Nutritional support for successful weaning in patients undergoing prolonged mechanical ventilation

Association between the geriatric nutritional risk index and postoperative delirium in gastric surgery patients: an analysis of the MIMIC-IV database

BACKGROUND

This study explores the correlation between nutritional status, as determined by the Geriatric Nutritional Risk Index (GNRI), and the incidence of postoperative delirium (POD) in patients undergoing gastric surgery.

METHODS

Data were obtained from the MIMIC-IV 2.2 database for patients aged 18 years or older who underwent gastric surgery. Patients were categorized into the malnourished group (GNRI < 98) and the non-malnourished group (GNRI ≥ 98). Multivariable logistic regression was performed to assess the association between GNRI and POD, and various potential confounders were adjusted to ensure the robustness of the results. Non-linear relationships between GNRI and POD risk were evaluated through restricted cubic spline (RCS) analysis. Subgroup analyses were conducted to examine the effect of GNRI on POD across different patient categories, and interactions were calculated. Propensity score matching (PSM) was employed to reduce confounding bias.

RESULTS

The study included a total of 4,818 patients, of whom 1,133 (23.5%) developed POD. Patients with a GNRI < 98 had a significantly higher risk of POD compared with those with a GNRI ≥ 98 (odds ratio (OR): 2.21, 95% confidence interval (CI): 1.93-2.53, p < 0.001). Even after adjustment for relevant confounders, GNRI remained significantly associated with POD (OR:1.24, 95% CI: 1.04-1.48, p < 0.001). This association was further supported by the results from PSM (OR:1.23, 95% CI: 1.01-1.51, p = 0.045). RCS analysis demonstrated a non-linear relationship between GNRI and POD risk (p < 0.05). Subgroup analyses revealed significant interactions within the cardiovascular disease, renal replacement therapy, benzodiazepine medication, and vasoactive drug subgroups (p for interaction < 0.05). After the patient population was adjusted to individuals aged 65 and older, this correlation remained significant (p for interaction < 0.05).

CONCLUSIONS

This study identifies a significant association between GNRI and the incidence of POD in patients undergoing gastric surgery. Improving nutritional status before surgery may lower the risk of developing POD.

Development and validation of a model for predicting prolonged weaning from mechanical ventilation in patients with abdominal trauma

BACKGROUND

This study aimed to develop and validate a model to predict the risk of prolonged weaning from mechanical ventilation in patients with abdominal trauma.

METHODS

Patients with abdominal trauma were included and were divided into the training cohort and the validation cohort. The model was constructed using predictive factors identified by univariable and multivariable logistic regressions, and was validated by receiver operating characteristic curve, calibration curve, and decision curve analysis. Clinical outcomes were compared between model-stratified risk groups.

RESULTS

In total,190 patients were included, with 133 in the training cohort and 57 in the validation cohort. Six predictive factors, the Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, Glasgow coma scale, total bilirubin, skeletal muscle index, and abdominal fat index, were identified and were included in the model. The model predicting prolonged weaning owned a good discrimination, had an excellent calibration, and exhibited a favorable net benefit within a reasonable range of threshold probabilities. Significant differences were shown in prolonged weaning and clinical outcomes between the high-risk and low-risk groups (P < .05). Multivariable Cox regression analysis showed that patients in the high-risk group had greater risk of 28-day mortality (P < .05).

CONCLUSION

This study established a model to predict the risk of prolonged weaning from mechanical ventilation and clinical outcomes in patients with abdominal trauma. Skeletal muscle index was identified as one of independent risk factors of prolonged weaning. The findings offer valuable insights for respiratory management in patients with abdominal trauma.

A Multidimensional Approach to the Management of Patients in Prolonged Weaning from Mechanical Ventilation: The Concept of Treatable Traits - A Narrative Review

BACKGROUND

Established structured weaning approaches, which are effective for patients in simple and difficult weaning, are often not appropriate for patients undergoing prolonged weaning. Addressing the complexity of weaning failure requires personalized precision medicine. The therapeutic concept of treatable traits (TTs) has been proposed as a new paradigm for the management of chronic respiratory diseases. It is based on a multidimensional assessment of specific characteristics, which can be addressed by specific interventions that go beyond traditional diagnostic criteria. The concept is increasingly adopted for other complex diseases.

SUMMARY

This is a narrative review and an expert opinion on the development of a concept of TTs for patients undergoing prolonged weaning. The proposed TTs are based on a systematic review of risk factors for prolonged weaning, an analysis of claims data to assess risk factors within 96 h of IMV onset and data from the WEAN SAFE study. A multidisciplinary team identified clinically important TTs and determined appropriate interventions. The following TTs have been identified: airway disorders and complications associated with tracheostomy or intubation, such as airway obstruction, strictures or tracheomalacia, infectious aspects, anxiety, depression, delirium, post-traumatic stress disorder, anemia, pulmonary and cardio-renal disease. The multidimensional holistic approach also includes tailored sedation and pain management, nutritional therapy, early mobilization, and physiotherapy.

KEY MESSAGE

We propose a framework of relevant considerations for a multidimensional approach to the management of patients undergoing prolonged weaning that supports the regain of respiratory capacity, reduces the respiratory load, and thus could resolve the respiratory workload imbalance.

Weaning Failure in Elderly Patients: A Systematic Review and Meta-Analysis

Background/Objectives: Weaning failure in elderly patients undergoing mechanical ventilation presents a complex clinical challenge due to age-related physiological changes and comorbidities. Understanding the dynamics of this phenomenon through systematic analysis can provide valuable insights for clinical management. This meta-analysis aims to investigate the factors contributing to weaning failure in elderly patients and to assess the efficacy of different strategies in mitigating this challenge. Design: The design of this study is a systematic review and meta-analysis. Methods: A systematic search of electronic databases was conducted to identify relevant studies focusing on weaning failure in elderly patients. Studies reporting outcomes related to mechanical ventilation weaning failure were included. Data extraction, quality assessment, and statistical analysis were performed following established guidelines. Results: A total of 15 studies met the inclusion criteria and were included in the meta-analysis. The average age of participants throughout the studies was 66.24 ± 10.21 years. This suggests that the study population largely consisted of older adults and displayed a moderate range of ages centered around the mean. The rate of weaning failure across these studies was slightly above 31.56%, indicating a significant occurrence of this complication in the patient cohorts. The analysis revealed age-related physiological changes, such as decreased respiratory muscle strength and increased chest wall stiffness, as significant contributors to weaning failure in elderly patients. Comorbidities, including chronic pulmonary diseases and cardiovascular conditions, further exacerbated the challenge. Various interventions, including tailored weaning protocols and respiratory therapies, showed promising results in improving weaning outcomes in this population. Conclusions: Weaning failure in elderly patients undergoing mechanical ventilation is influenced by a combination of age-related physiological changes and comorbidities. Tailored interventions addressing these factors are essential for optimizing weaning success rates in this vulnerable population. Further research is warranted to refine the strategies and enhance outcomes in elderly patients requiring mechanical ventilation.

Risk Factors and Predictors of Prolonged Mechanical Ventilation Following Cardiac Surgery: A Narrative Review

The subset of patients requiring prolonged mechanical ventilation is significantly high worldwide, making it an important topic of continuous and ongoing research. Over the years, various articles have shown that there may be predictors of prolonged ventilation that could be applied in healthcare to make it more patient-centered. The available literature suggests that authors have different definitions of "prolonged" ventilation. However, most critical care units embrace caution if a patient needs mechanical ventilation for more than 48 to 72 hours. The major benefits of mechanical ventilation are an overall decrease in the work of breathing and the facilitation of relatively easier pumping from an ailing heart. An elevated risk of prolonged ventilation after cardiac surgery exists in patients with higher classes of heart failure (as classified by the New York Heart Association (NYHA) or Canadian Cardiovascular Society (CCS)), a pre-existing congenital or acquired cardiac abnormality, and patients with renal failure, to name a few. The impact on quality of life has also been widely studied; as mortality rates increase with factors like age and days dependent on ventilation. Patients undergoing prolonged ventilation constitute an administrative challenge for critical care units, highlighting how multiple patients in this bracket can overwhelm the healthcare system. The use of prediction models in this context can aid healthcare delivery tremendously. Using different predictors, we can craft tailor-made treatment options and achieve the goal of more ventilator-free days per patient.

Implementation of a multidisciplinary nutritional support team and clinical outcomes in critically ill patients with COVID-19

BACKGROUND & AIMS

The South Korean government established the multidisciplinary nutritional support teams (NST) system for enhancing the evaluation and adequate supply of nutritional support to patients at high risk of malnutrition. However, the impact of the NST on clinical outcomes in critically ill patients with coronavirus disease 2019 (COVID-19) remains unclear. We aimed to investigate whether NST implementation affects survival outcomes in patients with COVID-19 requiring intensive care unit (ICU) admission.

METHODS

Using data from the National Health Insurance Service and Korea Disease Control and Prevention Agency in South Korea, adult patients with COVID-19 admitted to the ICU between October 8, 2020, and December 31, 2021, were included. The NST comprised four professional personnel (physicians, full-time nurses, full-time pharmacists, and full-time clinical dietitians). Patients admitted to ICUs with and without the NST system were assigned to the NST and non-NST groups, respectively.

RESULTS

A total of 13,103 critically ill adult patients were included in the final analysis; among them, 10,103 (77.1 %) and 3,000 (22.9 %) patients were included in the NST and non-NST groups, respectively. In the NST group, 2,803 (27.7 %) critically ill patients with COVID-19 were prescribed enteral or parenteral nutrition by the NST. In a covariate-adjusted multivariable model, the NST group showed a 40 % lower in-hospital mortality rate than the non-NST group (odds ratio: 0.60, 95 % confidence interval: 0.51, 0.71; P < 0.001). In subgroup analyses, compared with the non-NST group, the NST group showed significantly lower in-hospital mortality rates at 2, 3, 4, and 5 points on the World Health Organization clinical progression scale among patients with acute respiratory distress and mechanical ventilatory support.

CONCLUSIONS

NST implementation was associated with improved survival outcomes in critically ill patients with COVID-19; accordingly, it may be recommended for improving adequate nutritional support and evaluation in critically ill patients.

Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review

Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.

Patients with obstructive sleep apnea are at great risk of flavor disorders: a 15-year population-based cohort study

OBJECTIVE

Obstructive sleep apnea (OSA) results from upper airway remodeling, which has been suggested to alter sensory and motor neuron function due to hypoxia or snore vibration. This study investigated whether OSA was associated with the risk of flavor disorder (FD).

MATERIALS AND METHODS

Seven thousand and eight hundred sixty-five patients with OSA and 7865 propensity score-matched controls without OSA were enrolled between 1999 and 2013 through a nationwide cohort study. The propensity score matching was based on age, sex, comorbidities including hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), asthma, ankylosing spondylitis, and Charlson comorbidity index, and co-medications during the study period, including statins and angiotensin-converting enzyme (ACE) inhibitors. The adjusted hazard ratio (aHR) of incident FD following OSA was derived using a Cox proportional hazard model. A log-rank test was used to evaluate the time-dependent effect of OSA on FD. Age, sex, comorbidities, and co-medications were stratified to identify subgroups susceptible to OSA-associated FD.

RESULTS

Patients with OSA were at a significantly great risk of FD (aHR = 1.91, 95% CI = 1.08-3.38), which was time-dependent (log-rank test p = 0.013). Likewise, patients with hyperlipidemia were at a significant great risk of FD (aHR = 2.99, 95% CI = 1.33-6.69). Subgroup analysis revealed that female patients with OSA were at higher risks of FD (aHR = 2.39, 95%CI = 1.05-5.47).

CONCLUSIONS

Patients with OSA were at significantly great risk of incident FD during the 15-year follow-up period, especially in female patients with OSA.

CLINICAL RELEVANCE

Timely interventions for OSA may prevent OSA-associated FD.

Risk of primary Sjogren's Syndrome following human papillomavirus infections: a nationwide population-based cohort study

Introduction

Viral infection is an exogeneous factor for primary Sjogren's syndrome (pSS). This study investigated the association between human papillomavirus (HPV) infections and pSS through a nationwide population based cohort study.

Methods

Patients with HPV infections between January, 1999 and December, 2013 were included. The incidence of new-onset pSS in patients with HPV infections and non-HPV controls were derived. The multiple Cox regression model derived the risk of pSS in patients with HPV infections. Subgroup analysis and sensitivity analysis were performed to validate the association.

Results

During a follow-up period of 12 years, the adjusted hazard ratio (aHR) of pSS in patients with HPV infections was significantly higher than that in non-HPV controls (aHR=1.64, 95% CI=1.47-1.83, P<0.001). The risk of pSS increased with age and the risk increased by 2.64-fold (95% CI= 2.37-2.93) for those older than 45 years. The significant association between HPV infections and the risk of pSS persisted in the sensitivity analysis restricted in HPV infections that lasted over 12 months (aHR=1.63, 95%CI=1.45-1.83, P<0.0001). Subgroup analyses revealed that both male (aHR=1.83, 95%CI=1.47-2.28, P<0.0001) and female (aHR=1.58, 95%CI=1.40-1.79, P<0.0001) patients with HPV infections and HPV-infected patients aged between 16 and 45 years (aHR=1.60, 95%CI=1.34-1.91, P<0.0001) and over 45 years (aHR=1.67, 95%CI=1.46-1.91, P<0.0001) were associated with a significantly greater risk of pSS.

Conclusion

Patients with HPV infections presented with a significantly higher risk of pSS, regardless of age and sex.