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BackgroundRisk factors for delirium following cardiac surgery are incompletely understood. The aim of this study was to investigate whether intra-operative pathophysiological alterations and therapeutic interventions influence the risk of post-operative delirium.MethodsThis retrospective cohort study was performed in a 12-bed cardiosurgical intensive care unit (ICU) of a university hospital and included patients consecutively admitted after cardiac surgery during a 2-month period. The diagnosis of delirium was made clinically using validated scores. Comparisons between patients with and without delirium were performed with non-parametric tests. Logistic regression was applied to identify independent risk factors. Results are given as number (percent) or median (range).ResultsOf the 194 consecutive post-cardiac surgery patients, 50 (26 %) developed delirium during their ICU stay. Univariate analysis revealed that significant differences between patients with and without delirium occurred in the following intra-operative variables: duration of cardiopulmonary bypass (184 [72–299] vs 113 (37–717) minutes, p < 0.001), lowest mean arterial pressure (50 [30–70] vs 55 [30–75] mmHg, p = 0.004), lowest haemoglobin level (85 [56–133] vs 98 [53–150] g/L, p = 0.005), lowest body temperature (34.5 [24.4–37.2] vs 35.1 [23.9–37.2] °C, p = 0.035), highest noradrenaline support (0.11 [0.00–0.69] vs 0.07 [0.00–0.42] μg/kg/minute, p = 0.001), and frequency of red blood cell transfusions (18 [36 %] vs 26 [18 %], p = 0.018) and platelet transfusions (23 [46 %] vs 24 [17 %], p < 0.001). Only platelet transfusions remained an independent risk factor in the multivariate analysis (p < 0.001).ConclusionsIn patients undergoing cardiac surgery, various intra-operative events, such as transfusion of platelets, were risk factors for the development of a post-operative delirium in the ICU. Further research is needed to unravel the underlying mechanisms.

WHAT THIS PAPER ADDSThe use of chimney and periscope grafts for the treatment of aneurysms involving the supra-aortic branches is reported with mid-term follow-up. This tool uses off the shelf devices and it can be employed in the emergency setting. This single centre experience reports the use of self expandable covered stents for parallel graft construction with particular attention to a standardised technique. The limited experience and follow-up available allow the use of this technique in high risk patients unfit for conventional surgery.Purpose: Report mid-term outcomes of thoracic endovascular aneurysm repair (TEVAR) with chimney and periscope grafts (CPG) in supra-aortic branches (SAB). Methods: Retrospective analysis, from October 2009 to May 2014, of patients with aneurysms requiring TEVAR with zone 0/1/2 proximal landing in association with at least one CPG in the SAB. All patients were considered at high risk for conventional surgery. Peri-operative mortality and morbidity, retrograde type A dissection, maximum aortic transverse diameter (TD) and its post-operative evolution, endoleak, survival, freedom from cardiovascular re-interventions, and CPG freedom from occlusion during the follow-up were analysed. Results: Forty-one patients (28.05% EuroScore II) with thoraco-abdominal aortic aneurysm (17%), arch aneurysm (39%), descending aneurysm (34%), and aneurysm extending from the arch to the visceral aorta (10%) were included. Fifteen (37%) patients were treated non-electively. Fifty-nine SABs were treated with the CPG technique: one, two, three, and four CPG were employed in 71%, 19%, 5%, and 5% of patients, respectively. The proximal landing was in zone 0 in 49% of patients, zone 1 in 17%, and zone 2 in 34%. Technical success was 95%. Peri-operative complications and neurological events were registered in six (14.6%) patients and there were 5 deaths (12%). At a median follow-up of 21.2 (mean 22, SD 18; range 0e65) months, type I/III endoleaks were registered in three (7%) cases and re-intervention in six (15%) patients. A significant aneurysm sac shrinkage (p<.001) was reported at mean follow-up and no significant aneurysm sac increase (>5 mm). The estimated 2 year survival, freedom from re-intervention, freedom from endoleak, and freedom from branch occlusion were 75%, 77%, 86%, and 96%, respectively. Conclusion: The chimney and periscope grafts technique was shown to be safe in aortic aneurysm disease involving the supra aortic branches, even in an emergency setting using off the shelf devices. Mid-term follow-up results in this high risk population are good, but longer follow-up is mandatory before this technique is used in intermediate-risk patients. Ó

Aims This short communication aims to review the treatment of cardiogenic shock in patients with yew poisoning based on two case reports from our institution, focusing on the use of extracorporeal life support (ECLS). Methods and results We report two cases of Taxus baccata poisoning treated with ECLS at our institution and review the literature based on a search in PubMed and Google Scholar on the topic of yew poisoning and ECLS. All cases were combined for analysis of demographics, ECLS therapy, and outcome. Case 1: A 35‐year‐old woman developed polymorphic ventricular tachycardia followed by cardiovascular arrest 5 h after orally ingesting a handful of yew needles. Successful resuscitation required ECLS for 72 h due to ongoing cardiac arrhythmias and cardiogenic shock. The patient left the hospital without neurological sequelae after 10 days. Case 2: A 30‐year‐old woman developed refractory cardiac arrhythmias and circulatory arrest. Resuscitation included ECLS for 71 h. T. baccata needles found by gastroscopy confirmed the diagnosis. The patient had no neurologic deficits and was transferred to psychiatry after 11 days. Review of the literature: Nine case reports were found and analysed along with our two cases. Five out of the 11 (45%) patients were female. Median (range) age was 28 (19–46) years. T. baccata needles were ingested with a suicidal intention in all patients. Median (range) duration of ECLS was 70 h (24–120 h). Eight (73%) patients had full neurological recovery. Conclusions Yew poisoning is a differential diagnosis in young psychiatric patients presenting with polymorphic ventricular tachycardia and cardiogenic shock. A characteristic cardiac contraction pattern in echocardiography may present a diagnostic clue. The early use of ECLS is a valuable bridge to recovery in most of these patients.

Background: Extracorporeal life support (ECLS) therapy is increasingly used for cardiac and respiratory support postcardiotomy, refractory cardiogenic shock and cardiopulmonary resuscitation. This study aims to describe in-hospital mortality of patients requiring ECLS, identify independent predictors associated with mortality and analyze changes of mortality over time.Methods: This retrospective study includes all adult ECLS cases at the University Hospital Zurich, a designated ECLS center in Switzerland, in the period 2007 to 2019.Results: ECLS therapy was required in 679 patients (median age 60 years, 27.5% female). In-hospital mortality was 55.5%. Cubic spline interpolation did not detect evidence for a change in mortality over the whole period of 13 years. In-hospital mortality significantly varied between ECLS indications: 70.7% (152/215) for postcardiotomy, 67.9% (108/159) for cardiopulmonary resuscitation, 47.0% (110/234) for refractory cardiogenic shock, and 9.9% (7/71) for lung transplantation and expansive thoracic surgery (P<0.001). Logistic regression modelling showed excellent discrimination in the receiver operating characteristic (ROC) area under the curve (AUC) of 0.89 [95% confidence interval (CI): 0.87-0.92] and identified significant mortality predictors: age, simplified acute physiology score (SAPS) II, as well as new liver failure and each allogenic blood transfusion unit given per day. ECLS after cardiopulmonary resuscitation was associated with significantly higher mortality compared to ECLS for refractory cardiogenic shock. Conclusions:In-hospital mortality of patients treated with ECLS therapy is high. Outcomes have not changed significantly in the observed period. We identified age, SAPS II, new liver failure and each allogenic blood transfusion unit given per day as independent mortality predictors. Knowledge of predictors strongly associated with in-hospital mortality may affect future decisions about ECLS indications and the respective management to use this elaborate therapy more effectively.

Delirium in the general intensive care unit (ICU) population is common, associated with adverse outcomes and well studied. However, knowledge on delirium in the increasing number of ICU patients with malignancy is scarce. The aim was to assess the frequency of delirium and its impact on resource utilizations and outcomes in ICU patients with malignancy. This retrospective, single-center longitudinal cohort study included all patients with malignancy admitted to ICUs of a University Hospital during one year. Delirium was diagnosed by an Intensive Care Delirium Screening Checklist (ICDSC) score ≥ 4. Of 488 ICU patients with malignancy, 176/488 (36%) developed delirium. Delirious patients were older (66 [55–72] vs. 61 [51–69] years, p = 0.001), had higher SAPS II (41 [27–68] vs. 24 [17–32], p < 0.001) and more frequently sepsis (26/176 [15%] vs. 6/312 [1.9%], p < 0.001) and/or shock (30/176 [6.1%] vs. 6/312 [1.9%], p < 0.001). In multivariate analysis, delirium was independently associated with lower discharge home (OR [95% CI] 0.37 [0.24–0.57], p < 0.001), longer ICU (HR [95% CI] 0.30 [0.23–0.37], p < 0.001) and hospital length of stay (HR [95% CI] 0.62 [0.50–0.77], p < 0.001), longer mechanical ventilation (HR [95% CI] 0.40 [0.28–0.57], p < 0.001), higher ICU nursing workload (B [95% CI] 1.92 [1.67–2.21], p < 0.001) and ICU (B [95% CI] 2.08 [1.81–2.38], p < 0.001) and total costs (B [95% CI] 1.44 [1.30–1.60], p < 0.001). However, delirium was not independently associated with in-hospital mortality (OR [95% CI] 2.26 [0.93–5.54], p = 0.074). In conclusion, delirium was a frequent complication in ICU patients with malignancy independently associated with high resource utilizations, however, it was not independently associated with in-hospital mortality.

Shock in cardio-surgical intensive care unit (ICU) patients is a serious condition with a high morbidity and mortality.1,2 Prompt identification of the underlying conditions and correct management of the lifethreatening physiological deteriorations are crucial to save the patient's life. In daily practice, however, focusing on the main goal -to provide adequate oxygen delivery thereby preventing further organ damage -is often difficult due to multiple influences, distractions, and pending results. Hence, the setting up of priorities is necessary.In addition, many questions arise on how to optimally treat patients in shock: What blood pressure should we target? What fluid should we use and how much? Which vasoactive drug is best and which inotrope? While discussions about these issues can be very fruitful for experts, they risk confusing younger colleagues and nurses at the bedside. Disputes about controversial therapy opinions might consequently delay adequate resuscitation, putting the patient at risk of an adverse outcome. This review aims to give recommendations for the management during the early phase of shock of cardio-surgical patients hospitalised in the ICU. The focus is on the first 6 hours, which are also called 'the golden hours'. Methods Clinical SettingThe cardio-surgical ICU at the University Hospital Zurich is a 12-bed, high-intensity unit that cares for more than 1,100 patients every year.The majority of these critically ill patients undergo cardiac and/or major vascular surgery, most of them being mechanically ventilated and on inotrope/vasopressor support. The unit is part of a successful heart failure programme that includes extracorporeal life support, ventricular assist devices and a heart transplantation service. In order to optimise the initial resuscitation of patients and to avoid adverse effects of inadequate treatment, the consultants of the unit have agreed on treatment recommendations, which are presented here.They are based on current evidence and complemented by clinical experience in areas of uncertainty. Data ExtractionFor this narrative review, a search of the PubMed database and a review of bibliographies from selected articles were performed to identify original data relating to this topic. Key words used for the search were 'shock', 'cardiac surgery', 'critical care', 'inotropes', 'inotropic therapy', 'circulatory support', 'cardiogenic shock' and 'sepsis'. National and international guidelines were reviewed and integrated, e.g. The 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, 3 The 2014 ESC/ EACTS guidelines on myocardial revascularization 4 and The Surviving Sepsis Campaign guidelines 5 . Articles were scrutinised regarding their study design, population evaluated, interventions, outcomes, and limitations. Finally, personal recommendations were included and highlighted as such to give a comprehensive overview on this topic. Rationale for an Early Management of ShockShock in patients under...

Background: Many valvular pathologies of the heart may be only sufficiently treated by replacement of the valve if a reconstruction is not feasible. However, structural deterioration, thrombosis with thromboembolic events and infective endocarditis are commonly encountered complications over time and often demand a re-operation. In congenital heart disease the lack of small diameter valves with the potential to grow poses additional challenges and limits treatment options to homo-or xenograft implants.Methods: In this study, a chronic sheep model (24 months follow-up), a self-constructed valved conduit was created out of a tissue engineered (TE) patch (CorMatrix® Cardiovascular, Inc, USA) and implanted in orthotopic right ventricular (RV)-pulmonary artery (PA) position. Thereafter, the sheep were regularly monitored by clinical, laboratory and echocardiographic examinations to evaluate cardiac function and the implanted RV-PA-conduit.Discussion: Here, we summarize the study protocol and our experiences during the perioperative phase and the follow up period and explain how we constructed a valved conduit out of a commercially available TE patch.