Summary Background Antimicrobial treatment in critically ill patients can either be started as soon as infection is suspected or after objective data confirm an infection. We postulated that delaying antimicrobial treatment of patients with suspected infections in the surgical intensive care unit (SICU) until objective evidence of infection had been obtained would not worsen patient mortality. Methods We did a 2-year, quasi-experimental, before and after observational cohort study of patients aged 18 years or older who were admitted to the SICU of the University of Virginia (Charlottesville, VA, USA). From Sept 1, 2008, to Aug 31, 2009, aggressive treatment was used: patients suspected of having an infection on the basis of clinical grounds had blood cultures sent and antimicrobial treatment started. From Sept 1, 2009, to Aug 31, 2010, a conservative strategy was used, with antimicrobial treatment started only after objective findings confirmed an infection. Our primary outcome was in-hospital mortality. Analyses were by intention to treat. Findings Admissions to the SICU for the first and second years were 762 and 721, respectively, with 101 patients with SICU-acquired infections during the aggressive year and 100 patients during the conservative year. Compared with the aggressive approach, the conservative approach was associated with lower all-cause mortality (13/100 [13%] vs 27/101 [27%]; p=0.015), more initially appropriate therapy (158/214 [74%] vs 144/231 [62%]; p=0.0095), and a shorter mean duration of therapy (12.5 days [SD 10.7] vs 17.7 [28.1]; p=0.0080). After adjusting for age, sex, trauma involvement, acute physiology and chronic health evaluation (APACHE) II score, and site of infection, the odds ratio for the risk of mortality in the aggressive therapy group compared with the conservative therapy group was 2.5 (95% CI 1.5−4.0). Interpretation Waiting for objective data to diagnose infection before treatment with antimicrobial drugs for suspected SICU-acquired infections does not worsen mortality and might be associated with better outcomes and use of antimicrobial drugs.

Background-Death following trauma, infection, or other critical illness has been attributed to unbalanced inflammation, where dysregulation of cytokines leads to multiple organ dysfunction and death. We hypothesized that admission cytokine profiles associated with death would differ based on admitting diagnosis.

Objective Endovascular aortic repair (EVAR) is considered a lower risk option for treating abdominal aortic aneurysms (AAA), and is of particular utility in patients with poor functional status who may be poor candidates for open repair. However, the specific contribution of preoperative functional status EVAR outcomes remains poorly defined. We hypothesized that impaired functional status, based simply on the ability of patients to perform activities of daily living, is associated with worse outcomes after EVAR. Methods Patients undergoing non-emergent EVAR for AAA between 2010 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. The primary outcomes were 30-day mortality and major operative and systemic complications. Secondary outcomes were inpatient length of stay, need for reoperation, and discharge disposition. Using NSQIP defined preoperative functional status, patients were stratified as Independent or Dependent (either partial or totally dependent), and compared by univariate and multivariable analyses. Results Of 13,432 patients undergoing EVAR between 2010 – 2014, 13,043 were independent (97%) and 389 were dependent (3%) prior to surgery. Dependent patients were older and more frequently minorities; had higher rates of chronic pulmonary, heart, and kidney disease; and were more likely to have an American Society of Anesthesiologists score of 4 or 5. On multivariable analysis, preoperative dependent status was an independently risk factor for operative complications (OR 3.1, 95% CI 2.5 – 3.9), systemic complications (2.8, 2.0 – 3.9), and 30-day mortality (3.4, 2.1 – 5.6). Secondary outcomes were worse among dependent patients. Conclusions Although EVAR is a minimally invasive procedure with substantially less physiologic stress than open aortic repair, preoperative functional status is a critical determinant of adverse outcomes after EVAR, in spite of the minimally invasive nature of the procedure. Functional status, as measured by performance of activities of daily living, can be used as a valuable marker of increased perioperative risk, and may identify patients who may benefit from preoperative conditioning and specialized perioperative care.

There is ongoing research to restore liver function in cell biology, animal models and clinical trials using mature hepatocytes, liver progenitor cells, mesenchymal stem cells and embryonic stem cells.