Amr S. Omar

Rhabdomyolysis following Cardiac Surgery: A Prospective, Descriptive, Single-Center Study

Purpose. Rhabdomyolysis (RML) following cardiac surgery and its relationship with acute kidney injury (AKI) require investigation. Patients and Methods. All patients undergoing cardiac surgery in our hospital were enrolled in this prospective study during a 1-year period. To investigate the occurrence of RML and its association with AKI, all patients in the study underwent serial assessment of serum creatine kinase (CK) and myoglobin levels. Serial renal function, prior statin treatment, and outcome variables were recorded. Results. In total, 201 patients were included in the study: 185 men and 16 women with a mean age of 52.0 ± 12.4 years. According to the presence of RML (CK of ≥2,500 U/L), the patients were divided into Group I (RML present in 17 patients) and Group II (RML absent in 184 patients). Seven patients in Group I had AKI (41%) where 34 patients in group II had AKI (18.4%), P = 0.025. We observed a significantly longer duration of ventilation, length of stay in the ICU, and hospitalization in Group I (P < 0.001 for all observations). Conclusions. An early elevation of serum CK above 2500 U/L postoperatively in high-risk cardiac surgery could be used to diagnose RML that may predict the concomitance of early AKI.

Impact of leadership on ICU clinicians’ burnout

Dear Editor, The care of critically ill patients is recognized as a highly demanding and challenging profession as it requires extensive effort and communication between staff, during which professionals are exposed to varying amounts of work-related stress. Healthcare practitioners are vulnerable to burnout, especially in areas with increased stress. A high degree of burnout symptoms has been noted in intensive care unit (ICU) staff, where up to 45 % of practitioners experienced burnout symptoms that included insomnia, irritability, and depression [1]. Developing tools within the burnoutoriented field to aid in the early management of staff burnout is an important goal. The presence of leaders who possess an empowering attitude is significantly associated with a reduction in job tension and an enhancement of work effectiveness [2]. The aim of this study was to discover the prevalence of burnout within an ICU in Qatar, to find the precipitating demographics and working conditions associated with increased burnout, and to explore the influence of leadership and staff empowerment on burnout. After receiving approval from the ethical committee (14281/14), we employed a cross-sectional descriptive study with purposive sampling. A combined methodological approach (i.e., quantitative and qualitative) was used within the questionnaires. We used five instruments: Conditions of Work Effectiveness Scale (CWES), Work Stress Scale (WSS), Maslasch Burnout Inventory-Human Service Scale (MBI-HSS), Leadership Scale (LS), and Empowerment Scale (ES) (see electronic supplementary material Appendix 1). We studied 200 healthcare practitioners who practiced within medical and surgical ICUs. Our results showed a high prevalence of burnout (25.5 %), where physicians, nurses, and respiratory therapists were equally at risk (p = 0.19). We found a significant relationship between the used scores and burnout (Fig. 1). Younger individuals were more likely to burn out (p\ 0.001). We found a high association of burnout with the instruments that we used. Both positive leadership and staff empowerment had a negative effect on burnout variance (12.4 and 3.8 %, respectively). We noted that clinicians who were originally from Syria more frequently presented with burnout syndrome. More burnout was found in the medical ICU (Appendix 1). We found that respiratory therapists suffered from the same stressors as other healthcare practitioners. Guntupalli et al. (2014) reported severe burnout rates of 25 % in respiratory therapists in the USA [3]. Syrians suffered the highest burnout percentage (43.8 %). The influence related to specific nationality could affect the development of burnout [4]. Syrians have suffered from civil war for the last 3 years. Empowerment is symbolized by energizing; a direct effect of empowerment on emotional exhaustion has been reported [2]. In our work, empowerment accounted for only 3.8 % of the variance in practitioner burnout (Appendix 1). Multiple achievements associated with empowerment by practitioners in critical care settings include boosting the meaningfulness of work, decisionmaking involvement, smooth target achievements, providing autonomy, hastening bureaucratic boundaries, and expressing confidence in situations demanding high performance [5]. In conclusion, the reported high burnout rate among practitioners in ICU settings requires special attention in terms of positive leadership

Kinetics of Highly Sensitive Troponin T after Cardiac Surgery

Perioperative myocardial infarction (PMI) confers a considerable risk in cardiac surgery settings; finding the ideal biomarker seems to be an ideal goal. Our aim was to assess the diagnostic accuracy of highly sensitive troponin T (hsTnT) in cardiac surgery settings and to define a diagnostic level for PMI diagnosis. This was a single-center prospective observational study analyzing data from all patients who underwent cardiac surgeries. The primary outcome was the diagnosis of PMI through a specific level. The secondary outcome measures were the lengths of mechanical ventilation (LOV), stay in the intensive care unit (LOSICU), and hospitalization. Based on the third universal definition of PMI, patients were divided into two groups: no PMI (Group I) and PMI (Group II). Data from 413 patients were analyzed. Nine patients fulfilled the diagnostic criteria of PMI, while 41 patients were identified with a 5-fold increase in their CK-MB (≥120 U/L). Using ROC analysis, a hsTnT level of 3,466 ng/L or above showed 90% sensitivity and 90% specificity for the diagnosis of PMI. Secondary outcome measures in patients with PMI were significantly prolonged. In conclusion, the hsTnT levels detected here paralleled those of CK-MB and a cut-off level of 3466 ng/L could be diagnostic of PMI.

Time in Range: A Fourth Domain in Glycemic Control or a Glucose Variability Alternative?

To the Editor: The outcome of glucose control in critically ill patients has received significant attention. Krinsley has stated that hyperglycemia, hypoglycemia, and high glucose variability (GV) are the 3 domains that are independently associated with high mortality in critically ill patients. Moving away from tight to safe glucose control provides an optimum goal. The interest in measuring GV has been raised after multiple studies demonstrated its association with mortality in intensive care units (ICUs). Multiple approaches had to be used to measure GV, including average daily risk range; however, these measures seem to be too sophisticated to be implemented in each ICU. Time in range (TIR), defined as a measure of time where the blood glucose remains within the proposed target range, has been investigated by Omar et al. Our group found it to be a simple parameter that could be measured without specific requirements; therefore, it could be simply applied in any ICU. We calculated the whole time of insulin infusion (A) and the time being within the proposed target range (B) during insulin infusion, and expressed TIR as TIR 1⁄4 (B/A) 100. We found that patients with more than 80% TIR, whether or not they had diabetes, had better outcomes than those with less than 80% TIR, as determined by wound infection, lengths of ventilation, and ICU stay. In addition, they were not subject to frequent hypoglycemic events. Interestingly, Krinsley and Preiser followed the same technique in stratifying mortality in critically ill patients without diabetes in a retrospective descriptive study. The authors concluded that survival in critically ill patients without diabetes is strongly associated with a TIR 70 to 140 mg/dL value of more than 80%, independent of the ICU length of stay and severity of the individual’s illness. Individualized algorithms for patients with and without diabetes, as mentioned by Tafelski et al, could replace published working guidelines. Therefore, management of blood glucose in the ICU by a single target looks unnecessarily restrictive. The clinical settings could mandate a target to fit, as in cardiac surgery where 6.0 to 8.1 mmol/L seems to be an acceptable goal. In the view of the reports relating the TIR value to mortality and morbidity in those with and without diabetes, TIR value emerges. In addition to its simplicity, TIR could provide a possible alternative to GV measurements. Even if TIR and GV are mathematically and conceptually linked, they are not interchangeable. Research in ICU glucose control could move a step forward considering the proper intervention in intensive insulin therapy.

Kinetics of high sensitive troponin T (HSTNT) after cardiac surgery

Perioperative myocardial infarction (PMI) in the setting of cardiac surgery represent a considerable risk to patients with significant mortality and morbidity. The role of highly sensitive cardiac troponin T (hsTnT) has not been evaluated in the setting of cardiac surgery, instead Cardiac Troponin T (TnT) and Creatine Kinase MB (CK-MB) are commonly used for the diagnosis of PMI [1].

Leader behavior impact on intensive care practitioners' burnout.

Global spreads of burnout among healthcare practitioners, particularly within intensive care units (ICUs), has been described as a growing crisis with a variety of unwanted consequences as drawbacks [[1]].

Highly sensitive troponin t (hstnt) profile for outcome prediction after cardiac surgery

Changes in cardiac mediators remain a subject of research interest. Instantly obtainable biomarkers that are performed routinely, are inexpensive and are characterized by linkages to outcome in cardiac surgery settings are optimum. Post-operative conventional cardiac troponins are linked to short- and middle-length outcomes [1] but highly sensitive troponin T (hsTnT) has not been extensively evaluated in the same settings.

Recombinant activated factor VIIa to treat refractory lower gastrointestinal hemorrhage in a patient with recently implanted mechanical valve: a case report

BackgroundBleeding is a common complication after cardiac surgery. However, lower gastrointestinal bleeding is not usually associated with this type of surgery.Case presentationA 50-year-old man with a history of aortic regurgitation underwent elective mechanical valve replacement under cardiopulmonary bypass. He experienced a complicated intraoperative course involving unexplained cardiac arrest following induction of anesthesia. He also developed two episodes of massive lower gastrointestinal bleeding secondary to mucosal ischemia while convalescing in the cardiothoracic surgery intensive care unit. After unsuccessful attempts to control the bleeding, exhaustion of blood products, and consideration of the high risk of mortality associated with surgery and the possibility of early- and long-term surgical complications, the decision was made to administer two successive doses of recombinant activated factor VII at 60 mcg/kg. Hemostasis was achieved without adverse systemic or valvular effects.ConclusionsA favorable outcome was achieved after administration of recombinant activated factor VII, which controlled the patient’s severe lower gastrointestinal bleeding. This outcome suggests the need to raise awareness about the use of this drug in dire circumstances when other conventional measures fail or are unsuitable.