There has, however, been no investigation into how outcomes differ in patients receiving or not receiving mechanical ventilation.
The aim of this study was to evaluate the epidemiology and prognostic performance of the SAPS 3 in a retrospective electric chart review, and to describe the weaning pattern characteristics of patients receiving mechanical ventilation.
The performance of the model was evaluated in all patients, as well as, in two subgroups of patients who had received mechanical ventilation (MV group) or not (Non-MV group). Based on the ventilator weaning pattern, the MV group was further subdivided into two groups to compare the characteristics and prolonged, or chronic mechanical ventilation weaning.
Of the 154 patients admitted to the ICU between October and December 2014, 2 pediatric patients, 4 readmissions, and 7 patients with missing data, mostly due to ICU length of stay < 24 h, were excluded. The study group, therefore, comprised 141 patients: 76 males (53.9%) and mean age 67.7 yr. The characteristics of the study group are shown in (Table 1). There were no significant differences in demographic characteristics between patients in the MV group and the Non-MV group. The SAPS 3 score and ICU mortality were significantly higher in the MV group (p = 0.004 and p < 0.001, respectively). In addition, length of ICU stay was significantly longer (p = 0.007) for the MV group.
MV-SW: patients who received mechanical ventilation and simple weaning; MV-Others: patients who received mechanical ventilation and all other weaning groups; SAPS: Simplified Acute Physiology Score; IQR: inter-quartile range.
The MV group (n = 43; excluding 2 patients with missing weaning protocol data) was subdivided based on weaning pattern. When the reason for the intubation was compared between subgroups, the MV-SW group included patients requiring significantly more postoperative care, while the MV-Other group had significantly more intubations due to hypoxemia (p = 0.001). Observed mortality, SAPS 3 score, and predicted mortality were significantly higher in the MV-Other group (Table 2), and observed mortality (60.0%) was higher than the predicted mortality (39.4%).
Hospital mortality was considerably greater in patients with higher SAPS 3 scores. The highest hospital mortality rate was observed in patients with a SAPS 3 score greater than 90 (Figure 1). Discrimination, as measured by the AUC, was good (AUCs = 0.871), (Figure 2).
Many previous studies have shown that SAPS 3 is a scoring system model with good discrimination but poor calibration [5,8-10]. In the present study, the AUC value, which indicates discrimination, was 0.871; this is similar to previous studies (0.8-0.89) and indicates favorable discrimination [5,11]. While there were no in-hospital mortalities in patients with SAPS 3 scores of <40 points, patients with scores of 41-90 points had a mortality rate under 50%, and the mortality rate increased rapidly for patients with scores >90.
Unlike previous SAPS 3 studies that compared discrimination or calibration to outcomes from other scoring models or investigated regional variations [10,12-14], the present study focused on how outcomes differed in patients receiving or not receiving mechanical ventilation. This is because, among various factors affecting SAPS 3, the effect of applying mechanical ventilation on the score is minimal; however, a significant number of patients in the ICU receive ventilator care and applying mechanical ventilation has a clinically significant impact on the clinical course of critically ill patients.
The patient group requiring mechanical ventilation was divided into two subgroups based on the weaning pattern. The simple weaning (MV-SW) group included patients with successful 1st extubation after the 1st SBT. The other (MV-Other) group included all other weaning groups: Difficult weaning (failed 1st SBT trial, but succeeded within the 3rd SBT trials or successful weaning within 7 days after the 1st SBT); prolonged weaning (failed weaning on the 3rd SBT trial or required more than 7 days on the 1st SBT); and chronic mechanical ventilation weaning (the same as tracheostomy) [15,16].
The majority of patients from our hospital had chronic mechanical ventilation weaning when simple weaning failed; for this reason, we consolidated the three groups into one. Since most of the patients who had simple weaning were those who underwent extubation after maintaining mechanical ventilation for postoperative care due to old age, prolonged operation time, or underlying diseases (19 subjects, 82.6%), they not only showed lower SAPS 3 scores, but also lower mortality rates compared to the MV-Other group. Conversely, most ofthe patients within the MV-Other group were intubated for mechanical ventilation because of hypoxemia caused by impairment of normal ventilation function (17 subjects, 85%), which may have manifested as an increase in the severity of weaning.
The mean length of hospital stay for the MV-Other group, whose conditions were more severe, was not significantly different from the MV-SW group; this may be attributed to a shortened overall length of hospital stay due to the larger number of "do not resuscitates" (DNRs) and patients who passed away in this group. Moreover, it can be surmised that the observed mortality rate (60.0%) in this group was higher than the predicted mortality (39.4%) because of the influence limited proactive management for patients who were expected to have unfavorable prognosis and had effectuated DNRs in advance.
The limitations of this study include having a small number of participants, which resulted in a low number of patients in the ventilated group and corresponding subgroups. In addition, at the time of data collection, the hospital did not have a standard weaning protocol; weaning was carried out either by applying a T-piece or a pressure support ventilation (PSV) mode after the SBT and the protocol used was determined by the doctor in charge of the department. Consequently, the reason for a patient not having been placed into a weaning subgroup may not have been due to the patient's condition.
Furthermore, while all charts were reviewed by a single person responsible for the ICU, the SAPS 3 scores were inputted by different doctors who were in charge of the department at the time of admission; for this reason, individual evaluator errors cannot be eliminated. We plan to perform future studies with a larger number of patients; furthermore, the hospital plans to implement a standard SBT protocol, therefore data obtained after the protocol is applied may be compared to the results presented to allow the mechanical ventilation subgroups to be more clearly defined to determine any differences.
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Clinical Outcomes after Intravascular Ultrasound Assessment of Coronary Intermediate Lesions-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPYsubmitted by JuniperPublishers-CC to u/JuniperPublishers-CC
Juniper Publishers-Journal of Cardiology
Purpose: Coronary angiography has limitations in the assessment of intermediate coronary lesions (ICL). Intravascular ultrasound (IVUS) can evaluate more accurately the severity of a lesion to guide the therapeutic strategy. This study sought to evaluate long-term clinical outcomes after IVUS-guided coronary revascularization of ICL lesions in patients from the Western Mediterranean region of coastal North Africa (Maghreb) in whom IVUS severity criteria have not been validated.
Methods: We conducted a prospective monocentric study including 113 patients with angiographic ICL evaluated by IVUS. Minimal lumen area (MLA) cut-offs value to perform revascularization were 6 mm² for the left main coronary artery (LMCA) and 4 mm² for non- LMCA lesions. The primary outcome was defined as a composite of major adverse cardiac events (MACE) including death, myocardial infarction (MI), and target lesion revascularization (TLR) at 12 months.
Results: Mean age was 59,5 ± 12,0 years, 79% were men. Multi-vessel disease was present in 65.5% of our patients, of whom 36 patients had LMCA disease. We analysed 146 arteries with 178 lesions. Revascularization was deferred for n=46 (40.7%) patients after IVUS evaluation. After a mean follow-up of 20± 10 months, we observed no significant differences between the revascularized patients and the patients with a deferred revascularization strategy in terms of mortality (1.5% and 2.2% respectively, p=0.7), and a favourable safety trend for 12-month rate of MACE (10.6% and 2.2% respectively, p=0.165), MI (4.5% and 2.2%, p=0.44) and TLR (10.7% and 2.2%, p=0.23).
Conclusion: We demonstrate that previously validated IVUS criteria to defer revascularization of angiographically ICL can be safely applied to Maghrebi patients.
Keywords: Intravascular ultrasound; Coronary artery disease
Abbreviations: ICL: Intermediate Coronary Lesions; IVUS: Intra Vascular Ultra Sound; FFR: Fractional Flow Reserve; MACE: Major Adverse Cardiac Events; MI: Myocardial Infarction; TLR: Target Lesion Revascularization; LMCA: Left Main Coronary Artery; LAD: Left Anterior Descending Artery; MLA: Minimal Lumen Area; PB: Plaque Burden; LL: Lesion Length; RD: Reference Diameter; PCI: Percutaneous Coronary Intervention; CABG: Coronary Artery Bypass Graft; NSTEMI: Non ST Elevation Myocardial Infarction; STEMI: ST Elevation Myocardial Infarction
Clinical decision making and the management of intermediate coronary lesions (ICL) continues to be a therapeutic dilemma for cardiologists. The limitations of coronary angiography for the evaluation of such lesions are well recognized since 20 years , and adjunctive diagnostic techniques have been developed. Intravascular ultrasound (IVUS) offers the possibility to base decisions not only on lumeno grams but also on true lumen and vessel size and plaque accumulation in the coronary wall. The IVUS criteria reported in the literature defining a functional significant coronary stenosis have been recently reassessed and compared with the fractional flow reserve (FFR) derived from intracoronary pressure measurements. The princeps criteria of a significant stenosis based on a lumen area less than 4 mm² has been challenged by numerous investigators proposing down to 2.1 mm² [2-16].
However, many of these studies were only reporting a head to head comparison with a FFR cut off of 0.75 or 0.8 without outcome data, while a recent prospective study of nearly 700 patients demonstrated that ICL with a lumen area <4 mm² were associated with three more times major adverse cardiovascular events . The aim of this study was to evaluate long-term clinical outcomes in patients from Western Mediterranean region of coastal North Africa (Maghreb) where IVUS studies so far have not been conducted and reported. In these patients, Percutaneous coronary intervention of angiographically ICL was decided on the basis of the IVUS findings using criteria reported in Western population and Asia but so far not prospectively assess in this region of North Africa characterized by a high incidence of diabetes mellitus and hypertension [18,19].
Study population: Between October 2010 and December 2013, we conducted a prospective monocentric study including 113 patients with angiographically ICL who underwent IVUS assessment to decide whether to perform or not revascularization. Patients with acute myocardial infarction, significant distal lesions, those in whom the IVUS-imaging catheter failed to cross the lesion due to severe stenosis or tortuosity and small vessels (reference diameter <2.5mm) were excluded. The primary outcome was defined as a composite of major adverse cardiac events (MACE) including death, myocardial infarction (MI), and target lesion revascularization (TLR) at 12 months.
Angiographic analysis: Coronary angiography was performed with GE Innova® 2000 and Innova® 2100 IQ interventional cardiology systems. Visual estimation of lesion severity, length and reference diameter was performed and reported on the CARDIOREPORTTM database by a single operator who proposed an initial therapeutic strategy. All lesions were classified according to the ACC/AHA consensus . All ICL, defined by a diameter stenosis of 30% to 50% for the left main coronary artery (LMCA) and 40% to 70% for non- LMCA lesions, were revaluated on a heart team staff, and IVUS evaluation was decided each time that there was no unanimity on the therapeutic strategy.
IVUS analysis: Intravascular ultrasound guidance was performed using conventional 6-F guiding catheters and a 0.014- mm guide wire positioned distally, and 40 MHz IVUS catheters (Boston Scientific®) pulled back automatically at a constant speed of 0.5 mm/s. After imaging acquisition the lumen-intima and media-adventitia interfaces were measured at the target site following the guidelines of the American College of Cardiology :
Clinical Data, Definitions, and Outcomes: Hospital records of all patients were reviewed to obtain information on clinical demographics and medical history. Follow-up information was obtained through review of hospital charts or telephone interviews. The primary outcome was defined as a composite of major adverse cardiac events (MACE), including death, myocardial infarction (MI), and target lesion revascularization (TLR) at 12 months. Death was defined as cardiac mortality. The diagnosis of myocardial infarction was based on either the development of new pathological Q waves in ≥ 2 contiguous electrocardiogram leads and/or cardiac enzyme level elevation 3 times the upper limit of normal value. TLR included target lesion percutaneous coronary intervention (PCI) and bypass surgery of the target lesion (CABG).
Statistical analysis: Statistical analysis was performed using IBM® SPSS® Statistics version 20 for Windows. Data are expressed as mean ± SD for continuous variables and as percentages for discrete variables. The normal distribution of variables was verified by the Kolmogorov-Smirnov test for normality. Categorical data were compared using chi-square test. Event-free survival curves were established using the Kaplan-Meier estimation. All calculated p values were 2-sided and differences were considered to be statistically significant when the respective p values were < 0.05.
A total of 113 consecutive patients were included, 146 arteries and 178 lesions were analysed. Baseline clinical characteristics, angiographic and IVUS finding are summarized in (Table 1). Complete follow-up data were available for 112 patients over a mean follow-up time of 20 ± 10 months. There was no protocol violation and all patients with MLA values below the defined cutoffs underwent either PCI or CABG. Overall revascularization was deferred for 46 patients (40.7%) after IVUS assessment. There were significantly more patients with diabetes mellitus, hypercholesterolemia and complex lesions in the revascularized group (Table 2).
The majority of parents (92%, n=225) and children (54%, n=133) were female. The average age of child was six years ranging from one to nine years? The presence of siblings was identified by 32 respondents (12%). In terms of ethnicity, a majority of the parents identified their children as White (53%, n=131) followed by Black (21%, n=52) and multiple/mixed (20%, n=49), Asian (5%, n=11) and other (1%, n=3) ethnic groups. Here in after, respondents will be referred to as parents.
Three MI occurred: two patients had NSTEMI related to late stent thrombosis, and one patient had anterior STEMI one month after he underwent IVUS assessment for an ICL in the proximal LAD (MLA = 8.61 mm²). During the 12-month follow up period, 10 TLR were performed. Nine patients had PCI; eight with DES and one with BMS. Only one patient had CABG. We observed no significant differences between the revascularized patients and the patients whose revascularization was postponed in terms of mortality (1.5% and 2.2% respectively, p=0.7), 12-month rate of MACE (10.6% and 2.2%, p=0.165), myocardial infarction (4.5% and 2.2%, p=0.44) and 12-month rate of target lesion revascularization (10.7% and 2.2%, p=0.23) (Figures 5 & 6).
No cardiac events occurred during the first 12 months follow up for all the patients with LMCA ICL in whom revascularization was deferred. Age and diabetes mellitus were the only significant univariate predictors of, respectively, cardiac death (p<0.01) and TLR (p=0.015). The change of the therapeutic strategy after IVUS evaluation was not correlated with significant change in events rates (Table 3).
The present study showed the following:
The cut-off value for lumen area to predict ischemia is still disputed, and range from 2.1 to 4.4 mm² [2-16,26] for the non- LMCA lesions and 4.8 to 7.5 mm² [27-30] for the LMCA lesions. In 53 non LMCA intermediate lesions, Briguori et al  reported that an MLA cut off of 4 mm² was the best IVUS parameter correlated with identifying FFR < 0.75 with 92% sensitivity and 56% specificity. However, recent studies have found lower MLA cut off values and have used a combination of other IVUS parameters to predict FFR. In a multicenter, prospective, international registry of 350 patients with 367 intermediate coronary lesions (FIRST: Fractional Flow Reserve and Intravascular Ultrasound Relationship Study) , Walksman et al. reported that an MLA < 3,07 mm² (64.0% sensitivity, 64.9% specificity, area under curve [AUC] = 0.65) was the best threshold value for identifying FFR <0.8. Same results were founded by Ben Dor et al.  with improved accuracy when reference vessel-specific analyses were performed. Trials conducted in East Asia population have reported even lower MLA cut off, Kang et al.  established that the best cut off value of the MLA to predict FFR <0.80 was <2.4 mm², with a diagnostic accuracy of 68% (90% sensitivity, 60% specificity).
Few studies compared IVUS finding with FFR as the “gold standard” for determining the functional significance of LMCA ICL. In an analysis of 55 western patients, Jasti et al.  reported that an MLA < 6 mm2 strongly predicted FFR < 0.8 (sensitivity and specificity of 93% and 95%, respectively). Lower MLA cutoff was again reported in Asian population; Kang et al. suggested that 4,8 mm² was the best MLA cutoff correlated to an FFR < 0,8 with 89% sensitivity and 83% specificity.
Care must be taken in the interpretation of these studies conducted in different populations, many in Japan and Korea where there is a large usage of IVUS in the cat lab. There is presently no IVUS report from North Africa / Arabic countries characterized by a higher incidence of smoking, diabetes mellitus, and hypertension.
Different studies had reported that using IVUS to guide decision making induced a significant change in the therapeutic strategy. Mintz et al.  reported that pre intervention IVUS imaging performed in 301 patients led to a change on revascularisation therapy in 121 patients (40%). A higher rate of change in clinical decision after IVUS assessment was reported by other authors (60 to 70,6%) [32-34]. However there is few clinical trials that established the clinical safety of using IVUS MLA to defer a myocardial revascularization. The chosen MLA cut-off thresholds to defer revascularization in those studies were 4mm² for the non-LMCA ICL [35-37] and 6mm² [28,38]or 7.5 mm²  for the LMCA ICL (Table 4).
In 300 patients with non LMCA ICL, deferring PCI on the basis of an IVUS MLA ≥ 4.0 mm2 was associated with a low rate of events (8% at 12 months) . Clinical safety of this MLA cut off was confirmed by others studies showing even fewer cardiac events [36,37]. Otherwise, compare to FFR based decision making, Hernandez et al.  reported that even if IVUS assessment led to more revascularization procedures, there was no significant differences in MACE-free survival (97.7% at one year and 93.1% at two years in the FFR group and 97.7% at one year and 95.6% at two years in the IVUS group; p=0.35) and among those with deferred intervention (97.9% at one year and 94.2% at two years in the FFR group and 96.5% at one year and 93.6% at two years in the IVUS group; p=0.7).
For the LMCA ICL, different studies reported that using the IVUS MLA to defer myocardial revascularisation is also correlated with favourable outcomes [28,29,38]. In the LITRO study , which enrolled 354 patients with LMCA ICL, there was no significant difference between the deferred and revascularized groups in terms of cardiac death-free survival (97.7% vs 94.5%, respectively, P = 0.5) and event-free survival (87.3% vs 80.6%, respectively, P = 0.3) after a mean follow up of 24 months. Our study confirmed the high negative predictive value of this MLA cut-off and accordingly the clinical safety of delaying myocardial revascularization of ICL based on IVUS evaluation.
Study limitations: Principal’s limitations of the present study are:
The use of IVUS in a population from Maghreb to assess angiographically intermediate coronary lesions is correlated with a significant decrease of myocardial revascularization indications and favourable long term outcomes.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that they have no conflict of interest.
Ethical approval: All procedures performed involving human participants were in accordance with the ethical standards of the national research committee. There were no animal study.
Informed consent: Informed consent was obtained from all individual participants included in this study.
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