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OBJECTIVE:. Mean arterial pressure (MAP) plays a significant role in regulating tissue perfusion and urine output (UO). The optimal MAP target in critically ill patients remains a subject of debate. We aimed to explore the relationship between MAP and UO. DESIGN:. A retrospective observational study. SETTING:. A general ICU in a tertiary medical center. PATIENTS:. All critically ill patients admitted to the ICU for more than 10 hours. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. MAP values and hourly UO were collected in 5,207 patients. MAP levels were categorized into 10 groups of 5 mm Hg (from MAP < 60 mm Hg to MAP > 100 mg Hg), and 656,423 coupled hourly mean MAP and UO measurements were analyzed. Additionally, we compared the UO of individual patients in each MAP group with or without norepinephrine (NE) support or diuretics, as well as in patients with acute kidney injury (AKI). Hourly UO rose incrementally between MAP values of 65–100 mm Hg. Among 2,226 patients treated with NE infusion, mean UO was significantly lower in the MAP less than 60 mm Hg group (53.4 mL/hr; 95% CI, 49.3–57.5) compared with all other groups (p < 0.001), but no differences were found between groups of 75 less than or equal to MAP. Among 2500 patients with AKI, there was a linear increase in average UO from the MAP less than 60 mm Hg group (57.1 mL/hr; 95% CI, 54.2–60.0) to the group with MAP greater than or equal to 100 mm Hg (89.4 mL/hr; 95% CI, 85.7–93.1). When MAP was greater than or equal to 65 mm Hg, we observed a statistically significant trend of increased UO in periods without NE infusion. CONCLUSIONS:. Our analysis revealed a linear correlation between MAP and UO within the range of 65–100 mm Hg, also observed in the subgroup of patients treated with NE or diuretics and in those with AKI. These findings highlight the importance of tissue perfusion to the maintenance of diuresis and achieving adequate fluid balance in critically ill patients.

Abstract Surgery-related strokes are an important cause of morbidity following resection of high-grade glioma (HGG). We explored the incidence, risk factors and clinical consequences of intra-operative ischemic strokes in surgeries for resection of HGG. We retrospectively followed a cohort of 239 patients who underwent surgical resection of HGG between 2013 and 2017. Tumor types included both isocitrate dehydrogenase (IDH) wildtype glioblastoma and IDH-mutant WHO grade 4 astrocytoma. We analyzed pre- and post-operative demographic, clinical, radiological, anesthesiology and intraoperative neurophysiology data, including overall survival and functional outcomes. Acute ischemic strokes were seen on postoperative diffusion-weighted imaging (DWI) in 30 patients (12.5%), 13 of whom (43%) developed new neurological deficits. Infarcts were more common in insular (23%, p = 0.019) and temporal surgeries (57%, p = 0.01). Immediately after surgery, 35% of patients without infarcts and 57% of those with infarcts experienced motor deficits (p = 0.022). Six months later, rates of motor deficits decreased to 25% in the non-infarcts group and 37% in the infarcts group (p = 0.023 and 0.105, respectively) with a significantly lower Karnofsky-Performance Score (KPS, p = 0.001). Intra-operative language decline in awake procedures was a significant indicator of the occurrence of intra-operative stroke (p = 0.029). In conclusion, intraoperative ischemic events are more common in insular and temporal surgeries for resection of HGG and their intra-operative detection is limited. These strokes can impair motor and speech functions as well as patients’ performance status.

Abstract Background Most patients who are admitted non-intubated to surgery are extubated at surgery conclusion. Yet, 1–2% require unplanned postoperative ventilatory support. The outcome of these patients has not been thoroughly evaluated to date and is the focus of the present study. Methods Two-center observational study assessing characteristics and outcomes of surgical patients with unplanned mechanical ventilation during PACU stay between 2017 and 2019. Patients who arrived intubated to the operating room or were transferred directly to the intensive care unit (ICU) were excluded. The co-primary aims were to assess overall in-hospital mortality and to compare mortality between patients who were extubated in PACU and those who were discharged from PACU still intubated. The secondary aims were to compare postoperative respiratory infection and unplanned admissions to the ICU. Multivariate logistic regression was used to compare the groups and adjust for potential confounding variables. Results Overall, 698 patients were included. Of these, 135 died during hospital stay (mortality rate 19.3%, compared with 1.0% overall postoperative in-hospital mortality). Patients who still required ventilatory support at PACU discharge were significantly sicker, majority needed emergency surgery, and had more complicated surgical course compared to those who were extubated in PACU. In addition, their mortality rate [36% vs. 9%, adjusted OR (95% CI) 5.8 (3.8–8.8), p < 0.001], postoperative respiratory infection, and unplanned admission to ICU rates were also significantly higher. Conclusion Unplanned postoperative mechanical ventilation is associated with noteworthy morbidity and mortality, with significantly higher rates in those of need for protracted (vs. short) mechanical ventilation. The remarkable mortality rate in patients extubated shortly after arriving to the PACU emphasizes the need for further studies to explore prompting factors and whether we can intervene to improve patients’ outcome.

Abstract Rim restriction surrounding the resection cavity of glioma is often seen on immediate post-op diffusion-weighted imaging (DWI). The etiology and clinical impact of rim restriction are unknown. We evaluated the incidence, risk factors and clinical consequences of this finding. We evaluated patients that underwent surgery for low-grade glioma (LGG) and glioblastoma (GBM) without stroke on post-operative imaging. Analyses encompassed pre- and postoperative clinical, radiological, intraoperative monitoring, survival, functional and neurocognitive outcomes. Between 2013 and 2017, 63 LGG and 209 GBM patients (272 in total) underwent surgical resection and were included in our cohort. Post-op rim restriction was demonstrated in 68 patients, 32% (n = 20) of LGG and 23% (n = 48) of GBM patients. Risk factors for restriction included temporal tumors in GBM (p = 0.025) and insular tumors in LGG (p = 0.09), including longer surgery duration in LGG (p = 0.008). After a 1-year follow-up, LGG patients operated on their dominant with post-op restriction had a higher rate of speech deficits (46 vs 9%, p = 0.004). Rim restriction on postoperative imaging is associated with longer duration of glioma surgery and potentially linked to brain retraction. It apparently has no direct clinical consequences, but is linked to higher rates of speech deficits in LGG dominant-side surgeries.