Outcome of tracheotomized patients following reintubation

OBJECTIVE

To evaluate the outcome of tracheotomized patients after reintubation.

METHOD

Secondary analysis from a prospective, multicenter and observational study including 36 Intensive Care Units (ICUs) from 8 countries.

PATIENTS

A total of 180 patients under mechanical ventilation for more than 48 hours, extubated and reintubated within 48 hours.

INTERVENTIONS

None.

OUTCOMES

ICU mortality, length of ICU stay, organ failure.

RESULTS

Fifty-two patients (29%) underwent tracheotomy after reintubation. The median time from reintubation to tracheotomy was 2.5 days (interquartile range (IQR) 1-8 days). The length of ICU stay was significantly longer in the tracheotomy group compared with the group without tracheotomy (median time 25 days, IQR 17-43 versus 16.5 days (IQR 11-25); p<0.001). ICU mortality in the tracheotomy group was not significantly different (31% versus 27%; p 0.57).

CONCLUSIONS

In our cohort of reintubated patients, tracheotomy is a common procedure in the ICU. Patients with tracheotomy had an outcome similar to those without tracheotomy.

How is mechanical ventilation employed in the intensive care unit? An international utilization review

A 1-d point-prevalence study was performed with the aim of describing the characteristics of conventional mechanical ventilation in intensive care units ICUs from North America, South America, Spain, and Portugal. The study involved 412 medical-surgical ICUs and 1,638 patients receiving mechanical ventilation at the moment of the study. The main outcome measures were characterization of the indications for initiation of mechanical ventilation, the artificial airways used to deliver mechanical ventilation, the ventilator modes and settings, and the methods of weaning. The median age of the study patients was 61 yr, and the median duration of mechanical ventilation at the time of the study was 7 d. Common indications for the initiation of mechanical ventilation included acute respiratory failure (66%), acute exacerbation of chronic obstructive pulmonary disease (13%), coma (10%), and neuromuscular disorders (10%). Mechanical ventilation was delivered via an endotracheal tube in 75% of patients, a tracheostomy in 24%, and a facial mask in 1%. Ventilator modes consisted of assist/control ventilation in 47% of patients and 46% were ventilated with synchronized intermittent mandatory ventilation, pressure support, or the combination of both. The median tidal volume setting was 9 ml/kg in patients receiving assist/control and the median setting of pressure support was 18 cm H(2)O. Positive end-expiratory pressure was not employed in 31% of patients. Method of weaning varied considerably from country to country, and even within a country several methods were in use. We conclude that the primary indications for mechanical ventilation and the ventilator settings were remarkably similar across countries, but the selection of modes of mechanical ventilation and methods of weaning varied considerably from country to country.

Cost containment: the Americas. Argentina

For many years, the evolution of Argentina's healthcare system has been influenced by political and economic instability. Inflation and hyperinflation have led to anarchic development of both health administration systems and hospitals. Critical care grew in a similar manner, resulting in a mix of > 500 critical care units with very different levels of technology and trained personnel. Cost-containment policies have been implemented mainly by health administration systems. Public institutions (university and large provincial and county hospitals) have suffered hard budget cuts that have resulted in a decrease in the quality of care and the loss of trained human resources. Union organizations, which cover the healthcare costs of > 60% of the population, implemented a low reimbursement policy that resulted in low standards of care for critically ill patients. The country's private hospital system is extremely heterogenous, ranging from little, simple institutions with a 20- to 30-bed capacity to great private institutions with international standards of care. Cost-containment efforts have been sporadic and isolated, and statistical data to analyze the results are lacking. In order to formulate a strategy of cost-containment in the near future, accreditation and categorization of critical care units and human resources training are being implemented by health authorities and the Argentine Society of Critical Care Medicine.