Cardiac surgery and subsequent treatment in the intensive care unit (ICU) has been shown to be associated with functional decline, especially in elderly patients. Due to the different assessment tools and assessment periods, it remains yet unclear what parameters determine unfavorable outcomes. This study sought to identify risk factors during the entire perioperative period and focused on the decline in activity of daily living (ADL) half a year after cardiac surgery. Follow-ups of 125 patients were available. It was found that in the majority of patients (60%), the mean ADL declined by 4.9 points (95% CI, −6.4 to −3.5; p < 0.000). In the “No decline” -group, the ADL rose by 3.3 points (2.0 to 4.6; p < 0.001). A multiple regression analysis revealed that preoperative cognitive impairment (MMSE ≤ 26; Exp(B) 2.862 (95%CI, 1.192–6.872); p = 0.019) and duration of postoperative delirium ≥ 2 days (Exp(B) 3.534 (1.094–11.411); p = 0.035) was independently associated with ADL decline half a year after the operation and ICU. Of note, preoperative ADL per se was neither associated with baseline cognitive function nor a risk factor for functional decline. We conclude that the preoperative assessment of cognitive function, rather than functional assessments, should be part of risk stratification when planning complex cardiosurgical procedures.

The CytOSorb^Ⓡ treatMent Of critically ill patientS (COSMOS) registry is an observational, prospective, multicenter, international real-world data collection platform executed in countries where the CytoSorb^Ⓡ (CS) 300 mL device is approved and routinely used in everyday clinical practice. This study aims to investigate utilization patterns of the hemoadsorption device and associated outcomes in critical care. Since July 2022, patients who were treated with CS as part of their intensive care treatment were enrolled from 16 sites in Germany, Italy, and Spain in the registry. After informed consent, real-world clinical data are systematically collected at multiple intervals, including 24 h before CS start, during CS treatment, and 24 h post-CS treatment, as well as at discharge from intensive care unit (ICU) and hospital discharge, and final follow-up on day 90. Vital status was assessed as ICU survival, 30-day survival, overall hospital survival, and 90-day survival. We compared details on the type of extracorporeal circuit used, device flow rate, anticoagulation regimen, vasopressor requirements, fluid balance, ratio of partial pressure of oxygen in arterial blood to the fraction of inspiratory oxygen concentration (P/F ratio), myoglobin in the rhabdomyolysis cohort and bilirubin in the liver failure cohort before and after CS treatment. Safety of the device was assessed by investigator-reported device-related adverse effects. Data were presented as either mean ± standard deviation or as median with interquartile range (IQR). A total of 150 patients were enrolled, 23 patients did not have any data entry by the time of the data readout for this interim analysis conducted and therefore had to be excluded from the analysis (33 % female, mean age [59±17] years). CS indications included septic shock (57.6 %), cardiogenic shock (12.9 %), and rhabdomyolysis (10.6 %). CS was mainly integrated with renal replacement therapy (82.8 %). Median Acute Physiology and Chronic Health Evaluation II score was 23 (IQR: 17-29), Sequential Organ Failure Assessment score 12 (IQR: 9-15), and ICU stay 20 (IQR: 11-33) days. Median interleukin-6 decreased significantly from 862.4 (IQR: 142-97,457) pg/mL in the 24 h before CS treatment to 202.8 (IQR: 42-3247) pg/mL in the 24 h post-CS treatment (P <0.0001). Post-CS, lactate and creatinine levels significantly decreased, fluid balance improved from 1386 (IQR: 220-3168) mL to 275 (IQR: -768-1846) mL (P <0.0001) and median P/F ratio increased from 132 (IQR: 68-208) mmHg to 189 (IQR: 115-260) mmHg (P <0.0001). Norepinephrine requirements reduced from 0.30 (IQR: 0.18-0.46) µg/(kg·min) to 0.19 (IQR: 0.10-0.33) µg/(kg·min) (P=0.0003). In rhabdomyolysis patients, myoglobin decreased from 18,976 (IQR: 1934-34,275) to 835 (IQR: 623-5925) µg/L (P=0.0273). Observed ICU mortality was 35 %, lower than predicted by baseline scores. The COSMOS registry highlights CS-associated improvements in lactate, creatinine, norepinephrine needs, fluid balance, and oxygenation. Mortality was favorable compared with risk-based predictions.Trial registration Clinicaltrials.gov Identifier: NCT05146336.

Zusammenfassung: Desorientierung kann ein frühes Merkmal eines Delirs sein. Für die Überwachung eines Delirs testet die im deutschsprachigen Raum weit verbreitete „Confusion Assessment Method for Intensive Care Unit“ (CAM-ICU) die Orientierung nicht, da intubierte Intensivpatienten sich nicht verbal äußern können. Die Mehrheit der Patienten auf deutschen Intensivstationen ist aber nicht beatmet, sie könnten hinsichtlich ihrer Orientiertheit befragt werden. Die vorliegende Studie untersuchte, ob sich durch das Kriterium „Desorientierung“ bei extubierten Patienten im Vergleich zur CAM-ICU divergierende Befunde ergeben und ob sich die Sensitivität der CAM-ICU durch Kombination mit dem Merkmal „Desorientierung“ („CAM-IMC“) erhöhen lassen. Insgesamt 86 gepaarte Untersuchungen fanden bei 50 extubierten Patienten statt. Ein Delir fand sich bei 19,8 % (n = 17) aller Untersuchungen. Die CAM-ICU hatte eine Sensitivität von 71 % (95%-KI: 44–90 %) und eine Spezifität von 100 % (95–100 %). Für „Desorientierung“ als alleiniges Delir-Merkmal fand sich eine Sensitivität von 77 % (50–93 %) und eine Spezifität von 93 % (89–100 %). Die CAM-IMC erreichte eine Sensitivität von 88 % (64–99 %) bei einer Spezifität von 100 % (95–100 %). Die „Receiver-Operating-Characteristics(ROC)-Analyse“ fand mit einer „area under the curve“ (AUC) von 0,941 (95%-KI: 0,851–1,000) für die CAM-IMC den höchsten Wert im Vergleich zu den anderen Delir-Tests (CAM-ICU, AUC 0,853 [0,720–0,986]; Desorientierung, AUC 0,868 [0,745–0,991]). Diese Arbeit unterstreicht die Wertigkeit des Merkmals „Desorientierung“ für Delir-Tests bei verbal kommunikationsfähigen Patienten und erklärt einige diskrepante Beurteilungen schwierig einzuschätzender Patienten in der täglichen Praxis. Die CAM-IMC scheint als Delir-Test für extubierte Patienten günstigere Eigenschaften als die CAM-ICU zu haben und sollte eingehender überprüft werden.