Objectives: Vascular surgeons are frequently consulted to evaluate hospitalized patients with finger ischemia. We sought to characterized causes and outcomes of finger ischemia in intensive care unit (ICU) patients. Methods: ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger plethysmography (PPG). Patient demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were recorded. ICU patients were compared to concurrently evaluated non-ICU inpatients with finger ischemia. Results: We identified 97 ICU patients (54 men, 43 women). Mean age was 57 6 17 years. Forty-three percent were in the surgical and 57% in the medical ICU. Seventy-two percent had abnormal finger PPGs, 69% unilateral and 31% bilateral. Thirty-seven percent had a radial arterial line. Thirteen percent had concomitant toe ischemia. Seventy-eight percent were on vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (30%), epinephrine (26%), and vasopressin (25%). Treatment was with therapeutic anticoagulation in 47%, aspirin in 52%, and clopidogrel in 16%. Other frequent associated conditions included mechanical ventilation (37%), diabetes (33%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Five patients required finger amputation. Survival was 85% at 30 days, 73% at 1 year, and 65% at 2 years. By Cox modelling, cancer (hazard ratio, 6.3; P ¼ .012) and dialysis (hazard ratio, 4.9; P ¼ .026) were independent predictors of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P ¼ .05), be on antibiotics (38% vs 14%; P ¼ .02), and undergo finger amputations (16% vs 5%; P ¼ .03). Conclusions: Finger ischemia in ICU patients is often associated with the arterial lines and vasoactive medications, with phenylephrine and norepinephrine the most common. While progression to amputation is rare, patients with finger ischemia in the ICU have high mortality, particularly in the presence of cancer or dialysis. Non-ICU patients with finger ischemia more often require amputations, likely due to more frequent connective tissue disorders and finger infections.
Objective: Vascular surgeons may be consulted to evaluate hospitalized patients with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in intensive care unit (ICU) patients. Methods: All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger photoplethysmography. The patients' demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were also recorded. ICU patients were compared with concurrently evaluated non-ICU inpatients with finger ischemia. Results: There were 98 ICU patients (55 male, 43 female) identified. The mean age was 57.1 6 16.8 years. Of these patients, 42 (43%) were in the surgical ICU and 56 (57%) in the medical ICU. Seventy (72%) had abnormal findings on finger photoplethysmography, 40 (69%) unilateral and 30 (31%) bilateral. Thirty-six (37%) had ischemia associated with an arterial line. Twelve (13%) had concomitant toe ischemia. Eighty (82%) were receiving vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (31%), epinephrine (26%), and vasopressin (24%). Treatment was with anticoagulation in 88 (90%; therapeutic, 48%; prophylactic, 42%) and antiplatelet agents in 59 (60%; aspirin, 51%; clopidogrel, 15%). Other frequently associated conditions included mechanical ventilation at time of diagnosis (37%), diabetes (34%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 3-year survival was 84%, 69%, and 59%. By Cox proportional hazards modeling, cancer (hazard ratio, 2.4; 95% confidence interval, 1.1-5.6; P ¼ .035) was an independent predictor of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P ¼ .05) and hyperlipidemia (42% vs 24%; P ¼ .03) and to undergo finger amputations (16% vs 5%; P ¼ .03). Conclusions: Finger ischemia in the ICU is frequently associated with the presence of arterial lines and the use of vasopressor medications, of which phenylephrine and norepinephrine are most frequent. Anticoagulation or antiplatelet therapy is appropriate treatment. Whereas progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.
Background. In the United States, over half of pediatric candidates receive exceptions and status upgrades that increase their allocation model of end-stage liver disease/pediatric end-stage liver disease (MELD/PELD) score above their laboratory MELD/PELD score. We determined whether these “nonstandardized” MELD/PELD exceptions accurately depict true pretransplant mortality risk. Methods. Using data from the Scientific Registry of Transplant Recipients, we identified pediatric candidates (<18 y of age) with chronic liver failure added to the waitlist between June 2016 and September 2021 and estimated all-cause pretransplant mortality with mixed-effects Cox proportional hazards models that treated allocation MELD/PELD and exception status as time-dependent covariates. We also estimated concordance statistics comparing the performance of laboratory MELD/PELD with allocation MELD/PELD. We then compared the proportion of candidates with exceptions before and after the establishment of the National Liver Review Board. Results. Out of 2026 pediatric candidates listed during our study period, 403 (19.9%) received an exception within a week of listing and 1182 (58.3%) received an exception before delisting. Candidates prioritized by their laboratory MELD/PELD scores had an almost 9 times greater risk of pretransplant mortality compared with candidates who received the same allocation score from an exception (hazard ratio 8.69; 95% confidence interval, 4.71-16.03; P < 0.001). The laboratory MELD/PELD score without exceptions was more accurate than the allocation MELD/PELD score with exceptions (Harrell’s c-index 0.843 versus 0.763). The proportion of patients with an active exception at the time of transplant decreased significantly after the National Liver Review Board was implemented (67.4% versus 43.4%, P < 0.001). Conclusions. Nonstandardized exceptions undermine the rank ordering of pediatric candidates with chronic liver failure.
malnutrition (2.77; 1.79-4.31). Smokers had a lower rate of MACE (0.61; 0.49-0.75). History of MI, prior percutaneous coronary intervention, coronary artery bypass graft, or stroke did not have a significant effect on rate of MACE. Hospital characteristics, such as size, teaching status, and location, also were not significant. Patients who experienced MACE had a higher rate of complications including (Table IV): wound (7.25% vs 1.88%; P < .0001), infection (2.25% vs 0.24%; P < .0001), urinary (2.5% vs 1.14%; P ¼ .0109), pulmonary (10.75% vs 1.35%; P < .0001), gastrointestinal (1.25% vs 0.48%; P ¼ .0467), shock (2.25% vs 0.13%; P < .0001), intraoperative puncture (5% vs 0.7%; P < .0001), hemorrhage (5.5% vs 1.02%; P < .0001), and phlebitis (2.75% vs 0.55%; P < .0001). The average LOS was 9.54 days for patients with MACE compared to 2.53 days (P < .0001; Table V). Patients who experienced MACE incurred $53,630 per hospitalization compared with $26,915 (P < .0001). MACE was associated with a higher rate of nonroutine discharge (63% vs 16.49%; P < .0001) and mortality (22.5% vs 0.42%; P < .0001).Conclusions: The top predictors for MACE are fluid and electrolyte disorders, malnutrition, Asian race, and CAD. Although less than 1% of patients undergoing EVAR experience major cardiac complications, it is associated with a $26,715 increase in cost and a 22.5% mortality rate.
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