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Cheema HA, Shahid A, Ayyan M, Mustafa B, Zahid A, Fatima M, Ehsan M, Athar F, Duric N, Szakmany T. Probiotics for the Prevention of Ventilator-Associated Pneumonia: An Updated Systematic Review and Meta-Analysis of Randomised Controlled Trials. Nutrients 2022; 14:1600. [PMID: 35458162 PMCID: PMC9031795 DOI: 10.3390/nu14081600] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/07/2022] [Accepted: 04/10/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Presently, there is conflicting evidence regarding the efficacy of probiotics in the prevention of ventilator-associated pneumonia (VAP). This meta-analysis was conducted to update current clinical evidence and evaluate the efficacy and safety of probiotics for the prevention of VAP. METHODS We searched three databases and two trial registers to retrieve randomised controlled trials (RCTs) comparing probiotics or synbiotics with placebo or standard treatment for the prevention of VAP in adult patients receiving mechanical ventilation in the intensive care unit (ICU). RESULTS Our meta-analysis included 18 RCTs involving 4893 patients. Our results showed that probiotics may reduce the incidence of VAP (RR 0.68, 95% CI: 0.55-0.84; low certainty). However, in our subgroup and sensitivity analyses, the effect was not significant in double-blind studies, and in studies with a low risk of bias in the randomisation process. Probiotics reduced the length of ICU stay (MD -2.22 days, 95% CI: -4.17 to -0.28; moderate certainty) and the duration of antibiotic use (MD -1.25 days, 95% CI -1.86 to -0.64; moderate certainty). CONCLUSIONS Probiotics may reduce the incidence of VAP but due to the low quality of pooled evidence, the use of probiotics warrants caution. Further, large-scale, high-quality RCTs need to be conducted to provide conclusive evidence.
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Affiliation(s)
- Huzaifa Ahmad Cheema
- Department of Medicine, King Edward Medical University, Lahore 54000, Pakistan; (A.S.); (M.A.); (B.M.); (A.Z.); (M.F.); (M.E.); (F.A.)
| | - Abia Shahid
- Department of Medicine, King Edward Medical University, Lahore 54000, Pakistan; (A.S.); (M.A.); (B.M.); (A.Z.); (M.F.); (M.E.); (F.A.)
| | - Muhammad Ayyan
- Department of Medicine, King Edward Medical University, Lahore 54000, Pakistan; (A.S.); (M.A.); (B.M.); (A.Z.); (M.F.); (M.E.); (F.A.)
| | - Biah Mustafa
- Department of Medicine, King Edward Medical University, Lahore 54000, Pakistan; (A.S.); (M.A.); (B.M.); (A.Z.); (M.F.); (M.E.); (F.A.)
| | - Afra Zahid
- Department of Medicine, King Edward Medical University, Lahore 54000, Pakistan; (A.S.); (M.A.); (B.M.); (A.Z.); (M.F.); (M.E.); (F.A.)
| | - Maurish Fatima
- Department of Medicine, King Edward Medical University, Lahore 54000, Pakistan; (A.S.); (M.A.); (B.M.); (A.Z.); (M.F.); (M.E.); (F.A.)
| | - Muhammad Ehsan
- Department of Medicine, King Edward Medical University, Lahore 54000, Pakistan; (A.S.); (M.A.); (B.M.); (A.Z.); (M.F.); (M.E.); (F.A.)
| | - Farwa Athar
- Department of Medicine, King Edward Medical University, Lahore 54000, Pakistan; (A.S.); (M.A.); (B.M.); (A.Z.); (M.F.); (M.E.); (F.A.)
| | - Natalie Duric
- Critical Care Directorate, The Grange University Hospital, Aneurin Bevan University Health Board, Cwmbran NP44 2XJ, UK;
| | - Tamas Szakmany
- Critical Care Directorate, The Grange University Hospital, Aneurin Bevan University Health Board, Cwmbran NP44 2XJ, UK;
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
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Jones WS, Suklan J, Winter A, Green K, Craven T, Bruce A, Mair J, Dhaliwal K, Walsh T, Simpson AJ, Graziadio S, Allen AJ. Diagnosing ventilator-associated pneumonia (VAP) in UK NHS ICUs: the perceived value and role of a novel optical technology. Diagn Progn Res 2022; 6:5. [PMID: 35144691 PMCID: PMC8830125 DOI: 10.1186/s41512-022-00117-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnosing ventilator-associated pneumonia (VAP) in an intensive care unit (ICU) is a complex process. Our aim was to collect, evaluate and represent the information relating to current clinical practice for the diagnosis of VAP in UK NHS ICUs, and to explore the potential value and role of a novel diagnostic for VAP, which uses optical molecular alveoscopy to visualise the alveolar space. METHODS Qualitative study performing semi-structured interviews with clinical experts. Interviews were recorded, transcribed, and thematically analysed. A flow diagram of the VAP patient pathway was elicited and validated with the expert interviewees. Fourteen clinicians were interviewed from a range of UK NHS hospitals: 12 ICU consultants, 1 professor of respiratory medicine and 1 professor of critical care. RESULTS Five themes were identified, relating to [1] current practice for the diagnosis of VAP, [2] current clinical need in VAP diagnostics, [3] the potential value and role of the technology, [4] the barriers to adoption and [5] the evidence requirements for the technology, to help facilitate a successful adoption. These themes indicated that diagnosis of VAP is extremely difficult, as is the decision to stop antibiotic treatment. The analysis revealed that there is a clinical need for a diagnostic that provides an accurate and timely diagnosis of the causative pathogen, without the long delays associated with return of culture results, and which is not dangerous to the patient. It was determined that the technology would satisfy important aspects of this clinical need for diagnosing VAP (and pneumonia, more generally), but would require further evidence on safety and efficacy in the patient population to facilitate adoption. CONCLUSIONS Care pathway analysis performed in this study was deemed accurate and representative of current practice for diagnosing VAP in a UK ICU as determined by relevant clinical experts, and explored the value and role of a novel diagnostic, which uses optical technology, and could streamline the diagnostic pathway for VAP and other pneumonias.
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Affiliation(s)
- W S Jones
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
| | - J Suklan
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - A Winter
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - K Green
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - T Craven
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - A Bruce
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - J Mair
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - K Dhaliwal
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - T Walsh
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - A J Simpson
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - S Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - A J Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
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Salluh JIF, Souza-Dantas VCD, Martin-Loeches I, Lisboa TC, Rabello LSCF, Nseir S, Póvoa P. Ventilator-associated tracheobronchitis: an update. Rev Bras Ter Intensiva 2020; 31:541-547. [PMID: 31967230 PMCID: PMC7008988 DOI: 10.5935/0103-507x.20190079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/22/2019] [Indexed: 11/20/2022] Open
Abstract
Ventilator-associated lower respiratory tract infection is one of the most frequent complications in mechanically ventilated patients. Ventilator-associated tracheobronchitis has been considered a disease that does not warrant antibiotic treatment by the medical community for many years. In the last decade, several studies have shown that tracheobronchitis could be considered an intermediate process that leads to ventilator-associated pneumonia. Furthermore, ventilator-associated tracheobronchitis has a limited impact on overall mortality but shows a significant association with increased patient costs, length of stay, antibiotic use, and duration of mechanical ventilation. Although we still need clear evidence, especially concerning treatment modalities, the present study on ventilator-associated tracheobronchitis highlights that there are important impacts of including this condition in clinical management and epidemiological and infection surveillance.
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Affiliation(s)
- Jorge Ibrain Figueira Salluh
- Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil.,Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | | | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization, Department of Clinical Medicine, Trinity Centre for Health Sciences, St. James's University Hospital -Dublin, Ireland.,CIBER Enfermedades Respiratorias, Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona - Sabadell, Spain
| | - Thiago Costa Lisboa
- Rede Institucional de Pesquisa e Inovação em Medicina Intensiva, Complexo Hospitalar Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brasil.,Comitê do Departamento de Terapia Intensiva e Controle da Infecção, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Ligia Sarmet Cunha Farah Rabello
- Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil.,Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | - Saad Nseir
- Critical Care Center, Centre Hospitalier Universitaire de Lille - Lille, France.,School of Medicine, University of Lille - Lille, France
| | - Pedro Póvoa
- Unidade Polivalente de Terapia Intensiva, Centro Hospitalar de Lisboa Ocidental, São Francisco Xavier Hospital - Lisboa, Portugal.,NOVA Escola Médica, CEDOC, New Universidade de Lisboa, Campo Mártires da Pátria - Lisboa, Portugal
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Ventilator-associated pneumonia surveillance using two methods. J Hosp Infect 2020; 104:522-528. [PMID: 32035121 DOI: 10.1016/j.jhin.2020.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/28/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia surveillance is used as a quality indicator due to concerns that some cases may be preventable and may contribute to mortality. Various surveillance criteria exist for the purposes of national reporting, but a large-scale direct comparison has not been conducted. METHODS A prospective cohort study applied two routinely used surveillance criteria for ventilator-associated pneumonia from the European Centre for Disease Control and the American Centers for Disease Control to all patients admitted to two large general intensive care units. Diagnostic rates and concordance amongst diagnostic events were compared. FINDINGS A total of 713 at-risk patients were identified during the study period. The European surveillance algorithm returned a rate of 4.6 cases of ventilator-associated pneumonia per 1000 ventilation days (95% confidence interval 3.1-6.6) and the American surveillance system a rate of 5.4 (3.8-7.5). The concordance between diagnostic events was poor (Cohen's Kappa 0.127 (-0.003 to 0.256)). CONCLUSIONS The algorithms yield similar rates, but the lack of event concordance reveals the absence of inter-algorithm agreement for diagnosing ventilator-associated pneumonia, potentially undermining surveillance as an indicator of care quality.
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Yao YX, Wu JT, Zhu WL, Zhu SM. Immediate extubation after heart transplantation in a child by remifentanil-based ultra-fast anesthesia: A case report. Medicine (Baltimore) 2019; 98:e14348. [PMID: 30702622 PMCID: PMC6380724 DOI: 10.1097/md.0000000000014348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
RATIONALE Ventilator-associated complications comprise important fatal aetiologies during heart transplantation. Ultra-fast anesthesia might provide the most effective measure to prevent this type of complication. Immediate extubation after heart transplantation (IEAHT) has recently been reported in adult patients. However, IEAHT in children is much more challenging due to limitations in anesthesia protocols. Recently, we managed to perform an ultra-fast anesthesia protocol combined with IEAHT during a heart transplant operation in a child, who had an excellent postoperative outcome. PATIENT CONCERNS A 13-year-old girl had been diagnosed with dilated cardiomyopathy 5 years before this case, due to intractable dyspnoea and cough. She received multiple medical treatments after diagnosis, with minimal effects. Physical examination findings included a bulge in her left chest and pitting edema over both legs. Moist rales could be heard in the lung. Echocardiography revealed very large heart chambers, with an ejection fraction of 17%. DIAGNOSIS The patient was diagnosed with dilated cardiomyopathy and scheduled to undergo an emergent operation for heart transplantation. INTERVENTIONS The patient underwent an ultra-fast anesthesia protocol and ultra-fast reversal during heart transplantation. General anesthesia was induced with etomidate, fentanyl, and vecuronium; it was then maintained with remifentanil-based total intravenous anesthesia. OUTCOMES Immediately after the end of the operation, the patient was brought to consciousness with stable breathing and haemodynamics. The patient was successfully extubated on the operating table and transferred to the intensive care unit with spontaneous breathing, without postoperative mechanical ventilation. The recovery period was uneventful and the patient was discharged 1 month later without complications. LESSONS Our experience, in this case, revealed that IEAHT in children is achievable if the ultra-fast protocol is performed properly and carefully, in order to prevent ventilator-associated complications.
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Development of Process Control Methodology for Tracking the Quality and Safety of Pain, Agitation, and Sedation Management in Critical Care Units. Crit Care Med 2016; 44:564-74. [PMID: 26901544 DOI: 10.1097/ccm.0000000000001463] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. DESIGN A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. SETTING Eight Scottish ICUs over a 12-month period. PATIENTS Mechanically ventilated patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman ρ = 0.75) and were reliable in clinician-clinician (weighted kappa; κ = 0.66) and clinician-researcher (κ = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale (ρ = 0.24) and was reliable in clinician-clinician (κ = 0.58) and clinician-researcher (κ = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale (ρ = 0.54), and reliability in clinician-clinician (κ = 0.29) and clinician-researcher (κ = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. CONCLUSIONS Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time.
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Wallace FA, Alexander PDG, Spencer C, Naisbitt J, Moore JA, McGrath BA. A comparison of ventilator-associated pneumonia rates determined by different scoring systems in four intensive care units in the North West of England. Anaesthesia 2015; 70:1274-80. [DOI: 10.1111/anae.13211] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2015] [Indexed: 12/24/2022]
Affiliation(s)
| | - P. D. G. Alexander
- University Hospital of South Manchester NHS Foundation Trust; Manchester UK
| | - C. Spencer
- Lancashire Teaching Hospitals NHS Foundation Trust; Preston UK
| | - J. Naisbitt
- Salford Royal NHS Foundation Trust; Salford UK
| | - J. A. Moore
- Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
| | - B. A. McGrath
- University Hospital of South Manchester NHS Foundation Trust; Manchester UK
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Hulse EJ, Davies JOJ, Simpson AJ, Sciuto AM, Eddleston M. Respiratory complications of organophosphorus nerve agent and insecticide poisoning. Implications for respiratory and critical care. Am J Respir Crit Care Med 2015; 190:1342-54. [PMID: 25419614 DOI: 10.1164/rccm.201406-1150ci] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Organophosphorus (OP) compound poisoning is a major global public health problem. Acute OP insecticide self-poisoning kills over 200,000 people every year, the majority from self-harm in rural Asia. Highly toxic OP nerve agents (e.g., sarin) are a significant current terrorist threat, as shown by attacks in Damascus during 2013. These anticholinesterase compounds are classically considered to cause an acute cholinergic syndrome with decreased consciousness, respiratory failure, and, in the case of insecticides, a delayed intermediate syndrome that requires prolonged ventilation. Acute respiratory failure, by central and peripheral mechanisms, is the primary cause of death in most cases. However, preclinical and clinical research over the last two decades has indicated a more complex picture of respiratory complications after OP insecticide poisoning, including onset of delayed neuromuscular junction dysfunction during the cholinergic syndrome, aspiration causing pneumonia and acute respiratory distress syndrome, and the involvement of solvents in OP toxicity. The treatment of OP poisoning has not changed over the last 50 years. However, a better understanding of the multiple respiratory complications of OP poisoning offers additional therapeutic opportunities.
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Affiliation(s)
- Elspeth J Hulse
- 1 Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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A new definition of ventilator-associated pneumonia: far from perfect, better than before. Ann Am Thorac Soc 2014; 10:644-5. [PMID: 24364767 DOI: 10.1513/annalsats.201310-361ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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