The reality of patients requiring prolonged mechanical ventilation: a multicenter study

Acupuncture reduces mechanical ventilation time in critically ill patients: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Mechanical Ventilation (MV) is an essential life support machine, frequently utilized in an Intensive Care Unit (ICU). Recently, a growing number of clinical trials have investigated the effect of acupuncture treatment on MV outcomes.

OBJECTIVES

This study investigated the safety and efficacy of acupuncture treatment for critically ill patients under MV.

METHODS

In this systematic review and meta-analysis of randomized controlled trials, the efficacy of acupuncture related interventions was compared to routine ICU treatments, and sham/control acupuncture as control interventions applied to ICU patients undergoing MV. The databases of PubMed, Cochrane Library, and Web of Science were extensively searched in the month of April 2022. The primary outcome measurements were defined as total MV time, ICU length of stay, and mortality. The Cochrane Collaboration risk of bias tool was employed to analyze the severity of bias. The meta-analysis was conducted using Review Manager 5.3 software. The quality of evidence was evaluated according to the GRADE approach.

RESULTS

A total of 10 clinical trials were included in this investigation. When comparing the performance of acupuncture-related interventions to that of the reported control interventions, the results of the meta-analysis revealed a significant reduction in the total number of MV days as well as the duration of ICU length of stay following acupuncture treatment (MD -2.06 [-3.33, -0.79] P = 0.001, I2 = 55 %, MD-1.26 [-2.00, -0.53] P = 0.0008, I2 = 77 %, respectively). A reduction in the total mortality was similarly observed (RR = 0.67 [0.47, 0.94] P = 0.02, I2 = 0 %).

CONCLUSION

This systematic review and meta-analysis identified a noteworthy reduction in the total MV days, time spent in the ICU, as well as the total mortality following acupuncture related interventions. However, the small sample size, risk of bias and existing heterogeneity should be taken into consideration. The results of this study are promising and further investigations in this field are warranted.

Analysis of short-term ventilation weaning for patients in spontaneous supratentorial intracranial hemorrhage

Prolonged ventilation is a complication of spontaneous supratentorial hemorrhage patients, but the predictive relationship with successful weaning in this patient cohort is not understood. Here, we evaluate the incidence and factors of ventilation weaning in case of spontaneous supratentorial hemorrhage. We retrospectively studied data from 166 patients in the same hospital from January 2015 to March 2021 and analyzed factors for ventilation weaning. The clinical data recorded included patient age, gender, timing of operation, initial Glasgow Coma Scale (GCS), Intracranial hemorrhage (ICH) score, alcohol drinking, cigarette smoking, medical comorbidity, and the blood data. Predictors of patient outcomes were determined by the Student t test, chi-square test, and logistic regression. We recruited and followed 166 patients who received operation for spontaneous supratentorial hemorrhage with cerebral herniation. The group of successful weaning had 84 patients and the group of weaning failed had 82 patients. The patient's age, type of operation, GCS on admission to the Intensive care unit (ICU), GCS at discharge from the ICU, medical comorbidity was significantly associated with successful weaning, according to Student t test and the chi-square test. According to our findings, patients with stereotaxic surgery, less history of cardiovascular or prior cerebral infarction, GCS >8 before admission to the hospital for craniotomy, and a blood albumin value >3.5 g/dL have a higher chance of being successfully weaned off the ventilator within 14 days.

Predictors of Treatment Failure and Mortality among Patients with Septic Shock Treated with Meropenem in the Intensive Care Unit

Background

The aim of the study was to determine the predictors of meropenem treatment failure and mortality in the Intensive Care Unit (ICU).

Methods

This was a retrospective study, involving sepsis and septic shock patients who were admitted to the ICU and received intravenous meropenem. Treatment failure is defined as evidence of non-resolved fever, non-reduced total white cell (TWC), non-reduced C-reactive protein (CRP), subsequent culture negative and death in ICU.

Results

An Acute Physiology and Chronic Health Evaluation II (APACHE II) and duration of antibiotic treatment less than 5 days were associated with treatment failure with adjusted OR = 1.24 (95% CI: 1.15, 1.33; P < 0.001), OR = 65.43 (95% CI: 21.70, 197.23; P < 0.001). A higher risk of mortality was observed with higher APACHE and Sequential Organ Failure Assessment (SOFA) scores, initiating antibiotics > 72 h of sepsis, duration of antibiotic treatment less than 5 days and meropenem with renal adjustment dose with an adjusted OR = 1.21 (95% CI: 1.12, 1.30; P < 0.001), adjusted OR = 1.23 (95% CI: 1.08, 1.41; P < 0.001), adjusted OR = 6.38 (95% CI: 1.67, 24.50; P = 0.007), adjusted OR = 0.03 (95% CI: 0.01, 0.14; P < 0.001), adjusted OR = 0.30 (95% CI: 0.14, 0.64; P = 0.002).

Conclusion

A total of 50 (14.12%) patients had a treatment failure with meropenem with 120 (48.02%) ICU mortality. The predictors of meropenem failure are higher APACHE score and shorter duration of meropenem treatment. The high APACHE, high SOFA score, initiating antibiotics more than 72 h of sepsis, shorter duration of treatment and meropenem with renal adjustment dose were predictors of mortality.

Acupuncture for ventilator-dependent patients at a hospital-based respiratory care center: A randomized controlled trial

Background

In intensive care units, mechanical ventilation is an important therapy to help patients with dyspnea. However, long-term ventilator dependence would consume huge medical resources and increase the risk of morbidity and mortality. The aim of the study was to examine the efficacy of the acupuncture combined with western medical care on ventilator parameters in ventilator-dependent patients.

Methods

In this clinical trial, 80 ventilator-dependent patients aged 20 to 80 years old were randomly assigned to acupuncture group and control group in the respiratory care center (RCC) of Changhua Christian Hospital. Besides regular medical care and therapy, participants in the acupuncture group received acupuncture therapy at the same 17 acu-points for 20 minutes once a day, a total of 12 sessions. The ventilator parameters were recorded to evaluate the respiratory efficiency for all participants. The primary outcome was rapid shallow breathing index (RSBI), and secondary outcomes were respiratory rate (RR), tidal volume (TV) and ventilation per minute (MV).

Results

Though there was no significant difference in the parameter between the acupuncture group and the control group, we found the trend of decreasing RSBI in the acupuncture group. In subgroup analyses, the mean of RSBI significantly decreased 16.02 (with the SD in 60.84) in acupuncture group, while it increased 17.84 (with the SD in 39.38) in control group (p=0.036) after 12 sessions.

Conclusion

Acupuncture treatment can improve breathing ability of patients with respirator dependence in respiratory care center.

Cervical Epidural Electrical Stimulation Increases Respiratory Activity through Somatostatin-Expressing Neurons in the Dorsal Cervical Spinal Cord in Rats

We tested the hypothesis that dorsal cervical epidural electrical stimulation (CEES) increases respiratory activity in male and female anesthetized rats. Respiratory frequency and minute ventilation were significantly increased when CEES was applied dorsally to the C2-C6 region of the cervical spinal cord. By injecting pseudorabies virus into the diaphragm and using c-Fos activity to identify neurons activated during CEES, we found neurons in the dorsal horn of the cervical spinal cord in which c-Fos and pseudorabies were co-localized, and these neurons expressed somatostatin (SST). Using dual viral infection to express the inhibitory Designer Receptors Exclusively Activated by Designer Drugs (DREADD), hM4D(Gi), selectively in SST-positive cells, we inhibited SST-expressing neurons by administering Clozapine N-oxide (CNO). During CNO-mediated inhibition of SST-expressing cervical spinal neurons, the respiratory excitation elicited by CEES was diminished. Thus, dorsal cervical epidural stimulation activated SST-expressing neurons in the cervical spinal cord, likely interneurons, that communicated with the respiratory pattern generating network to effect changes in ventilation.SIGNIFICANCE STATEMENT A network of pontomedullary neurons within the brainstem generates respiratory behaviors that are susceptible to modulation by a variety of inputs; spinal sensory and motor circuits modulate and adapt this output to meet the demands placed on the respiratory system. We explored dorsal cervical epidural electrical stimulation (CEES) excitation of spinal circuits to increase ventilation in rats. We identified dorsal somatostatin (SST)-expressing neurons in the cervical spinal cord that were activated (c-Fos-positive) by CEES. CEES no longer stimulated ventilation during inhibition of SST-expressing spinal neuronal activity, thereby demonstrating that spinal SST neurons participate in the activation of respiratory circuits affected by CEES. This work establishes a mechanistic foundation to repurpose a clinically accessible neuromodulatory therapy to activate respiratory circuits and stimulate ventilation.

Modified Nutrition Risk in Critically Ill Score, A Prognostic Marker of Morbidity and Mortality in Mechanically Ventilated Patients: A Prospective Observational Study

BACKGROUND

Critically ill (CI) patients, especially those requiring mechanical ventilation (MV) are at a higher risk of malnutrition, which in turn is associated with increased hospitalization and excess mortality. The modified Nutrition Risk in Critically Ill (mNUTRIC) score, a predictor of mortality, has not been validated adequately in CI Indian patients. Thus, this study evaluated the mNUTRIC score as a prognostic marker of morbidity and mortality in CI patients requiring MV.

MATERIALS AND METHODS

This prospective observational study was performed, between January 2018 and June 2019, in the intensive critical care unit (ICCU) of the medicine department of a tertiary care hospital. A total of 250 patients aged above 12 years, admitted in ICCU, and requiring MV for &gt;48 hours were included. Based on the data collected, mNUTRIC score was calculated and patients were classified as at low (0-4) and high (5-9) nutritional risk. Mortality was the outcome variable.

RESULTS

More than a quarter of patients had a high mNUTRIC score (28.4%) and the overall mortality was 35.6%. A significantly greater proportion of non-survivors had a high mNUTRIC score (p-value&lt;0.0001). Likewise, the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, and mNUTRIC score (all p-values&lt;0.0001) were significantly higher among the non-survivors than the survivors. On receiver operator characteristic (ROC) curve analysis, a cutoff value of &gt;2 predicted mortality [area under the curve (AUC): 0.83; 95% confidence interval: 0.778-0.874] with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 80.9, 76.4, 65.5, and 87.9%, respectively.

CONCLUSION

At a cutoff of &gt;2, mNUTRIC score had high sensitivity and specificity in the prediction of mortality.

Association between rectus femoris cross-sectional area and diaphragmatic excursion with weaning of tracheostomized patients in the intensive care unit

OBJECTIVE

To verify the relationship between the rectus femoris cross-sectional area and diaphragmatic excursion with successful weaning from mechanical ventilation in chronic critically tracheostomized patients.

METHODS

This was a prospective observational cohort study. We included chronic critically ill patients (those who underwent tracheostomy placement after 10 days under mechanical ventilation). The rectus femoris cross-sectional area and diaphragmatic excursion were obtained by ultrasonography performed within the first 48 hours after tracheostomy. We measured rectus femoris cross-sectional area and diaphragmatic excursion to assess their association with weaning from mechanical ventilation, including their potential to predict successful weaning and survival throughout the intensive care unit stay.

RESULTS

Eighty-one patients were included. Forty-five patients (55%) were weaned from mechanical ventilation. The mortality rates were 42% and 61.7% in the intensive care unit and hospital, respectively. The fail group in relation to the success group at weaning presented a lower rectus femoris cross-sectional area (1.4 [0.8] versus 1.84 [0.76]cm2, p = 0.014) and lower diaphragmatic excursion (1.29 ± 0.62 versus 1.62 ± 0.51cm, p = 0.019). When rectus femoris cross-sectional area ≥ 1.80cm2 and diaphragmatic excursion ≥ 1.25cm was a combined condition, it had a strong association with successful weaning (adjusted OR = 20.81, 95%CI 2.38 - 182.28; p = 0.006) but not with intensive care unit survival (adjusted OR = 0.19, 95%CI 0.03 - 1.08; p = 0.061).

CONCLUSION

Successful weaning from mechanical ventilation in chronic critically ill patients was associated with higher measurements of rectus femoris cross-sectional area and diaphragmatic excursion.

Timing of tracheostomy in patients with severe traumatic brain injuries: The need for tailored practice management guidelines

INTRODUCTION

Traumatic brain injury (TBI) is one of the leading causes of fatal trauma, and patients often require prolonged ventilation and tracheostomy. There are currently no standardized guidelines regarding the optimal timing of tracheostomy placement for mechanically ventilated patients with severe TBI. This review aims to investigate the impact of tracheostomy timing on the clinical outcomes in patients with severe TBI.

METHODS

A literature search was conducted according to PRISMA 2020 guidelines. PubMed, Google Scholar, EMBASE, MedLine, Web of Science, Cochrane, and CINAHL were searched for studies evaluating the impact of early versus late tracheostomy on TBI patient outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Newcastle-Ottawa Scale (NOS) were used for quality of evidence and risk of bias assessment, respectively.

RESULTS

A total of nine studies met eligibility criteria. All nine studies investigated tracheostomy timing in severe TBI patients and demonstrated that early tracheostomy is associated with decreased ICU length-of-stay (LOS) and increased ventilator free-days compared to late tracheostomy.

CONCLUSION

Current evidence suggests that patients with severe TBI following traumatic injury may benefit from an early tracheostomy due to improved clinical outcomes, including decreased MV duration and ICU-LOS, compared to late tracheostomy. Further multi-institutional studies are needed to develop evidence-based guidelines.

Risk factors and lethality associated with Candidemia in severe COVID-19 patients

BACKGROUND AND PURPOSE

Candidemia remained important in the intensive care units (ICU) during the COVID-19 pandemic. This study aimed to investigate the clinical and laboratory data on candidemia in COVID-19 patients.

MATERIALS AND METHODS

The baseline characteristics, as well as laboratory and clinical findings of candidemia and non-candidemia patients, were compared. Candidemia was defined as the isolation of Candida spp. from blood cultures. The isolates were identified by VITEK® 2 (bioMérieux, France) commercial method. Antifungal susceptibility was assessed using the E-test method. Univariate and multiple binary logistic regression analyses were performed to compare the variables.

RESULTS

In total, 126 patients with the COVID-19 disease were included. Candidemia was diagnosed in 44 (35%) of the patients. The number of patients with diabetes mellitus and chronic renal failure was higher in the candidemia group. In the candidemia group, the duration of ICU stay of patients, the 30-day mortality rate, mechanical ventilation therapy, and systemic corticosteroids (Prednisone) usage were significantly higher in candidemia patients. Moreover, the median white blood cell, neutrophils, and lactate dehydrogenase were higher in the candidemia group.Univariate and multiple binary logistic regression analyses were performed to compare the variables. Isolated species were identified as Candida albicans (n=12, 41%), Candida parapsilosis (n=7, 24%), Candida glabrata (n=6, 21%), Candida tropicalis (n=3, 10%), and Candida dublinensis (n=1, 3%). In total, three isolates of six C. glabrata species had dose-dependent sensitivity to fluconazole, and one C. parapsilosis was determined to be resistant.

CONCLUSION

The COVID-19 patients who are admitted to ICU have many risk factors associated with candidemia. The most common risk factors for the development of candidemia were mechanical ventilation, diabetes mellitus, neutrophilia, and low hemoglobin level. The most frequently isolated species was C. albicans. Moreover, caspofungin was found to be the most effective drug in vitro. No significant resistance pattern was detected against the isolated species. It should be noted that risk-stratified antifungal prophylaxis in the ICU is possible.

Impact of Inspiratory Muscle Training on Weaning Parameters in Prolonged Ventilator-Dependent Patients: A Preliminary Study

Introduction

Patients require prolonged mechanical ventilation to overcome respiratory failure in the chronic respiratory care ward; however, how to facilitate ventilator weaning using a nurse-led strategy is limited.

Objectives

This study aimed to examine the impact of adjusting ventilator trigger sensitivity as inspiratory muscle training on weaning parameters in patients with prolonged ventilator dependence.

Methods

Multiple pre-test–post-test with a non-equivalent control group design was conducted at a chronic respiratory care ward in southern Taiwan. A convenience sampling method was used to recruit patients who received prolonged mechanical ventilation for more than 21 days into control (n  =  20) and intervention groups (n  =  22). Adjustment of ventilator trigger sensitivity started from 10% of the initial maximum inspiratory pressure and increased to 40% after a training period of six weeks. The weaning parameters were collected for pre-test and multiple post-tests, and statistical analysis of treatment effects was performed using the generalized estimating equation.

Results

Magnitude of weaning parameters was significantly higher in the intervention group after the six-week training, including maximum inspiratory pressure, rapid shallow breathing index, tidal volume, and ratio of arterial-to-inspired oxygen.

Conclusion

Adjustment of ventilator trigger sensitivity as inspiratory muscle training can help prolonged ventilator-dependent patients improve their respiratory muscle strength, breathing patterns, and oxygenation.

Effectiveness of neuromuscular electrostimulation in COPD subjects on mechanical ventilation. A systematic review and meta-analysis

OBJECTIVE

To estimate the effectiveness of Neuromuscular Electrostimulation (NMES) in adults with COPD undergoing MV.

METHOD

A sensitive search was performed in MEDLINE, Embase, CENTRAL, CINAHL and other resources. Randomized Controlled Clinical Trials (RCTs) or non-RCTs that enrolled adults with COPD on MV due to an exacerbation of their disease were included. Two independent reviewers screened, extracted information, and assessed the risk of bias (RoB 2 tool) and the certainty of evidence (GRADE approach) from the included studies.

RESULTS

Four RCTs (144 participants) were included. Subjects who underwent NMES were able to move from bed to chair independently in less time (MD = 4.98 days less; 95% CI -8.55 to -1.47; 2 RCTs; low certainty of the evidence) and they were fewer days on MV (MD = 2.89 days less; 95% CI -4.58 to -1.21); 3 RCTs; low certainty of the evidence) than the control group. However, the effect of NMES on muscle strength is unclear (very low certainty of the evidence).

CONCLUSIONS

NMES may improve functional independence and decrease MV time in adults with COPD; however, its effectiveness on muscle strength is uncertain. More and better RCTs are needed to determine with greater certainty the effectiveness of NMES in this population.

The Epidemiology of Adult Tracheostomy in the United States 2002-2017: A Serial Cross-Sectional Study

Describe the longitudinal national epidemiology of tracheostomies performed in acute care hospitals and describe the annual rate of tracheostomy performed for patients with respiratory failure with invasive mechanical ventilation.

DESIGN

Serial cross-sectional study.

SETTING

The 2002-2014 and 2016-2017 Healthcare Utilization Project's National Inpatient Sample datasets.

PATIENTS

Discharges greater than or equal to 18 years old, excluding those with head and neck cancer or transferred from another hospital. We used diagnostic and procedure codes from the International Classification of Diseases, 9th and 10th revisions to define cases of respiratory failure, invasive mechanical ventilation, and tracheostomy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were an estimated 80,612 tracheostomies performed in 2002, a peak of 89,545 tracheostomies in 2008, and a nadir of 58,840 tracheostomies in 2017. The annual occurrence rate was 37.5 (95% CI, 34.7-40.4) tracheostomies per 100,000 U.S. adults in 2002, with a peak of 39.7 (95% CI, 36.5-42.9) in 2003, and with a nadir of 28.4 (95% CI, 27.2-29.6) in 2017. Specifically, among the subgroup of hospital discharges with respiratory failure with invasive mechanical ventilation, an annual average of 9.6% received tracheostomy in the hospital. This changed over the study period from 10.4% in 2002, with a peak of 10.9% in 2004, and with a nadir of 7.4% in 2017. Among respiratory failure with invasive mechanical ventilation discharges with tracheostomy, the annual proportion of patients 50-59 and 60-69 years old increased, whereas patients from 70 to 79 and greater than or equal to 80 years old decreased. The mean hospital length of stay decreased, and in-hospital mortality decreased, whereas discharge to intermediate care facilities increased.

CONCLUSIONS

Over the study period, there were decreases in the annual total case volume and adult occurrence rate of tracheostomy as well as decreases in the rate of tracheostomy among the subgroup with respiratory failure with invasive mechanical ventilation. There is some evidence of changing patterns of patient selection for in-hospital tracheostomy among those with respiratory failure with invasive mechanical ventilation with decreasing proportions of patients with advanced age.

Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Critical Illness and Heart, Kidney, and Liver Diseases

Specialty palliative care (PC) clinicians are frequently asked to discuss prognosis with patients and their families. When conveying information about prognosis, PC clinicians need also to discuss the likelihood of prolonged hospitalization, cognitive and functional disabilities, and death. As PC moves further and further upstream, it is crucial that PC providers have a broad understanding of curative and palliative treatments for serious diseases and can collaborate in prognostication with specialists. In this article, we present 10 tips for PC clinicians to consider when caring and discussing prognosis for the seriously ill patients along with their caregivers and care teams. This is the second in a three-part series around prognostication in adult and pediatric PC.

Diaphragm Pacing and a Model for Respiratory Rehabilitation After Spinal Cord Injury

BACKGROUND AND PURPOSE

Cervical spinal cord injury (CSCI) can cause severe respiratory impairment. Although mechanical ventilation (MV) is a lifesaving standard of care for these patients, it is associated with diaphragm atrophy and dysfunction. Diaphragm pacing (DP) is a strategy now used acutely to promote MV weaning and to combat the associated negative effects. Initial reports indicate that DP also may promote neuromuscular plasticity and lead to improvements in spontaneous diaphragm activation and respiratory function. These outcomes suggest the need for reevaluation of respiratory rehabilitation for patients with CSCI using DP and consideration of new rehabilitation models for these patients and their unique care needs.

SUMMARY OF KEY POINTS

This article discusses the rationale for consideration of DP as a rehabilitative strategy, particularly when used in combination with established respiratory interventions. In addition, a model of respiratory rehabilitation and recovery (RRR) is presented, providing a framework for rehabilitation and consideration of DP as an adjuvant rehabilitation approach. The model promotes goals such as respiratory recovery and independence, and lifelong respiratory health, via interdisciplinary care, respiratory training, quantitative measurement, and use of adjuvant strategies such as DP. Application of the model is demonstrated through a description of an inpatient rehabilitation program that applies model components to patients with CSCI who require DP.

RECOMMENDATIONS FOR CLINICAL PRACTICE

As DP use increases for patients with acute CSCI, so does the need and opportunity to advance rehabilitation approaches for these patients. This perspective article is a critical step in addressing this need and motivating the advancement of rehabilitation strategies for CSCI patients. (See Video Abstract, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A348).

Ventilator-associated pneumonia in patients on prolonged mechanical ventilation: description, risk factors for mortality, and performance of the SOFA score

Objective:

Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV). However, data on VAP in patients on prolonged MV (PMV) are scarce. We aimed to describe the characteristics of VAP patients on PMV and to identify factors associated with mortality.

Methods:

This was a retrospective cohort study including VAP patients on PMV. We recorded baseline characteristics, as well as 30-day and 90-day mortality rates. Variables associated with mortality were determined by Kaplan-Meier survival analysis and Cox regression model.

Results:

We identified 80 episodes of VAP in 62 subjects on PMV. The medians for age, Charlson Comorbidity Index, SOFA score, and days on MV were, respectively, 69.5 years, 5, 4, and 56 days. Episodes of VAP occurred between days 21 and 50 of MV in 28 patients (45.2%) and, by day 90 of MV, in 48 patients (77.4%). The 30-day and 90-day mortality rates were 30.0% and 63.7%, respectively. There were associations of 30-day mortality with the SOFA score (hazard ratio [HR] = 1.30; 95% CI: 1.12-1.52; p < 0.001) and use of vasoactive agents (HR = 4.0; 95% CI: 1.2-12.9; p = 0.02), whereas 90-day mortality was associated with age (HR = 1.03; 95% CI: 1.00-1.05; p = 0.003), SOFA score (HR = 1.20; 95% CI: 1.07-1.34; p = 0.001), use of vasoactive agents (HR = 4.07; 95% CI: 1.93-8.55; p < 0.001), and COPD (HR = 3.35; 95% CI: 1.71-6.60; p < 0.001).

Conclusions:

Mortality rates in VAP patients on PMV are considerably high. The onset of VAP can occur various days after MV initiation. The SOFA score is useful for predicting fatal outcomes. The factors associated with mortality could help guide therapeutic decisions and determine prognosis.

Elevated procalcitonin concentrations in severe Covid-19 may not reflect bacterial co-infection

BACKGROUND

The variability of Covid-19 severity between patients has driven efforts to identify prognosticating laboratory markers that could aid clinical decision-making. Procalcitonin is classically used as a diagnostic marker in bacterial infections, but its role in predicting Covid-19 disease severity is emerging. We aimed to identify the association between procalcitonin and Covid-19 disease severity in a critical care setting and whether bacterial co-infection is implicated.

METHODS

We retrospectively reviewed Covid-19 patients with procalcitonin concentrations measured in a critical care setting at our institution between February and September 2020. Laboratory markers including peak procalcitonin values and a range of bacterial culture results were analysed. Outcomes were the requirement and duration of invasive mechanical ventilation as well as inpatient mortality.

RESULTS

In total, 60 patients were included; 68% required invasive mechanical ventilation and 45% died as inpatient. Univariate analysis identified higher peak procalcitonin concentrations significantly associated with both the requirement for invasive mechanical ventilation (OR: 3.2, 95% CI 1.3-9.0, P = 0.02) and inpatient mortality (OR: 2.6, 95% CI 1.1-6.6, P = 0.03). Higher peak procalcitonin concentrations was an independent predictor of mortality on multivariate analysis (OR 3.7, 95% CI 1.1-12.4, P = 0.03). There was a significant positive correlation between increased peak procalcitonin concentrations and duration on invasive mechanical ventilation. No significant difference was found between peak procalcitonin concentrations of patients with positive and negative bacterial cultures.

CONCLUSIONS

Elevated procalcitonin concentrations in Covid-19 patients are associated with respiratory failure requiring prolonged invasive mechanical ventilation and inpatient mortality. This association may be independent of bacterial co-infection.

Respiratory morbidity and mortality of traumatic cervical spinal cord injury at a level I trauma center in India

STUDY DESIGN

Descriptive retrospective.

OBJECTIVES

To evaluate the burden of respiratory morbidity in terms of ventilator dependence (VD) days and length of stay in neurotrauma ICU (NICU) and hospital, and to determine mortality in patients with traumatic cervical spinal cord injury (CSCI) in a low middle-income country (LMIC).

SETTING

Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India.

METHODS

A total of 135 patients admitted with CSCI in the NICU between January 2017 to December 2018 were screened. Information regarding age, gender, American Spinal Injury Association (ASIA) impairment scale (AIS), level of injury, duration of VD, length of NICU, hospital stay, and outcome in terms of mortality or discharge from the hospital were obtained from the medical records.

RESULTS

A total of 106 CSCI patients were analyzed. The mean (SD) age of patients was 40 (±16) years and male: female ratio was 5:1. The duration of VD, duration of NICU, and hospital stay was a median of 8 days (IQR 1127), 6 days (IQR 1118), and 15 days (IQR 3127) respectively. Mortality was 19% (20/106). The mortality was significantly associated with poorer AIS score, VD, and duration of ICU and hospital stay. All patients were discharged to home only after they became ventilator-free.

CONCLUSIONS

The ventilator burden, hospital stay, and mortality are high in patients with CSCI in LMICs. Poor AIS scores, prolonged VD, ICU and hospital stay are associated with mortality. There is a need for comprehensive CSCI rehabilitation programs in LMICs to improve outcome.

Influence of ventilatory strategies on outcomes and length of hospital stay: assist-control and synchronized intermittent mandatory ventilation modes

The use of synchronized intermittent mandatory ventilation with pressure support ventilation (SIMV + PSV) mode has been discontinued. This study analyzed the association between medical outcomes related to the use of assist-control (A/C) and SIMV + PSV in an intensive care unit. In this observational and retrospective study, modes of ventilation and medical data were collected from electronic medical records for three consecutive years and were related to medical outcomes (mortality), duration of mechanical ventilation, length of hospital stay and the need for tracheostomy. Participants were divided into groups according to the modes of ventilation: A/C and SIMV + PSV. Statistical analyses were performed in the R environment. Alpha = 0.05. The using chi-square, Fisher's exact, Mann-Whitney and Kruskal-Wallis tests were used. 345 adult participants were included; 211/345 (61.16%) were males. Of the participants, 151/345 (43.77%) were on SIMV + PSV and 194/345 (56.23%) were on A/C. The comparative analysis between the modes of ventilation showed no significant differences in length of hospital stay (p = 0.675), duration of mechanical ventilation (p = 0.952), mortality (p = 0.241), failed extubation (p = 0.411) and the need for tracheostomy (p = 0.301). SIMV + PSV as a mode of ventilation showed similar statistical results to the A/C mode, when compared to analyzed medical outcomes.

A comparative two-cohort study of pediatric patients with long term stay in ICUs

During the last decades, the number of patients with long stay admissions (LSA) in PICU has increased. The purpose of this study was to identify factors associated with PICU LSA, assessing healthcare resources use and changes in the profile of these patients. A retrospective, observational, single-center study was carried out. Characteristics of LSA were compared between two periods (2006–2010 and 2011–2015). During the earlier period there were 2,118 admissions (3.9% of them LSA), whereas during the second period, there were 1,763 (5.4% of them LSA) (p = 0.025). LSA accounted for 33.7% PICU stay days during the first period and 46.7% during the second (p < 0.001). Higher use of non-invasive ventilation (80.2% vs. 37.8%, p = 0.001) and high-flow oxygen therapy (68.8% vs. 37.8%, p = 0.005) was observed in the 2011–2015 cohort, whereas the use of arterial catheter (77.1% vs. 92.6%, p = 0.005), continuous infusion of adrenaline (55.2% vs. 75.9%, p = 0.004), and hemoderivative transfusion (74% vs. 89.2%, p = 0.010) was less frequent. In the 2006–2010 cohort, hospital-acquired infections were more common (95.2% vs. 68.8%, p < 0.001) and mortality was higher (26.8% vs. 13.8%, p = 0.026). The number of long-stay PICU admissions have increased entailing an intensive use of healthcare resources. These patients have a high risk for complications and mortality.

Prevalence and Intensive Care Bed Use in Subjects on Prolonged Mechanical Ventilation in Swedish ICUs

BACKGROUND

The number of patients requiring prolonged mechanical ventilation (PMV) is predicted to escalate due to an aging population. International studies on prevalence and resource utilization of this patient group exist, but data are lacking from Scandinavian ICUs, where there is a relatively low number of ICU beds in relation to population. The primary aim was to identify prevalence of admissions requiring mechanical ventilation ≥ 7-21 d and PMV > 21 d, and their use of ICU bed days in Sweden. Secondary aims were to describe patient characteristics and outcomes.

METHODS

We obtained data from the Swedish Intensive Care Registry on admissions age ≥ 18 y mechanically ventilated ≥ 7 d and used open source registry data to calculate the prevalence and use of bed days of admissions ventilated ≥ 7-21 d and PMV > 21 d.

RESULTS

Of the 39,510 ICU admissions to Swedish ICUs in 2017, those mechanically ventilated ≥ 7-21 d accounted for 1,643 (4%) admissions, and those with PMV > 21 d accounted for 307 (0.8%) admissions. Of the 109,457 ICU bed days, 22% were consumed by admissions ventilated ≥ 7-21 d and 10% by those with PMV > 21 d. The ICU mortality of both groups was 21%. Admissions with mechanical ventilation ≥ 7 d had a median age of 65 y and were predominantly male (64%).

CONCLUSIONS

Admissions to Swedish ICUs who required mechanical ventilation ≥ 7-21 d and PMV > 21 d form a relatively small proportion of all ICU admissions, but consume a significant proportion of ICU beds days. Prevalence of admissions, ICU bed days, and ICU mortality were lower than reports from other countries, but the admissions were predominantly elderly and male, in accordance with other reports.

Extubation during extracorporeal membrane oxygenation in adults: An international qualitative study on experts' opinions

BACKGROUND

Extracorporeal membrane oxygenation in adults (adult-ECMO), a modification of cardiopulmonary bypass is increasingly used. Liberation from mechanical ventilation, or extubation, during adult-ECMO remains a challenge.

OBJECTIVES

This study aimed to understand expert perceptions of the reasonableness of extubation during adult-ECMO and the usefulness of an extubation clinical practice guideline (ECPG).

METHODS

Homogeneous purposive sampling, focus groups, and interviews with a discussion guide, and direct content, thematic analysis were used.

RESULTS

Fourteen volunteers participated with different educational levels (79% Doctor of Medicine, 14% Registered Nurse, 7% Nurse Practitioner), from high-volume ECMO centers of various annual ECMO runs (50% 30-49 ECMO/year, 36% 50-99 ECMO/year, 14% >100 ECMO/year) worldwide (64% North America, 21% South America, 7% Europe, 7% Asia). Seven themes were identified: paucity of evidence, mindsets towards using an ECPG, barriers, criteria and benefits of extubation, culture towards extubation and vision of the future. Participants recommended aiming for extubation based on patient selection, and a standardized extubation approach with an ECPG or team decision-making.

CONCLUSION

Application of adult-ECMO is expanding, during which extubation remains difficult. Experts recommend two methods of a standardized extubation approach.

Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country

Background

An increasing number of patients become chronic critically ill (CCI) and dependent on long-term therapies in the intensive care unit (ICU). Mortality and healthcare costs increase in these patients. In order to deal with this problem, the magnitude and risk factors for CCI must first be determined. Therefore, we aimed at evaluating the incidence cost and risk factors for CCI in our ICU.

Materials and methods

This retrospective cohort study was compiled by recruiting patients admitted to our ICU between January 1, 2017, and December 31, 2018. Patients with an ICU stay of more than 21 days were defined as CCI. Patients who did not survive in the first 21 days were excluded from the study because it could be not known whether these patients would progress to CCI. During the study period, 1,166 patients were followed up, and 475 (40%) of them were excluded and 691 patients were included in the final analyses.

Results

During the study period, 691 patients were included in the study and 152 of them (22%) were CCI. Age, acute physiology and chronic health evaluation (APACHE)-2 score, length of stay, and daily costs were higher in patients with CCI. The cost for a patient with CCI is sixfold that of a patient without CCI. ICU mortality was 47% in patients without CCI and 54% in the CCI patients (p < 0.001).

Conclusion

CCI affects an increasing number of patients and leads to increased mortality rates and cost. Prolonged duration in ICU may cause complications such as secondary infections, sepsis episodes, and acute renal injury. The treatment of these complications may lead to increased mortality and cost.

How to cite this article

Yildirim S, Durmaz Y, Şan Y, Taşkiran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021;25(5):519–523.

Long-Term Prognosis of Older Adults Who Survive Emergency Mechanical Ventilation

CONTEXT

Emergent mechanical ventilation represents an important inflection point in seriously ill older adults' illness trajectories. Data are lacking on the long-term prognosis after surviving mechanical ventilation to inform shared decision making in serious illness conversations.

OBJECTIVES

Describe the long-term prognosis of older adults who survive emergency mechanical ventilation to inform shared decision making.

METHODS

This is a retrospective cohort study from a single-center intensive care unit in an academic, urban, and tertiary care medical center. We included adults aged 75 years and older consecutively admitted with mechanical ventilation between 2008 and 2012 in the Multiparameter Intelligent Monitoring of Intensive Care III database. We excluded patients who were electively admitted. Our primary outcome was the long-term prognosis after leaving the hospital stratified by discharge location. Our secondary outcome was the frequency of documented serious illness conversations within 48 hours of hospitalization recommended by the National Quality Forum.

RESULTS

We identified 415 patients (454 hospital admissions) consecutively admitted to the intensive care unit. The median age was 82.6 years, 54.0% were female, 78.2% were white, non-Hispanic, and in-hospital mortality rate was 36.6%. Among the survivors, the median survival after hospital discharge was 163.5 days (interquartile range 37.5-476.8). Only 49.1% of patients had documented serious illness conversations within 48 hours of hospitalization. About 63.4% of patients (59 of 93) who were discharged to long-term acute care hospitals died by six months.

CONCLUSION

This study demonstrated the long-term prognosis of older adults who underwent emergent mechanical ventilation. These data could be used to inform shared decision making in serious illness conversations.

Stapled Repair of Benign Acquired Tracheoesophageal Fistula: Description of Novel Technique and Assessment of Outcomes

Compared to less invasive measures, surgical repair is the most effective modality for managing benign acquired tracheoesophageal fistula (TEF). Traditionally, this involves dismantling of the fistula and suture repair of tracheal and esophageal defects using a lateral or direct approach. However, the best approach remains a subject of debate. We describe a novel and simple technique for dismantling a benign acquired TEF with the use of an endo-stapler and interposition with sternocleidomastoid (SCM) muscle flap. Eleven TEF patients underwent repair using this stapled repair technique. Retrospectively, the perioperative and long-term outcomes were assessed in these patients. There were no cases of procedure-related mortality or airway-related complications. Two patients developed transient vocal cord palsy and one developed esophageal leak. At a mean follow-up of 21.4 months, no fistula recurrence, dysphagia, or tracheal stenosis was observed. Hence stapled dismantling and SCM muscle interposition is a simple and safe technique for repair of benign acquired TEF.

Clinical study of Dysfunctional Ventilatory Weaning Response in critically ill patients

Objective:

to clinically validate the nursing diagnosis of Dysfunctional Ventilatory Weaning Response in adult patients admitted to Intensive Care Units.

Method:

a concurrent cohort performed with 93 patients admitted to Intensive Care Units. The incidence and incidence density of the diagnosis were estimated, its related factors were identified based on bivariate analysis and clinical indicators for determining its occurrence, according to the global and temporal presentation.

Results:

the overall incidence of the diagnosis was 44.09% and the incidence density was 14.49 occurrences for every 100 extubations/day. The factors related to the diagnosis were the following: age, clinical severity, fluid balance, oliguria, hemodialysis, edema in upper/lower limbs, anasarca, number of antibiotics, hypothermia, hyperthermia, amount of secretion, muscle retraction, anxiety score, heart rate, use of vasopressors and non-invasive ventilation after extubation. The clinical indicators most frequently identified for determining the diagnosis were the following: tachypnea, drop of saturation and tachycardia. Temporal progression in the severity of these manifestations was found.

Conclusion:

the Dysfunctional Ventilatory Weaning Response is a common finding in critically ill patients. Some components of the diagnosis of the NANDA-International (2018) version could be clinically validated. It is noteworthy that there are variables not yet described in the taxonomy, demonstrating the need to review this nursing diagnosis.

Effects of Inspiratory Muscle Training and Early Mobilization on Weaning of Mechanical Ventilation: A Systematic Review and Network Meta-analysis

OBJECTIVE

To compare the effectiveness and rank order of physical therapy interventions, including conventional physical therapy (CPT), inspiratory muscle training (IMT), and early mobilization (EM) on mechanical ventilation (MV) duration and weaning duration.

DATA SOURCES

PubMed, The Cochrane Library, Scopus, and CINAHL complete electronic databases were searched through August 2019.

STUDY SELECTION

Randomized controlled trials (RCTs) investigating the effect of IMT, EM, or CPT on MV duration and the weaning duration in patients with MV were included. Studies that were determined to meet the eligibility criteria by 2 independent authors were included. A total of 6498 relevant studies were identified in the search, and 18 RCTs (934 participants) were included in the final analysis.

DATA EXTRACTION

Data were extracted independently by 2 authors and assessed the study quality by the Cochrane risk-of-bias tool. The primary outcomes were MV duration and weaning duration.

DATA SYNTHESIS

Various interventions of physical therapy were identified in the eligible studies, including IMT, IMT+CPT, EM, EM+CPT, and CPT. The data analysis demonstrated that compared with CPT, IMT+CPT significantly reduced the weaning duration (mean difference; 95% confidence interval) (-2.60; -4.76 to -0.45) and EM significantly reduced the MV duration (-2.01; -3.81 to -0.22). IMT+CPT and EM had the highest effectiveness in reducing the weaning duration and MV duration, respectively.

CONCLUSION

IMT or EM should be recommended for improving the weaning outcomes in mechanically ventilated patients. However, an interpretation with caution is required due to the heterogeneity.

Characteristics and predictors of chronic critical illness in the intensive care unit

Objective

To characterize patients with chronic critical illness and identify predictors of development of chronic critical illness.

Methods

Prospective data was collected for 1 year in the intensive care unit of a general hospital in Southern Brazil. Three logistic regression models were constructed to identify factors associated with chronic critical illness.

Results

Among the 574 subjects admitted to the intensive care unit, 200 were submitted to mechanical ventilation. Of these patients, 85 (43.5%) developed chronic critical illness, composing 14.8% of all the patients admitted to the intensive care unit. The regression model that evaluated the association of chronic critical illness with conditions present prior to intensive care unit admission identified chronic renal failure in patients undergoing hemodialysis (OR 3.57; p = 0.04) and a neurological diagnosis at hospital admission (OR 2.25; p = 0.008) as independent factors. In the model that evaluated the association of chronic critical illness with situations that occurred during intensive care unit stay, muscle weakness (OR 2.86; p = 0.01) and pressure ulcers (OR 9.54; p < 0.001) had the strongest associations. In the global multivariate analysis (that assessed previous factors and situations that occurred in the intensive care unit), hospital admission due to neurological diseases (OR 2.61; p = 0.03) and the development of pressure ulcers (OR 9.08; p < 0.001) had the strongest associations.

Conclusion

The incidence of chronic critical illness in this study was similar to that observed in other studies and had a strong association with the diagnosis of neurological diseases at hospital admission and chronic renal failure in patients undergoing hemodialysis, as well as complications developed during hospitalization, such as pressure ulcers and muscle weakness.

Risk factors associated with mortality among patients who had candidemia in a university hospital

INTRODUCTION:

Bloodstream infection due to Candida spp. is a primary cause of morbidity and mortality in tertiary hospitals.

METHODS:

In this retrospective study, we included patients with a positive blood culture for Candida spp. after 48 h of hospitalization.

RESULTS

A total of 335 patients who had candidemia were included in this study. Risk factors associated with mortality were hospitalization in internal medicine units and surgical clinics, age >60 years, mechanical ventilation, orotracheal intubation, hemodialysis, corticosteroids use, and C. parapsilosis infection.

CONCLUSIONS:

This study highlights the importance of health care related to invasive procedures and actions to improve patient immunity.

Obesity as a Predictor of Prolonged Mechanical Ventilation

Objective

To examine the effect of including obesity with parameters of the I-TRACH scale in predicting the need for prolonged mechanical ventilation.

Study Design

A retrospective cohort study.

Setting

Tertiary care academic medical center.

Subjects and Methods

Consecutive patients were identified retrospectively over a 45-month period based on need for mechanical ventilation in the medical intensive care unit. Chart review was performed to collect demographic information as well as clinical data, including duration of mechanical ventilation, body mass index (BMI), and I-TRACH parameters (heart rate >110, serum urea nitrogen >25, serum pH <7.25, serum creatinine >2, serum bicarbonate <20). Statistical analysis was performed to identify any predictors of prolonged mechanical ventilation, defined as ≥14 days and as ≥10 days.

Results

In total, 455 patients were identified, with an average duration of mechanical ventilation of 10.4 days (range, 0-248 days). On univariate and multivariate regression analysis, only BMI >30 reached statistical significance with respect to prolonged mechanical ventilation ( P < .05). The I-TRACH parameters—either alone or in combination—were not significantly predictive.

Conclusion

This study challenges previous findings regarding the I-TRACH scale and the relation of its parameters to prolonged mechanical ventilation. Furthermore, BMI >30 alone was predictive of prolonged intubation. Inclusion of BMI in predictive models could assist current decision making in determining the likelihood of prolonged mechanical ventilation in medical intensive care unit patients going forward, and obesity should be considered a predictor of prolonged mechanical ventilation.

Impact of a multidisciplinary checklist on the duration of invasive mechanical ventilation and length of ICU stay

Objective:

To assess the impact that implementing a checklist during daily multidisciplinary rounds has on the duration of invasive mechanical ventilation (IMV) and length of ICU stay.

Methods:

This was a non-randomized clinical trial in which the pre-intervention and post-intervention duration of IMV and length of ICU stay were evaluated in a total of 466 patients, including historical controls, treated in three ICUs of a hospital in the city of Caxias do Sul, Brazil. We evaluated 235 and 231 patients in the pre-intervention and post-intervention periods, respectively. The following variables were studied: age; gender; cause of hospitalization; diagnosis on admission; comorbidities; the Simplified Acute Physiology Score 3; the Sequential Organ Failure Assessment score; days in the ICU; days on IMV; reintubation; readmission; in-hospital mortality; and ICU mortality.

Results:

After the implementation of the checklist, the median (interquartile range) for days in the ICU and for days on IMV decreased from 8 (4-17) to 5 (3-11) and from 5 (1-12) to 2 (< 1-7), respectively, and the differences were significant (p ≤ 0.001 for both).

Conclusions:

The implementation of the checklist during daily multidisciplinary rounds was associated with a reduction in the duration of IMV and length of ICU stay among the patients in our sample.

Effect of Dexmedetomidine on duration of mechanical ventilation in septic patients: a systematic review and meta-analysis

Background

Because of its analgesic and light sedative properties, the highly selective alpha-2 adrenergic receptor agonist dexmedetomidine (DEX) has been suggested for the treatment of septic patients, but its effect on the duration of mechanical ventilation remains unclear. The present study was conducted to review the extant literature in DEX and determine its influence on ventilation time in adult septic patients.

Methods

Databases of PubMed, Cochrane, and EMBASE were applied till 20th January 2019 without language restriction. The searching strategy as following: sepsis OR septic AND mechanical ventilation AND dexmedetomidine. Two authors screened titles, abstracts, and even articles to meet the including criterion independently. In addition, references of related articles or reviews were also referred. Data was recorded in a table and analyzed using the software of Review Manager 5.0.

Results

Four studies with a total of 349 patients were included. Three trials with 267 patients revealed the effect of DEX on duration of mechanical ventilation, two trials with 264 patients on ventilator-free days and four trials with 334 patients on 28-day mortality. The analyzed results indicated that DEX was not associated with significantly different durations of mechanical ventilation (MD 0.65, 95% CI, − 0.13 to 1.42, P = 0.10). However, there were significant differences in ventilator-free days (MD 3.57, 95% CI, 0.26 to 6.89, P = 0.03) and 28-day mortality (RR 0.61, 95% CI, 0.49 to 0.94, P = 0.02) in the septic patients.

Conclusion

Administration of DEX for sedation in septic patients was not associated with the duration of mechanical ventilation, but it increased the ventilator-free days and reduced 28-day mortality.

Risk factors and outcomes among delirium subtypes in adult ICUs: A systematic review

PURPOSE

Use systematic review methodology to summarize risk factors and outcomes for each delirium subtype (hypoactive, hyperactive and mixed) in an adult ICU population.

MATERIALS AND METHODS

We searched the MEDLINE, Embase, CINAHL, SCOPUS, Web of Science and PsycINFO databases from database inception until August 13, 2018, with no restrictions.

RESULTS

Of 9635 abstracts, 20 studies were included. Older age was not associated with any delirium subtype in 4/7 (57%) studies. Sex was not associated with any delirium subtype in 4/4 (100%) studies. Mortality was consistently associated with hypoactive delirium in 4/7 (57%) studies. The evidence supporting the association of APACHE-II score, mechanical ventilation, length of stay, duration of delirium and removal of tubes were inconsistent across studies.

CONCLUSIONS

Although included studies reported on many subtype-specific risk factors and outcomes, heterogeneity in reporting and methodological quality limited the generalizability of the results and the evidence for many subtype-specific risk factors or outcomes is inconsistent across studies. Standardized methodology and the creation of a universal template for collecting data in ICU delirium studies are essential moving forward; helping to identify subtype-specific risk factors or outcomes and strengthen the association of potential risk factors or outcomes.

Clinical features and outcomes of prolonged mechanical ventilation: a single-center retrospective observational study

Background

Information on epidemiology of prolonged mechanical ventilation (PMV) patients in the acute care setting in Japan is totally lacking. We aimed to investigate clinical features, impact, and long-term outcomes of PMV patients.

Methods

This was a retrospective observational study conducted in a tertiary care hospital. Adult patients who were admitted to our intensive care unit (ICU) from April 2009 to March 2014 and required mechanical ventilation (MV) for ≥ 2 days were included. PMV was defined as having MV for ≥ 21 consecutive days.

Results

Among 1282 MV patients, 93 (7.3%) required PMV, and median duration of MV was 37.0 days. Compared with the non-PMV patients, PMV patients had longer total ICU and high care unit (HCU) stay (34.0 vs. 7.0 days, p < 0.001), longer hospital stay (74.0 vs. 35.0 days, p < 0.001), and higher hospital mortality (54.8 vs. 21.4%, p < 0.001). In multivariable logistic regression analysis, emergency ICU admission and steroid use during MV were associated with PMV. The Kaplan–Meier curves for MV withdrawal and ICU/HCU discharge were almost identical. Among PMV patients, 52 (55.9%) died, 29 (31.2%) were successfully liberated from MV during hospitalization, and 12 (12.9%) still required MV at discharge.

Conclusion

In this investigation, 7.3% of the patients with MV required PMV. Most PMV patients were liberated from MV during hospitalization, while occupying critical care beds for an extended period. A nationwide survey is required to further elucidate the overall picture of PMV patients and to discuss whether specialized weaning centers to treat PMV patients are required in Japan.

De novo lung biofabrication: clinical need, construction methods, and design strategy

Chronic lung disease is the 4th leading cause of death in the United States. Due to a shortage of donor lungs, alternative approaches to support failing, native lungs have been attempted, including mechanical ventilation and various forms of artificial lungs. However, each of these support methods causes significant complications when used for longer than a few days and are thus not capable of long-term support. For artificial lungs, complications arise due to interactions between the artificial materials of the device and the blood of the recipient. A potential new approach is the fabrication of lungs from biological materials, such that the gas exchange membranes provide a more biomimetic blood-contacting interface. Recent advancements with three-dimensional, soft-tissue biofabrication methods and the engineering of thin, basement membranes demonstrate the potential of fabricating a lung scaffold from extracellular matrix materials. This scaffold could then be seeded with endothelial and epithelial cells, matured within a bioreactor, and transplanted. In theory, this fully biological lung could provide improved, long-term biocompatibility relative to artificial lungs, but significant work is needed to perfect the organ design and construction methods. Like artificial lungs, biofabricated lungs do not need to follow the shape and structure of a native lung, allowing for simpler manufacture. However, various functional requirements must still be met, including stable, efficient gas exchange for a period of years. Design decisions depend on the disease state, how the organ is implanted, and the latest biofabrication methods available in a rapidly evolving field.

Microbiological analysis of endotracheal aspirate and endotracheal tube cultures in mechanically ventilated patients

Background

To compare the microbiological culture within endotracheal aspirate specimens (ETAs) and endotracheal tube specimens (ETTs) in patients undergoing mechanical ventilation (MV) by statistical tools.

Method

ETAs and ETTs from a total number of 81 patients, who were undergoing MV at the intensive care unit (ICU) of Jiading Central Hospital Affiliated Shanghai University of Medicine & Health Sciences from September 1st, 2017 to August 31st, 2018, were collected for microbiological culture analysis. Correlation of ETAs and ETTs cultures were obtained by Spear-men correlation analysis, while the consistency of the two specimens was determined by Kappa analysis and principal component analysis (PCA).

Results

Microbiological culture from both ETAs and ETTs showed that Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella pneumoniae were the main pathogens, with Spear-man correlation coefficients of 0.676, 0.951, 0.730 and 0.687 respectively (all P < 0.01), and the overall Spear-man correlation coefficient is 0.757 (P < 0.01). This result shows that two samples were positively correlated. Kappa analysis also revealed high consistency of the microbial culture results from the ETAs and the ETTs (overall κ = 0.751, P < 0.01). The κ values for the four bacteria detected were 0.670, 0.949, 0.723, and 0.687, respectively (all P < 0.001). PCA also revealed high similarity.

Conclusion

Combining microbiological culture and statistical analysis of samples collected from 81 patients who were undergoing MV in ICU, we showed that microbe found in the ETAs had high similarity with that found in the ETTs which collected at the end of the catheters. In clinical practice, ETAs analysis is easily accessible meanwhile provides a valuable information for MV patients.

Electronic supplementary material

The online version of this article (10.1186/s12890-019-0926-3) contains supplementary material, which is available to authorized users.

Predicting Mortality and Life Expectancy in Patients under Prolonged Mechanical Ventilation and Maintenance Dialysis

Background: The number of patients receiving prolonged mechanical ventilation (PMV) or maintenance dialysis (MD) is increasing worldwide. Identification of those with a short life expectancy is useful for early referral of palliative care.

Objective: To determine the survival rate, life expectancy, and major prognostic factors in patients under both PMV and MD.

Design: We extracted a 1:3.4 random sample of patients treated with mechanical ventilation (MV) from the National Health Insurance (NHI) Research Database of Taiwan from 2003 to 2007. Subjects who had undergone MD and received MV for longer than 21 days were enrolled.

Setting/Subjects: There were 1035 patients who received both PMV and MD.

Measurements: The survival rates and life expectancy were estimated. A multivariate proportional hazards model was constructed to validate the effects of different prognostic factors, including age, gender, hospital size, and major comorbidities.

Results: The median length of survival of patients under both PMV and MD was 54 days. The three-month, six-month, and one-year survival rates were 40.8%, 24.1%, and 12.6%, respectively. The life expectancies of those older than 70 years were five months; those comorbid with cancer and septicemia were 112 and 90 days, respectively. After adjustments for covariates, we found following prognostic factors were statistically significant: gangrene, peritonitis, liver cirrhosis, cancer, septicemia, hydrocephalus, having device complications, and shock.

Conclusions: More than 85% of patients receiving both PMV and MD died within one year. Communication and early referral for palliative care would be indicated for those comorbid with significant prognostic factors.

Prognosis of patients with acute respiratory failure and prolonged intensive care unit stay

Background

Reasons for the prolonged critical care support include uncertainty of outcome, the complex dynamic created between physicians with care team members and the patient's family over a general unwillingness to surrender to unfavorable outcomes. The purpose of this study was to investigate outcomes and identify risk factors of patients with acute respiratory failure (ARF) who required a prolonged intensive care unit (ICU) stay (≥21 days). It may provide reference to screen patients who are suitable for hospice care.

Methods

The medical records of all ARF patients with a prolonged ICU stay were retrospectively reviewed. The primary outcome was in-hospital mortality.

Results

We identified 1,189 patients. Sepsis (n=896, 75.4%) was the most common cause of prolonged ICU stays, following by renal failure (n=232, 19.5%), and unstable hemodynamic status vasopressors or arrhythmia (n=208, 17.5%). Using multivariable logistic regression, we identified eight risk factors of death: age >75 years, ICU stay for more than 28 days, APACHE II score ≥25, unstable hemodynamic status, renal failure, hepatic failure, massive gastrointestinal tract bleeding, and using a fraction of inspired oxygen (FiO₂) ≥40%. The overall in-hospital mortality rate was 53.6% (n=637), and it up to 75.3% (216/287) for patients with at least three risk factors.

Conclusions

The outcome of patients with ARF who required prolonged ICU stay was poor. They had a high risk of in-hospital mortality. Palliative care should be considered as a reasonable option for the patients at high risk of death.

Impact of post-traumatic stress symptoms on the health-related quality of life in a cohort study with chronically critically ill patients and their partners: age matters

Background

Survivors of an acute critical illness with continuing organ dysfunction and uncontrolled inflammatory responses are prone to become chronically critically ill. As mental sequelae, a post-traumatic stress disorder and an associated decrease in the health-related quality of life (QoL) may occur, not only in the patients but also in their partners. Currently, research on long-term mental distress in chronically critically ill patient-partner dyads, using appropriate dyadic analysis strategies (patients and partners being measured and linked on the same variables) and controlling for contextual factors, is lacking.

Methods

The present study investigates the interdependence of post-traumatic stress symptoms (PTSS) and the health-related QoL in n = 70 dyads of chronically critically ill patients and their partners, using the Actor-Partner-Interdependence Model (APIM) under consideration of contextual factors (age, gender, length of partnership). The Post-traumatic Stress Scale (PTSS-10) and Euro-Quality of Life (EQ-5D-3L) were applied in both the patients and their partners, within up to 6 months after the transfer from acute care ICU to post-acute ICU.

Results

Clinically relevant post-traumatic stress symptoms were reported by 17.1% of the patients and 18.6% of the partners. Both the chronically critically ill patients and their partners with more severe post-traumatic stress symptoms also showed a decreased health-related QoL. The latter was more pronounced in male partners compared to female partners or female patients. In younger partners (≤ 57 years), higher values of post-traumatic stress symptoms were associated with a decreased QoL in the patients.

Conclusions

Mental health screening and psychotherapeutic treatment options should be offered to both the chronically critically ill patients and their partners. Future research is required to address the special needs of younger patient-partner dyads, following protracted ICU treatment.

Trial registration

German Clinical Trials Register No. DRKS00003386. Registered 13 November 2011

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2321-0) contains supplementary material, which is available to authorized users.

Left ventricular-arterial coupling is associated with prolonged mechanical ventilation in severe post-cardiac surgery patients: an observational study

Background

Weaning post-cardiac surgery patients from mechanical ventilation (MV) poses a big challenge to these patients. Optimized left ventricular-arterial coupling (VAC) may be crucial for reducing the MV duration of these patients. However, there is no research exploring the relationship between VAC and the duration of MV. We performed this study to investigate the relationship between left ventricular-arterial coupling (VAC) and prolonged mechanical ventilation (MV) in severe post-cardiac surgery patients.

Methods

This was a single-center retrospective study of 56 severe post-cardiac surgery patients from January 2015 to December 2017 at the Department of Critical Care Medicine of Peking Union Medical College Hospital. Patients were divided into two groups according to the duration of MV (PMV group: prolonged mechanical ventilation group, MV > 6 days; Non-PMV group: non-prolonged mechanical ventilation group, MV ≤ 6 days). Hemodynamics and tissue perfusion data were collected or calculated at admission (T0) and 48 h after admission (T1) to the ICU.

Results

In terms of hemodynamic and tissue perfusion data, there were no differences between the two groups at admission (T0). Compared with the non-prolonged MV group after 48 h in the ICU (T1), the prolonged MV group had significantly higher values for heart rate (108 ± 13 vs 97 ± 12, P = 0.018), lactate (2.42 ± 1.24 vs.1.46 ± 0.58, P < 0.001), and Ea/Ees (5.93 ± 1.81 vs. 4.05 ± 1.20, P < 0.001). Increased Ea/Ees (odds ratio, 7.305; 95% CI, 1.181–45.168; P = 0.032) and lactate at T1 (odds ratio, 17.796; 95% CI, 1.377–229.988; P = 0.027) were independently associated with prolonged MV. There was a significant relationship between Ea/Ees_T1 and the duration of MV (r = 0.512, P < 0.01). The area under the receiver operating characteristic (AUC) of the left VAC for predicting prolonged MV was 0.801, and the cutoff value for Ea/Ees was 5.12, with 65.0% sensitivity and 90.0% specificity.

Conclusions

Left ventricular-arterial coupling was associated with prolonged mechanical ventilation in severe post-cardiac surgery patients. The assessment and optimization of left VAC might be helpful in reducing duration of MV in these patients.

Prolonged Mechanical Ventilation Assistance Interacts Synergistically with Carbapenem for Clostridium difficile Infection in Critically Ill Patients

Objectives: Interactions between mechanical ventilation (MV) and carbapenem interventions were investigated for the risk of Clostridium difficile infection (CDI) in critically ill patients undergoing concurrent carbapenem therapy. Methods: Taiwan’s National Intensive Care Unit Database (NICUD) was used in this analytical, observational, and retrospective study. We analyzed 267,871 intubated patients in subgroups based on the duration of MV support: 7–14 days (n = 97,525), 15–21 days (n = 52,068), 22–28 days (n = 35,264), and 29–60 days (n = 70,021). The primary outcome was CDI. Results: Age (>75 years old), prolonged MV assistance (>21 days), carbapenem therapy (>15 days), and high comorbidity scores were identified as independent risk factors for developing CDI. CDI risk increased with longer MV support. The highest rate of CDI was in the MV 29–60 days subgroup (adjusted hazard ratio (AHR) = 2.85; 95% confidence interval (CI) = 1.46–5.58; p < 0.02). Moreover, higher CDI rates correlated with the interaction between MV and carbapenem interventions; these CDI risks were increased in the MV 15–21 days (AHR = 2.58; 95% CI = 1.12–5.91) and MV 29–60 days (AHR = 4.63; 95% CI = 1.14–10.03) subgroups than in the non-MV and non-carbapenem subgroups. Conclusions: Both MV support and carbapenem interventions significantly increase the risk that critically ill patients will develop CDI. Moreover, prolonged MV support and carbapenem therapy synergistically induce CDI. These findings provide new insights into the role of MV support in the development of CDI.

Chronic critical illness: are we saving patients or creating victims?

The technological advancements that allow support for organ dysfunction have led to an increase in survival rates for the most critically ill patients. Some of these patients survive the initial acute critical condition but continue to suffer from organ dysfunction and remain in an inflammatory state for long periods of time. This group of critically ill patients has been described since the 1980s and has had different diagnostic criteria over the years. These patients are known to have lengthy hospital stays, undergo significant alterations in muscle and bone metabolism, show immunodeficiency, consume substantial health resources, have reduced functional and cognitive capacity after discharge, create a sizable workload for caregivers, and present high long-term mortality rates. The aim of this review is to report on the most current evidence in terms of the definition, pathophysiology, clinical manifestations, treatment, and prognosis of persistent critical illness.

Predictors and pattern of weaning and long-term outcome of patients with prolonged mechanical ventilation at an acute intensive care unit in North India

Objective

This study aimed to examine the clinical characteristics, weaning pattern, and outcome of patients requiring prolonged mechanical ventilation in acute intensive care unit settings in a resource-limited country.

Methods

This was a prospective single-center observational study in India, where all adult patients requiring prolonged ventilation were followed for weaning duration and pattern and for survival at both intensive care unit discharge and at 12 months. The definition of prolonged mechanical ventilation used was that of the National Association for Medical Direction of Respiratory Care.

Results

During the one-year period, 49 patients with a mean age of 49.7 years had prolonged ventilation; 63% were male, and 84% had a medical illness. The median APACHE II and SOFA scores on admission were 17 and 9, respectively. The median number of ventilation days was 37. The most common reason for starting ventilation was respiratory failure secondary to sepsis (67%). Weaning was initiated in 39 (79.5%) patients, with success in 34 (87%). The median weaning duration was 14 (9.5 - 19) days, and the median length of intensive care unit stay was 39 (32 - 58.5) days. Duration of vasopressor support and need for hemodialysis were significant independent predictors of unsuccessful ventilator liberation. At the 12-month follow-up, 65% had survived.

Conclusion

In acute intensive care units, more than one-fourth of patients with invasive ventilation required prolonged ventilation. Successful weaning was achieved in two-thirds of patients, and most survived at the 12-month follow-up.

Coping as a Multifaceted Construct: Associations With Psychological Outcomes Among Family Members of Mechanical Ventilation Survivors

OBJECTIVES

To develop and evaluate a preliminary multifaceted model for coping among family members of patients who survive mechanical ventilation.

DESIGN AND SETTING

In this multicenter cross-sectional survey, we interviewed family members of mechanically ventilated patients at the time of transfer from the ICU to the hospital ward. We constructed a theoretic model of coping that included characteristics attributable to family members, family-clinician rapport, and patients. We then explored relationships between coping factors and symptoms of psychological distress (anxiety, depression, and posttraumatic stress).

SUBJECTS

Fifty-six family members of survivors of mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

Psychological distress measured by the Hospital Anxiety and Depression Scale and Posttraumatic Stress Scale. Optimism measured using the Life Orientation Test scale, resiliency by Conner-Davidson Resilience Scale, and social support using the Patient Reported Outcomes Measurement Information System inventory. Family members had moderate levels of psychological distress with median total Hospital Anxiety and Depression Scale equal to 14 (interquartile range, 5-20) and Posttraumatic Stress Scale equal to 22 (interquartile range, 15-31). Among family member characteristics, greater optimism (p = 0.001, Hospital Anxiety and Depression Scale; p = 0.010, Posttraumatic Stress Scale), resilience (p = 0.012, Hospital Anxiety and Depression Scale), and social support (p = 0.013, Hospital Anxiety and Depression Scale) were protective against psychological distress. On the contrary, characteristics of family-clinician rapport such as communication quality and presence of conflict did not have any associations with psychological distress.

CONCLUSION

To our knowledge, this is the first study to explore coping as a multifaceted construct and its relationship with family psychological outcomes among survivors of mechanical ventilation. We found certain family characteristics of coping such as optimism, resilience, and social support to be associated with less psychological distress. Further research is warranted to identify potentially modifiable aspects of coping that might guide future interventions.

Clinical factors associated with weaning failure in patients requiring prolonged mechanical ventilation

BACKGROUND

For patients requiring prolonged mechanical ventilation (PMV), weaning is difficult and mortality is very high. PMV has been defined recently, by consensus, as constituting ≥21 consecutive days of mechanical ventilation (MV) for ≥6 hours per day. This study aimed to evaluate the clinical factors predicting weaning failure in patients undergoing PMV in medical intensive care unit (ICU).

METHODS

We retrospectively reviewed the clinical and laboratory characteristics of 127 patients who received MV for more than 21 days in the medical ICU at Chonnam National University Hospital in South Korea between January 2005 and December 2014. Patients who underwent surgery or experienced trauma were excluded from this study.

RESULTS

Among the 127 patients requiring PMV, 41 (32.3%) were successfully weaned from MV. The median age of the weaning failure group was higher than that of the weaning success group (74.0 vs. 70.0 years; P=0.003). The proportion of male patients was 58.5% in the weaning success group and 72.1% in the weaning failure group, respectively. The most common reasons for ICU admission were respiratory causes (66.1%) followed by cardiovascular causes (16.5%) in both groups. ICU mortality and in-hospital mortality rates were 55.1% and 55.9%, respectively. In the multivariate analysis, respiratory causes of ICU admission [odds ratio (OR), 3.98; 95% confidence interval (CI), 1.29-12.30; P=0.016] and a high sequential organ failure assessment (SOFA) score on day 21 of MV (OR, 1.47; 95% CI, 1.17-1.85; P=0.001) were significantly associated with weaning failure in patients requiring PMV. The area under the receiver operating characteristic (ROC) curve of the SOFA score on day 21 of MV for predicting weaning failure was 0.77 (95% CI, 0.67-0.87; P=0.000).

CONCLUSIONS

Respiratory causes of ICU admission and a high SOFA score on day 21 of MV could be predictive of weaning failure in patients requiring PMV.

The outcomes and prognostic factors of patients requiring prolonged mechanical ventilation

The aims of this study were to investigate the outcomes of patients requiring prolonged mechanical ventilation (PMV) and to identify risk factors associated with its mortality rate. All patients admitted to the respiratory care centre (RCC) who required PMV (the use of MV ≥21 days) between January 2006 and December 2014 were enrolled. A total of 1,821 patients were identified; their mean age was 69.8 ± 14.2 years, and 521 patients (28.6%) were aged >80 years. Upon RCC admission, the APACHE II scores were 16.5 ± 6.3, and 1,311 (72.0%) patients had at least one comorbidity. Pulmonary infection was the most common diagnosis (n = 770, 42.3%). A total of 320 patients died during hospitalization, and the in-hospital mortality rate was 17.6%. A multivariate stepwise logistic regression analysis indicated that patients were more likely to die if they who were >80 years of age, had lower albumin levels (<2 g/dl) and higher APACHE II scores (≥15), required haemodialysis, or had a comorbidity. In conclusion, the in-hospital mortality for patients requiring PMV in our study was 17%, and mortality was associated with disease severity, hypoalbuminaemia, haemodialysis, and an older age.

Effect of probiotics on the incidence of ventilator-associated pneumonia in critically ill patients: a randomized controlled multicenter trial

PURPOSE

To evaluate the potential preventive effect of probiotics on ventilator-associated pneumonia (VAP).

METHODS

This was an open-label, randomized, controlled multicenter trial involving 235 critically ill adult patients who were expected to receive mechanical ventilation for ≥48 h. The patients were randomized to receive (1) a probiotics capsule containing live Bacillus subtilis and Enterococcus faecalis (Medilac-S) 0.5 g three times daily through a nasogastric feeding tube plus standard preventive strategies or (2) standard preventive strategies alone, for a maximum of 14 days. The development of VAP was evaluated daily, and throat swabs and gastric aspirate were cultured at baseline and once or twice weekly thereafter.

RESULTS

The incidence of microbiologically confirmed VAP in the probiotics group was significantly lower than that in the control patients (36.4 vs. 50.4 %, respectively; P = 0.031). The mean time to develop VAP was significantly longer in the probiotics group than in the control group (10.4 vs. 7.5 days, respectively; P = 0.022). The proportion of patients with acquisition of gastric colonization of potentially pathogenic microorganisms (PPMOs) was lower in the probiotics group (24 %) than the control group (44 %) (P = 0.004). However, the proportion of patients with eradication PPMO colonization on both sites of the oropharynx and stomach were not significantly different between the two groups. The administration of probiotics did not result in any improvement in the incidence of clinically suspected VAP, antimicrobial consumption, duration of mechanical ventilation, mortality and length of hospital stay.

CONCLUSION

Therapy with the probiotic bacteria B. Subtilis and E. faecalis are an effective and safe means for preventing VAP and the acquisition of PPMO colonization in the stomach.

The Outcomes and Prognostic Factors of the Very Elderly Requiring Prolonged Mechanical Ventilation in a Single Respiratory Care Center

This study investigated the outcomes and the prognostic factors among the very elderly (patients ≥80 years old) requiring prolonged mechanical ventilation (PMV).Between 2006 and 2014, all of the very elderly patients of age 80 or more transferred to respiratory care center (RCC) of a tertiary medical center were retrospectively identified, and only patients who used mechanical ventilation (MV) for >3 weeks were included in this study.A total of 510 very elderly patients undergoing PMV were identified. The mean age of the patients was 84.3 ± 3.3 years, and it ranged from 80 to 96 years. Male comprised most of the patients (n = 269, 52.7%), and most of the patients were transferred to RCC from medical ICU (n = 357, 70.0%). The APACHE II scores on RCC admission was 17.6 ± 6.0. At least 1 comorbidity was found in 419 (82.2%) patients. No significant differences of gender, disease severity, diagnosis, dialysis, laboratory examinations, comorbidities, and outcome were found between octogenarians (aged 80-89) and nonagenarians (aged ≥ 90). The overall in-hospital mortality rate was 21.8%. In the multivariate analysis, patients who had APACHE II score ≥ 15(odds ratio [OR], 2.30, 95% confidence interval [CI], 1.36-3.90), or albumin ≤ 2 g/dL (OR, 3.92, 95% CI, 2.17-7.01) were more likely to have significant in-hospital mortality (P < 0.05).The in-hospital mortality rate of the very elderly PMV patients in our RCC is 21.8%, and poor outcomes in this specific population were found to be associated with a higher APACHE II score and lower albumin level.