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De Cassai A, Pettenuzzo T, Busetto V, Legnaro C, Pretto C, Rotondi A, Boscolo A, Sella N, Munari M, Navalesi P. Chlorhexidine is not effective at any concentration in preventing ventilator-associated pneumonia: a systematic review and network meta-analysis. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:30. [PMID: 38702835 PMCID: PMC11067293 DOI: 10.1186/s44158-024-00166-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Oral chlorhexidine has been widely used for ventilator-associated pneumonia prevention in the critical care setting; however, previous studies and evidence synthesis have generated inconsistent findings. Our study aims to investigate if different concentrations of oral chlorhexidine may be effective in preventing such complication in intensive care unit patients. METHODS After pre-registration (Open Science Framework: 8CUKF), we conducted a network meta-analysis with the following PICOS: adult patients (age > 18 years old) undergoing invasive mechanical ventilation admitted in ICU (P); any concentration of chlorhexidine used for oral hygiene (I); placebo, sham intervention, usual care, or no intervention (C); rate of VAP (primary outcome), mechanical ventilation length, ICU length of stay (LOS), hospital LOS, mortality (secondary outcomes) (O); randomized controlled trials (S). We used the following database: PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and EMBASE without any limitation in publication date or language. RESULTS Chlorhexidine did not demonstrate any significant advantage over the control group in preventing ventilator-associated pneumonia or reducing mortality, duration of mechanical ventilation, length of stay in the intensive care unit, or overall mortality. CONCLUSIONS Chlorhexidine oral decontamination does not reduce the rate of ventilator-associated pneumonia in critically ill adult patients and its routine use could not be recommended. TRIAL REGISTRATION Registration number: Open Science Framework: 8CUKF.
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Affiliation(s)
- Alessandro De Cassai
- Sant'Antonio Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy.
| | - Tommaso Pettenuzzo
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Veronica Busetto
- Cardiac Surgery Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | | | - Chiara Pretto
- Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Alessio Rotondi
- Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Annalisa Boscolo
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
- Department of Medicine - DIMED, University of Padova, Padua, Italy
- Thoracic Surgery and Lung Transplant Unit - Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Nicolò Sella
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Marina Munari
- Sant'Antonio Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Paolo Navalesi
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
- Department of Medicine - DIMED, University of Padova, Padua, Italy
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Borah K, Ramamoorthy L, Senthilnathan M, Murugesan R, Lalthanthuami HT, Subramaniyan R. Effect of fourth hourly oropharyngeal suctioning on ventilator-associated events in patients requiring mechanical ventilation in intensive care units of a tertiary care center in South India: a randomized controlled trial. Acute Crit Care 2023; 38:460-468. [PMID: 38052511 DOI: 10.4266/acc.2022.01501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 08/03/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is a necessary life-saving measure for critically ill patients. Ventilator-associated events (VAEs) are potentially avoidable complications associated with MV that can double the rate of death. Oral care and oropharyngeal suctioning, although neglected procedures, play a vital role in the prevention of VAE. METHODS A randomized controlled trial was conducted in the intensive care units to compare the effect of fourth hourly oropharyngeal suctioning with the standard oral care protocol on VAE among patients on MV. One hundred twenty mechanically ventilated patients who were freshly intubated and expected to be on ventilator support for the next 72 hours were randomly allocated to the control or intervention groups. The intervention was fourth hourly oropharyngeal suctioning along with the standard oral care procedure. The control group received standard oral care (i.e., thrice a day) and on-demand oral suctioning. On the 3rd and 7th days following the intervention, endotracheal aspirates were sent to rule out ventilator-associated pneumonia. RESULTS Both groups were homogenous at baseline with respect to their clinical characteristics. The intervention group had fewer VAEs (56.7%) than the control group (78.3%) which was significant at P<0.01. A significant reduction in the status of "positive culture" on ET aspirate also been observed following the 3rd day of the intervention (P<0.001). CONCLUSIONS One of the most basic preventive strategies is providing oral care. Oropharyngeal suctioning is also an important component of oral care that prevents microaspiration. Hence, fourth-hourly oropharyngeal suctioning with standard oral care significantly reduces the incidence of VAE.
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Affiliation(s)
- Khanjana Borah
- College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Lakshmi Ramamoorthy
- College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Muthapillai Senthilnathan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Rajeswari Murugesan
- Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Hmar Thiak Lalthanthuami
- College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Rani Subramaniyan
- College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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Definitions, rates and associated mortality of ICU-acquired pneumonia: A multicenter cohort study. J Crit Care 2023; 75:154284. [PMID: 36870801 DOI: 10.1016/j.jcrc.2023.154284] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION We aimed to analyze intensive care unit (ICU)-acquired pneumonia according to 7 definitions, estimating associated hospital mortality. METHODS This cohort study was nested within an international randomized trial, evaluating the effect of probiotics on ICU-acquired pneumonia in 2650 mechanically ventilated adults. Each clinically suspected pneumonia was adjudicated by two physicians blinded to allocation and center. The primary outcome was ventilator-associated pneumonia (VAP) informed by ventilation for ≥2 days, new, progressive or persistent infiltrate plus 2 of: temperature > 38 °C or < 36 °C; leukopenia (<3 × 10(Fernando et al., 20206)/L) or leukocytosis (>10 × 10(Fernando et al., 20206)/L); and purulent sputum. We also used 6 other definitions estimating the risk of hospital mortality. RESULTS The frequency of ICU-acquired pneumonia varied by definition: the trial primary outcome VAP (21.6%), Clinical Pulmonary Infection Score (CPIS) (24.9%), American College Chest Physicians (ACCP) (25.0%), International Sepsis Forum (ISF) (24.4%), Reducing Oxidative Stress Study (REDOXS) (17.6%), Centers for Disease Control (CDC) (7.8%), and invasively microbiologically confirmed (1.9%). The trial primary outcome VAP (HR 1.31 [1.08, 1.60]), ISF (HR 1.32 [1.09,1.60]), CPIS (HR 1.30 [1.08,1.58]) and ACCP definitions (HR 1.22 [1.00,1.47]) were associated with hospital mortality. CONCLUSIONS Rates of ICU-acquired pneumonia vary by definition and are associated with differential increased risk of death.
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Arabi YM, Al Aseri Z, Alsaawi A, Al Khathaami AM, Al Qasim E, Alzahrani AA, Al Qarni M, Abdukahil SAI, Al-Dorzi HM, Alattasi A, Mandourah Y, Alaama TY, Alabdulaali MK, Alqahtani A, Shuaibi A, Al Qarni A, Alkatheri M, Al Hazme RH, Vishwakarma RK, Aldibasi O, Alshahrani MS, Attia A, Alharthy A, Mady A, Abdelrahman BA, Mhawish HA, Abdallah HA, Al-Hameed F, Alghamdi K, Alghamdi A, Almekhlafi GA, Qasim SAH, Al Haji HA, Al Mutairi M, Tashkandi N, Alabbasi SO, Al Shehri T, Moftah E, Kalantan B, Matroud A, Naidu B, Al Zayer S, Burrows V, Said Z, Soomro NA, Yousef MH, Fattouh AA, Tahoon MA, Muhammad M, Alruwili AM, Al Hanafi HA, Dandekar PB, Ibrahim K, AlHomsi M, Al Harbi AR, Saleem A, Masih E, Al Rashidi NM, Amanatullah AK, Al Mubarak J, Al Radwan AAA, Al Hassan A, Al Muoalad S, Alzahrani AA, Chalabi J, Qureshi A, Al Ansari M, Sallam H, Elhazmi A, Alkhaldi F, Malibary A, Ababtain A, Latif A, Berenholtz SM. Impact of a national collaborative project to improve the care of mechanically ventilated patients. PLoS One 2023; 18:e0280744. [PMID: 36716310 PMCID: PMC9886257 DOI: 10.1371/journal.pone.0280744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/19/2022] [Indexed: 02/01/2023] Open
Abstract
This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).
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Affiliation(s)
- Yaseen M. Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- * E-mail:
| | - Zohair Al Aseri
- Department of Emergency, Department of Intensive Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulmohsen Alsaawi
- Department of Medical Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali M. Al Khathaami
- Quality and Patient Safety Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Eman Al Qasim
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah A. Alzahrani
- Quality and Patient Safety Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Al Qarni
- Quality and Patient Safety Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sheryl Ann I. Abdukahil
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Hasan M. Al-Dorzi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaleem Alattasi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Yasser Mandourah
- Department of Military Medical Services, Ministry of Defense, Riyadh, Saudi Arabia
| | - Tareef Y. Alaama
- Deputyship of Curative Services, Ministry of Health, Riyadh, Saudi Arabia
| | | | - Abdulrahman Alqahtani
- Executive Director of Medical Affairs Department, Ministry of Health, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ahmad Shuaibi
- Department of Medical Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Dammam, Saudi Arabia
| | - Ali Al Qarni
- Department of Medicine, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia
| | - Mufareh Alkatheri
- Quality and Patient Safety Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Raed H. Al Hazme
- Department of Health Informatics, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Biomedical Informatics, College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Ramesh Kumar Vishwakarma
- Department of Bioinformatics and Biostatistics, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Statistics Department, European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Omar Aldibasi
- Department of Bioinformatics and Biostatistics, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Saeed Alshahrani
- Department of Critical Care, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Ashraf Attia
- Department of Critical Care, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | | | - Ahmed Mady
- Department of Intensive Care, King Saud Medical City, Riyadh, Saudi Arabia
- Department of Anesthesiology and Intensive Care, Tanta University Hospital, Tanta, Egypt
| | | | - Huda Ahmad Mhawish
- Department of Intensive Care, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Fahad Al-Hameed
- Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Khalid Alghamdi
- Department of Intensive Care, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Adnan Alghamdi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ghaleb A. Almekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Saleh Abdorabo Haider Qasim
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Hussain Ali Al Haji
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Al Mutairi
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nabiha Tashkandi
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shatha Othman Alabbasi
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Tariq Al Shehri
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Emad Moftah
- Rehabilitation Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Basim Kalantan
- Rehabilitation Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Amal Matroud
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Brintha Naidu
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Salha Al Zayer
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Victoria Burrows
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Zayneb Said
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | | | - Majdi Muhammad
- Department of Intensive Care, Gurayat General Hospital, AlGurayat, Saudi Arabia
| | | | | | | | - Kamel Ibrahim
- Department of Intensive Care, King Khalid General Hospital, Majmaah, Saudi Arabia
| | - Mwafaq AlHomsi
- Department of Intensive Care, Buraydah Central Hospital, AlQassim, Saudi Arabia
| | - Asma Rayan Al Harbi
- Department of Intensive Care, King Fahad Specialist Hospital, AlQassim, Saudi Arabia
| | - Adel Saleem
- Department of Intensive Care, King Faisal Hospital, Makkah, Saudi Arabia
| | - Ejaz Masih
- Department of Intensive Care, King Khaled Hospital, Tabuk, Saudi Arabia
| | | | | | - Jaffar Al Mubarak
- Respiratory Services, King Khalid General Hospital, Hafer Al Batin, Saudi Arabia
| | | | - Ali Al Hassan
- Department of Intensive Care, King Khalid Hospital, Najran, Saudi Arabia
| | - Sadiyah Al Muoalad
- Nursing Services, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ammar Abdullah Alzahrani
- Respiratory Services Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Jamal Chalabi
- Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia
| | - Ahmad Qureshi
- Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Madinah, Saudi Arabia
| | - Maryam Al Ansari
- Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Dammam, Saudi Arabia
| | - Hend Sallam
- Department of Intensive Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Alyaa Elhazmi
- Department of Intensive Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fawziah Alkhaldi
- Nursing Services, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrauf Malibary
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah Ababtain
- Respiratory Services, Royal Commission Health Services Program, Jubayl, Saudi Arabia
| | - Asad Latif
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Sean M. Berenholtz
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Tan Y, Young M, Girish A, Hu B, Kurian Z, Greenstein JL, Kim H, Winslow RL, Fackler J, Bergmann J. Predicting respiratory decompensation in mechanically ventilated adult ICU patients. Front Physiol 2023; 14:1125991. [PMID: 37123253 PMCID: PMC10140580 DOI: 10.3389/fphys.2023.1125991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/06/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction: Mechanical ventilation is a life-saving treatment in the Intensive Care Unit (ICU), but often causes patients to be at risk of further respiratory complication. We created a statistical model utilizing electronic health record and physiologic vitals data to predict the Center for Disease Control and Prevention (CDC) defined Ventilator Associated Complications (VACs). Further, we evaluated the effect of data temporal resolution and feature generation method choice on the accuracy of such a constructed model. Methods: We constructed a random forest model to predict occurrence of VACs using health records and chart events from adult patients in the Medical Information Mart for Intensive Care III (MIMIC-III) database. We trained the machine learning models on two patient populations of 1921 and 464 based on low and high frequency data availability. Model features were generated using both basic statistical summaries and tsfresh, a python library that generates a large number of derived time-series features. Classification to determine whether a patient will experience VAC one hour after 35 h of ventilation was performed using a random forest classifier. Two different sample spaces conditioned on five varying feature extraction techniques were evaluated to identify the most optimal selection of features resulting in the best VAC discrimination. Each dataset was assessed using K-folds cross-validation (k = 10), giving average area under the receiver operating characteristic curves (AUROCs) and accuracies. Results: After feature selection, hyperparameter tuning, and feature extraction, the best performing model used automatically generated features on high frequency data and achieved an average AUROC of 0.83 ± 0.11 and an average accuracy of 0.69 ± 0.10. Discussion: Results show the potential viability of predicting VACs using machine learning, and indicate that higher-resolution data and the larger feature set generated by tsfresh yield better AUROCs compared to lower-resolution data and manual statistical features.
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Affiliation(s)
- Yvette Tan
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Michael Young
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Akanksha Girish
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Beini Hu
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Zina Kurian
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Joseph L. Greenstein
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Han Kim
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Raimond L Winslow
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - James Fackler
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Jules Bergmann
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- *Correspondence: Jules Bergmann,
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Wu RY, Yeh HJ, Chang KJ, Tsai MW. Effects of different types and frequencies of early rehabilitation on ventilator weaning among patients in intensive care units: A systematic review and meta-analysis. PLoS One 2023; 18:e0284923. [PMID: 37093879 PMCID: PMC10124886 DOI: 10.1371/journal.pone.0284923] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/11/2023] [Indexed: 04/25/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the effects of different types and frequencies of physiotherapy on ventilator weaning among patients in the intensive care unit (ICU) and to identify the optimal type and frequency of intervention. DATA SOURCES PubMed, Cochrane Library, EMBASE, and Airiti Library. STUDY SELECTION Randomized controlled trials that provided information on the dosage of ICU rehabilitation and the parameters related to ventilator weaning were included. DATA EXTRACTION AND MANAGEMENT Treatment types were classified into conventional physical therapy, exercise-based physical therapy, neuromuscular electrical stimulation (NEMS), progressive mobility, and multi-component. The frequencies were divided into high (≥ 2 sessions/day or NEMS of > 60 minutes/day), moderate (one session/day, 3-7 days/week or NEMS of 30-60 minutes/day), and low (one session/day, < 3 days/week, or NEMS of < 30 minutes/day). DATA SYNTHESIS Twenty-four articles were included for systematic review and 15 out of 24 articles were analyzed in the meta-analysis. Early rehabilitation, especially the progressive mobility treatment exerted an optimal effect in reducing the ventilator duration in patients in the ICU (standardized mean difference [SMD] = 0.91; 95% confidence interval [CI] = 0.23-1.58; P < 0.01). Regarding the treatment frequency, the high-frequency intervention did not result in a favorable effect on ventilator duration compared with the moderate frequency of treatment (SMD = 0.75; 95% CI = -1.13-2.64; P = 0.43). CONCLUSION Early rehabilitation with progressive mobility is highly recommended to decrease the ventilation duration received by patients in the ICU. Depending on clinical resources and the tolerance of patients, the frequency of interventions should reach moderate-to-high frequency, that is, at least one session per day and 3 days a week. TRIAL REGISTRATION Registration number: PROSPERO (CRD42021243331).
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Affiliation(s)
- Ruo-Yan Wu
- Division of Physical Medicine and Rehabilitation, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
- The Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huan-Jui Yeh
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- The Department of Physical Medicine and Rehabilitation, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Kai-Jie Chang
- Division of Physical Medicine and Rehabilitation, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Mei-Wun Tsai
- The Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Chang HYM, Flahive J, Bose A, Goostrey K, Osgood M, Carandang R, Hall W, Muehlschlegel S. Predicting mortality in moderate-severe TBI patients without early withdrawal of life-sustaining treatments including ICU complications: The MYSTIC-score. J Crit Care 2022; 72:154147. [PMID: 36166912 DOI: 10.1016/j.jcrc.2022.154147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 08/12/2022] [Accepted: 08/28/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To develop and internally validate the MortalitY in Moderate-Severe TBI plus ICU Complications (MYSTIC)-Score to predict in-hospital mortality of msTBI patients without early (<24 h) withdrawal-of-life-sustaining treatments. METHODS We analyzed data from a Neuro-Trauma Intensive Care Unit prospectively collected between 11/2009-5/2019. Consecutive adult msTBI patients were included if Glasgow Coma Scale≤12, and neither died nor had withdrawal-of-life-sustaining treatments within 24 h of admission (n = 485). Using univariate and multivariable logistic regression in a random-split cohort approach (2/3 derivation;1/3 validation), we identified independent predictors of in-hospital mortality while adjusting for validated predictors of mortality (IMPACT-variables). We constructed the MYSTIC-Score and examined discrimination and calibration. RESULTS The MYSTIC-Score included the ICU complications brain edema, herniation, systemic inflammatory response syndrome, sepsis, acute kidney injury, cardiac arrest, and urinary tract infection. In the derivation cohort(n = 324), discrimination and calibration were excellent (area-under-the-receiver-operating-curve [AUC-ROC] = 0.95;Hosmer-Lemeshow p-value = 0.09, with p > 0.05 indicating good calibration). Internal validation revealed an AUC-ROC = 0.93 and Hosmer-Lemeshow-p-value = 0.76 (n = 161). CONCLUSIONS Certain ICU complications are independent predictors of in-hospital mortality and strengthen outcome prediction in msTBI when combined with validated admission predictors of mortality. However, external validation is needed to determine robustness and practical applicability of our model given the high potential for residual confounders.
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Affiliation(s)
- Han Yan Michelle Chang
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Julie Flahive
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Abigail Bose
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Kelsey Goostrey
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Marcey Osgood
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Surgery and University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Raphael Carandang
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Surgery and University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Anesthesia/Critical Care, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Wiley Hall
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Surgery and University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Surgery and University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA; Anesthesia/Critical Care, University of Massachusetts Chan Medical School, 55 Lake Ave North, S-5., Worcester, MA 01655, USA.
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8
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Zhang F, Zhuang J, Li Z, Gong H, de Ávila BEF, Duan Y, Zhang Q, Zhou J, Yin L, Karshalev E, Gao W, Nizet V, Fang RH, Zhang L, Wang J. Nanoparticle-modified microrobots for in vivo antibiotic delivery to treat acute bacterial pneumonia. NATURE MATERIALS 2022; 21:1324-1332. [PMID: 36138145 PMCID: PMC9633541 DOI: 10.1038/s41563-022-01360-9] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/09/2022] [Indexed: 05/03/2023]
Abstract
Bioinspired microrobots capable of actively moving in biological fluids have attracted considerable attention for biomedical applications because of their unique dynamic features that are otherwise difficult to achieve by their static counterparts. Here we use click chemistry to attach antibiotic-loaded neutrophil membrane-coated polymeric nanoparticles to natural microalgae, thus creating hybrid microrobots for the active delivery of antibiotics in the lungs in vivo. The microrobots show fast speed (>110 µm s-1) in simulated lung fluid and uniform distribution into deep lung tissues, low clearance by alveolar macrophages and superb tissue retention time (>2 days) after intratracheal administration to test animals. In a mouse model of acute Pseudomonas aeruginosa pneumonia, the microrobots effectively reduce bacterial burden and substantially lessen animal mortality, with negligible toxicity. Overall, these findings highlight the attractive functions of algae-nanoparticle hybrid microrobots for the active in vivo delivery of therapeutics to the lungs in intensive care unit settings.
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Affiliation(s)
- Fangyu Zhang
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Jia Zhuang
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Zhengxing Li
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Hua Gong
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | | | - Yaou Duan
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Qiangzhe Zhang
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Jiarong Zhou
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Lu Yin
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Emil Karshalev
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Weiwei Gao
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Victor Nizet
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Ronnie H Fang
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Liangfang Zhang
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA.
| | - Joseph Wang
- Department of NanoEngineering and Chemical Engineering Program, University of California San Diego, La Jolla, CA, USA.
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9
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Yang L, Zhang Q, Zhai H. Comparative efficacy of different concentrations of chlorhexidine for prevention of
ventilator‐associated
pneumonia in intensive care units: A systematic review and network
meta‐analysis. Nurs Crit Care 2022. [DOI: 10.1111/nicc.12849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Li Yang
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
| | - Qin Zhang
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
| | - Huaixiang Zhai
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
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10
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Lan SH, Hung SH, Chang SP, Lu LC, Lai CC, Lin WT. Pro-, pre- and synbiotics for the prevention of incidental ventilator-associated pneumonia among critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Expert Rev Anti Infect Ther 2022; 20:1205-1215. [PMID: 35695312 DOI: 10.1080/14787210.2022.2089652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study investigated the preventive effects of pro-, pre- and synbiotics on ventilator-associated pneumonia (VAP) among critically ill patients. METHODS The PubMed, Web of Science, Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for relevant articles written before 19 February 2022. Only randomized controlled trials (RCTs) comparing the clinical efficacy of pro-, pre- and synbiotics with placebos or standard treatments for the prevention of incidental VAP were included. RESULTS A total of 15 RCTs were included. Patients receiving pro-, pre- and synbiotics had a lower risk than the control group of contracting VAP (risk ratio [RR], 0.70; 95% CI, 0.57-0.85; I2 = 67%). The duration of mechanical ventilation was significantly shorter in the study group than in the control group (mean difference [MD], -1.61 days; 95% CI, -2.72 to -0.50; I2 = 86%), and the study group had a shorter duration of stay in the intensive care unit than the control group did (MD, -1.72 days; 95% CI, -3.22 to -0.23; I2 = 87%). CONCLUSIONS Pro-, pre- and synbiotics can prevent VAP and the use of probiotics for patients who are critically ill should be supported.
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Affiliation(s)
- Shao-Huan Lan
- School of Pharmaceutical Sciences and Medical Technology, Putian University, Putian, Fujian, China
| | - Shun-Hsing Hung
- Division of Urology, Department of Surgery, Chi-Mei Hospital, Chia Li, Taiwan
| | | | - Li-Chin Lu
- School of Management, Putian University, Putian, Fujian, China
| | - Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Taiwan
| | - Wei-Ting Lin
- Department of Orthopedic, Chi Mei Medical Center, Tainan Taiwan.,Department of Mechanical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
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11
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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12
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Cardoso R, Parola V, Neves H, Bernardes RA, Duque FM, Mendes CA, Pimentel M, Caetano P, Petronilho F, Albuquerque C, Sousa LB, Malça C, Durães R, Xavier W, Parreira P, Apóstolo J, Cruz A. Physical Rehabilitation Programs for Bedridden Patients with Prolonged Immobility: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116420. [PMID: 35682005 PMCID: PMC9180781 DOI: 10.3390/ijerph19116420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/19/2022] [Accepted: 05/21/2022] [Indexed: 12/04/2022]
Abstract
Bedridden patients usually stay in bed for long periods, presenting several problems caused by immobility, leading to a long recovery process. Thus, identifying physical rehabilitation programs for bedridden patients with prolonged immobility requires urgent research. Therefore, this scoping review aimed to map existing physical rehabilitation programs for bedridden patients with prolonged immobility, the rehabilitation domains, the devices used, the parameters accessed, and the context in which these programs were performed. This scoping review, guided by the Joanna Briggs Institute’s (JBI) methodology and conducted in different databases (including grey literature), identified 475 articles, of which 27 were included in this review. The observed contexts included research institutes, hospitals, rehabilitation units, nursing homes, long-term units, and palliative care units. Most of the programs were directed to the musculoskeletal domain, predominantly toward the lower limbs. The devices used included lower limb mobilization, electrical stimulation, inclined planes, and cycle ergometers. Most of the evaluated parameters were musculoskeletal, cardiorespiratory, or vital signs. The variability of the programs, domains, devices and parameters found in this scoping review revealed no uniformity, a consequence of the personalization and individualization of care, which makes the development of a standard intervention program challenging.
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Affiliation(s)
- Remy Cardoso
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
- Correspondence: (R.C.); (V.P.); (A.C.)
| | - Vitor Parola
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
- Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence (PCEBP), 3000 Coimbra, Portugal
- Correspondence: (R.C.); (V.P.); (A.C.)
| | - Hugo Neves
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
- Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence (PCEBP), 3000 Coimbra, Portugal
| | - Rafael A. Bernardes
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
| | - Filipa Margarida Duque
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
- Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence (PCEBP), 3000 Coimbra, Portugal
| | - Carla A. Mendes
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
| | - Mónica Pimentel
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
| | - Pedro Caetano
- Centro Hospitalar Universitário Cova da Beira (CHUCB), 6200 Covilhã, Portugal;
| | - Fernando Petronilho
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
- School of Nursing, University of Minho, 4710 Braga, Portugal
| | - Carlos Albuquerque
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
- Health School, Polytechnic Institute of Viseu, 3500 Viseu, Portugal
| | - Liliana B. Sousa
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
| | - Cândida Malça
- Mechanical Engineering Department, Institute of Engineering (ISEC), Polytechnic Institute of Coimbra (IPC), 3030 Coimbra, Portugal;
- Centre for Rapid and Sustainable Product Development (CDRSP), Polytechnic Institute of Leiria (IPL), 2430 Marinha Grande, Portugal
| | - Rúben Durães
- ORTHOS SSI, Unipessoal LDA, 4809 Guimarães, Portugal;
| | | | - Pedro Parreira
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
| | - João Apóstolo
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
- Portugal Centre for Evidence Based Practice: A JBI Centre of Excellence (PCEBP), 3000 Coimbra, Portugal
| | - Arménio Cruz
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), 3000 Coimbra, Portugal; (H.N.); (R.A.B.); (F.M.D.); (C.A.M.); (M.P.); (F.P.); (C.A.); (L.B.S.); (P.P.); (J.A.)
- Correspondence: (R.C.); (V.P.); (A.C.)
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13
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Ravikumar N, McGee WT. How Much Fluid Should I Give to My Patient on a Ventilator? Crit Care Med 2022; 50:349-350. [PMID: 35100200 DOI: 10.1097/ccm.0000000000005257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Nakul Ravikumar
- Division of Pulmonary and Critical Care, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - William T McGee
- Division of Pulmonary and Critical Care, University of Massachusetts Medical School-Baystate, Springfield, MA
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14
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Song H, Hu W, Zhou X, Tao J, Zhang S, Su X, Wu W. Clinical Benefits From Administering Probiotics to Mechanical Ventilated Patients in Intensive Care Unit: A PRISMA-Guided Meta-Analysis. Front Nutr 2022; 8:798827. [PMID: 35155520 PMCID: PMC8829544 DOI: 10.3389/fnut.2021.798827] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/14/2021] [Indexed: 12/14/2022] Open
Abstract
Background The use of probiotics has been considered as a new intervention for ventilator-associated pneumonia (VAP) prevention in the intensive care unit (ICU). The aim of this meta-analysis was to evaluate the effect of probiotics on mechanical-ventilated patients in ICU. Methods PubMed, Embase, Scopus, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) from their respective inception through October 10, 2021. All studies meeting the inclusion criteria were selected to evaluate the effect of probiotics on patients receiving mechanical ventilation in ICU. Results A total of 15 studies involving 4,693 participants met our inclusion criterion and were included in this meta-analysis. The incidence of VAP in the probiotic group was significantly lower (odds ratio [OR] 0.58, 95% CI 0.41 to 0.81; p = 0.002; I2 = 71%). However, a publication bias may be present as the test of asymmetry was significant (p = 0.007). The probiotic administration was associated with a significant reduction in the duration of mechanical ventilation (mean difference [MD] −1.57, 95% CI −3.12 to −0.03; p = 0.05; inconsistency [I]2 = 80%), length of ICU stay (MD −1.87, 95% CI −3.45 to −0.28; p = 0.02; I2 = 76%), and incidence of bacterial colonization (OR 0.59, 95% CI 0.45 to 0.78; p = 0.0001; I2 = 34%). Moreover, no statistically significant differences were observed regarding the incidence of diarrhea (OR 0.90, 95% CI 0.65 to 1.25; p = 0.54; I2 = 12%) and mortality (OR 0.91, 95% CI 0.80 to 1.05; p = 0.19; I2 = 0%) between probiotics group and control group. Conclusion Our meta-analysis shows that probiotics are associated with a reduction in VAP, as well as the duration of mechanical ventilation, ICU length of stay, and bacterial colonization, but no significant effects on ICU mortality and occurrence of diarrhea. However, in consideration of the significant heterogeneity and publication bias, our findings need to be further validated. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42020150770.
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Affiliation(s)
- Hongzhuan Song
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Wenqing Hu
- Department of Emergency, Haining People's Hospital, Haining, China
| | - Xiujie Zhou
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Jiaping Tao
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Siyi Zhang
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Xuhong Su
- Department of Hematology, Haining People's Hospital, Haining, China
| | - Wenjun Wu
- Department of Hematology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Wenjun Wu
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15
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Weinberger J, Rhee C, Klompas M. Incidence, Characteristics, and Outcomes of Ventilator-associated Events during the COVID-19 Pandemic. Ann Am Thorac Soc 2022; 19:82-89. [PMID: 34170781 PMCID: PMC8787787 DOI: 10.1513/annalsats.202103-364oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/24/2021] [Indexed: 02/07/2023] Open
Abstract
Rationale: Ventilator-associated event (VAE) surveillance provides an objective means to measure and compare complications that develop during mechanical ventilation by identifying patients with sustained increases in ventilator settings after a period of stable or decreasing ventilator settings. The impact of the coronavirus disease (COVID-19) pandemic on VAE rates and characteristics is unknown. Objectives: To compare the incidence, causes, and outcomes of VAE during the COVID-19 pandemic year versus prepandemic years and among ventilated patients with and without COVID-19. Methods: In this retrospective cohort study of mechanically ventilated adults at four academic and community hospitals in Massachusetts, we compared VAE incidence rates between March 1 and August 31 for each year from 2017 to 2020 (corresponding to the time frame of the pandemic first wave in 2020) and among COVID-19-positive and COVID-19-negative patients in 2020. The medical records of 200 randomly selected patients with VAEs in 2020 (100 with COVID-19 and 100 without COVID-19) were analyzed to compare conditions precipitating VAEs in patients with versus without COVID-19. Results: VAEs per 100 episodes of mechanical ventilation were more common in 2020 than in prior years (11.2 vs. 6.7; P < 0.01) but the rate of VAEs per 1,000 ventilator-days was similar (14.2 vs. 12.7; P = 0.08). VAEs were more frequent in COVID-19-positive patients than in COVID-19-negative patients in 2020 (29.0 vs. 7.1 per 100 ventilator episodes [P < 0.01] and 17.2 vs. 12.2 per 1,000 ventilator-days [P < 0.01]). Compared with patients without COVID-19 with VAEs, patients with COVID-19 and VAEs had similar rates of infection-related ventilator-associated complications, longer median durations of mechanical ventilation (22 vs. 14 d; P < 0.01), and similar in-hospital mortality (30% vs. 38%; P = 0.15). Progressive acute respiratory distress syndrome (ARDS) accounted for 53% of VAEs in patients with COVID-19, whereas it accounted for 14% of VAEs among patients without COVID-19. Conclusions: VAE rates per 100 episodes of mechanical ventilation and per 1,000 ventilator-days were higher among COVID-19-positive patients than among COVID-19-negative patients. Over 50% of VAEs in patients with COVID-19 were caused by progressive ARDS, whereas less than 15% of VAEs in patients without COVID-19 were caused by progressive ARDS. These findings provide insight into the natural history of COVID-19 in ventilated patients and may inform targeted strategies to mitigate complications in this population.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts; and
- Division of Pulmonary and Critical Care Medicine, and
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts; and
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts; and
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
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16
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Weinberger J, Cocoros N, Klompas M. Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention. Infect Dis Clin North Am 2021; 35:871-899. [PMID: 34752224 DOI: 10.1016/j.idc.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA
| | - Noelle Cocoros
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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17
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Dale CM, Rose L, Carbone S, Pinto R, Smith OM, Burry L, Fan E, Amaral ACKB, McCredie VA, Scales DC, Cuthbertson BH. Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial. Intensive Care Med 2021; 47:1295-1302. [PMID: 34609548 PMCID: PMC8490143 DOI: 10.1007/s00134-021-06475-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
Purpose Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients. Methods A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors. Results A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period. Conclusion Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06475-2.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, Room 1.1.3, London, SE1 8WA, UK.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Orla M Smith
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Pharmacy, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network and Sinai Health System, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network and Sinai Health System, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Krembil Research Institute, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Brian H Cuthbertson
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada. .,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.
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18
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Rittayamai N, Ratchaneewong N, Tanomsina P, Kongla W. Validation of rapid shallow breathing index displayed by the ventilator compared to the standard technique in patients with readiness for weaning. BMC Pulm Med 2021; 21:310. [PMID: 34600522 PMCID: PMC8486963 DOI: 10.1186/s12890-021-01680-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rapid shallow breathing index (RSBI) is the most commonly used parameter for predicting weaning outcome. Measurement of RSBI by Wright spirometer (RSBIstandard) is the standard method in routine clinical practice. Data specific to the accuracy and reliability of the RSBI value displayed by the ventilator (RSBIvent) are scarce. Accordingly, this study aimed to evaluate the association between the average value of RSBIvent at different time points and RSBIstandard, 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) (RSBIstandard), and (2) the values displayed on the ventilator at 0, 15, 30, 45, and 60 s (RSBIvent). RESULTS Forty-seven patients were enrolled. The RSBIvent value was significantly higher than the RSBIstandard 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 RSBIstandard and the RSBIvent 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 RSBIvent value among 5 time points (0, 15, 30, 45, and 60 s) was found to best correlate with RSBIstandard.
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Affiliation(s)
- Nuttapol Rittayamai
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Natwipha Ratchaneewong
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Pirat Tanomsina
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Withoon Kongla
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
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19
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Clinical outcomes and risk factors for mortality from ventilator-associated events: A registry-based cohort study among 30,830 intensive care unit patients. Infect Control Hosp Epidemiol 2021; 43:48-55. [PMID: 33691823 DOI: 10.1017/ice.2021.64] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the clinical impact of ventilator-associated events (VAEs) on adverse prognoses and risk factors for mortality among intensive care unit (ICU) patients receiving invasive mechanical ventilation (IMV) based on an ICU healthcare-associated infection (ICU-HAI) registry. DESIGN A cohort study was conducted based on an ICU-HAI registry including 30,830 patients between 2015 and 2018. SETTING The study was conducted using data from 5 adult ICUs of a referral hospital. PATIENTS Adult patients in the ICU-HAI registry who received ≥4 consecutive IMV days. METHODS Clinical outcomes and mortality risk factors for VAEs were analyzed using propensity score matching (PSM), multivariate regression models, and sensitivity analyses. RESULTS Of 6,426 included patients, 1,803 developed 1,899 VAEs. After PSM, patients with VAEs did have prolonged length of stay in the ICU and in the hospital, increased hospitalization costs, longer days on mechanical ventilation, higher proportion of ≥9 days on mechanical ventilation, higher rate of failure in extubating mechanical ventilation, and excess all-cause mortality in the ICU. Older age (adjusted OR [aOR], 1.02), higher APACHE II score on ICU admission (aOR, 1.06), pneumonia (aOR, 1.49), blood transfusion (aOR 1.43), immunosuppressive drugs (aOR, 1.69), central-line catheter (aOR, 2.06), and ≥2 VAEs in the ICU (aOR, 1.99) were associated with higher risks for all-cause mortality in an ICU. CONCLUSIONS Patients with VAEs indeed had poorer clinical outcomes. Older age, higher APACHE II score on ICU admission, pneumonia, blood transfusion, immunosuppressive drugs, central-line catheter, and ≥2 VAEs in the ICU were risk factors for all-cause mortality of VAE patients in the ICU.
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20
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Evaluation of ventilator associated events in critically ill patients with invasive mechanical ventilation: A prospective cohort study at a resource limited setting in Northern India. J Crit Care 2021; 64:29-35. [PMID: 33773301 DOI: 10.1016/j.jcrc.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The primary aim of this study was to identify the modifiable risk factors for acquiring ventilator associated events (VAE). Secondary aims were to investigate the intensive care unit (ICU) course and impact of VAE on patient outcome. METHODS This prospective, observational single center cohort study included 247 patients on mechanical ventilation for 4 calendar days at a 20-bed ICU between January 2018-June 2019. RESULTS VAE occurred in 59 episodes (rate 11.3 per 1000 ventilator-days). The Ventilator Utilization Ratio (VUR) was 0.57. The median time to onset of VAE was 6 days. Sepsis was the most common reason for initiating patients on invasive mechanical ventilation (IMV). Cumulative fluid balance ≥2 l (Odds Ratio 30.92; 95% CI 9.82-97.37) and greater number of days with vasopressor support (Odds Ratio 1.92; 95% CI 1.57-2.36) within 7 days of initiating IMV were significant risk factors for acquiring VAE (p < 0.001). VAE cases were ventilated for significantly more days (20 vs 14 days, p = 0.001, had longer days of ICU stay (29 vs 18 days; p = 0.002) and higher hospital mortality (p = 0.02). Klebsiella pneumoniae was the most common isolate (N = 28) and 32.1% were colistin resistant. CONCLUSIONS Prospective intervention studies are needed to determine if targeting these risk factors can lower VAE rates in our setting.
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21
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Nanao T, Nishizawa H, Fujimoto J, Ogawa T. Additional medical costs associated with ventilator-associated pneumonia in an intensive care unit in Japan. Am J Infect Control 2021; 49:340-344. [PMID: 32721417 DOI: 10.1016/j.ajic.2020.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Additional health care costs associated with ventilator-associated pneumonia (VAP) vary widely per country; none of which have been explored in Japan. Thus, we aimed to examine the economic and clinical effects of VAP in Japan. METHODS This was a retrospective matched case-control study of 22 patients with VAP who were treated in the intensive care unit of Yokohama Rosai Hospital between January 2012 and December 2018. Twenty-two matched controls were selected based on 5 variables (ie, sex, age, diagnosis and surgical procedure, underlying disease with or without advanced malignant tumor, and best motor response). The additional health care costs incurred owing to VAP were calculated from the difference between the mean costs of VAP and control cases. RESULTS VAP incurred an additional cost of approximately United States Dollars (USD) 34,884 per case. The length of hospitalization itself was the major factor contributing to additional medical costs, generating a difference of 9,824 USD. DISCUSSION VAP not only worsens patient outcomes but also generates significant additional medical costs. Patients who had developed VAP required more medical resources such as the performance of a tracheostomy. CONCLUSIONS VAP incurs a higher mean total hospital medical cost. Thus, appropriate infection control strategies should be implemented.
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Affiliation(s)
- Taikan Nanao
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan; International University of Health and Welfare Graduate School of Public Health, Tokyo, Japan.
| | - Hideo Nishizawa
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Junichi Fujimoto
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Toshio Ogawa
- International University of Health and Welfare Graduate School of Public Health, Tokyo, Japan
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22
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He Q, Wang W, Zhu S, Wang M, Kang Y, Zhang R, Zou K, Zong Z, Sun X. The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study. Crit Care 2021; 25:44. [PMID: 33531078 PMCID: PMC7851639 DOI: 10.1186/s13054-021-03484-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection (HAI) in intensive care units (ICUs). Ventilator-associated event (VAE), a more objective definition, has replaced traditional VAP surveillance and is now widely used in the USA. However, the adoption outside the USA is limited. This study aims to describe the epidemiology and clinical outcomes of VAEs in China, based on a prospectively maintained registry. Methods An observational study was conducted using an ICU-HAI registry in west China. Patients that were admitted to ICUs and underwent mechanical ventilation (MV) between April 1, 2015, and December 31, 2018, were included. The characteristics and outcomes were compared between patients with and without VAEs. The rates of all VAEs dependent on different ICUs were calculated, and the pathogen distribution of patients with possible VAP (PVAP) was described. Results A total of 20,769 ICU patients received MV, accounting for 21,723 episodes of mechanical ventilators and 112,697 ventilator-days. In all, we identified 1882 episodes of ventilator-associated condition (VAC) events (16.7 per 1000 ventilator-days), 721 episodes of infection-related ventilator-associated complications (IVAC) events (6.4 per 1000 ventilator-days), and 185 episodes of PVAP events (1.64 per 1000 ventilator-days). The rates of VAC varied across ICUs with the highest incidence in surgical ICUs (23.72 per 1000 ventilator-days). The median time from the start of ventilation to the onset of the first VAC, IVAC, and PVAP was 5 (3–8), 5 (3–9), and 6 (4–13) days, respectively. The median length of hospital stays was 28.00 (17.00–43.00), 30.00 (19.00–44.00), and 30.00 (21.00–46.00) days for the three VAE tiers, which were all longer than that of patients without VAEs (16.00 [12.00–23.00]). The hospital mortality among patients with VAEs was more than three times of those with non-VAEs. Conclusions VAE was common in ICU patients with ≥ 4 ventilator days. All tiers of VAEs were highly correlated with poor clinical outcomes, including longer ICU and hospital stays and increased risk of mortality. These findings highlight the importance of VAE surveillance and the development of new strategies to prevent VAEs.
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Affiliation(s)
- Qiao He
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Wen Wang
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Shichao Zhu
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Mingqi Wang
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yan Kang
- Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Rui Zhang
- Information Center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Kang Zou
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, 610041, China. .,Center of Infection Diseases, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Xin Sun
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China.
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Zhao J, Li LQ, Chen CY, Zhang GS, Cui W, Tian BP. Do probiotics help prevent ventilator-associated pneumonia in critically ill patients? A systematic review with meta-analysis. ERJ Open Res 2021; 7:00302-2020. [PMID: 33532460 PMCID: PMC7836470 DOI: 10.1183/23120541.00302-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/28/2020] [Indexed: 12/18/2022] Open
Abstract
Background Probiotic treatments might contribute to the prevention of ventilator-associated pneumonia (VAP). Due to its unclear clinical effects, here we intend to assess the preventive effect and safety of probiotics on intensive care unit (ICU) patients. Methods Eligible randomised controlled trials were selected in databases until 30 September 2019. The characteristics of the studies were extracted, including study design, definition of VAP, probiotics intervention, category of included patients, incidence of VAP, mortality, duration of mechanical ventilation (MV) and ICU stay. Heterogeneity was evaluated by Chi-squared and I2 tests. Results 15 studies involving 2039 patients were identified for analysis. The pooled analysis suggests significant reduction on VAP (risk ratio, 0.68; 95% Cl, 0.60 to 0.77; p<0.00001) in a fixed-effects model. Subgroup analyses performed on the category of clinical and microbiological criteria both support the above conclusion; however, there were no significant differences in duration of MV or length of ICU stay in a random-effects model. Also, no significant differences in total mortality, overall mortality, 28-day mortality or 90-day mortality were found in the fixed-effects model. Conclusions The probiotics helped to prevent VAP without impacting the duration of MV, length of ICU stay or mortality.
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Affiliation(s)
- Jie Zhao
- Dept of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Lei-Qing Li
- Dept of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Cheng-Yang Chen
- Dept of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Gen-Sheng Zhang
- Dept of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Wei Cui
- Dept of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Bao-Ping Tian
- Dept of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
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Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation. We sought to investigate factors associated with the development of VAP in critically ill trauma patients. METHODS We conducted a retrospective review of trauma patients admitted to our trauma intensive care unit between 2016 and 2018. Patients with ventilator-associated pneumonia were identified from the trauma database. Data collected from the trauma database included demographics (age, gender and race), mechanism of injury (blunt, penetrating), injury severity (injury severity score "ISS"), the presence of VAP, transfused blood products and presenting vital signs. RESULTS A total of 1403 patients were admitted to the trauma intensive care unit (TICU) during the study period; of these, 45 had ventilator-associated pneumonia. Patients with VAP were older (p = 0.030), and they had a higher incidence of massive transfusion (p = 0.015) and received more packed cells in the first 24 h of admission (p = 0.028). They had a higher incidence of face injury (p = 0.001), injury to sternum (p = 0.011) and injury to spine (p = 0.024). Patients with VAP also had a higher incidence of acute kidney injury (AKI) (p < 0.001) and had a longer ICU (p < 0.001) and hospital length of stay (p < 0.001). Multiple logistic regression models controlling for age and injury severity (ISS) showed massive transfusion (p = 0.017), AKI (p < 0.001), injury to face (p < 0.001), injury to sternum (p = 0.007), injury to spine (p = 0.047) and ICU length of stay (p < 0.001) to be independent predictors of VAP. CONCLUSIONS Among critically ill trauma patients, acute kidney injury, injury to the spine, face or sternum, massive transfusion and intensive care unit length of stay were associated with VAP.
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Siddiq MAB, Rathore FA, Clegg D, Rasker JJ. Pulmonary Rehabilitation in COVID-19 patients: A scoping review of current practice and its application during the pandemic. Turk J Phys Med Rehabil 2020; 66:480-494. [PMID: 33364571 PMCID: PMC7756838 DOI: 10.5606/tftrd.2020.6889] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
The novel coronavirus-2019 (COVID-19) pandemic primarily affects the respiratory system. Elderly individuals with comorbidity are severely affected. Survivors weaned from mechanical ventilation are at a higher risk of developing post-intensive care syndrome (PICS). This scoping review, based on 40 recent publications, highlights pulmonary rehabilitation (PR) in COVID-19. There is a paucity of high-quality research on this topic. However, rehabilitation societies including the Turkish Society of Physical Medicine and Rehabilitation have issued PR recommendations in COVID-19 pneumonia with productive cough can benefit from diaphragmatic breathing, pursed-lip breathing, and resistance-breathing training. Besides, those in mechanical ventilation and post-PICS COVID-19 cases, oxygen therapy, early mobilization, airway clearance, aerobic exercise, gradual-graded limb muscle resistance exercise, nutritional and psychological interventions should be consideration. During PR, careful evaluation of vital signs and exercise-induced symptoms is also required. When in-person PR is not possible, telerehabilitation should be explored. However, the long-term effects of PR in COVID-19 need further evaluation.
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Affiliation(s)
- Md Abu Bakar Siddiq
- Department of Physical Medicine and Rehabilitation, Brahmanbaria Medical College, Brahmanbaria, Bangladesh
- School of Health Sports and Professional Practice, University of South Wales, Pontypridd, United Kingdom
| | - Farooq Azam Rathore
- Department of Rehabilitation Medicine, PNS Shifa Hospital, Karachi, Pakistan
| | - Danny Clegg
- School of Health and Social Care, London South Bank University, London, United Kingdom
| | - Johannes J. Rasker
- Department of Psychology, Health and Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, the Netherlands
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Lau VI, Cook DJ, Fowler R, Rochwerg B, Johnstone J, Lauzier F, Marshall JC, Basmaji J, Heels-Ansdell D, Thabane L, Xie F. Economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (E-PROSPECT): study protocol. BMJ Open 2020; 10:e036047. [PMID: 32595159 PMCID: PMC7322334 DOI: 10.1136/bmjopen-2019-036047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in the intensive care unit (ICU). Probiotics are defined as live microorganisms that may confer health benefits when ingested. Prior randomised trials suggest that probiotics may prevent infections such as VAP and Clostridioides difficile-associated diarrhoea (CDAD). PROSPECT (Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial) is a multicentre, double-blinded, randomised controlled trial comparing the efficacy of the probiotic Lactobacillus rhamnosus GG with usual care versus usual care without probiotics in preventing VAP and other clinically important outcomes in critically ill patients admitted to the ICU. METHODS AND ANALYSIS The objective of E-PROSPECT is to determine the incremental cost-effectiveness of L. rhamnosus GG plus usual care versus usual care without probiotics in critically ill patients. E-PROSPECT will be performed from the public healthcare payer's perspective over a time horizon from ICU admission to hospital discharge.We will determine probabilities of in-ICU and in-hospital events from all patients alongside PROSPECT. We will retrieve unit costs for each resource use item using jurisdiction-specific public databases, supplemented by individual site unit costs if such databases are unavailable. Direct costs will include medications, personnel costs, radiology/laboratory testing, operative/non-operative procedures and per-day hospital 'hoteling' costs not otherwise encompassed. The primary outcome is the incremental cost per VAP prevented between the two treatment groups. Other clinical events such as CDAD, antibiotic-associated diarrhoea and in-hospital mortality will be included as secondary outcomes. We will perform pre-specified subgroup analyses (medical/surgical/trauma; age; frailty status; antibiotic use; prevalent vs no prevalent pneumonia) and probabilistic sensitivity analyses for VAP, then generate confidence intervals using the non-parametric bootstrapping approach. ETHICS AND DISSEMINATION Study approval for E-PROSPECT was granted by the Hamilton Integrated Research Ethics Board of McMaster University on 29 July 2019. Informed consent was obtained from the patient or substitute decision-maker in PROSPECT. The findings of this study will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT01782755; Pre-results.
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Affiliation(s)
- Vincent Issac Lau
- Department of Critical Care, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Robert Fowler
- Sunnybrook Health Sciences Institute, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Jennie Johnstone
- Public Health Ontario, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care, Western University, London, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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A Comparison of Outcomes of Trauma Patients With Ventilator-Associated Events by Diagnostic Criteria Set. Shock 2020; 51:599-604. [PMID: 29958241 DOI: 10.1097/shk.0000000000001214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Centers for Disease Control and Prevention replaced the definition for ventilator-associated pneumonia with an algorithm comprised of three categories: ventilator-associated condition (VAC), infection-related ventilator associated complication (IVAC), and possible ventilator-associated pneumonia (PVAP). We sought to compare the outcome of trauma patients with VAEs to those with no VAEs. METHODS Patients admitted from 2013 to 2017 were identified from trauma registry. Logistic regression was performed for the association between VAEs and mortality. RESULTS Two thousand six hundred eighty patients were admitted to our trauma center, 2,290 had no VAE, 100 had VACs, 85 had IVACs, and 205 had PVAPs. Adjusted for race, sex, blunt injury mechanisms, and Injury Severity Score, all VAEs had a longer hospital length of stay, intensive care unit stay, and days of ventilator support when compared with those with no VAE (all P < 0.0001). Nosocomial complication rates were not different by VAE group. Compared with patients with no VAE, an over 2-fold increased mortality odds was observed for VAC (OR 2.39, 95% CI 1.50-3.80) and IVAC patients (OR 2.07, 95% CI 1.23-3.47), and a 50% mortality increased was observed for PVAP patients (OR 1.46, 95% CI 1.00-2.12). These associations became similar with an approximate 2.5-fold increased mortality odds among patients with at least 1 week on ventilator support. CONCLUSION VAEs increase the odds of mortality, particularly for patients with VACs and IVACs. Among patients on ventilator support for at least a week, the associations are similar among VAE types, suggesting no single VAE type is more severe than others.
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Ferrel E, Chapple KM, Calugaru LG, Maxwell J, Johnson JA, Mezher AW, Bogert JN, Soe-Lin H, Weinberg JA. Minor change in initial PEEP setting decreases rates of ventilator-associated events in mechanically ventilated trauma patients. Trauma Surg Acute Care Open 2020; 5:e000455. [PMID: 32420453 PMCID: PMC7223473 DOI: 10.1136/tsaco-2020-000455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022] Open
Abstract
Background Surveillance of ventilator-associated events (VAEs) as defined by the National Healthcare Safety Network (NHSN) is performed at many US trauma centers and considered a measure of healthcare quality. The surveillance algorithm relies in part on increases in positive end-expiratory pressure (PEEP) to identify VAEs. The purpose of this cohort study was to evaluate the effect of initiating mechanically ventilated trauma patients at marginally higher PEEP on incidence of VAEs. Methods Analysis of level-1 trauma center patients mechanically ventilated 2+ days from 2017 to 2018 was performed after an institutional ventilation protocol increased initial PEEP setting from 5 (2017) to 6 (2018)cm H2O. Incidence of VAEs per 1000 vent days was compared between PEEP groups. Logistic regression modelling was performed to evaluate the impact of the PEEP setting change adjusted to account for age, ventilator days, injury mechanism and injury severity. Results 519 patients met study criteria (274 PEEP 5 and 245 PEEP 6). Rates of VAEs were significantly reduced among patients with initial PEEP 5 versus 6 (14.61 per 1000 vent days vs. 7.13 per 1000 vent days; p=0.039). Logistic regression demonstrated that initial PEEP 6 was associated with 62% reduction in VAEs. Conclusions Our data suggest that an incrementally increased baseline PEEP setting was associated with a significantly decreased incidence of VAEs among trauma patients. This minor change in practice may have a major impact on a trauma center’s quality metrics. Level of evidence IV.
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Affiliation(s)
- Ethan Ferrel
- Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Kristina M Chapple
- Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Liviu Gabriel Calugaru
- Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jennifer Maxwell
- Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jessica A Johnson
- Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew W Mezher
- Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona, USA
| | - James N Bogert
- Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Hahn Soe-Lin
- Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona, USA
| | - Jordan A Weinberg
- Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Kuzovlev A, Shabanov A, Grechko A. Nosocomial Pneumonia: An Update on Early Diagnosis and Prevention. CURRENT RESPIRATORY MEDICINE REVIEWS 2020. [DOI: 10.2174/1573398x15666190808111757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Nosocomial pneumonia and nosocomial tracheobronchitis present a significant problem of anesthesiology and critical care medicine. This review presents the results of our own research on the usefulness of new molecular biomarkers in the early diagnosis of nosocomial pneumonia, as well as modern principles for its prevention. A promising direction for the early diagnosis of nosocomial pneumonia and its complications is the study of new molecular biomarkers, in particular, Club cell protein and surfactant proteins. Effective prevention of nosocomial pneumonia should be based on a complex of modern evidence-based methods.
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Affiliation(s)
- Artem Kuzovlev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation
| | - Aslan Shabanov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation
| | - Andrey Grechko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation
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Pouly O, Lecailtel S, Six S, Préau S, Wallet F, Nseir S, Rouzé A. Accuracy of ventilator-associated events for the diagnosis of ventilator-associated lower respiratory tract infections. Ann Intensive Care 2020; 10:6. [PMID: 31932982 PMCID: PMC6957592 DOI: 10.1186/s13613-020-0624-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 01/07/2020] [Indexed: 12/15/2022] Open
Abstract
Background The aim of this study was to investigate the concordance between ventilator-associated events (VAE) and ventilator-associated lower respiratory tract infections (VA-LRTI), and their impact on outcome. Methods This retrospective study was performed in five 10-bed ICUs of a teaching hospital, during a 2-year period. Ventilator-associated lower respiratory tract infections (VA-LRTI), including ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP) were prospectively diagnosed. The agreement between VAE, VAT and VAP was assessed by k statistics. Results A total of 1059 patients (15,029 ventilator-days) were included. 268 VAP (17.8 per 1000 ventilator-days), 127 VAT (8.5 per 1000 ventilator-days) and 262 VAE (17.4 per 1000 ventilator-days) were diagnosed. There was no agreement between VAT and VAE, and the agreement was poor between VAP and VAE (k = 0.12, 95% CI 0.03–0.20). VAE and VA-LRTI were associated with significantly longer duration of mechanical ventilation, ICU and hospital length of stay. VAP, VAT and VAE were not significantly associated with mortality in multivariate analysis. Conclusions The agreement was poor between VAE and VAP. No agreement was found between VAE and VAT. VAE episodes were significantly associated with longer duration of mechanical ventilation and length of stay, but not with ICU mortality.
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Affiliation(s)
- Olivier Pouly
- Critical Care Center, CHU Lille, 59000, Lille, France.,Medicine Faculty, Lille University, 59000, Lille, France
| | | | - Sophie Six
- Critical Care Center, CHU Lille, 59000, Lille, France
| | | | - Frédéric Wallet
- Centre de Biologie et de Pathologie, CHU Lille, 59000, Lille, France
| | - Saad Nseir
- Critical Care Center, CHU Lille, 59000, Lille, France. .,Medicine Faculty, Lille University, 59000, Lille, France.
| | - Anahita Rouzé
- Critical Care Center, CHU Lille, 59000, Lille, France
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Sharma A, Das M, Mishra B, Thakur A, Loomba P. Ventilator-associated events: Incidence and mortality in intensive care unit of a superspecialty hospital of North India. ACTA ACUST UNITED AC 2020. [DOI: 10.4103/ijhas.ijhas_96_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Michelángelo H, Angriman F, Pizarro R, Bauque S, Kecskes C, Staneloni I, García D, Espínola F, Mazer G, Ferrari C. Implementation of an experiential learning strategy to reduce the risk of ventilator-associated pneumonia in critically ill adult patients. J Intensive Care Soc 2019; 21:320-326. [PMID: 34093734 DOI: 10.1177/1751143719887285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective We evaluated the impact of an experiential learning strategy on both the adherence to the use of bundles and the incidence of ventilator-associated pneumonia in critically ill adult patients. Methods Longitudinal, quasi-experimental interrupted time-series study in a tertiary teaching hospital in Buenos Aires, Argentina. Successive measurements were made before and after the intervention was implemented between January 2016 and December 2018. Our main exposure was experiential learning, which was based on a combination of play activities, simulation models, knowledge and attitude competencies, role-playing and feedback. The adherence to the bundle for the care of mechanically ventilated critically-ill adult patients and the occurrence of ventilator-associated pneumonia were the main outcomes of interest. We used generalized linear models including time as a linear spline to estimate the effect of the experiential learning strategy both on the adherence to the bundle of care and the occurrence of ventilator-associated pneumonia during long-term follow-up. Results The overall proportion of adequate bundle use before and after the implementation of the intervention was 60.8% (95% CI: 56.9-64.7) and 85.6% (95% CI: 81.2-90.1), respectively. The incidence rate of ventilator-associated pneumonia before and after the intervention was 6.11 (95% CI: 5.82-6.40) and 3.55 (95% CI: 2.96-4.14) every 1000 days of mechanical ventilation, respectively. The estimated baseline monthly change in the adherence to the mechanical ventilation bundle was 0.4% (95%CI: -0.3-1.2%, p = 0.31) and 1.1% (95% CI: 0.2-2.2%, p < 0.01) before and after the implementation of the intervention, respectively. These results were consistent across our statistical quality control analysis. Conclusions The implementation of experiential learning strategies improves the adherence to bundles in the care of mechanically ventilated critically ill adult patients. Such strategies also decrease the incidence rate of ventilator-associated pneumonia. Both effects appear to remain constant during long-term follow-up.
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Affiliation(s)
- Hernán Michelángelo
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Quality Improvement Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Federico Angriman
- Department of Critical Care, Sunnybrook Health Sciences Center, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Rodolfo Pizarro
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Susana Bauque
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Claudia Kecskes
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Inés Staneloni
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - David García
- Quality Improvement Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fidencia Espínola
- Quality Improvement Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo Mazer
- Quality Improvement Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Cristina Ferrari
- Medical School, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
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Dale CM, Rose L, Carbone S, Smith OM, Burry L, Fan E, Amaral ACKB, McCredie VA, Pinto R, Quiñonez CR, Sutherland S, Scales DC, Cuthbertson BH. Protocol for a multi-centered, stepped wedge, cluster randomized controlled trial of the de-adoption of oral chlorhexidine prophylaxis and implementation of an oral care bundle for mechanically ventilated critically ill patients: the CHORAL study. Trials 2019; 20:603. [PMID: 31651364 PMCID: PMC6814100 DOI: 10.1186/s13063-019-3673-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/21/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Routine application of chlorhexidine oral rinse is recommended to reduce risk of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Recent reappraisal of the evidence from two meta-analyses suggests chlorhexidine may cause excess mortality in non-cardiac surgery patients and does not reduce VAP. Mechanisms for possible excess mortality are unclear. The CHORAL study will evaluate the impact of de-adopting chlorhexidine and implementing an oral care bundle (excluding chlorhexidine) on mortality, infection-related ventilator-associated complications (IVACs), and oral health status. METHODS The CHORAL study is a stepped wedge, cluster randomized controlled trial in six academic intensive care units (ICUs) in Toronto, Canada. Clusters (ICU) will be randomly allocated to six sequential steps over a 14-month period to de-adopt oral chlorhexidine and implement a standardized oral care bundle (oral assessment, tooth brushing, moisturization, and secretion removal). On study commencement, all clusters begin with a control period in which the standard of care is oral chlorhexidine. Clusters then begin crossover from control to intervention every 2 months according to the randomization schedule. Participants include all mechanically ventilated adults eligible to receive the standardized oral care bundle. The primary outcome is ICU mortality; secondary outcomes are IVACs and oral health status. We will determine demographics, antibiotic usage, mortality, and IVAC rates from a validated local ICU clinical registry. With six clusters and 50 ventilated patients on average each month per cluster, we estimate that 4200 patients provide 80% power after accounting for intracluster correlation to detect an absolute reduction in mortality of 5.5%. We will analyze our primary outcome of mortality using a generalized linear mixed model adjusting for time to account for secular trends. We will conduct a process evaluation to determine intervention fidelity and to inform interpretation of the trial results. DISCUSSION The CHORAL study will inform understanding of the effectiveness of de-adoption of oral chlorhexidine and implementation of a standardized oral care bundle for decreasing ICU mortality and IVAC rates while improving oral health status. Our process evaluation will inform clinicians and decision makers about intervention delivery to support future de-adoption if justified by trial results. TRIAL REGISTRATION ClinicalTrials.gov, NCT03382730 . Registered on December 26, 2017.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, UK
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Orla M Smith
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Department of Critical Care, St. Michael's Hospital, Toronto, Canada.,Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Lisa Burry
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Susan Sutherland
- Department of Dentistry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Sunnybrook Research Institute, Toronto, Canada. .,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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Barriers to the adoption of ventilator-associated events surveillance and prevention. Clin Microbiol Infect 2019; 25:1180-1185. [DOI: 10.1016/j.cmi.2019.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/28/2019] [Accepted: 03/28/2019] [Indexed: 12/12/2022]
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Liu J, Zhang S, Chen J, Mao Y, Shao X, Li Y, Cao J, Zheng W, Zhang B, Zong Z. Risk factors for ventilator-associated events: A prospective cohort study. Am J Infect Control 2019; 47:744-749. [PMID: 30584021 DOI: 10.1016/j.ajic.2018.09.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/28/2018] [Accepted: 09/28/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND In January 2013, the Centers for Disease Control and Prevention released new surveillance definitions for ventilator-associated event (VAE) to replace ventilator-associated pneumonia (VAP) in adult patients. VAEs are associated with prolonged mechanical ventilation and hospital death, but little is known about their risk factors and how best to prevent them. METHODS We compared VAE cases with non-VAE cases with regard to demographics, comorbidities, sedative exposures, opioids exposures, paralytic exposures, routes of nutrition, blood products, gastric retention, and fluid balance. Patients mechanically ventilated for ≥4 days between January 1, 2017, and December 31, 2017, in 2 adult intensive care units of a tertiary care teaching hospital in China were included. RESULTS On multivariable logistic regression, significant risk factors for VAEs were positive daily fluid balances of ≥ 50 mL between day of intubation and the fourth day of mechanical ventilation (relative risk [RR], 8.39; 95% confidence interval [CI], 2.99-23.50), sedative administered between the first day and the fourth day of invasive mechanical ventilation (RR, 15.69; 95% CI, 1.62-152.06), and daily gastric retention of ≥200 mL between day of intubation and the fourth day of mechanical ventilation (RR, 9.27; 95% CI, 1.89-45.47). CONCLUSIONS Positive daily fluid balances of ≥50 mL, sedatives administered, and gastric retention of ≥200 mL are risk factors for VAEs. Intervention studies are needed to determine if targeting these risk factors can lower VAE rates.
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Affiliation(s)
- Ji Liu
- School of Nursing, Xuzhou Medical University, Xuzhou, China; Emergency Intensive Care Unit, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Shenglei Zhang
- Intensive Care Unit, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiaxuan Chen
- School of Clinical Medicine, Xuzhou Medical University, Xuzhou, China
| | - Yiping Mao
- Department of Nosocomial Infection Management, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.
| | - Xiaoqing Shao
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Yang Li
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Jianmei Cao
- Department of Nosocomial Infection Management, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Wei Zheng
- Department of Nosocomial Infection Management, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Bing Zhang
- Department of Nosocomial Infection Management, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China; Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
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Ziegler KM, Haywood JD, Sontag MK, Mourani PM. Application of the New Centers for Disease Control and Prevention Surveillance Criteria for Ventilator-Associated Events to a Cohort of PICU Patients Identifies Different Patients Compared With the Previous Definition and Physician Diagnosis. Crit Care Med 2019; 47:e547-e554. [PMID: 30985451 PMCID: PMC7089756 DOI: 10.1097/ccm.0000000000003766] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to compare the performance of the 2008 Centers for Disease Control and Prevention Pediatric criteria for ventilator-associated pneumonia, the 2013 Adult Ventilator-Associated Condition criteria, the new Draft Pediatric Ventilator-Associated Condition criteria, and physician-diagnosed ventilator-associated pneumonia in a cohort of PICU patients. DESIGN Secondary analysis of a previously conducted prospective observational study. SETTING PICU within a tertiary care children's hospital between April 1, 2010, and April 1, 2011. PATIENTS Patients between 31 days and 18 years old, mechanically ventilated via endotracheal tube for more than 72 hours and no limitations of care. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Ventilator-associated pneumonia criteria applied in real time and ventilator-associated condition criteria applied retrospectively. Outcomes assessed between cases and noncases within criteria. Of the 133 eligible participants, 24 (18%) had ventilator-associated pneumonia by 2008 Pediatric criteria and 27 (20%) by physician diagnosis. Sixteen (12%) and 10 (8%) had ventilator-associated condition by 2013 Adult and Draft Pediatric criteria, respectively. We found significant overlap between cases identified with 2008 Pediatric criteria and physician diagnosis (p = 0.549), but comparisons between the other definitions revealed that the newer criteria identify different patients than previous Centers for Disease Control and Prevention ventilator-associated pneumonia criteria and physician diagnosis (p < 0.01). Although 20 participants were diagnosed with ventilator-associated pneumonia by 2008 Pediatric criteria and physician diagnosis, only three participants were identified by all four criteria. Three subjects uniquely identified by the Draft Pediatric criteria were noninfectious in etiology. Cases identified by all criteria except Draft Pediatric had higher ratios of actual ICU length of stay to Pediatric Risk of Mortality III-adjusted expected length of stay compared with noncases. CONCLUSIONS The Draft Pediatric criteria identify fewer and different patients than previous ventilator-associated pneumonia criteria or physician diagnosis, potentially missing patients with preventable harms, but also identified patients with potentially preventable noninfectious respiratory deteriorations. Further investigations are required to maximize the identification of patients with preventable harms from mechanical ventilation.
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Affiliation(s)
- Katherine M Ziegler
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| | - Jonathan D Haywood
- Department of Anesthesiology, Section of Pediatric Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Marci K Sontag
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| | - Peter M Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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Johnstone J, Heels-Ansdell D, Thabane L, Meade M, Marshall J, Lauzier F, Duan EH, Zytaruk N, Lamarche D, Surette M, Cook DJ. Evaluating probiotics for the prevention of ventilator-associated pneumonia: a randomised placebo-controlled multicentre trial protocol and statistical analysis plan for PROSPECT. BMJ Open 2019; 9:e025228. [PMID: 31227528 PMCID: PMC6596980 DOI: 10.1136/bmjopen-2018-025228] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in critically ill patients. Prior studies suggest that probiotics may reduce VAP and other infections in critically ill patients; however, most previous randomised trials were small, single centre studies. The Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT) aims to determine the impact of the probiotic Lactobacillus rhamnosus GG on VAP and other clinically important outcomes in critically ill adults. METHODS PROSPECT is a multicentre, concealed, randomised, stratified, blinded, controlled trial in patients ≥18 years old, anticipated to be mechanically ventilated ≥72 hours, in intensive care units (ICUs) in Canada, the USA and Saudi Arabia. Patients receive either 1×1010 colony forming units of L. rhamnosus GG twice daily or an identical appearing placebo. Those at increased risk of probiotic infection are excluded. The primary outcome is VAP. Secondary outcomes are other ICU-acquired infections including Clostridioides difficile infection, diarrhoea (including antibiotic-associated diarrhoea), antimicrobial use, ICU and hospital length of stay and mortality. The planned sample size of 2650 patients is based on an estimated 15% VAP rate and will provide 80% power to detect a 25% relative risk reduction. ETHICS AND DISSEMINATION This protocol and statistical analysis plan outlines the methodology, primary and secondary analyses, sensitivity analyses and subgroup analyses. PROSPECT is approved by Health Canada (#9427-M1133-45C), the research ethics boards of all participating hospitals and Public Health Ontario. Results will be disseminated via academic channels (peer reviewed journal publications, professional healthcare fora including international conferences) and conventional and social media. The results of PROSPECT will inform practice guidelines worldwide. TRIALREGISTRATION NUMBER NCT02462590; Pre-results.
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Affiliation(s)
- Jennie Johnstone
- Public Health Ontario, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Maureen Meade
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - John Marshall
- Surgery/Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Francois Lauzier
- Critical Care, CHU de Quebec-Universite Laval, Quebec, Quebec, Canada
| | | | - Nicole Zytaruk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daphnee Lamarche
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael Surette
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Chumpia MM, Ganz DA, Chang ET, de Peralta SS. Reducing the rare event: lessons from the implementation of a ventilator bundle. BMJ Open Qual 2019; 8:e000426. [PMID: 31259278 PMCID: PMC6568166 DOI: 10.1136/bmjoq-2018-000426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 04/02/2019] [Accepted: 05/20/2019] [Indexed: 11/24/2022] Open
Abstract
The ventilator-associated event (VAE) is a potentially avoidable complication of mechanical ventilation (MV) associated with poor outcomes. Although rare, VAEs and other nosocomial events are frequently targeted for quality improvement efforts consistent with the creed to ‘do no harm’. In October 2016, VA Greater Los Angeles (GLA) was in the lowest-performing decile of VA medical centres on a composite measure of quality, owing to GLA’s relatively high VAE rate. To decrease VAEs, we sought to reduce average MV duration of patients with acute respiratory failure to less than 3 days by 1 July 2017. In our first intervention (period 1), intensive care unit (ICU) attending physicians trained residents to use an existing ventilator bundle order set; in our second intervention (period 2), we updated the order set to streamline order entry and incorporate new nurse-driven and respiratory therapist (RT)-driven spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) protocols. In period 1, the proportion of eligible patients with SAT and SBT orders increased from 29.9% and 51.2% to 67.4% and 72.6%, respectively, with sustained improvements through December 2017. Mean MV duration decreased from 7.2 days at baseline to 5.5 days in period 1 and 4.7 days in period 2; statistical process control charts revealed no significant differences, but the difference between baseline and period 2 MV duration was statistically significant at p=0.049. Bedside audits showed RTs consistently performed indicated SBTs, but there were missed opportunities for SATs due to ICU staff concerns about the SAT protocol. The rarity of VAEs, small population of ventilated patients and infrequent use of sedative infusions at GLA may have decreased the opportunity to achieve staff acceptance and use of the SAT protocol. Quality improvement teams should consider frequency of targeted outcomes when planning interventions; rare events pose challenges in implementation and evaluation of change.
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Affiliation(s)
- Maryanne Matinee Chumpia
- Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - David A Ganz
- Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Evelyn T Chang
- Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Shelly S de Peralta
- Nursing, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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NAKAMURA Y, AINODA Y. A Study of Medical Expenses for Infectious Diseases in a Ventilator-associated Event. ACTA ACUST UNITED AC 2019. [DOI: 10.4058/jsei.34.206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yukari NAKAMURA
- Department of Infection Control and Prevention, Mitsui Memorial Hospital
| | - Yusuke AINODA
- Department of Infection Control and Prevention, Mitsui Memorial Hospital
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Among Trauma Patients, Younger Men with Ventilator-Associated Pneumonia Have Worse Outcomes Compared to Older Men-An Exploratory Study. Healthcare (Basel) 2019; 7:healthcare7020067. [PMID: 31052226 PMCID: PMC6627876 DOI: 10.3390/healthcare7020067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/25/2019] [Accepted: 04/28/2019] [Indexed: 12/27/2022] Open
Abstract
Background: Ventilator-associated pneumonia is associated with significant morbidity. Although the association of gender with outcomes in trauma patients has been debated for years, recently, certain authors have demonstrated a difference. We sought to compare the outcomes of younger men and women to older men and women, among critically ill trauma patients with ventilator-associated pneumonia (VAP). Methods: We reviewed our trauma data base for trauma patients with ventilator-associated pneumonia admitted to our trauma intensive care unit between January 2016 and June 2018. Data collected included demographics, injury mechanism and severity (ISS), admission vital signs and laboratory data and outcome measures including hospital length of stay, ICU stay and survival. Patients were also divided into younger (<50) and older (≥50) to account for hormonal status. Linear regression and binary logistic regression models were performed to compare younger men to older men and younger women to older women, and to examine the association between gender and hospital length of stay (LOS), ICU stay (ICUS), and survival. Results: Forty-five trauma patients admitted to our trauma intensive care unit during the study period (January 2016 to August 2018) had ventilator-associated pneumonia. The average age was 58.9 ± 19.6 years with mean ISS of 18.2 ± 9.8. There were 32 (71.1%) men, 27 (60.0%) White, and 41 (91.1%) had blunt trauma. Mean ICU stay was 14.9 ± 11.4 days and mean total hospital length of stay (LOS) was 21.5 ± 14.6 days. Younger men with VAP had longer hospital LOS 28.6 ± 17.1 days compared to older men 16.7 ± 6.6 days, (p < 0.001) and longer intensive care unit stay 21.6 ± 15.6 days compared to older men 11.9 ± 7.3 days (p = 0.02), there was no significant difference in injury severity (ISS was 22.2 ± 8.4 vs. 17 ± 8, p = 0.09). Conclusions: Among trauma patients with VAP, younger men had longer hospital length of stay and a trend towards longer ICU stay. Further research should focus on the mechanisms behind this difference in outcome using a larger database.
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Shinoda T, Nishihara H, Shimogai T, Ito T, Takimoto R, Seo R, Kanai M, Izawa KP, Iwata K. Relationship between Ventilator-Associated Events and Timing of Rehabilitation in Subjects with Emergency Tracheal Intubation at Early Mobilization Facility. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15122892. [PMID: 30562993 PMCID: PMC6313321 DOI: 10.3390/ijerph15122892] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/12/2018] [Accepted: 12/14/2018] [Indexed: 11/24/2022]
Abstract
The present study aimed to investigate the relationship between the occurrence of ventilator-associated events (VAE) in the intensive care unit and the timing of rehabilitation intervention. We included subjects who underwent emergency tracheal intubation and received rehabilitation. We performed rehabilitation according to our hospital’s protocol. We assessed the mechanical ventilation parameters of inspired oxygen fraction and positive-end expiratory pressure, and a VAE was identified if these parameters stabilized or decreased for ≥2 days and then had to be increased for ≥2 days. We defined time in hours from tracheal intubation to the first rehabilitation intervention as Timing 1 and that to first sitting on the edge of the bed as Timing 2. Data were analyzed by the t-test and χ2 tests. We finally analyzed 294 subjects. VAE occurred in 9.9% and high mortality at 48.3%. Median values of Timing 1 and Timing 2 in the non-VAE and VAE groups were 30.3 ± 24.0 and 30.0 ± 20.7 h, and 125.7 ± 136.6 and 127.9 ± 111.4 h, respectively, and the differences were not significant (p = 0.95 and p = 0.93, respectively). We found no significant relationship between the occurrence of VAE leading to high mortality and timing of rehabilitation intervention.
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Affiliation(s)
- Taku Shinoda
- Department of Rehabilitation, Division of Physical Therapy, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan.
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe 654-0142, Japan.
- Cardiovascular Stroke Renal Project (CRP), Kobe 654-0142, Japan.
| | - Hiromasa Nishihara
- Department of Rehabilitation, Division of Physical Therapy, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan.
| | - Takayuki Shimogai
- Department of Rehabilitation, Division of Physical Therapy, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan.
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe 654-0142, Japan.
- Cardiovascular Stroke Renal Project (CRP), Kobe 654-0142, Japan.
| | - Tsubasa Ito
- Department of Rehabilitation, Division of Physical Therapy, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan.
| | - Ryuya Takimoto
- Department of Rehabilitation, Division of Physical Therapy, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan.
| | - Ryutaro Seo
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan.
| | - Masashi Kanai
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe 654-0142, Japan.
- Cardiovascular Stroke Renal Project (CRP), Kobe 654-0142, Japan.
| | - Kazuhiro P Izawa
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe 654-0142, Japan.
- Cardiovascular Stroke Renal Project (CRP), Kobe 654-0142, Japan.
| | - Kentaro Iwata
- Department of Rehabilitation, Division of Physical Therapy, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan.
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Ventilator-associated events in children: A review of literature. Aust Crit Care 2018; 32:55-62. [PMID: 30554940 DOI: 10.1016/j.aucc.2018.11.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 11/12/2018] [Accepted: 11/16/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The complexity and variation in ventilator associated pneumonia (VAP) definitions in paediatrics may pose threats to the reliable identification of VAP. The revision of the surveillance definition to ventilator-associated event (VAE) has been mandated in adult populations, to overcome these issues. However, the evidence for application of the definition is unknown in children. OBJECTIVES To review the evidence on the application of the new VAE surveillance definition in paediatric population and examine the potential challenges in clinical practice. REVIEW METHODS A systematic approach was used to locate and synthesise the relevant paediatric literature. Studies were appraised according to epidemiological appraisal instrument (EAI) and the grades of evidence in the National Health Medical Research Council (NHMRC) guidelines. RESULTS Seven studies met the inclusion criteria. Quality of study methods was above 50% on the EAI. The overall grade of evidence was assessed as C (satisfactory). The incidence of VAE in children ranged from 1.1 to 20.9 per 1000 ventilator days as a result of variations in surveillance criteria across included studies. There is little agreement between the new VAE and PNU/VAP surveillance definition in the identification of VAP. Challenges in the application of VAE surveillance were related to; the difference in modes of ventilation used in children versus adults, inconclusive criteria tailored to paediatric samples and a lack of data that support for automatic data extraction applied in paediatric studies. CONCLUSION This review demonstrated promising evidence using the new VAE surveillance definition to define the VAE in children, but the level of the evidence is low. Before the possibility of real implementation in clinical settings, challenges related to VAE paediatric specific criteria' and the value of automated data collection need to be considered.
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Nakahashi S, Imai H, Imanaka H, Ohshimo S, Satou T, Shima M, Yanagisawa M, Yamashita C, Ogura T, Yamada T, Shime N. Ventilator-associated events: prevalence and mortality in Japan. J Thorac Dis 2018; 10:6942-6949. [PMID: 30746240 DOI: 10.21037/jtd.2018.12.40] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In 2013, the Centers for Disease Control and Prevention (CDC) issued the concept of the ventilator-associated events (VAEs) as a quality indicator (QI) in the intensive care unit (ICU). A number of studies have been conducted in the United States and other Western countries to evaluate its practicality. However, information on VAEs in non-Western countries is scarce. The purpose of this preliminary study was to illuminate the incidence and associated mortality rate of VAEs in Japan, as a first step in the effort to determine its practicality. Methods We conducted a multi-center, retrospective review of patient medical record using VAEs surveillance algorithm. We analyzed 785 patients with ≥2 days of mechanical ventilator (MV), admitted to the ICU at seven urban hospital in Japan. The prevalence of VAEs, including its three subtypes, and in-ICU mortality were researched. Results Forty-nine VAEs were identified, affecting 5.7% of patients requiring MV for ≥2 days and 6.4 per 1,000 MV days. Mortality in those who developed VAEs was 42.9%, significantly higher than the rest of the cohort (vs. 15.4%, P<0.001). The overall equivalent distribution of the three VAEs subtype incidences was evaluated: the incidences of VAC only, IVAC only and PVAP were 2.20, 1.90 and 2.29 per 1,000 MV days respectively (P=0.933). However, VAE etiology and mortality was facility dependent. ICUs with a large proportion of surgical patients and more severe cases tended to have increased VAE incidence, with a converse decrease in closed ICUs. Conclusions The prevalence of VAEs appears low in Japanese ICUs. Nonetheless, mortality was substantially higher in patients who developed VAEs. Although some potential indices of VAEs are suggested to serve as QIs, additional studies to elaborate its practicality would further be required.
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Affiliation(s)
- Susumu Nakahashi
- Department of Emergency & Critical Care Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroshi Imai
- Department of Emergency & Critical Care Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideaki Imanaka
- Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomoko Satou
- Intensive Care Unit, Akita University Hospital, Akita, Japan
| | - Masanori Shima
- Department of Nursing, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Masami Yanagisawa
- Department of Medical Engineering, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Chizuru Yamashita
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital, Mie, Japan
| | - Tomomi Yamada
- Department of Medical Innovation, Osaka University Hospital, Osaka, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
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Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
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Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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Ramirez-Estrada S, Peña-Lopez Y, Kalwaje Eshwara V, Rello J. Ventilator-associated events versus ventilator-associated respiratory infections-moving into a new paradigm or merging both concepts, instead? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:425. [PMID: 30581833 PMCID: PMC6275412 DOI: 10.21037/atm.2018.10.54] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/21/2018] [Indexed: 01/06/2023]
Abstract
Despite ventilator-associated respiratory infections (VARI) are reported as the most common and fatal complications related to mechanical ventilation (MV), they are not the unique occurrences. The new classification of ventilator-associated events (VAE) proposed by the centers for disease control and prevention (CDC) enhance the spectra of complications due to MV including both infection-related and non-infectious events. Both VAEs and VARIs are associated with prolonged duration of MV, longer stay in hospital and in the intensive care unit (ICU) and more antibiotic consumption, nonetheless patients with VAEs have worst outcomes. The VARI and VAE algorithms are focused on different targets and the correlation between both classifications is shown to be poor. The diagnostic criteria of the traditional classification have limited accuracy and the non-infectious complications may be misinterpreted as VARI. While the VAE surveillance enhances the spectra of MV complications but excludes less severe VARIs. Noninfective events explain up to 30% of VAEs, the main causes being atelectasis, acute respiratory distress syndrome, pulmonary edema and pulmonary embolism. The bundles assessing VAE are associated with less incidence of VAP and improved outcomes but they fail to reduce the rates of VAE. Automated VAE surveillance is efficient and useful as a quality indicator in the ICU while the differences in the interpretation of VARI criteria limit its role in the design of global protocols and preventive strategies. We suggest that a more comprehensive strategy should combine both algorithms with emphasis on clinical outcomes.
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Affiliation(s)
- Sergio Ramirez-Estrada
- Critical Care Department, Clínica Corachan, Barcelona, Spain
- Medicine Department, Universitat Autónoma de Barcelona, (UAB), Barcelona, Spain
| | | | - Vandana Kalwaje Eshwara
- Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Jordi Rello
- Vall d'Hebron Institut of Research, Barcelona, Spain
- Centro de Investigación Biomédica en Red (CIBERES), Instituto Salud Carlos III, Madrid, Spain
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Klarin B, Adolfsson A, Torstensson A, Larsson A. Can probiotics be an alternative to chlorhexidine for oral care in the mechanically ventilated patient? A multicentre, prospective, randomised controlled open trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:272. [PMID: 30368249 PMCID: PMC6204275 DOI: 10.1186/s13054-018-2209-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 09/25/2018] [Indexed: 01/14/2023]
Abstract
Background Pathogenic enteric bacteria aspirated from the oropharynx are the main cause of ventilator-associated pneumonia (VAP). Using chlorhexidine (CHX) orally or selective decontamination has been shown to reduce VAP. In a pilot study we found that oral care with the probiotic bacterium Lactobacillus plantarum 299 (Lp299) was as effective as CHX in reducing enteric bacteria in the oropharynx. To confirm those results, in this expanded study with an identical protocol we increased the number of patients and participating centres. Methods One hundred and fifty critically ill patients on mechanical ventilation were randomised to oral care with either standard 0.1% CHX solution (control group) or a procedure comprising final application of an emulsion of Lp299. Samples for microbiological analyses were taken from the oropharynx and trachea at inclusion and subsequently at defined intervals. Student’s t test was used for comparisons of parameters recorded daily and Fisher’s exact test was used to compare the results of microbiological cultures. Results Potentially pathogenic enteric bacteria not present at inclusion were identified in oropharyngeal samples from 29 patients in the CHX group and in 31 samples in the probiotic group. Considering cultures of tracheal secretions, enteric bacteria were found in 17 and 19 samples, respectively. Risk ratios show a difference in favour of the Lp group for fungi in oropharyngeal cultures. VAP was diagnosed in seven patients in the Lp group and in 10 patients among the controls. Conclusions In this multicentre study, we could not demonstrate any difference between Lp299 and CHX used in oral care procedures regarding their impact on colonisation with emerging potentially pathogenic enteric bacteria in the oropharynx and trachea. Trial registration ClinicalTrials.gov, NCT01105819. Registered on 9 April 2010. First part: Current Controlled Trials, ISRCTN00472141. Registered on 22 November 2007 (published Critical Care 2008, 12:R136).
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Affiliation(s)
- Bengt Klarin
- Department of Anaesthesiology and Intensive Care, Lund University and Skåne University Hospital, SE-221 85, Lund, Sweden.
| | - Anne Adolfsson
- Department of Anaesthesiology and Intensive Care, Lund University and Skåne University Hospital, SE-221 85, Lund, Sweden
| | | | - Anders Larsson
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
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Battaglia CC, Hale K. Hospital-Acquired Infections in Critically Ill Patients With Cancer. J Intensive Care Med 2018; 34:523-536. [PMID: 30012057 DOI: 10.1177/0885066618788019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hospital-acquired infections are a common and costly problem facing critically ill patients in the intensive care unit (ICU). Critically ill patients with cancer are a particularly vulnerable subpopulation who possesses additional, nonmodifiable risk factors for developing these infections and, in many cases, are at increased risk of death as a result. This review will describe the most common nosocomial infections patients with cancer acquire while in the ICU: ventilator-associated events, central line-associated bloodstream infection, catheter-associated urinary tract infections, and Clostridium difficile infection.
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Affiliation(s)
| | - Kaye Hale
- 2 Anesthesia and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Ramírez-Estrada S, Lagunes L, Peña-López Y, Vahedian-Azimi A, Nseir S, Arvaniti K, Bastug A, Totorika I, Oztoprak N, Bouadma L, Koulenti D, Rello J. Assessing predictive accuracy for outcomes of ventilator-associated events in an international cohort: the EUVAE study. Intensive Care Med 2018; 44:1212-1220. [PMID: 30003304 PMCID: PMC7095084 DOI: 10.1007/s00134-018-5269-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/05/2018] [Indexed: 01/20/2023]
Abstract
Purpose To analyze the impact on patient outcome of ventilator-associated events (VAEs) as defined by the Centers for Disease Control and Prevention (CDC) in 2008, 2013, and the correlation with ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT). Methods This was a prospective, observational, multicenter, international study conducted at 13 intensive care units (ICUs); thirty consecutive adults mechanically ventilated for ≥ 48 h per site were eligible, with daily follow-up being recorded in a collaborative web database; VAEs were assessed using the 2013 CDC classification and its 2015 update. Results A total of 2856 ventilator days in 244 patients were analyzed, identifying 33 VAP and 51 VAT episodes; 30-day ICU mortality was significantly higher (42.8 vs. 19.6%, p < 0.007) in patients with VAP than in those with VAT. According to the 2013 CDC definitions, 117 VAEs were identified: 113 (96%) were infection-related ventilator-associated complication-plus (IVAC-plus), while possible ventilator-associated pneumonia (PVAP) was found in 64 (56.6%) of them. VAE increased the number of ventilator days and prolonged ICU and hospital LOS (by 5, 11, and 12 days, respectively), with a trend towards increased 30-day mortality (43 vs 28%, p = 0.06). Most episodes (26, 55%) classified as IVAC-plus without PVAP criteria were due to atelectasis. PVAP significantly increased (p < 0.05) ventilator days as well as ICU and hospital LOS (by 10.5, 14, and 13 days, respectively). Only 24 (72.7%) of VAP and 15 (29.4%) of VAT episodes met IVAC-plus criteria. Conclusions Respiratory infections (mainly VAT) were the most common complication. VAE algorithms only identified events with surrogates of severe oxygenation deterioration. As a consequence, IVAC definitions missed one fourth of the episodes of VAP and three fourths of the episodes of VAT. Identifying VAT (often missed by IVAC-plus criteria) is important, as VAP and VAT have different impacts on mortality. Electronic supplementary material The online version of this article (10.1007/s00134-018-5269-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sergio Ramírez-Estrada
- Vall d'Hebron Institute of Research, Pg Vall d'Hebron 119-129, AMI-14, 08035, Barcelona, Spain.,Medicine Department, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Leonel Lagunes
- Medicine Department, Universitat Autónoma de Barcelona, Barcelona, Spain.,Clinical Research in Pneumonia and Sepsis, Vall d´Hebron Research Institute, Barcelona, Spain
| | - Yolanda Peña-López
- Vall d'Hebron Institute of Research, Pg Vall d'Hebron 119-129, AMI-14, 08035, Barcelona, Spain.,Medicine Department, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Saad Nseir
- Critical Care Center, Centre Hospitalier Universitaire Lille, Lille, France.,Inflammation Research International Center, Université Lille, Lille, France
| | | | - Aliye Bastug
- Infectious Diseases and Clinical Microbiology Department, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Izarne Totorika
- Intensive Care Department, Donostia University Hospital, Donostia, Spain
| | | | - Lilla Bouadma
- Hôpital Bichat-Claude-Bernard, Diderot, Paris, France
| | - Despoina Koulenti
- Burns, Trauma and Critical Care Research Centre-UQCCR, Faculty of Medicine, University of Queensland, Brisbane, Australia.,Critical Care Department, Attikon University Hospital, Athens, Greece
| | - Jordi Rello
- Vall d'Hebron Institute of Research, Pg Vall d'Hebron 119-129, AMI-14, 08035, Barcelona, Spain. .,Clinical Research in Pneumonia and Sepsis, Vall d´Hebron Research Institute, Barcelona, Spain. .,European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Infections in Critically Ill Patients (ESGCIP), Basel, Switzerland. .,Centro de Investigación Biomédica en Red, Enfermedades Respiratorias, CIBERES, Madrid, Spain.
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49
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Liu J, Li N, Hao J, Li Y, Liu A, Wu Y, Cai M. Impact of the Antibiotic Stewardship Program on Prevention and Control of Surgical Site Infection during Peri-Operative Clean Surgery. Surg Infect (Larchmt) 2018; 19:326-333. [PMID: 29461929 DOI: 10.1089/sur.2017.201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are the leading cause of hospital-acquired infections and are associated with substantial healthcare costs, with increased morbidity and mortality. To investigate the effects of the antibiotic stewardship program on prevention and control of SSI during clean surgery, we investigated this situation in our institution. PATIENTS AND METHODS We performed a quasi-experimental study to compare the effect before and after the antibiotic stewardship program intervention. During the pre-intervention stage (January 1, 2010 through December 31, 2011), comprehensive surveillance was performed to determine the SSI baseline data. In the second stage (January 1, 2012 through December 31, 2016), an infectious diseases physician and an infection control practitioner identified the surgical patients daily and followed up on the duration of antimicrobial prophylaxis. RESULTS From January 1, 2010 to December 31, 2016, 41,426 patients underwent clean surgeries in a grade III, class A hospital. The rate of prophylactic antibiotic use in the 41,426 clean surgeries was reduced from 82.9% to 28.0% after the interventions. The rate of antibiotic agents administered within 120 minutes of the first incision increased from 20.8% to 85.1%. The rate at which prophylactic antimicrobial agents were discontinued in the first 24 hours after surgery increased from 22.1% to 60.4%. Appropriate antibiotic selection increased from 37.0% to 93.6%. Prophylactic antibiotic re-dosing increased from 3.8% to 64.8%. The SSI rate decreased from 0.7% to 0.5% (p < 0.05). The pathogen detection rate increased from 16.7% up to 41.8% after intervention. The intensity of antibiotic consumption reduced from 74.9 defined daily doses (DDDs) per 100 bed-days to 34.2 DDDs per 100 bed-days after the interventions. CONCLUSION Long-term and continuous antibiotic stewardship programs have important effects on the prevention and control of SSI during clean surgery.
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Affiliation(s)
- Juyuan Liu
- 1 Division of Hospital Infection Control and Prevention, Beijing Hospital, National Center of Gerontology , Beijing, China
| | - Na Li
- 1 Division of Hospital Infection Control and Prevention, Beijing Hospital, National Center of Gerontology , Beijing, China
| | - Jinjuan Hao
- 2 Division of Hospital Administration Office, Beijing Hospital, National Center of Gerontology , Beijing, China
| | - Yanming Li
- 1 Division of Hospital Infection Control and Prevention, Beijing Hospital, National Center of Gerontology , Beijing, China
| | - Anlei Liu
- 3 Division of Emergency Department, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital , Beijing, China
| | - Yinghong Wu
- 4 Division of Hospital Infection Control and Prevention, Peking University People's Hospital , Beijing, China
| | - Meng Cai
- 1 Division of Hospital Infection Control and Prevention, Beijing Hospital, National Center of Gerontology , Beijing, China
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50
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He S, Wu F, Wu X, Xin M, Ding S, Wang J, Ouyang H, Zhang J. Ventilator-associated events after cardiac surgery: evidence from 1,709 patients. J Thorac Dis 2018; 10:776-783. [PMID: 29607148 DOI: 10.21037/jtd.2018.01.49] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Ventilator-associated event (VAE) is a new surveillance for nosocomial infections in mechanically ventilated patients. To date, little is known about VAEs after cardiac surgeries. The present study firstly focused on patients who have undergone heart operations, intending to draw a comprehensive description of VAEs. Methods Postoperative patients from September 2012 to December 2015 were monitored for VAEs. By reviewing electronic medical records and preserved files retrospectively, clinical data were further analyzed. Results A total of 1,709 adult patients were enrolled, of which 166 episodes met the criteria for VAE. The mean incidence rate reached up to 9.7% and 49.9 per 1,000 mechanical ventilation days. By using both univariate analysis and multiple logistic regression analysis, chronic obstructive pulmonary disease (COPD), left ventricle ejection fraction (LVEF) <30%, cardiopulmonary bypass time, aortic clamping time, mechanical ventilation time, reintubation, dosage of blood products and acute kidney injury (AKI) were found to be risk factors for VAEs. Compared with non-VAE group, VAEs were closely related to higher mortality, longer intensive care unit stay time and hospitalization time. In addition, 91 strains of pathogens were isolated from endotracheal aspirates of 81 patients with VAE, of which Pseudomonas aeruginosa was the most common pathogenic microorganism (30 isolates, 37.0%), followed by Acinetobacter baumannii (27 isolates, 33.3%) and other five types. Conclusions VAE algorithm is a valid and reliable surveillance for possible infections caused by mechanical ventilation, which could easily occur in patients after cardiac surgery and is associated with poor prognosis. The risks and pathogens that we have investigated will provide potential preventive strategies.
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Affiliation(s)
- Siyi He
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Fan Wu
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Xiaochen Wu
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Mei Xin
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Sheng Ding
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Jian Wang
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Hui Ouyang
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Jinbao Zhang
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu 610083, China
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