Ventilator Days Research Articles

Effects of extracorporeal CO2 removal on gas exchange and ventilator settings: a systematic review and meta-analysis

PurposeA systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO2R) on gas exchange and respiratory settings in critically ill adults with respiratory failure.MethodsWe conducted a comprehensive database search, including observational studies and randomized controlled trials (RCTs) from January 2000 to March 2022, targeting adult ICU patients undergoing ECCO2R. Primary outcomes were changes in gas exchange and ventilator settings 24 h after ECCO2R initiation, estimated as mean of differences, or proportions for adverse events (AEs); with subgroup analyses for disease indication and technology. Across RCTs, we assessed mortality, length of stay, ventilation days, and AEs as mean differences or odds ratios.ResultsA total of 49 studies encompassing 1672 patients were included. ECCO2R was associated with a significant decrease in PaCO2, plateau pressure, and tidal volume and an increase in pH across all patient groups, at an overall 19% adverse event rate. In ARDS and lung transplant patients, the PaO2/FiO2 ratio increased significantly while ventilator settings were variable. “Higher extraction” systems reduced PaCO2 and respiratory rate more efficiently. The three available RCTs did not demonstrate an effect on mortality, but a significantly longer ICU and hospital stay associated with ECCO2R.ConclusionsECCO2R effectively reduces PaCO2 and acidosis allowing for less invasive ventilation. “Higher extraction” systems may be more efficient to achieve this goal. However, as RCTs have not shown a mortality benefit but increase AEs, ECCO2R’s effects on clinical outcome remain unclear. Future studies should target patient groups that may benefit from ECCO2R.PROSPERO Registration No: CRD 42020154110 (on January 24, 2021).Graphical abstract

Evaluation of the Efficacy of Remdesivir for the Treatment of Coronavirus Disease 2019.

Coronavirus disease 2019 (COVID-19), caused by a novel coronavirus, SARS-CoV-2, has accounted for more than 1 000 000 deaths in the United States alone. In May 2020, the Food and Drug Administration issued an Emergency Use Authorization to allow the investigational use of intravenous remdesivir for the treatment of suspected or confirmed COVID-19 in hospitalized children and adults. Several other agents, such as hydroxychloroquine, dexamethasone, and tocilizumab have been investigated as potential treatment options; however, dexamethasone is currently the only agent that has been proven to reduce mortality in patients who require supplemental oxygen. The purpose of this study was to determine if initiation of remdesivir treatment in patients who presented with early symptoms of COVID-19 (defined as symptom onset < 7 days) had a significant impact on in-patient all-cause mortality compared to initiation of remdesivir treatment in patients who presented with symptom onset of at least 7 days. This ethics-committee-approved, retrospective, multicenter, double-arm study was conducted across 10 facilities in the HCA Healthcare West Florida Division. Adult inpatients age 18 and older with confirmed COVID-19 and administered intravenous remdesivir from May 1, 2020, to July 31, 2020, were included. Exclusion criteria included patients less than 18 years of age, the concomitant use of hydroxychloroquine or tocilizumab for any indication, or an estimated glomerular filtration rate less than 30 milliliters per minute. The primary outcome of this study was in-patient all-cause mortality. Secondary outcomes included total length of stay, time to discharge, oxygen requirements, and number of ventilator days. A total of 217 patients from facilities in the HCA Healthcare West Florida Division were evaluated for inclusion. The primary outcome of all-cause mortality occurred in 34.9% of patients with symptom onset of fewer than 7 days versus 31.0% of patients with symptom onset of at least 7 days (P = .57). There were no statistical differences found among the secondary outcomes. Time since symptom onset did not result in a statistically significant difference in all-cause mortality in patients who received intravenous remdesivir for the treatment of COVID-19.

Tele-ICU Management of a Trauma Patient at a Peripheral Center

Methods: A 23-year-old male was admitted to a peripheral center following a fall from a tractor. Examination at admission revealed a conscious, stable patient with significant chest pain. The tele-ICU (intensive care unit) was called, and when they received the patient, he was stabilized and managed immediately. The tele-ICU connection was provided through the Command Center in Apollo Hospitals, Jubilee Hills, Hyderabad, India, which is connected to multiple spoke locations at peripheral centers using audio-visual aids. An intensivist is available 24 h daily to provide critical care services to the peripheral centers through audio-visual aids. The tele-ICU connection is provided to the peripheral centers through commercial audio-visual and bedside data transfer devices. The tele-ICU team supervised the primary survey remotely via a central monitor, viewing the patient’s vitals along with the audio/video calling capabilities of the cameras as a part of the tele-ICU program. Results: Chest X-rays showed bilateral pneumothorax, lung compression, and multiple rib fractures. The team at the peripheral center was immediately advised to institute bilateral intercostal drainage (ICD). High-resolution CT chest (HRCT) reveals extensive right and minor left pneumothorax, bilateral lung contusions, a right clavicle medial end fracture, and multiple rib fractures. Ultrasonography of the abdomen showed altered splenic echo texture and moderate left pleural effusion. Flail chest and paradoxical breathing pattern warranted endotracheal intubation. The patient was ventilated for 4 days. On day 3, the patient experienced an air leak from the left ICD, increased drain output, and decreased hemoglobin. The tele-ICU team consulted the cardiothoracic surgeon regarding the air leak and followed their advice to attach a vacuum bottle to the ICD. The patient’s breathing improved gradually. Mechanical ventilator settings (i.e., tidal volume, respiratory rate, and peak airway pressures) were reviewed daily by the tele-ICU team during the regular morning and evening rounds. In addition, the ventilator and the bedside monitor were continuously monitored from the Command Center through video conferencing, which is integrated with electronic software and regularly captures the patient’s vitals. After 4 days of mechanical ventilation, the patient was extubated and started on oxygen therapy. Oxygen was gradually tapered and stopped. After 8 days of uneventful hospitalization, the patient was discharged. Conclusion: Studies show that telemedicine can provide expert-guided mentoring for life-saving procedures, including pre-hospital assessment and triage for polytrauma, tube thoracotomies, and extended focused assessment with sonography in trauma (eFAST). Technology may help resource-constrained places adopt telemedicine and its benefits.

Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients

IntroductionRelative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival. MethodsRetrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05. ResultsIn 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89). ConclusionsThis is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival.

Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients.

To evaluate the association between driving pressure and tidal volume based on predicted body weight and mortality in a cohort of patients with acute respiratory distress syndrome caused by COVID-19. This was a prospective, observational study that included patients with acute respiratory distress syndrome due to COVID-19 admitted to two intensive care units. We performed multivariable analyses to determine whether driving pressure and tidal volume/kg predicted body weight on the first day of mechanical ventilation, as independent variables, are associated with hospital mortality. We included 231 patients. The mean age was 64 (53 - 74) years, and the mean Simplified Acute and Physiology Score 3 score was 45 (39 - 54). The hospital mortality rate was 51.9%. Driving pressure was independently associated with hospital mortality (odds ratio 1.21, 95%CI 1.04 - 1.41 for each cm H2O increase in driving pressure, p = 0.01). Based on a double stratification analysis, we found that for the same level of tidal volume/kg predicted body weight, the risk of hospital death increased with increasing driving pressure. However, changes in tidal volume/kg predicted body weight were not associated with mortality when they did not lead to an increase in driving pressure. In patients with acute respiratory distress syndrome caused by COVID-19, exposure to higher driving pressure, as opposed to higher tidal volume/kg predicted body weight, is associated with greater mortality. These results suggest that driving pressure might be a primary target for lung-protective mechanical ventilation in these patients.

704 Hydroxocobalamin Is Not Associated with Methemoglobinemia in Patients with Inhalation Injury and Suspected Cyanide Toxicity

Abstract Introduction Cyanide poisoning is a serious threat to burn patients, especially those exposed to smoke from fires, often leading to cyanide toxicity and cardiovascular collapse. Cyanokit, a widely used hydroxocobalamin product able to convert cyanide molecules into safe compounds, is known for its potential to avoid methemoglobinemia, a side effect of other treatments. Concerns about cyanokit's safety, especially in burn patients, have arisen due to recent cases with elevated methemoglobin levels. This study investigates methemoglobin levels in burn patients treated with Cyanokit, aiming to enhance our understanding of cyanide antidote therapy complexities, ultimately leading to safer treatment strategies. Methods A retrospective study was conducted of burn patients admitted to a single institution from 2013-2023 with inhalation injury treated with cyanokit for suspected cyanide toxicity. We also analyzed a control cohort of similar patients with inhalation injury not treated with cyanokit. We analyzed changes and peaks in methemoglobin, lactate levels, kidney function tests, ventilator days, % total body surface area (TBSA), medications and dressings, and mortality. Results In the study, 36 patients with suspected inhalation injury were treated with cyanokit, compared to 32 patients with inhalation injury who weren't treated with cyanokit. Baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in methemoglobin levels, initial lactate levels, mortality, Baux score, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups (Table 1). When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that cyanokit administration was not significantly associated with changes in methemoglobin or mortality. Conclusions Contrary to our initial hypothesis, our study did not find significant harm or benefit of cyanokit in burn patients during the acute phase. Methemoglobin, lactate levels, mortality, and kidney function remained largely unchanged. This study's limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of cyanokit administration on burn patients' outcomes. Applicability of Research to Practice Given the high stakes involved in treating cyanide poisoning promptly, our study holds significance for refining treatment strategies and enhancing patient safety. This insight is vital for medical practitioners making critical decisions in managing cyanide poisoning in burn patients, while also underlining the need for further research to fully understand the broader impact of cyanokit administration in this context.

Risk of Post-Intubation Laryngotracheal Stenosis With Respect to COVID-19 Status in a Large Multicenter Cohort Cross-Sectional Study.

Occurrence of post-intubation laryngotracheal stenosis (LTS) with respect to COVID-19 status. Retrospective cross-sectional inpatient database. Eleven Midwest academic and community hospitals, United States. Adults, mechanically ventilated, from January 2020 to August 2022, who were subsequently readmitted within 6 months with a new diagnosis of LTS. None. Six thousand eight hundred fifty-one COVID-19 negative and 1316 COVID-19 positive patients were intubated and had similar distribution by age (median 63.77 vs. 63.16 yr old), sex (male, 60.8%; n = 4173 vs. 60%; n = 789), endotracheal tube size (≥ 7.5, 75.8%; n = 5192 vs. 75.5%; n = 994), and comorbidities. The ICU length of stay (median [interquartile range (IQR)], 7.23 d [2.13-16.67 d] vs. 3.95 d [1.91-8.88 d]) and mechanical ventilation days (median [IQR], 5.57 d [1.01-14.18 d] vs. 1.37 d [0.35-4.72 d]) were longer in the COVID-19 positive group. The occurrence of LTS was double in the COVID-19 positive group (12.7%, n = 168 vs. 6.4%, n = 440; p < 0.001) and was most commonly diagnosed within 60 days of intubation. In multivariate analysis, the risk of LTS increased by 2% with each additional ICU day (hazard ratio [HR], 1.02; 95% CI, 1.02-1.03; p < 0.001), by 3% with each additional day of ventilation (HR, 1.03; 95% CI, 1.02-1.04; p < 0.001), and by 52% for each additional reintubation (HR, 1.52; 95% CI, 1.36-1.71; p < 0.001). We observed no significant association COVID-19 status and risk of LTS. The occurrence of post-intubation LTS was double in a COVID-19 positive cohort, with higher risk with increasing number of days intubated, days in the ICU and especially with the number of reintubations. COVID-19 status was not an independent risk factor for LTS.

A prospective study on clinical profile, severity, microbiology, and outcome of patients with ventilator associated infective complications admitted in intensive care unit of a tertiary care hospital

: Mechanical ventilation epitomizes intensive care medicine. Ventilator‑associated complications are mainly Ventilator associated respiratory infections (VARI); These are a major cause of concern in the intensive care units (ICUs) worldwide, especially in developing countries. VARI includes patients with ventilator‑associated tracheobronchitis (VAT) and ventilator‑associated pneumonia (VAP).The clinical profile, severity, microbiology, and outcomes of such infections is not well described in Eastern India. The primary objective of the study was to study the risk factors, severity scoring, microbiological profile and 28 days outcome of patients admitted in intensive care unit of our hospital.Secondary objective of our study was to find out any correlation between risk factors, severity scoring, microbiological profile, and outcome of patients with VAT and VAP admitted in intensive care unit of our hospital.: This was a prospective observational study done in the ICU of a tertiary care centre in eastern India. A total 50 patients of clinically, microbiologically and/or radiologically diagnosed case of VAP and VAT were included in the study. A structured data collection proforma was prepared and data collection was done. Raw data was tabulated and analysed: 66% of our patients were male, Smoking was the commonest addiction(24%), VARI developed early with 17% on Day 3, 72% developed VARI within 5 days of ventilation. 16% had history of recent admission, Diabetes and hypertension were the commonest comorbidities. 58% of the patients developed VAP, the median SOFA score in VAP was 6 also similar in VAT. Patients with neurological diseases had the maximum number of VAT and VAP. Klebsiella pneumoniae was the commonest organism causing VAT (42%) while Acinetobacter Baumanii was commonest to cause VAP (44%). 51% of VAP patients were on volume control mode, while it was 52% of VAT patients. Most isolates are MDR pathogens with intermediate sensitivity to Polymyxin being most common (66%) 1 isolate was pan resistant. Mortality was 58% for VAP and 19% in VAT. Both Klebsiella and Acinetobacter accounts for 41% death in VAP group, in VAT group Klebsiella was commonest however no statistical significance with other organism.: Gram negative bacteria were the predominant cause of VAT and VAP, Acinetobacter and Klebsiella are the commonest organisms. Most Isolates are MDR with intermediate sensitivity to Polymyxins. Median SOFA scores were the same in both. Mortality was high in VAP group. Volume control mode was predominant mode of ventilation, Neurological causes was predominant cause that leads to ventilation and subsequent VARI.

Factors Associated with Fatigue in COVID-19 ICU Survivors.

Approximately 30% of people infected with COVID-19 require hospitalization, and 20% of them are admitted to an intensive care unit (ICU). Most of these patients experience symptoms of fatigue weeks post-ICU, so understanding the factors associated with fatigue in this population is crucial. Fifty-nine patients (38-78 yr) hospitalized in ICU for COVID-19 infection for 32 (6-80) d, including 23 (3-57) d of mechanical ventilation, visited the laboratory on two separate occasions. The first visit occurred 52 ± 15 d after discharge and was dedicated to questionnaires, blood sampling, and cardiopulmonary exercise testing, whereas measurements of the knee extensors neuromuscular function and performance fatigability were performed in the second visit 7 ± 2 d later. Using the FACIT-F questionnaire, 56% of patients were classified as fatigued. Fatigued patients had worse lung function score than non-fatigued (i.e., 2.9 ± 0.8 L vs 3.6 ± 0.8 L; 2.4 ± 0.7 L vs 3.0 ± 0.7 L for forced vital capacity and forced expiratory volume in 1 s, respectively), and forced vital capacity was identified as a predictor of being fatigued. Maximal voluntary activation was lower in fatigued patients than non-fatigued patients (82% ± 14% vs 91% ± 3%) and was the only neuromuscular variable that discriminated between fatigued and non-fatigued patients. Patient-reported outcomes also showed differences between fatigued and non-fatigued patients for sleep, physical activity, depression, and quality of life ( P < 0.05). COVID-19 survivors showed altered respiratory function 4 to 8 wk after discharge, which was further deteriorated in fatigued patients. Fatigue was also associated with lower voluntary activation and patient-reported impairments (i.e., sleep satisfaction, quality of life, or depressive state). The present study reinforces the importance of exercise intervention and rehabilitation to counteract cardiorespiratory and neuromuscular impairments of COVID-19 patients admitted in ICU, especially individuals experiencing fatigue.

Implementation of an Extubation Readiness Guideline for Preterm Infants.

Intubated preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 32 6 / 7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV NICU. This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt. Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 32 6 / 7 weeks or less of gestation.

The Effect of COVID-19 on Rib Fracture Patients in Michigan.

This study aims to compare outcomes of rib fracture patients with and without COVID-19 in Michigan. Data from the Michigan Trauma Quality Improvement Program (MTQIP) identified adults hospitalized from January 1, 2020, to October 31, 2022, with at least one rib fracture and a completed COVID-19 test on admission. Patients were propensity score matched 1:1 using 20 variables. The primary outcome was hospital length of stay (LOS). Secondary outcomes were mortality, ventilator days, intensive care unit (ICU) LOS, pneumonia, and ventilator-assisted pneumonia (VAP). 13,305 total patients were identified. 232 patients matched into both the COVID+ and COVID- groups. COVID was associated with increased LOS (7days vs. 5days, P < 0.001). There were no significant differences between the two groups when evaluating secondary outcomes. Our study indicates that although COVID-19 infection is associated with increased LOS, COVID may not contribute to additional morbidity or mortality in traumatic rib fracture patients.

Thrombosis in severely ill patients admitted in ICU due to COVID-19 pneumonia. Data from a Greek Hospital

Background: SARS-CoV-2 can lead to a prothrombotic state and the activation of the body's coagulation mechanism, resulting in thrombotic episodes, especially in critically ill patients. The rates of thromboembolic disease in patients with COVID-19 vary and range from 10-40%, while in Greece the existing epidemiological data on the incidence of thromboembolic disease in the ICU are limited. Aim This study aimed to determine the proportion of hospitalized COVID-19 patients who developed thromboembolic disease (pulmonary embolism, deep vein thrombosis, or arterial embolism). It was also crucial to investigate at the relationship between the incidence of VTE (venothrombosis-VTE) and Covid infection in ICU patients. After 28 days from ICU admission, the survival rate of patients with Covid infection admitted to ICUs within the specified time frame was also noted. Method and Material: The study included 85 patients with Covid-19 infection who were hospitalized in two ICU departments in a large adult hospital in Athens between June and September 2021. The occurrence of VTE was diagnosed by computed tomography angiography, regarding the pulmonary embolism and with triplex veins of the lower extremities. Various epidemiological factors, laboratory findings and characteristics of the patients' hospitalization in the Intensive Care Unit were recorded. Results: The incidence of VTE in patients with Covid-19 infection admitted to the Intensive Care Unit was 14% (12/85 patients). Patients who experienced VTE during their hospitalization in the Intensive Care Unit had more days on mechanical ventilation support, more days on vasoconstrictor drugs, and had been transfused more times with blood plasma. In the multivariate analysis that followed, it was found that total days of mechanical ventilation (p=0.02), total days of vasoconstrictor administration (p=0.03) and plasma transfusion (p=0.03) were still statistically significant. Conclusion: In patients with Covid-19 infection and hospitalization in the Intensive Care Unit, longer stay on mechanical respiratory support, more days of vasoconstrictor drug administration and plasma administration are independent predisposing factors for the occurrence of VTE.

265 Inpatient Outcomes in Pediatric Patients With Non-accidental Versus Accidental Head Trauma: National Trauma Data Bank Analysis

INTRODUCTION: Non-accidental trauma (NAT) is a leading cause of pediatric traumatic brain injury (TBI). Recent studies suggest NAT results in worse outcomes than accidental TBI, independent of severity of the injury and interventions. METHODS: Patients under 18 years old diagnosed with head trauma with or without NAT during 2019-2021 were identified in the NTDB. The predictor variables were demographics; previously validated prognostic factors , including motor score, verbal score, pupillary score, pupillary reactivity, image findings; neurosurgical interventions including EVD, ICPM, PbO2 monitoring; length of stay, and number of ventilated days. Data evaluation and univariate analysis were performed using summary statistics, t-tests, chi-square tests, and non-parametric tests. Mortality, length of ICU stay and complication rates were modeled using a multivariate logistic regression model. Outcomes were controlled for age, race, sex, and teaching vs nonteaching hospital. RESULTS: A total of 90,607 pediatric TBI events were identified in the database, 1721 (1.90%) cases with NAT. NAT was observed most often in 0-2 year-olds (64.78%), followed by 2-5 year-olds (22.66%), 6-10 and 15-18 year-olds (0.09% each), then 11-14 year-olds (0.07%). Patients with NAT had longer ICU stays (6.18 vs 4.93 days, p &lt; 0.0001) and ventilator days, despite similar injury severity scores (p &lt; 0.0001). In-hospital mortality was 30% more likely if NAT was the MOI (LR 1.3046, p &lt; 0.001). CONCLUSIONS: Pediatric TBI patients with NAT have worse inpatient outcomes than similar patients with accidental injuries. Accurate diagnosis and better prognostication scales specific to patients with non-accidental trauma may lead to improved management and resource allocations for these sicker patients.

Hydroxocobalamin is not associated with methemoglobinemia in patients with inhalation injury and suspected cyanide toxicity and a proposed algorithm for hydroxocobalamin administration

BackgroundCyanide poisoning poses a significant threat to burn patients exposed to smoke in residential or workplace fires, leading to central nervous system dysfunction, hemodynamic instability, cardiovascular collapse, and death. Prompt administration of an effective antidote is critical. Hydroxocobalamin, a form of vitamin B12, is the gold standard treatment for cyanide toxicity, by binding to cyanide molecules and converting them into non-toxic cyanocobalamin that is eliminated by the kidneys. This mechanism is distinct from previous cyanide antidotes, which induce the formation of methemoglobin to bind to cyanide. Recent case studies have reported elevated methemoglobin levels after hydroxocobalamin administration, raising concerns regarding its safety. The current study investigates smoke inhalation patients treated with hydroxocobalamin at a single institution Burn Unit in hopes of enhancing our understanding of the complexities surrounding cyanide antidote therapy. MethodsAfter Institutional Board Approval, a retrospective cohort study was conducted. Our sample comprised burn patients with inhalation injury admitted to a single institution from 2013 to 2023 and treated with hydroxocobalamin for suspected cyanide toxicity. We also analyzed a matched control cohort of similar patients with inhalation injury not treated with hydroxocobalamin. We analyzed changes and peaks in methemoglobin levels, lactate levels, blood urea nitrogen (BUN) and creatinine, ventilator days, % total body surface area (TBSA), various types of medications and dressings, and mortality. Statistical analyses included t-tests, chi-square, linear and logistic regressions, and correlation analysis. ResultsIn the study, 36 patients with suspected inhalation injury were treated with hydroxocobalamin at the Los Angeles General (LAG) Burn Unit from 2013 to 2023, who were matched to 32 control patients with inhalation injury who were not treated with hydroxocobalamin. Demographic and baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in methemoglobin levels. The study also revealed no significant disparities in initial lactate levels, mortality, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups. When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that hydroxocobalamin administration was not significantly associated with changes in methemoglobin or mortality. Increased %TBSA, however, was linked to elevated lactate levels. ConclusionsOur investigation sought to assess the potential risks associated with hydroxocobalamin administration in burn patients with concomitant inhalation injury. Contrary to our initial hypothesis, we found no statistically significant differences in methemoglobinemia, lactate levels, mortality, or kidney function. The influence of other factors, such as methemoglobinemia-inducing drugs or hydroxocobalamin's interference with co-oximetry, adds complexity. Although elevated methemoglobin levels were observed in some cases, their clinical significance was limited. However, this study's limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of hydroxocobalamin administration on burn patients' outcomes.

929 Outcomes in Pediatric Spinal Cord Injuries Based on Time to Surgery

INTRODUCTION: Early surgery in individuals with traumatic spinal cord injury (SCI) has been associated with improved neurological recovery, lower risk of complications, and reduced resource utilization. Patient and healthcare-related factors may contribute to delay in surgery. This study aimed to determine factors contributing to longer time-to-surgery in pediatric patients with complete and incomplete SCI. METHODS: Patients with SCI were identified in the National Trauma Data Bank based on AIS codes. Patients who died in the ED or were transferred to another hospital were excluded. Procedure codes were used to identify patients who underwent spinal surgery. Patients were grouped by time to surgery less than or greater than 12 hours. RESULTS: 549 patients were identified with 235 incomplete and 314 complete SCI. 399 patients underwent surgery (177 incomplete; 222 complete). Of patients who underwent surgery, 55% of incomplete and 52% of complete SCI went to surgery after 12 hours. SCI patients with greater than 12-hour time-to-surgery had worse injury severity scores (32 vs 28, p &lt; 0.05). Additionally, ICU LOS, total ventilation days, and total LOS were longer. Time-to-surgery greater than 12 hours was statistically associated with unplanned ICU stay (incomplete), unplanned OR (complete), ventilator associated pneumonia (complete), and delirium (incomplete). Time-to-surgery was not significantly associated with race, gender, or mechanism of injury. pneumonia (complete), and delirium (incomplete). Time-to-surgery was not significantly associated with race, gender, or mechanism of injury. CONCLUSIONS: Greater time-to-surgery is associated with higher risk of complications and longer hospital stays in patients with complete and incomplete SCI in the pediatric population. This data raises the question as to whether earlier surgery could reduce complications.

461 Outcomes and Healthcare Utilization of Adult Spinal Cord Injury Associated With Time to Surgery: An Analysis of the National Trauma Data Bank (NTDB): 2019-2021

INTRODUCTION: Prior studies have established evidence that early surgical decompression following traumatic spinal cord injury (SCI) is associated with better outcomes. However, it is not clear whether increased time to surgery is correlated with worse complications and increased healthcare utilization. METHODS: Patients with traumatic SCIs were identified in NTDB. For surgical patients, time to surgery was extracted and patients classified by time to surgery of &gt;=12 hours. Chi-sq and non-parametric tests were used. RESULTS: 9,987 patients with SCI were identified; 40.49% were complete. 66.24% of incomplete and 56.66% of complete had a time to surgery greater than 12 hours. Those with incomplete SCI and surgery after 12 hours had increased Injury Severity Score (ISS) (μ = 0.36), ICU length of stay (LOS) (μ = 0.91 days), days on ventilation (μ = 2.01 days), and days to discharge (μ = 1.39 days) (p &lt; 0.005). Those with complete SCI and surgery after 12 hours had increased ICU LOS (μ = 2.7 days, p &lt; 0.0001). Mortality rate was not positively associated with time to surgery greater than 12 hours for complete and incomplete SCI group. CONCLUSIONS: Although prior studies support earlier surgical intervention for those experiencing SCI, the majority of patients are undergoing surgery more than 12 hours after their injury. Additionally, patients with incomplete SCI waiting &gt;=12 hours have longer ICU stay, more ventilated days, longer hospitalization, and increased ISS. Additional studies are needed to identify barriers to earlier surgery and to establish cutoff times for maximum benefit.

Respiratory Morbidity and Mortality of Traumatic Cervical Spinal Injury.

Traumatic cervical spinal injuries can severely affect respiratory function and cause significant morbidity and mortality. The typical respiratory morbidity in cervical spine injury is Atelectasis, Ventilator-associated pneumonia, acute respiratory distress syndrome and delayed weaning, etc. The study aims to see the prevalence of respiratory morbidity as well as mortality associated with cervical spine injury. Cross sectional study based on retrospective data was conducted on the X Sciences with the existing hospital record during the period of 3 years to find out the prevalence respiratory morbidity like Ventilatory Associated Pneumonia, delayed weaning, ARDS, atelectasis of traumatic cervical spine injury, determine the prevalence, type, and impact of respiratory morbidity and mortality in this population. Total no 76 patients data meeting the inclusion criteria included in study. Male patients were more prone to develop traumatic cervical spinal injuries (SCI). The prevalence of respiratory morbidity in term of VAP(57.89), delayed weaning(46.05) and Atelectasis(22.36) was high. Patients with Asia A Neurology has higher association for VAP and delayed weaning, while Asia E Neurology patients had no respiratory morbidity. The study found a significant positive association between respiratory morbidity with hospital stay, and ventilator days (p-value: 0.019 and 0.048). A total of 15 patients died, 28.95% were discharged on request and 40.8% leaving the hospital against medical advice. The prevalence of respiratory morbidity higher in cervical spine injury. Furthermore, it has associated with prolonged ICU and ventilator days and increase in mortality.

Mechanical Ventilation, Retinal Avascularity and Rate of Vascularisation: A Triad of Predictors for Retinopathy of Prematurity Treatment.

The temporal avascular area of the retina and the duration of mechanical ventilation (DMV) may predict the need to treat retinopathy of prematurity (ROP). This study considers whether the rate of retinal vascularisation and related risk factors should be included in a predictive model of the need for ROP treatment. This single-centre, observational retrospective case-control study was conducted on 276 preterm infants included in an ROP screening programme. All had undergone at least three examinations of the fundus. The main outcome measures considered were DMV (in days of treatment), the temporal avascular area (in disc diameters, DD) and the rate of temporal retinal vascularisation (DD/week). The multivariate logistic model that best explains ROP treatment (R2 = 63.1%) has three significant risk factors: each additional day of mechanical ventilation (OR, 1.05 [95% CI, 1.02-1.09]; p = 0.001); each additional DD of temporal avascular area (OR, 2.2 [95% CI, 1.7-2.9]; p < 0.001) and a vascularisation rate <0.5 DD/week (OR, 19.0 [95% CI, 6.5-55.5]; p < 0.001). Two tables are presented for calculating the expected need for ROP treatment according to these three risk factors. A greater DMV, a broad avascular area of the temporal retina at the first binocular screening and slow retinal vascularisation strongly predict the need for ROP treatment. The predictive model we describe must be validated externally in other centres.

Effects of Trauma Center Consolidation on Adult Trauma at a Rural Level 1 Trauma Center.

The aim was to determine the impact of consolidation of two rural level 1 trauma centers on adult trauma patients presenting to the remaining level 1 trauma center. To our knowledge, a study assessing the impact of trauma center consolidation on adult trauma patients had yet to be performed. A single institution, retrospective study was conducted at a rural level 1 trauma center. Adult trauma patients who presented to our center from January 2017 to January 2022 were included. The cohorts spanned 33 months pre- and post-consolidation. Multiple demographic and outcome measures were gathered. Data were analyzed using the student's t-test and Chi-squared testing. There was a 33% increase in overall trauma activations and 9% increase in transfers from outside facilities post-consolidation. The post-consolidation group was significantly older, had higher mean injury severity score, and decreased hospital-free days. The post-consolidation group also saw an increase in ICU admission and surgical intervention. While there were no significant differences in ICU-free days or ventilator days, patients in the post-consolidation group with the highest level of activation who required both surgical intervention and ICU admission experienced decreased mortality. The consolidation of trauma services to a single level 1 trauma center in a rural Appalachian health system led to higher trauma volume and acuity, but most importantly decreased mortality for the most severely injured trauma patients.

Propofol vs etomidate for induction prior to invasive mechanical ventilation in patients with acute myocardial infarction

BackgroundPatients with acute myocardial infarction (AMI) requiring invasive mechanical ventilation (IMV) have a high mortality. However, little is known regarding the impact of induction agents, used prior to IMV, on clinical outcomes in this population. We assessed for the association between induction agent and mortality in patients with AMI requiring IMV. MethodsWe compared clinical outcomes between those receiving propofol compared to etomidate for induction among adults with AMI between October 2015 and December 2019 using the Vizient® Clinical Data Base, a multicenter, US national database. We used inverse probability treatment weighting (IPTW) to assess for the association between induction agent and in-hospital mortality. ResultsWe identified 5,147 patients, 1,386 (26.9%) of received propofol and 3,761 (73.1%) received etomidate for IMV induction. The mean (SD) age was 66.1 (12.4) years, 33.0% were women, and 51.6% and 39.8% presented with STEMI and cardiogenic shock, respectively. Patients in the propofol group were more likely to require preintubation vasoactive medication and mechanical circulatory support (both, P < .05). Utilization of propofol was associated with lower mortality compared to etomidate (32.3% vs 36.1%, P = .01). After propensity weighting, propofol use remained associated with lower mortality (weighted mean difference −4.7%; 95% confidence interval: −7.6% to −1.8%, P = .002). Total cost, ventilator days, and length of stay were higher in the propofol group (all, P < .001). ConclusionsInduction with propofol, compared with etomidate, was associated with lower mortality for patients with AMI requiring IMV. Randomized trials are needed to determine the optimal induction agent for this critically ill patient population.