Amal, Tanya

Background: Mixed venous oxygen saturation (SVO2), a direct marker of circulatory adequacy measured in the pulmonary artery, has been proposed as a more immediate reflection of perfusion compared to serum lactate, which can be delayed due to clearance variability and lab turnaround. While central venous oxygen saturation (ScVO2) is commonly used in shock management, data on the prognostic value of SVO2 remains inconsistent. This study evaluates whether trends in SVO2 and lactic acid over 72 hours are associated with ICU mortality, and whether monitoring SVO2 offers clinical benefit. Methods: From the MIMIC-IV ICU database (n=34,222), 3,149 patients with SVO2 measurements were included. Patients were stratified into four groups based on SVO2 and lactate trends from ICU admission to 72 hours: SVO2 Groups: BB: Below–Below: SVO2 <55% at both timepoints (q1: 51%, q3: 60%) BA: Below–Above: SVO2 <55% initially, improved to >65% (q1: 58%, q3: 68%) AA: Above–Above: SVO2 ≥65% consistently (q1: 72%, q3: 79%) AB: Above–Below: SVO2 >65% initially, dropped to <55% (q1: 62%, q3: 72%) Lactic Acid Groups: BB: Below–Below: <2 mmol/L throughout (q1: 1, q3: 1.6) BA: Below–Above: <2 initially, rose to >2 (q1: 1.5, q3: 2.8) AA: Above–Above: >2 consistently (q1: 2.6, q3: 5.4) AB: Above–Below: >2 initially, fell to <2 (q1: 1.6, q3: 2.9) We then constructed a heat map to compare %mortality at 30 days in these groups. Results: The highest mortality (100%) occurred in patients with persistently elevated lactate (>2 mmol/L) and low SVO2 (<55%) (group 3a). The second-highest mortality (75%) was observed in those with persistently elevated lactate but improved SVO2(3c). Notably, among patients with improved lactate, mortality was similar regardless of whether SVO2 improved or remained low ($a vs 4c). This suggests that lactic acid trends may be a more reliable prognostic marker than SVO2. Conclusion: Improvement in SVO2 over 72 hours does not necessarily correlate with improved ICU survival. Persistent hyperlactatemia remains a stronger predictor of mortality. These findings question the clinical utility and cost-effectiveness of routine SVO2 monitoring in ICU settings.

The efficacy and safety of extracorporeal membrane oxygenation (ECMO) support during transcatheter aortic valve replacement (TAVR) remains unknown. We conducted a meta-analysis to compare benefit and risk of ECMO in TAVR patients. Bibliographic databases were searched from inception to January 1, 2024. Included studies involved patients ≥18 years old undergoing TAVR and using ECMO emergently or prophylactically. Mortality and procedure success were primary outcomes. Peri- or postoperative complications were the secondary outcomes. We identified 11 observational studies, including 2,275 participants (415 ECMO and 1,860 non-ECMO). The unadjusted mortality risk in ECMO-supported patient was higher than non-ECMO patients (odds ratio [OR] 1.73). The mortality unadjusted risk remained high (OR 3.89) and statistically significant for prophylactic ECMO. Prophylactic ECMO had lower mortality risk compared with emergent ECMO (OR 0.17). Extracorporeal membrane oxygenation-supported patients had lower procedural success rate (OR 0.10). Extracorporeal membrane oxygenation patients undergoing TAVR had significantly increased risk of bleeding (OR 3.32), renal failure (OR 2.38), postoperative myocardial infarction (OR 1.89), and stroke (OR 2.32) compared with non-ECMO patients. Clinical results are not improved by ECMO support in patients with high-risk TAVR. Prophylactic ECMO outperforms emergent. Overall, ECMO support increases mortality and postoperative complications. Transcatheter aortic valve replacement outcomes may improve with prophylactic ECMO in high-risk situations.

Objective To provide insights into the nature, risk factors, impact and existing measures for reporting and preventing violence in the healthcare system. The under-reporting of violence against healthcare workers (HCWs) globally highlights the need for increased public awareness and education. Methods The Violence Study of Healthcare Workers and Systems study used a survey questionnaire created using Research Electronic Data Capture (REDCap) forms and distributed from 6 June to 9 August 2022. Logistic regression analysis evaluated violence predictors, including gender, age, years of experience, institution type, respondent profession and night shift frequency. A χ 2 test was performed to determine the association between gender and different violence forms. Results A total of 5405 responses from 79 countries were analysed. India, the USA and Venezuela were the top three contributors. Female respondents comprised 53%. The majority (45%) fell within the 26–35 age group. Medical students (21%), consultants (20%), residents/fellows (15%) and nurses (10%) constituted highest responders. Nearly 55% HCWs reported firsthand violence experience, and 16% reported violence against their colleagues. Perpetrators were identified as patients or family members in over 50% of cases, while supervisor-incited violence accounted for 16%. Around 80% stated that violence incidence either remained constant or increased during the COVID-19 pandemic. Among HCWs who experienced violence, 55% felt less motivated or more dissatisfied with their jobs afterward, and 25% expressed willingness to quit. Univariate analysis revealed that HCWs aged 26–65 years, nurses, physicians, ancillary staff, those working in public settings, with >1 year of experience, and frequent night shift workers were at significantly higher risk of experiencing violence. These results remained significant in multivariate analysis, except for the 55–65 age group, which lost statistical significance. Conclusion This global cross-sectional study highlights that a majority of HCWs have experienced violence, and the incidence either increased or remained the same during the COVID-19 pandemic. This has resulted in decreased job satisfaction.