The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study

Relationship between microaspiration and ventilator-associated events: A post-hoc analysis of a randomized controlled trial

OBJECTIVE

The relationship between ventilator-associated events (VAE) and microaspiration in intubated patients has not be studied. The objective of this study was to evaluate the relationship between abundant microaspiration of oropharyngeal secretions or gastric contents and the incidence of VAE.

PATIENTS AND METHODS

This was a post hoc analysis of the BESTCUFF study, which was a multicenter, cluster randomized, cross-over, controlled, open-label trial in adult patients ventilated for over 48 h. All tracheal aspirates were sampled for 48 h following enrollment, with quantitative measurement of pepsin and alpha-amylase. VAE were identified using National Healthcare Safety Network criteria, based on PEEP or FiO2 variations compared to stable parameters in previous days. The primary objective was to assess the relationship between abundant global microaspiration and the incidence of VAE, adjusted for pre-specified confounding factors (sex, SAPS II score and Glasgow coma scale).

RESULTS

261 patients were included, of which 31 (11.9%) developed VAE, with an overall median age of 65 (interquartile range 52-74), a majority of male patients (164, 62.8%), a median SAPS II score of 50 [40-61], a median SOFA score of 8 [5-11], and acute respiratory failure as main reason for ICU admission (117, 44.8%).The incidence of VAE was not significantly associated with abundant global microaspiration (adjusted cause-specific hazard ratio (cHR): 1.55 [0.46-5.17), abundant gastric microaspiration (adjusted cHR: 1.24 [0.61-2.53), or with abundant oropharyngeal microaspiration (adjusted HR: 1.07 [0.47-2.42]).

CONCLUSIONS

Our results suggest no significant association between abundant global, gastric or oropharyngeal microaspiration and the incidence of VAE.

IMPLICATIONS FOR CLINICAL PRACTICE

This study underscores that measuring microaspiration in intubated critically ill patients might not be useful to predict the diagnosis of VAE or to evaluate interventions aiming at preventing these complications.

Ventilator-associated events in adults: A secondary analysis assessing the impact of monitoring ventilator settings on outcomes

BACKGROUND

Ventilator-associated events (VAE) is a tier implemented for surveillance by the CDC in the USA. Implementation usefulness for clinical decisions is unknown.

METHODS

We conducted a secondary analysis from a prospective, multicentre, international study, to assess the impact on outcomes of using tiers with shorter follow-up (VAE24), lower oxygenation requirements (light-VAE) or both (light VAE24).

RESULTS

A cohort of 261 adults with 2706 ventilator-days were included. The median (IQR) duration of mechanical ventilation (MV) was 9 days (5-21), and the median (IQR) length of stay in the intensive care unit (ICU) was 14 days (8-26). A VAE tier was associated with a trend to increase from 32% to 44% in the ICU mortality rates. VAE Incidence was 24 per 1,000 ventilator-days, being increased when reduced the oxygenation settings requirement (35 per 1,000 ventilator-days), follow-up (41 per 1,000 ventilator-days) or both (55 per 1,000 ventilator-days). A VAE tier was associated with 13 extra (21 vs. 8) days of ventilation, 11 (23 vs. 12) ICU days and 7 (31 vs. 14) hospitalization days, outperforming the modified tiers' performance.

CONCLUSIONS

The modification of ventilator settings (consistent with ventilator-associated events) was associated with worse outcomes among adults with prolonged mechanical ventilation. Monitoring ventilator-associated events at the bedside represents a new tool for quality improvement.

Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events

INTRODUCTION

Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP.

AREAS COVERED

This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles.

EXPERT OPINION

Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.

Impact of Ventilator-Associated Pneumonia Preventative Measures and Ventilator Bundle Care in a Tertiary Care Hospital's Adult Intensive Care Unit

BACKGROUND

The mitigation of ventilator-associated pneumonia (VAP) is a vital undertaking in safeguarding patient well-being. The research aimed to evaluate the impact of a multidisciplinary, comprehensive monitoring approach on VAP incidence in a tertiary medical-surgical-trauma critical care unit.

METHODOLOGY

The research was conducted within an adult medical-surgical ICU from June 2021 to December 2022. VAP data were collected by prospective targeted surveillance in accordance with the guidelines provided by the National Healthcare Safety Network (NHSN) and the Centers for Disease Control and Prevention. In contrast, a cross-sectional design was used to gather bundle data, according to the defined methodology of the Institute for Healthcare Improvement (IHI), and the rate of variation in admission prior to the bundle's installation was evaluated.

RESULT

The features of ventilated patients in adult medical-surgical ICUs were studied between 2021 and 2022. Regarding demographics, men comprised 42.6% and 45.3% of VAP patients and 65.3% and 50.7% of bundle care patients, respectively. Notably, 33.1% of patients in VAP and 54.5% in bundle care were over 60 years old. Clinical indicators such as median age (12.6 vs. 8 months for non-VAP vs. VAP patients), antibiotic usage (65% vs. 99% for non-VAP vs. VAP patients), and risk factors like trauma diagnosis (HR: 2.59, 95% CI: 2.07-3.23), and accidental extubation (HR: 4.11, 95% CI: 1.93-8.73) differed significantly between the bundle and non-bundle care groups. A significant increase in bundle compliance was seen from 90% in 2021 to 97% in 2022 (P-value <0.001), which helped to lower VAP rates and highlight the need for ongoing quality improvement in ICU treatment.

CONCLUSION

The use of ventilator bundles at a tertiary care hospital resulted in improvements in ventilator utilization, with an approximate increase of 20% and VAP rates of over 70% for adult critical patients.

Epidemiological patterns of bacterial and fungal healthcare-associated infection outbreaks in Ministry of Health hospitals in Saudi Arabia, 2020-2021

BACKGROUND

Healthcare-Associated Infections (HAI) outbreaks remain a huge challenge to the healthcare sectors worldwide. Their impact on morbidity and mortality, economic and healthcare burden remains a public health problem and a challenge to the HAI surveillance system, infection control, and HAI management strategies.

AIM

This study aimed to investigate the epidemiological patterns, distribution, causative agents of HAI outbreaks and the influence of age, COVID-19 co-infection, medical invasive procedures, and hospital units on mortality among HAI outbreaks cases.

METHODS

This chart review study involved HAI outbreak cases recorded in Ministry of Health hospitals during 2020-2021 in Saudi Arabia. HAI outbreak notification and investigation forms were used for data collection. A binary logistic regression model was performed to determine the significant predictors of mortality. Univariate analyses were performed to determine the association between hospital units, organisms, and COVID-19 co-infection to the site of infection.

RESULTS

A total of 217 HAI outbreaks with 1003 cases were recorded in 2020-2021. Gram-negative bacteria were isolated from 73.8% of the cases. The overall specific case fatality rate was 47.5%. The significant predictors of mortality were age, invasive medical procedures, COVID-19 co-infection, and intensive care units' admission. Moreover, ventilator-associated events were more associated with cases co-infected with COVID-19.

CONCLUSION

HAI outbreaks were most prevalent in the Western and Central region and in intensive care units. Gram negative bacteria were responsible for most of cases while ventilator-associated events and central line-associated bloodstream infections were the most common infection sites. Implementing targeted and effective prevention and control strategies is recommended.

Impact of mechanical ventilation on clinical outcomes in ICU-admitted Alzheimer's disease patients: a retrospective cohort study

Background

Alzheimer's disease (AD) is increasingly recognized as a pressing global public health issue, demanding urgent development of scientific AD management strategies. In recent years, the proportion of AD patients in Intensive Care Units (ICU) has been on the rise. Simultaneously, the use of mechanical ventilation (MV) is becoming more prevalent among this specific patient group. Considering the pathophysiological characteristics of AD, the application of MV in AD patients may lead to different outcomes. However, due to insufficient research data, the significant impact of MV on the prognosis of AD patients in the ICU remains unclear. Therefore, we conducted this study to comprehensively evaluate the potential influence of MV on the survival rate of AD patients in the ICU.

Methods

We obtained data from the MIMIC-IV database for patients diagnosed with AD. Using propensity score matching (PSM), we paired patients who received MV treatment with those who did not receive treatment. Next, we conducted Cox regression analysis to evaluate the association between MV and in-hospital mortality, 7-day mortality, 28-day mortality, 90-day mortality, 4-year mortality, length of hospital stay, and ICU stay.

Results

The data analysis involved a cohort of 641 AD patients spanning from 2008 to 2019, inclusive. Following a 1:2 propensity score matching (PSM) procedure, 300 patients were successfully paired, comprising 123 individuals who underwent MV treatment and 177 who did not. MV demonstrated an association with an elevated risk of in-hospital mortality (HR 5.782; 95% CI 2.981-11.216; p < 0.001), 7-day mortality (HR 6.353; 95% CI 3.014-13.392; p < 0.001), 28-day mortality (HR 3.210; 95% CI 1.977-5.210; p < 0.001), 90-day mortality (HR 2.334; 95% CI 1.537-3.544; p < 0.001), and 4-year mortality (HR 1.861; 95% CI 1.370-2.527; p < 0.001). Furthermore, it was associated with a prolonged length of ICU stay [3.6(2.2,5.8) vs. 2.2(1.6,3.7); p = 0.001]. In the subgroup analysis, we further confirmed the robustness of the results obtained from the overall population. Additionally, we observed a significant interaction (p-interaction <0.05) between age, admission type, aspirin use, statin use, and the use of MV.

Conclusion

In patients with AD who are receiving treatment in the ICU, the use of MV has been linked to higher short-term, medium-term, and long-term mortality rates, as well as prolong ICU stays. Therefore, it is crucial to break away from conventional thinking and meticulously consider both the medical condition and personal preferences of these vulnerable patients. Personalized treatment decisions, comprehensive communication between healthcare providers and patients, formulation of comprehensive treatment plans, and a focus on collaboration between the ICU and community organizations become imperative.

Epidemiology and Burden of Ventilator-Associated Pneumonia among Adult Intensive Care Unit Patients: A Portuguese, Multicenter, Retrospective Study (eVAP-PT Study)

Ventilator-associated pneumonia (VAP) is a prevailing nosocomial infection in critically ill patients requiring invasive mechanical ventilation (iMV). The impact of VAP is profound, adversely affecting patient outcomes and placing a significant burden on healthcare resources. This study assessed for the first time the contemporary VAP epidemiology in Portugal and its burden on the healthcare system and clinical outcomes. Additionally, resource consumption (duration of iMV, intensive care unit (ICU), hospital length of stay (LOS)) and empirical antimicrobial therapy were also evaluated. This multicenter, retrospective study included patients admitted to the hospital between July 2016 and December 2017 in a participating ICU, who underwent iMV for at least 48 h. Patients with a VAP diagnosis were segregated for further analysis (n = 197). Control patients, ventilated for >48 h but without a VAP diagnosis, were also included in a 1:1 ratio. Cumulative VAP incidence was computed. All-cause mortality was assessed at 28, 90, and 365 days after ICU admission. Cumulative VAP incidence was 9.2% (95% CI 8.0-10.5). The all-cause mortality rate in VAP patients was 24.9%, 34.0%, and 40.6%, respectively, and these values were similar to those observed in patients without VAP diagnosis. Further, patients with VAP had significantly longer ICU (27.5 vs. 11.0 days, p < 0.001) and hospital LOS (61 vs. 35.9 days, p < 0.001), more time under iMV (20.7 vs. 8.0 days, p < 0.001) and were more often subjected to tracheostomy (36.5 vs. 14.2%; p < 0.001). Patients with VAP who received inappropriate empirical antimicrobials had higher 28-day mortality, 34.3% vs. 19.5% (odds ratio 2.16, 95% CI 1.10-4.23), although the same was not independently associated with 1-year all-cause mortality (p = 0.107). This study described the VAP impact and burden on the Portuguese healthcare system, with approximately 9% of patients undergoing iMV for >48 h developing VAP, leading to increased resource consumption (longer ICU and hospital LOS). An unexpectedly high incidence of inappropriate, empirical antimicrobial therapy was also noted, being positively associated with a higher mortality risk of these patients. Knowledge of the Portuguese epidemiology characterization of VAP and its multidimensional impact is essential for efficient treatment and optimized long-term health outcomes of these patients.

Treatment and Management of Acinetobacter Pneumonia: Lessons Learned from Recent World Event

Acinetobacter pneumonia is a significant healthcare-associated infection that poses a considerable challenge to clinicians due to its multidrug-resistant nature. Recent world events, such as the COVID-19 pandemic, have highlighted the need for effective treatment and management strategies for Acinetobacter pneumonia. In this review, we discuss lessons learned from recent world events, particularly the COVID-19 pandemic, in the context of the treatment and management of Acinetobacter pneumonia. We performed an extensive literature review to uncover studies and information pertinent to the topic. The COVID-19 pandemic underscored the importance of infection control measures in healthcare settings, including proper hand hygiene, isolation protocols, and personal protective equipment use, to prevent the spread of multidrug-resistant pathogens like Acinetobacter. Additionally, the pandemic highlighted the crucial role of antimicrobial stewardship programs in optimizing antibiotic use and curbing the emergence of resistance. Advances in diagnostic techniques, such as rapid molecular testing, have also proven valuable in identifying Acinetobacter infections promptly. Furthermore, due to the limited availability of antibiotics for treating infections caused A. baumannii, alternative strategies are needed like the use of antimicrobial peptides, bacteriophages and their enzymes, nanoparticles, photodynamic and chelate therapy. Recent world events, particularly the COVID-19 pandemic, have provided valuable insights into the treatment and management of Acinetobacter pneumonia. These lessons emphasize the significance of infection control, antimicrobial stewardship, and early diagnostics in combating this challenging infection.

Risk factors for prolonged postoperative ICU stay in the patients with Stanford type A aortic dissection

OBJECTIVE

To investigate the independent risk factors for postoperative prolonged ICU stay in patients with Stanford type A aortic dissection (TAAD) and assess the clinical outcomes of prolonged ICU stay.

METHOD

The clinical data of 100 patients with TAAD admitted to the Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University from December 2018 to September 2022 were retrospectively collected and analyzed. Patients were divided into two groups, based on the postoperative ICU stay (7 days as the threshold), regular ICU stay group (< 7 days) and prolonged ICU stay group (≥ 7 days). First, preoperative and intraoperative materials were collected for univariate analysis. Then, the significant variables after univariate analysis were analyzed using logistic regression, and the final independent risk factors for prolonged ICU stay were determined. Meanwhile, the postoperative clinical outcomes were analyzed with the aim of assessing the clinical outcomes due to prolonged ICU stay.

RESULTS

There were 65 and 35 patients in the regular ICU stay group and the prolonged ICU stay group, respectively. In accordance with the result of univariate analysis in the two groups, emergency surgery (χ2 = 13.598; P < 0.001), preoperative urea nitrogen (t = 3.006; P = 0.004), cardiopulmonary bypass (CPB) time (t = 2.671; P = 0.001) and surgery time (t = 2.630; P = 0.010) were significant. All significant variates were analyzed through logistic regression, and it was found that emergency surgery (OR = 0.192; 95% CI: 0.065-0.561), preoperative urea nitrogen (OR = 0.775; 95% CI: 0.634-0.947) and cardiopulmonary time (OR = 0.988; 95% CI: 0.979-0.998) were independent risk factors for prolonged postoperative ICU stay. The Receiver Operating Characteristic (ROC) curves of these three factors were also effective in predicting postoperative prolonged ICU stay (Emergency surgery, AUC = 0.308, 95% CI: 0.201-0.415; Preoperative urea nitrogen, AUC = 0.288, 95% CI: 0.185-0.392; cardiopulmonary time, AUC = 0.340, 95% CI: 0.223-0.457). Moreover, compared with a single factor, the predictive value of combined factors was more significant (AUC = 0.810, 95% CI: 0.722-0.897). For the comparison of postoperative data in the two groups,, compared with the regular ICU stay group, the incidence of adverse events in the prolonged ICU stay group increased significantly, including limb disability of limbs (χ2 = 22.182; P < 0.001), severe organ injury (χ2 = 23.077; P < 0.001), tracheotomy (χ2 = 17.582; P < 0.001), reintubation (χ2 = 28.020; P < 0.001), 72 h tracheal extubation after surgery (χ2 = 29.335; P < 0.001), 12 h consciousness recovery after surgery (χ2 = 18.445; P < 0.001), ICU re-entering (χ2 = 9.496; P = 0.002) and irregular discharging (χ2 = 24.969; P < 0.001).

CONCLUSION

Emergency surgery, preoperative urea nitrogen, and CPB time are risk factors for postoperative prolonged ICU stay after TAAD surgery. Furthermore, prolonged ICU stay is associated with worse clinical outcomes. Hence, a reasonable strategy should be adopted proactively focusing on the risk factors to shorten ICU stays and improve clinical outcomes.

Factors Predicting Prolonged Mechanical Ventilation in Guillain-Barré Syndrome

BACKGROUND

Up to 30% of patients with Guillain-Barré syndrome require mechanical ventilation and 5% die due to acute complications of mechanical ventilation. There is a considerable group of patients that will need prolonged mechanical ventilation (considered as >14 days) and should be considered for early tracheostomy. The objective of this study is to identify risk factors for prolonged mechanical ventilation.

METHODS

We prospectively analyzed patients with Guillain-Barré diagnosis with versus without prolonged mechanical ventilation. We considered clinical and electrophysiological characteristics and analyzed factors associated with prolonged mechanical ventilation.

RESULTS

Three hundred and three patients were included; 29% required mechanical ventilation. When comparing the groups, patients with prolonged invasive mechanical ventilation (IMV) have a lower score on the Medical Research Council score (19.5 ± 16.2 vs 27.4 ± 17.5, p = 0.03) and a higher frequency of dysautonomia (42.3% vs 19.4%, p = 0.037), as well as lower amplitudes of the distal compound muscle action potential (CMAP) of the median nerve [0.37 (RIQ 0.07-2.25) vs. 3.9 (RIQ1.2-6.4), p = <0.001] and ulnar nerve [0.37 (RIQ0.0-3.72) vs 1.5 (RIQ0.3-6.6), p = <0.001], and higher frequency of severe axonal damage in these nerves (distal CMAP ≤ 1.0 mV). Through binary logistic regression, severe axonal degeneration of the median nerve is an independent risk factor for prolonged IMV OR 4.9 (95%CI 1.1-21.5) p = 0.03, AUC of 0.774, (95%CI 0.66-0.88), p = < 0.001.

CONCLUSIONS

Severe median nerve damage is an independent risk factor for prolonged mechanical ventilation.

Robust airway microbiome signatures in acute respiratory failure and hospital-acquired pneumonia

Respiratory microbial dysbiosis is associated with acute respiratory distress syndrome (ARDS) and hospital-acquired pneumonia (HAP) in critically ill patients. However, we lack reproducible respiratory microbiome signatures that can increase our understanding of these conditions and potential treatments. Here, we analyze 16S rRNA sequencing data from 2,177 respiratory samples collected from 1,029 critically ill patients (21.7% with ARDS and 26.3% with HAP) and 327 healthy controls, sourced from 17 published studies. After data harmonization and pooling of individual patient data, we identified microbiota signatures associated with ARDS, HAP and prolonged mechanical ventilation. Microbiota signatures for HAP and prolonged mechanical ventilation were characterized by depletion of a core group of microbes typical of healthy respiratory samples, and the ARDS microbiota signature was distinguished by enrichment of potentially pathogenic respiratory microbes, including Pseudomonas and Staphylococcus. Using machine learning models, we identified clinically informative, three- and four-factor signatures that predicted ARDS, HAP and prolonged mechanical ventilation with relatively high accuracy (area under the curve of 0.751, 0.72 and 0.727, respectively). We validated the signatures in an independent prospective cohort of 136 patients on mechanical ventillation and found that patients with microbiome signatures associated with ARDS, HAP or prolonged mechanical ventilation had longer times to successful extubation than patients lacking these signatures (hazard ratios of 1.56 (95% confidence interval (CI) 1.07-2.27), 1.51 (95% CI 1.02-2.23) and 1.50 (95% CI 1.03-2.18), respectively). Thus, we defined and validated robust respiratory microbiome signatures associated with ARDS and HAP that may help to identify promising targets for microbiome therapeutic modulation in critically ill patients.

Effects of Tanreqing Injection on ICU Mortality among ICU Patients Receiving Mechanical Ventilation: Time-Dependent Cox Regression Analysis of A Large Registry

OBJECTIVE

To assess whether the use of Tanreqing (TRQ) Injection could show improvements in time to extubation, intensive care unit (ICU) mortality, ventilator-associated events (VAEs) and infection-related ventilator associated complication (IVAC) among patients receiving mechanical ventilation (MV).

METHODS

A time-dependent cox-regression analysis was conducted using data from a well-established registry of healthcare-associated infections at ICUs in China. Patients receiving continuous MV for 3 days or more were included. A time-varying exposure definition was used for TRQ Injection, which were recorded on daily basis. The outcomes included time to extubation, ICU mortality, VAEs and IVAC. Time-dependent Cox models were used to compare the clinical outcomes between TRQ Injection and non-use, after controlling for the influence of comorbidities/conditions and other medications with both fixed and time-varying covariates. For the analyses of time to extubation and ICU mortality, Fine-Gray competing risk models were also used to measure competing risks and outcomes of interest.

RESULTS

Overall, 7,685 patients were included for the analyses of MV duration, and 7,273 patients for the analysis of ICU mortality. Compared to non-use, patients with TRQ Injection had a lower risk of ICU mortality (Hazards ratios (HR) 0.761, 95% CI, 0.581-0.997), and was associated with a higher hazard for time to extubation (HR 1.105, 95% CI, 1.005-1.216), suggesting a beneficial effect on shortened time to extubation. No significant differences were observed between TRQ Injection and non-use regarding VAEs (HR 1.057, 95% CI, 0.912-1.225) and IVAC (HR 1.177, 95% CI, 0.929-1.491). The effect estimates were robust when using alternative statistic models, applying alternative inclusion and exclusion criteria, and handling missing data by alternative approaches.

CONCLUSION

Our findings suggested that the use of TRQ Injection might lower mortality and improve time to extubation among patients receiving MV, even after controlling for the factor that the use of TRQ changed over time.

Ventilator-associated events: From surveillance to optimizing management

Mechanical ventilation (MV) is a life-support therapy that may predispose to morbid and lethal complications, with ventilator-associated pneumonia (VAP) being the most prevalent. In 2013, the Center for Disease Control (CDC) defined criteria for ventilator-associated events (VAE). Ten years later, a growing number of studies assessing or validating its clinical applicability and the potential benefits of its inclusion have been published. Surveillance with VAE criteria is retrospective and the focus is often on a subset of patients with higher than lower severity. To date, it is estimated that around 30% of ventilated patients in the intensive care unit (ICU) develop VAE. While surveillance enhances the detection of infectious and non-infectious MV-related complications that are severe enough to impact the patient's outcomes, there are still many gaps in its classification and management. In this review, we provide an update by discussing VAE etiologies, epidemiology, and classification. Preventive strategies on optimizing ventilation, sedative and neuromuscular blockade therapy, and restrictive fluid management are warranted. An ideal VAE bundle is likely to minimize the period of intubation. We believe that it is time to progress from just surveillance to clinical care. Therefore, with this review, we have aimed to provide a roadmap for future research on the subject.

Pendelluft as a predictor of weaning in critically ill patients: An observational cohort study

Objective: Weaning failure is associated with adverse clinical outcomes. This study aimed to evaluate the accuracy of pendelluft during the spontaneous breathing trials (SBT) as a predictor of weaning outcome of patients with mechanical ventilation.

Methods: An observational cohort study included 60 critically ill patients who were eligible for extubation. Pendelluft and electrical activity of the diaphragm (Edi) were monitored at baseline and every 10 minutes for the first 30 min of SBT denoted as T0, T1, T2, and T3. The pendelluft was measured using electrical impedance tomography (EIT), and Edi parameters were collected by Edi catheter. Patients were followed up after extubation and were divided into success group and failure group. Pendelluft, Edi parameters, respiratory parameters, and clinical outcomes such as intensive care units (ICU) stay, mortality, and 28-day ventilator-free days were compared between the two groups. Receiver operating characteristic (ROC) curves were constructed to evaluate the ability of pendelluft to predict weaning outcome.

Results: Fifty patients (50/60) were successfully weaned from the machine and 10 (10/60) failed, with weaning failure rate of 16.7%. Respiratory parameters such as rapid shallow breathing index (RSBI), respiratory rate (RR) and Edi parameters such as maximum value of Edi (Edimax), Edi variation between a maximum and minimum(ΔEdi) in the failure group were higher than those in the success group. The ICU stay and the 28-day ventilator-free days in the failure group were significantly longer than those in the success group. The 28-day mortality rate was higher in the failure group. The pendelluft mainly occurred in the early stage of SBT. Ventral pendelluft and total pendelluft in the failure group were higher than those in the success group at T1. Edimax and ΔEdi were positively correlated with pendelluft. The area under ROC curve (AUC) showed moderate predictive ability for ventral pendelluft in predicting weaning failure at T1 (AUC 0.76, 95% CI 0.58–0.94, cut-off value &gt; 3% global tidal variation).

Conclusion: Pendelluft is one of the factors leading to weaning failure, which may be related to diaphragm function. Measuring pendelluft volume maybe helpful to predict weaning.

Antimicrobial materials for endotracheal tubes: A review on the last two decades of technological progress

Ventilator-associated pneumonia (VAP) is an unresolved problem in nosocomial settings, remaining consistently associated with a lack of treatment, high mortality, and prolonged hospital stay. The endotracheal tube (ETT) is the major culprit for VAP development owing to its early surface microbial colonization and biofilm formation by multiple pathogens, both critical events for VAP pathogenesis and relapses. To combat this matter, gradual research on antimicrobial ETT surface coating/modification approaches has been made. This review provides an overview of the relevance and implications of the ETT bioburden for VAP pathogenesis and how technological research on antimicrobial materials for ETTs has evolved. Firstly, certain main VAP attributes (definition/categorization; outcomes; economic impact) were outlined, highlighting the issues in defining/diagnosing VAP that often difficult VAP early- and late-onset differentiation, and that generate misinterpretations in VAP surveillance and discrepant outcomes. The central role of the ETT microbial colonization and subsequent biofilm formation as fundamental contributors to VAP pathogenesis was then underscored, in parallel with the uncovering of the polymicrobial ecosystem of VAP-related infections. Secondly, the latest technological developments (reported since 2002) on materials able to endow the ETT surface with active antimicrobial and/or passive antifouling properties were annotated, being further subject to critical scrutiny concerning their potentialities and/or constraints in reducing ETT bioburden and the risk of VAP while retaining/improving the safety of use. Taking those gaps/challenges into consideration, we discussed potential avenues that may assist upcoming advances in the field to tackle VAP rampant rates and improve patient care. STATEMENT OF SIGNIFICANCE: The use of the endotracheal tube (ETT) in patients requiring mechanical ventilation is associated with the development of ventilator-associated pneumonia (VAP). Its rapid surface colonization and biofilm formation are critical events for VAP pathogenesis and relapses. This review provides a comprehensive overview on the relevance/implications of the ETT biofilm in VAP, and on how research on antimicrobial ETT surface coating/modification technology has evolved over the last two decades. Despite significant technological advances, the limited number of gathered reports (46), highlights difficulty in overcoming certain hurdles associated with VAP (e.g., persistent colonization/biofilm formation; mechanical ventilation duration; hospital length of stay; VAP occurrence), which makes this an evolving, complex, and challenging matter. Challenges and opportunities in the field are discussed.

Theoretical definition of nurse-conscious mechanically ventilated patient communication: a scoping review with qualitative content analysis

Providing critical nursing care for conscious mechanically ventilated patients is mediated via effective communication. This study aimed to identify and map the antecedents, attributes, consequences, and definition of nurse-conscious mechanically ventilated patient communication (N-CMVPC). This scoping review was conducted by searching the Cochrane Library and the CINAHL, EMBASE, PubMed, Web of Science, and Scopus databases, between 2001 and 2021. The keywords queried included "nurses," "mechanically ventilated patients," "mechanical ventilation," "intubated patients," "communication," "interaction," "relationships," "nurse-patient communication," "nurse-patient relations," "intensive care units," and "critical care." Studies related to communication with healthcare personnel or family members were excluded. The results indicated that N-CMVPC manifests as a set of attributes in communication experiences, emotions, methods, and behaviors of the nurse and the patient and is classified into three main themes, nurse communication, patient communication, and quantitative-qualitative aspects. N-CMVPC is a complex, multidimensional, and multi-factor concept. It is often nurse-controlled and can express itself as questions, sentences, or commands in the context of experiences, feelings, and positive or negative behaviors involving the nurse and the patient.

Efficacy of Intermittent and Continuous Subglottic Secretion Drainage in Preventing the Risk of Ventilator-Associated Pneumonia: A Meta-Analysis of Randomized Control Trials

Ventilator-associated pneumonia (VAP) is hospital-acquired pneumonia that develops 48 h or longer following mechanical ventilation. However, cuff pressure fluctuates significantly due to patient or tube movement, which might result in microaspiration. Subglottic secretion drainage (SSD) has been suggested as a method for VAP prevention bundles. This systematic review and meta-analysis aims to investigate the efficacy and safety of subglottic SSD in preventing VAP. The secondary outcomes of this study are to investigate the intensive care unit (ICU) stay length and mortality rate regarding VAP. This study followed the Preferred Reporting Item for Systematic Review and Meta-Analysis guidelines. A thorough search of PubMed, Embase, and the Web of Science was conducted between June and August 2022. The study analysis used the Mantel-Haenszel method, and the quality of the included study was assessed using the Cochrane Risk of Bias 2. Eighteen randomized controlled trials with a total of 2537 intubated patients were included. It was found that SSD was associated with a lower risk of VAP (RR 1.44; 95% CI; 1.20-1.73; p < 0.0001). The subgroup analysis (utilizing intermittent and continuous methods) found no statistically significant difference between the two groups (p = 0.28). The secondary endpoints showed that there was no significant difference in mortality (RR 1.02; 95% CI; 0.87-1.20; p = 0.83), but there were substantial differences in ICU stays (mean difference, 3.42 days; 95% CI; 2.07-4.76; p < 0.00001) in favor of the SSD group. This was based on a very low certainty of evidence due to concerns linked to the risk of bias and inconsistency. The use of SSD was associated with a reduction in VAP incidence and ICU stay length, but there was no significant difference in the mortality rate.

Infection-Related Ventilator-Associated Complications in Critically Ill Patients with Trauma: A Retrospective Analysis

BACKGROUND

Trauma is a leading cause of death and disability. Patients with trauma undergoing invasive mechanical ventilation (IMV) are at risk for ventilator-associated events (VAEs) potentially associated with a longer duration of IMV and increased stay in the intensive care unit (ICU).

METHODS

We conducted a retrospective cohort study aimed to evaluate the incidence of infection-related ventilator-associated complications (IVACs), possible ventilator-associated pneumonia (PVAP), and their characteristics among patients experiencing severe trauma that required ICU admission and IMV for at least four days. We also determined pathogens implicated in PVAP episodes and characterized the use of antimicrobial therapy.

RESULTS

In total, 88 adult patients were included in the main analysis. In this study, we observed that 29.5% of patients developed a respiratory infection during ICU stay. Among them, five patients (19.2%) suffered from respiratory infections due to multi-drug resistant bacteria. Patients who developed IVAC/PVAP presented lower total GCS (median value, 7; (IQR, 9) vs. 12.5, (IQR, 8); p = 0.068) than those who did not develop IVAC/PVAP.

CONCLUSIONS

We observed that less than one-third of trauma patients fulfilling criteria for ventilator associated events developed a respiratory infection during the ICU stay.

Therapeutic hypothermia can cause non-infective C-reactive protein elevating

Objective

To analyze the relationship between therapeutic hypothermia (TH) and whole blood high-sensitivity C-reactive protein (hs-CRP) in neonates with hypoxic-ischemic encephalopathy (HIE).

Method

Retrospective analysis was made on the clinical data of hospitalized infants diagnosed with asphyxia in our neonatal intensive care unit from January 2014 to June 2021. According to whether TH was performed, they were divided into two groups, the control group (missed the time in other hospitals and did not receive TH) and the treatment group (TH group). In their first ten days, analysis was made on the hs-CRP, white blood cell (WBC) count, neutrophil percentage, platelet count (PLT), and brain MRI. The correlation analysis was carried out based on the severity of brain injury displayed by the brain MRI and the time of hs-CRP elevation to summarize the relationship between TH and the time of hs-CRP elevation and the severity of HIE.

Results

83 infants were included, 28 in the control group and 55 in the TH group. After birth, 33 infants (60.0%) in the TH group and 2 patients (7.1%) in the control group had elevated hs-CRP, which was statistically significant (P < 0.05). The time window for CRP elevation after TH was 72-96 h after the end of treatment; The results of the brain MRI showed 23 in the TH group and 11in the control group with moderate and severe HIE. 21 infants (all in the TH group) had elevated hs-CRP. MRI showed that the number of infants with mild injury or regular infants whose hs-CRP raised in the TH group was 12, and the rate of hs-CRP elevation was 37.5%; in the control group, the rate was 11.8%. The difference was significant. TH can decrease PLT and WBC, but no significance in the two groups. Blood and sputum cultures were negative in all infants, and there were no signs of infection.

Conclusions

TH can increase the blood hs-CRP of HIE neonates, and the probability of its occurrence is related to the severity of HIE. The heavier the HIE, the higher the risk of hs-CRP elevation after TH; The hs-CRP elevation has little to do with infection, and it doesn't recommend using antibiotics actively.

A Method to Explore Variations of Ventilator-Associated Event Surveillance Definitions in Large Critical Care Databases in the United States

The Centers for Disease Control has well-established surveillance programs to monitor preventable conditions in patients supported by mechanical ventilation (MV). The aim of the study was to develop a data-driven methodology to examine variations in the first tier of the ventilator-associated event surveillance definition, described as a ventilator-associated condition (VAC). Further, an interactive tool was designed to illustrate the effect of changes to the VAC surveillance definition, by applying different ventilator settings, time-intervals, demographics, and selected clinical criteria.

DESIGN

Retrospective, multicenter, cross-sectional analysis.

SETTING

Three hundred forty critical care units across 209 hospitals, comprising 261,910 patients in both the electronic Intensive Care Unit Clinical Research Database and Medical Information Mart for Intensive Care III databases.

PATIENTS

A total of 14,517 patients undergoing MV for 4 or more days.

MEASUREMENTS AND MAIN RESULTS

We designed a statistical analysis framework, complemented by a custom interactive data visualization tool to depict how changes to the VAC surveillance definition alter its prognostic performance, comparing patients with and without VAC. This methodology and tool enable comparison of three clinical outcomes (hospital mortality, hospital length-of-stay, and ICU length-of-stay) and provide the option to stratify patients by six criteria in two categories: patient population (dataset and ICU type) and clinical features (minimum Fio₂, minimum positive end-expiratory pressure, early/late VAC, and worst first-day respiratory Sequential Organ Failure Assessment score). Patient population outcomes were depicted by heatmaps with mortality odds ratios. In parallel, outcomes from ventilation setting variations and clinical features were depicted with Kaplan-Meier survival curves.

CONCLUSIONS

We developed a method to examine VAC using information extracted from large electronic health record databases. Building upon this framework, we developed an interactive tool to visualize and quantify the implications of variations in the VAC surveillance definition in different populations, across time and critical care settings. Data for patients with and without VAC was used to illustrate the effect of the application of this method and visualization tool.

Early mechanical ventilation for grade IV hepatic encephalopathy is associated with increased mortality among patients with cirrhosis: an exploratory study

BACKGROUND

Unresponsive patients with toxic-metabolic encephalopathies often undergo endotracheal intubation for the primary purpose of preventing aspiration events. However, among patients with pre-existing systemic comorbidities, mechanical ventilation itself may be associated with numerous risks such as hypotension, aspiration, delirium, and infection. Our primary aim was to determine whether early mechanical ventilation for airway protection was associated with increased mortality in patients with cirrhosis and grade IV hepatic encephalopathy.

METHODS

The National Inpatient Sample was queried for hospital stays due to grade IV hepatic encephalopathy among patients with cirrhosis between 2016 and 2019. After applying our exclusion criteria, including cardiopulmonary failure, data from 1,975 inpatient stays were analyzed. Patients who received mechanical ventilation within 2 days of admission were compared to those who did not. Univariable and multivariable logistic regression analyses were performed to identify clinical factors associated with in-hospital mortality.

RESULTS

Of 162 patients who received endotracheal intubation during the first 2 hospital days, 64 (40%) died during their hospitalization, in comparison to 336 (19%) of 1,813 patients in the comparator group. In multivariable logistic regression analysis, mechanical ventilation was the strongest predictor of in-hospital mortality in our primary analysis (adjusted odds ratio, 3.00; 95% confidence interval, 2.14-4.20; P<0.001) and in all sensitivity analyses.

CONCLUSIONS

Mechanical ventilation for the sole purpose of airway protection among patients with cirrhosis and grade IV hepatic encephalopathy may be associated with increased in-hospital mortality. Future studies are necessary to confirm and further characterize our findings.

Infection-Related Ventilator-Associated Complication and Possible Ventilator-Associated Pneumonia among Mechanically Ventilated Patients of Adult Medical and Surgical Intensive Care Units

Objective An observational study was conducted to evaluate (1) the incidence rates of infection-related ventilator-associated complication (IVAC) and possible ventilator-associated pneumonia (PVAP) among mechanically ventilated patients of adult medical and surgical intensive care units (ICUs) and (2) the pathogen distribution in patients with PVAP.

Materials and Methods The IVAC and PVAP rates of medical and surgical ICUs, between July 1, 2017, and June 30, 2021, per 1,000 mechanical ventilator (MV) days were calculated. The significance of difference in IVAC and PVAP rates between medical and surgical ICUs was calculated. The level of significance was set at less than 0.05.

Results MV utilization ratios of adult medical and surgical ICUs were 0.32 and 0.26, respectively (p < 0.001). About 8 and 7 episodes of IVAC and 14 and 6 episodes of PVAP were reported from adult medical and surgical ICUs, accounting for IVAC rates of 3.17 and 1.8 per 1,000 MV (p > 0.05) and PVAP rates of 2.46 and 1.59 per 1,000 MV days in medical and surgical ICUs, respectively (p > 0.05). Acinetobacter baumannii complex either singly or in combination was isolated in 11/20 PVAP cases.

Conclusion IVAC and PVAP were more in medical compared with surgical ICUs. The most common pathogen in patients with PVAP was A. baumannii complex. More studies are warranted to monitor the significance of ventilator-associated event on patient outcomes.

Associations Between Antithrombosis and Ventilator-Associated Events, ICU Stays, and Mortality Among Mechanically Ventilated Patients: A Registry-Based Cohort Study

Background: The effect of thromboembolism prophylaxis on clinical outcomes, such as ventilator-associated events (VAEs), ICU stays, and mortality, remains controversial. This study was conducted to evaluate the effect of pharmacological thromboprophylaxis on VAEs, ICU stays, and ICU mortality among patients receiving mechanical ventilation (MV).

Materials and Methods: A retrospective cohort study was conducted based on a well-established registry of healthcare-associated infections at ICUs in the West China Hospital system. Patients who consistently received MV for at least 4 days from 1 April 2015 to 31 December 2018 were included. Hazard ratios (HRs) were compared for three tiers of VAEs, ICU stays, and ICU mortality among patients receiving pharmacological thromboprophylaxis versus those without using the time-dependent Cox model. For the analyses of ICU stays and ICU mortality, we also used Fine-Gray models to disentangle the competing risks and outcomes of interest.

Results: Overall, 6,140 patients were included. Of these, 3,805 received at least one prescription of antithrombosis agents. Treatments with antithrombosis agents were associated with lower risk of VAEs (HR: 0.87, 95% CI: 0.77, 0.98) and ICU mortality (HR: 0.72, 95% CI: 0.61, 0.86) than those without. Anticoagulants but not antiplatelet agents were associated with decreased risk of VAEs (HR: 0.86, 95% CI: 0.75, 0.98), ICU mortality (HR: 0.62, 95% CI: 0.51, 0.76), and less time to ICU discharge (HR: 1.15, 95% CI: 1.04, 1.28). Antithrombosis may be associated with decreased risk of VAEs in patients with D-dimer >5 mg/LFEU (HR: 0.84, 95%CI: 0.72, 0.98).

Conclusions: Pharmacological thromboprophylaxis was associated with lower risk of VAEs and ICU mortality. Similar effects were observed between unfractionated heparins versus low-molecular-weight heparins.

Lung function and exercise capacity 6 months after hospital discharge for critical COVID-19

BACKGROUND

The significant morbidity caused by COVID-19 necessitates further understanding of long-term recovery. Our aim was to evaluate long-term lung function, exercise capacity, and radiological findings in patients after critical COVID-19.

METHODS

Patients who received treatment in ICU for COVID-19 between March 2020 and January 2021 underwent pulmonary function tests, a 6MWD and CXR 6 months after hospital discharge.

RESULTS

A restrictive ventilatory defect was found in 35% (23/65) and an impaired diffusing capacity in 52% (32/62) at 6 months. The 6-minute walk distance was reduced in 33% (18/55), and 7% (4/55) of the patients had reduced exercise capacity. Chest X-ray was abnormal in 78% (52/67) at 6 months after hospital discharge.

CONCLUSION

A significant number of patients had persisting lung function impairment and radiological abnormalities at 6 months after critical COVID-19. Reduced exercise capacity was rare.

Associations of Fentanyl, Sufentanil, and Remifentanil With Length of Stay and Mortality Among Mechanically Ventilated Patients: A Registry-Based Cohort Study

Background: As the first-line treatment for mechanically ventilated patients with critical illness, fentanyl and its analogs (e.g., sufentanil and remifentanil) are commonly used in the intensive care unit (ICU). However, the pharmacokinetics, metabolism, and potency of these agents differed. Their effects on clinical outcomes have not been well-understood.

Materials and Methods: Using a well-established registry, we conducted a cohort study. Patients who consistently underwent mechanical ventilation (MV) for more than 24 h were identified. We used a time-varying exposure definition, in which we coded each type of opioids as prescribed or not prescribed on each day from initiation of MV to extubation and ICU discharge. We used Fine-Gray competing risk models to compare the effects of fentanyl, sufentanil, and remifentanil on hazards for extubation, ventilator mortality, ICU discharge, and ICU mortality. All models were adjusted using a combination of fixed-time and time-varying covariates. Missing data were imputed using multiple imputation by chained equations.

Results: A total of 8,165 patients were included. There were, respectively, 4,778, 4,008, and 2,233 patients receiving at least 1 day of fentanyl, sufentanil, and remifentanil dose. Compared to fentanyl, sufentanil was associated with shorter duration to extubation (hazard ratio 1.31, 95% CI, 1.20–1.41) and ICU discharge (hazard ratio 1.63, 95% CI, 1.38–1.92), and remifentanil was associated with shorter duration to extubation (hazard ratio 1.60, 95% CI, 1.40–1.84) and ICU discharge (hazard ratio 2.02, 95% CI, 1.43–2.84). No significant differences in time to extubation (Hazard ratio 1.14, 95% CI, 0.92–1.41) and ICU discharge (Hazard ratio 1.31, 95% CI, 0.81–2.14) were found between sufentanil and remifentanil. No differences were observed between any two of the agents regarding ventilator mortality or ICU mortality. The effects were similar in patients with versus without surgery.

Conclusion: Sufentanil and remifentanil may be superior to fentanyl in shortening the time to extubation and ICU discharge. The effects on ventilator mortality and ICU mortality appeared similar across these agents, while further research is warranted.

Application of Precise Positioning for Sputum Expectoration in ICU Patients with Pulmonary Infection

Objective

To determine the application value of precise positioning for sputum expectoration in intensive care unit (ICU) hospitalized patients with pulmonary infection (PI).

Methods

A total of 183 patients with PI treated in the ICUs of Shengjing Hospital of China Medical University from June 2019 to June 2020 were divided into a control group (n = 91) and an observation group (n = 92), all of whom received conventional drug therapy. The control group was given routine nursing intervention, based on which, the observation group was supplemented with precise positioning for sputum expectoration. The 24-hour sputum volume, respiratory rate (RR), blood gas analysis indexes, inflammatory indicators, Clinical Pulmonary Infection Score (CPIS), Modified Medical Research Council (mMRC) dyspnea scale score, and quality of life (36-Item Short-Form Health Survey, SF-36) were observed in both arms before and after intervention. The incidence of adverse reactions was counted.

Results

The observation group showed better mMRC scores than the control group (P < 0.05). Compared with the control group, the sputum volume, RR, and CPIS score were lower, and the SF-36 score was higher in the observation group 7 days after intervention (P < 0.05). After intervention, the oxygen saturation (SaO2) and partial pressure of oxygen (PaO2) were higher, while the carbon dioxide partial pressure (PaCO2), C-reactive protein (CRP), procalcitonin (PCT), and leukocyte count were lower in the observation group compared with the control group (P < 0.05). There was no significant difference in the incidence of complications between the two arms (P > 0.05).

Conclusion

The application of precise positioning for sputum expectoration in nursing intervention of ICU patients with PI can alleviate the severity of PI and dyspnea, reduce inflammatory reaction, and improve the quality of life of patients.

The Correlation Between Mechanical Ventilation Duration, Pediatric Sequential Organ Failure Assessment Score, and Blood Lactate Level in Children in Pediatric Intensive Care

OBJECTIVE

This study aimed to investigate whether the ventilation duration for children undergoing invasive mechanical ventilation (IMV) in pediatric intensive care unit (PICU) is correlated with pediatric sequential organ failure (pSOFA) score, white blood cell (WBC) count, blood lactate level, and duration of fever.

METHODS

Retrospectively reviewed that the medical records of patients who received IMV in the PICU of Jingzhou Central Hospital between January 2018 and December 2020. According to the duration of IMV in diagnosis-related groups, these patients were divided into two groups: group A, ventilation duration <96 h, and group B, ventilation duration ≥96 h. Each group's pSOFA scores, WBC counts, blood lactate levels, and durations of fever were compared. Logistic regression analysis was used to analyze the clinical risk factors of ventilation duration ≥96 h, and the receiver operator characteristic (ROC) curve was drawn.

RESULTS

A total of 42 patients were included, including 23 in group A and 19 in group B. The difference in pSOFA score between group A and group B was statistically significant (P < 0.05), while the differences in blood lactate level, duration of fever, and WBC count between the two groups were not statistically significant (P > 0.05). Logistic regression analysis was conducted to analyze the influencing factors of mechanical ventilation duration ≥96 h. An ROC curve was drawn with pSOFA score as a test variable and duration of mechanical ventilation ≥96 h as a state variable, revealing that the area under the curve was 0.76 (SE = 0.075, 95% CI: 0.614-0.906, P = 0.005). The sensitivity and specificity were 68.4 and 73.9%, respectively, and the corresponding pSOFA score was 7.5.

CONCLUSION

When the pSOFA score ≥8, the risk of mechanical ventilation duration ≥96 h increases.

An automated retrospective VAE-surveillance tool for future quality improvement studies

Ventilator-associated pneumonia (VAP) is a frequent complication of mechanical ventilation and is associated with substantial morbidity and mortality. Accurate diagnosis of VAP relies in part on subjective diagnostic criteria. Surveillance according to ventilator-associated event (VAE) criteria may allow quick and objective benchmarking. Our objective was to create an automated surveillance tool for VAE tiers I and II on a large data collection, evaluate its diagnostic accuracy and retrospectively determine the yearly baseline VAE incidence. We included all consecutive intensive care unit admissions of patients with mechanical ventilation at Bern University Hospital, a tertiary referral center, from January 2008 to July 2016. Data was automatically extracted from the patient data management system and automatically processed. We created and implemented an application able to automatically analyze respiratory and relevant medication data according to the Centers for Disease Control protocol for VAE-surveillance. In a subset of patients, we compared the accuracy of automated VAE surveillance according to CDC criteria to a gold standard (a composite of automated and manual evaluation with mediation for discrepancies) and evaluated the evolution of the baseline incidence. The study included 22'442 ventilated admissions with a total of 37'221 ventilator days. 592 ventilator-associated events (tier I) occurred; of these 194 (34%) were of potentially infectious origin (tier II). In our validation sample, automated surveillance had a sensitivity of 98% and specificity of 100% in detecting VAE compared to the gold standard. The yearly VAE incidence rate ranged from 10.1-22.1 per 1000 device days and trend showed a decrease in the yearly incidence rate ratio of 0.96 (95% CI, 0.93-1.00, p = 0.03). This study demonstrated that automated VAE detection is feasible, accurate and reliable and may be applied on a large, retrospective sample and provided insight into long-term institutional VAE incidences. The surveillance tool can be extended to other centres and provides VAE incidences for performing quality control and intervention studies.

Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.

Characteristics of Carbapenem-Resistant Gram-Negative Bacilli in Patients with Ventilator-Associated Pneumonia

Carbapenem-resistant Gram-negative bacilli (CR-GNB) has become a global threat. In hospital settings, the association of CR-GNB with ventilator-associated pneumonia (VAP) is a critical public health concern owing to their high resistance rate to most antibiotics. The present study aims to identify the frequency of carbapenem-resistance and to determine the rate of multidrug resistance (MDR), extensive drug resistance (XDR) and pan-drug resistance (PDR) among CR-GNB infections in VAP. Antimicrobial susceptibility testing was carried out using the disk diffusion method and the detection of carbapenemases was screened using the imipenem-E test and the modified carbapenem-inactivation method (mCIM). The isolates were verified by polymerase chain reaction (PCR) for the presence of bla_NDM, bla_SPM, bla_VIM, bla_IMP and bla_GIM genes. 89.5%, 14%, 17.5%, 10.5%, 3.5% of isolates exhibited the presence of bla_NDM, bla_VIM, bla_SPM, bla_IMP and bla_GIM, respectively. 76%, 17% and 7% of isolates were PDR, XDR, and MDR, respectively. Carbapenem-resistance genes were identified in a significant percentage and bla_NDM was the most predominant gene. All isolates were highly resistant to most antibiotics. This health concern has proven to be a big challenge in developing countries such as Egypt, as it is associated with high morbidity, high mortality, and raised healthcare costs.

Validation of rapid shallow breathing index displayed by the ventilator compared to the standard technique in patients with readiness for weaning

BACKGROUND

Rapid shallow breathing index (RSBI) is the most commonly used parameter for predicting weaning outcome. Measurement of RSBI by Wright spirometer (RSBI_standard) is the standard method in routine clinical practice. Data specific to the accuracy and reliability of the RSBI value displayed by the ventilator (RSBI_vent) are scarce. Accordingly, this study aimed to evaluate the association between the average value of RSBI_vent at different time points and RSBI_standard, and to assess the accuracy and reliability of these two RSBI measurement techniques.

METHODS

This prospective cohort study included mechanically ventilated patients who were ready to wean. At the beginning of spontaneous breathing trial using the flow-by method, RSBI was measured by two different techniques at the same time, including: (1) Wright spirometer (breathing frequency/average tidal volume in 1 min) (RSBI_standard), and (2) the values displayed on the ventilator at 0, 15, 30, 45, and 60 s (RSBI_vent).

RESULTS

Forty-seven patients were enrolled. The RSBI_vent value was significantly higher than the RSBI_standard value for every comparison. According to Spearman's correlation coefficient (r) and intraclass correlation coefficient (ICC), the average value of RSBI from 5 time points (0, 15, 30, 45, and 60 s) showed the best correlation with the standard technique (r = 0.76 [P < 0.001], and ICC = 0.79 [95% CI 0.61-0.88], respectively). Bland-Altman plot also showed the best agreement between RSBI_standard and the RSBI_vent value averaged among 5 time points (mean difference - 17.1 breaths/min/L).

CONCLUSIONS

We found that the ventilator significantly overestimates the RSBI value compared to the standard technique by Wright spirometer. The average RSBI_vent value among 5 time points (0, 15, 30, 45, and 60 s) was found to best correlate with RSBI_standard.

Effect of Nebulized Amphotericin B in Critically ill Patients With Respiratory Candida spp. De-colonization: A Retrospective Analysis

The potential relationship among airway Candida spp. de-colonization, nebulized amphotericin B (NAB), and occurrence of ventilator-associated pneumonia (VAP) in patients who are critically ill has not been fully investigated, especially concerning effects on survival. In this observational, retrospective, cohort study in a 22-bed central intensive care unit, we included patients aged >18 years who required mechanical ventilation (MV) for >48 h, with at least two consecutive positive Candida spp. test results. Patients were categorized into NAB and no NAB (control) groups. Propensity matching at 1:1 was performed according to strict standards, and multiple Cox proportional hazard model and multivariate analyses were performed to evaluate the effects of NAB treatment. Throughout an 8-year study period, 526 patients had received MV and had positive respiratory tract Candida spp. cultures. Of these, we included 275 patients and excluded 251 patients. In total, we successfully matched 110 patients from the two groups (each group, n = 55; total population median age, 64 years; Acute Physiology and Chronic Health Evaluation II [APACHE II] score, 25.5; sequential organ failure assessment score, 9). The Candida spp. de-colonization rate was 69.1% in patients treated with NAB. VAP incidence did not differ significantly between the NAB (10.91%) and control (16.36%) groups (P = 0.405). Pseudomonas aeruginosa-related VAP rates differed significantly between the NAB (10.91%) and control (25.45%) groups (P = 0.048). Five (9.1%) patients in the NAB group died during hospitalization compared with 17 (30.9%) controls (P = 0.014). At 28 days, 9 (16.4%) and 16 (29.1%) deaths occurred in the NAB and control groups, respectively, (P = 0.088). The cumulative 90-day mortality rate differed significantly between the two groups (23.6 vs. 43.6%, P = 0.015). Multivariate logistic regression analyses indicated a decreased 90-day mortality in the NAB group (adjusted odds ratio 0.413; 95% confidence interval 0.210–0.812; P = 0.01). In subgroup analyses, the NAB-associated decreased risk of death at 90 days was consistent across subgroups of patients with a Candida score of 2, younger age (<64 years), a higher APACHE II score (≥25), fewer Candida sites (<2), or MV at admission. NAB treatment contributed to Candida spp. airway de-colonization, was associated with a reduced risk of P. aeruginosa-related VAP, and improved 90-day mortality in patients critically ill with Candida spp. tracheobronchial colonization who had received MV for >2 days. NAB may be an alternative treatment option for critically ill patients with VAP.

Utilization of traditional Chinese medicine in the intensive care unit

Previous studies showed that traditional Chinese medicine (TCM) may be effective for patients with critical conditions. However, the extent to which TCM is used in intensive care units (ICUs) remains less investigated. This study aimed to investigate the utilization of TCM among ICU patients. Using a cross-sectional study design, we examined the use of TCMs among ICU patients. The data were from a well-established ICU registry from a large teaching hospital in west China. Our study found that TCM was widely used among ICU, in particular TCM injections and oral liquids. The use of TCM often differed by ICUs, and TCM injections and oral liquids were mostly used in neurological ICU, while Chinese herbal medicines (CHMs) were often used in general ICU. The use of TCM was also highly associated with patient characteristics. Patients with pancreatitis were administered with most TCM, patients with cerebrovascular disease with most TCM injections and those with chronic renal failure with most oral liquids. Future efforts should include generation of high-quality evidence guidelines about clinical effects of TCM interventions among ICU patients.

Association between blood transfusion and ventilator-associated events: a nested case-control study

OBJECTIVES

The association between blood transfusion and ventilator-associated events (VAEs) has not been fully understood. We sought to determine whether blood transfusion increases the risk of a VAE.

DESIGN

Nested case-control study.

SETTING

This study was based on a registry of healthcare-associated infections in intensive care units at West China Hospital system.

PATIENTS

1,657 VAE cases and 3,293 matched controls were identified.

METHODS

For each case, 2 controls were randomly selected using incidence density sampling. We defined blood transfusion as a time-dependent variable, and we used weighted Cox models to calculate hazard ratios (HRs) for all 3 tiers of VAEs.

RESULTS

Blood transfusion was associated with increased risk of ventilator-associated complication-plus (VAC-plus; HR, 1.47; 95% CI, 1.22-1.77; P <.001), VAC-only (HR, 1.29; 95% CI, 1.01-1.65; P = .038), infection-related VAC-plus (IVAC-plus; HR, 1.78; 95% CI, 1.33-2.39; P < .001), and possible ventilator-associated pneumonia (PVAP; HR, 2.10; 95% CI, 1.10-3.99; P = .024). Red blood cell (RBC) transfusion was also associated with increased risk of VAC-plus (HR, 1.34; 95% CI, 1.08-1.65; P = .007), IVAC-plus (HR, 1.70; 95% CI, 1.22-2.36; P = .002), and PVAP (HR, 2.49; 95% CI, 1.17-5.28; P = .018). Compared to patients without transfusion, the risk of VAE was significantly higher in patients with RBC transfusions of >3 units (HR, 1.73; 95% CI, 1.25-2.40; P = .001) but not in those with RBC transfusions of 0-3 units.

CONCLUSION

Blood transfusions were associated with increased risk of all tiers of VAE. The risk was significantly higher among patients who were transfused with >3 units of RBCs.