Mechanical ventilation in septic shock

Prevalence of mortality among mechanically ventilated patients in the intensive care units of Ethiopian hospitals and the associated factors: A systematic review and meta-analysis

BACKGROUND

In the intensive care unit (ICU), mechanical ventilation (MV) is a typical way of respiratory support. The severity of the illness raises the likelihood of death in patients who require MV. Several studies have been done in Ethiopia; however, the mortality rate differs among them. The objective of this systematic review and meta-analysis is to provide a pooled prevalence of mortality and associated factors among ICU-admitted patients receiving MV in Ethiopian hospitals.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria to conduct a comprehensive systematic review and meta-analysis in this study. We searched PubMed/Medline, SCOPUS, Embase, Hinari, and Web of Science and found 22 articles that met our inclusion criteria. We used a random-effects model. To identify heterogeneity within the included studies, meta-regression and subgroup analysis were used. We employed Egger's regression test and funnel plots for assessing publication bias. STATA version 17.0 software was used for all statistical analyses.

RESULTS

In this systematic review and meta-analysis, the pooled prevalence of mortality among 7507 ICU-admitted patients from 22 articles, who received MV was estimated to be 54.74% [95% CI = 47.93, 61.55]. In the subgroup analysis by region, the Southern Nations, Nationalities, and Peoples (SNNP) subgroup (64.28%, 95% CI = 51.19, 77.37) had the highest prevalence. Patients with COVID-19 have the highest mortality rate (75.80%, 95% CI = 51.10, 100.00). Sepsis (OR = 6.85, 95%CI = 3.24, 14.46), Glasgow Coma Scale (GCS) score<8 (OR = 6.58, 95%CI = 1.96, 22.11), admission with medical cases (OR = 4.12, 95%CI = 2.00, 8.48), Multi Organ Dysfunction Syndrome (MODS) (OR = 2.70, 95%CI = 4.11, 12.62), and vasopressor treatment (OR = 19.06, 95%CI = 9.34, 38.88) were all statistically associated with mortality.

CONCLUSION

Our review found that the pooled prevalence of mortality among mechanically ventilated ICU-admitted patients in Ethiopia was considerably high compared to similar studies in the United States (US), China, and other countries. Sepsis, GCS<8, medical cases, MODS, and use of vasopressors were statistically associated with mortality. Clinicians should exercise caution while mechanically ventilating ICU-admitted patients with these factors. However, it should be noted that the exact cause and effect relationship could not be established with this meta-analysis, as the available evidence is not sufficient. Thus, more studies using prospective methods will be required.

Clinical effect of perioperative stellate ganglion block on mechanical ventilation and respiratory function of elderly patients with septic shock

BACKGROUND

Here we investigated the effect of a stellate ganglion block on the perioperative mechanical ventilation and postoperative recovery of respiratory function of elderly patients with infectious shock.

METHODS

Thirty-six elderly patients with septic shock who underwent emergency general anesthesia at our hospital were randomly divided into treatment (T) and control (C) groups (n = 18 each). Group T received a preoperative stellate ganglion block, whereas group C received normal saline. Procalcitonin and C-reactive protein levels were compared preoperatively and at 1 and 7 days postoperative. Mean arterial pressure, oxygen saturation, and mean pulmonary artery pressure were measured preoperative and postoperative as well as at 1 and 7 days later. A blood gas analysis was performed preoperatively, at the end of the operation, during extubation, and at 1 and 7 days postoperative. Intubation under general anesthesia, the completion of anesthesia, and spontaneous respiratory recovery involve pulmonary dynamic compliance, plateau pressure, and mechanical ventilation.

RESULTS

General condition did not differ significantly between groups (P > .05). However, mean arterial pressure at the end of surgery and at 1 and 7 days postoperative were significantly higher in group T versus C (P < .05). Furthermore, mean oxygen saturation at the end of surgery and at 1 and 7 days postoperative was significantly lower in group T versus C (P < .05), while procalcitonin and C-reactive protein levels were significantly lower at 1 and 7 days postoperative. Group T had significantly better arterial partial pressure of carbon dioxide, partial pressure of oxygen, and partial pressure of oxygen/fraction of inspired oxygen than group C at the end of surgery, during extubation, and at 1 and 7 days postoperative (P < .05).

CONCLUSION

Group T exhibited superior inflammatory responses and respiratory function. Stellate ganglion block in elderly patients with septic shock reduces inflammation, improves mechanical ventilation perioperatively, and promotes postoperative recovery and respiratory function.

Intraoperative Ventilator Management of the Critically Ill Patient

Strategies for the intraoperative ventilator management of the critically ill patient focus on parameters used for lung protective ventilation with acute respiratory distress syndrome, preventing or limiting the deleterious effects of mechanical ventilation, and optimizing anesthetic and surgical conditions to limit postoperative pulmonary complications for patients at risk. Patient conditions such as obesity, sepsis, the need for laparoscopic surgery, or one-lung ventilation may benefit from intraoperative lung protective ventilation strategies. Anesthesiologists can use risk evaluation and prediction tools, monitor advanced physiologic targets, and incorporate new innovative monitoring techniques to develop an individualized approach for patients.

Risk factors of mortality and severe disability in the patients with cerebrovascular diseases treated with perioperative mechanical ventilation

BACKGROUND

The prognosis of cerebrovascular diseases treated with mechanical ventilation during perioperative has not been clearly reported.

AIM

To analyze mortality and functional disability and to determine predictors of unfavorable outcome in the patients with cerebrovascular diseases treated with mechanical ventilation.

METHODS

A retrospective follow-up study of 111 cerebrovascular disease patients who underwent mechanical ventilation during the perioperative period in the First Hospital of Jilin University from June 2016 to June 2019 was performed. Main measurements were mortality and functional outcome in-hospital and after 3-month follow-up. According to the modified rankin scale (mRS), the functional outcome was divided into three groups: Good recovery (mRS ≤ 3), severe disability (mRS = 4 or 5) and death (mRS = 6). Univariate analysis was used to compare the differences between three functional outcomes. Multivariate logistic regression analysis was used to for risk factors of mortality and severe disability.

RESULTS

The average age of 111 patients was 56.46 ± 12.53 years, 59 (53.15%) were males. The mortality of in-hospital and 3-month follow-up were 36.9% and 45.0%, respectively. Of 71 discharged patients, 46.47% were seriously disabled and 12.67% died after three months follow-up. Univariate analysis showed that preoperative glasgow coma scale, operation start time and ventilation reasons had statistically significant differences in different functional outcomes. Multiple logistic regression analysis showed that the cause of ventilation was related to the death and poor prognosis of patients with cerebrovascular diseases. Compared with brainstem compression, the risk of death or severe disability of pulmonary disease, status epilepticus, impaired respiratory center function, and shock were 0.096 (95%CI: 0.028-0.328), 0.026 (95%CI: 0.004-0.163), 0.095 (95%CI: 0.013-0.709), 0.095 (95%CI: 0.020-0.444), respectively.

CONCLUSION

The survival rate and prognostic outcomes of patients with cerebrovascular diseases treated with mechanical ventilation during the perioperative period were poor. The reason for mechanical ventilation was a statistically significant predictor for mortality and severe disability.

Hyaluronic acid plasma levels during high versus low tidal volume ventilation in a porcine sepsis model

Background

Shedding of the endothelial glycocalyx can be observed regularly during sepsis. Moreover, sepsis may be associated with acute respiratory distress syndrome (ARDS), which requires lung protective ventilation with the two cornerstones of application of low tidal volume and positive end-expiratory pressure. This study investigated the effect of a lung protective ventilation on the integrity of the endothelial glycocalyx in comparison to a high tidal volume ventilation mode in a porcine model of sepsis-induced ARDS.

Methods

After approval by the State and Institutional Animal Care Committee, 20 male pigs were anesthetized and received a continuous infusion of lipopolysaccharide to induce septic shock. The animals were randomly assigned to either low tidal volume ventilation, high tidal volume ventilation, or no-LPS-group groups and observed for 6 h. In addition to the gas exchange parameters and hematologic analyses, the serum hyaluronic acid concentrations were determined from central venous blood and from pre- and postpulmonary and pre- and postcerebral circulation. Post-mortem analysis included histopathological evaluation and determination of the pulmonary and cerebral wet-to-dry ratios.

Results

Both sepsis groups developed ARDS within 6 h of the experiment and showed significantly increased serum levels of hyaluronic acid in comparison to the no-LPS-group. No significant differences in the hyaluronic acid concentrations were detected before and after pulmonary and cerebral circulation. There was also no significant difference in the serum hyaluronic acid concentrations between the two sepsis groups. Post-mortem analysis showed no significant difference between the two sepsis groups.

Conclusion

In a porcine model of septic shock and ARDS, the serum hyaluronic acid levels were significantly elevated in both sepsis groups in comparison to the no-LPS-group. Intergroup comparison between lung protective ventilated and high tidal ventilated animals revealed no significant differences in the serum hyaluronic acid levels.