Duration Of Invasive Ventilation Research Articles

Physiological Effects of High-Flow Tracheal Oxygen in Tracheostomized Patients Weaning From Mechanical Ventilation.

High-flow tracheal oxygen (HFTO) is being used as supportive therapy during weaning in tracheostomized patients difficult to wean from invasive mechanical ventilation. There is, however, no clinical evidence for such a strategy. Therefore, we conducted a systematic review to summarize studies evaluating the physiologic effects of HFTO during tracheostomy-facilitated weaning and to identify potential areas for future research in this field. Observational and interventional studies on critically ill subjects weaning from mechanical ventilation via tracheostomy published until December 22, 2022, were eligible. Studies on high-flow oxygen, only in children, non-human models or animals, on clinical outcome only, abstracts without full-text availability, case reports, and reviews were excluded. Main outcomes were end-expiratory lung volume (EELV) and tidal volume using electrical impedance tomography, respiratory effort assessed by esophageal manometry, work of breathing and neuroventilatory drive as assessed by electrical activity of the diaphragm (EAdi) signal, airway pressure (Paw), oxygenation (PaO2 /FIO2 or SpO2 /FIO2 ), breathing frequency, tidal volume, and PaCO2 . In total, 1,327 references were identified, of which 5 were included. In all studies, HFTO was administered with flow 50 L/min and compared to conventional O2 therapy in a crossover design. The total average duration of invasive ventilation at time of measurements ranged from 11-27 d. In two studies, PaO2 /FIO2 and mean Paw were higher with HFTO. EELV, tidal volumes, esophageal pressure swings, and EAdi were similar during high-flow tracheal oxygen and conventional O2 therapy. The main physiological effect of HFTO as compared to conventional O2 therapy in tracheostomized subjects weaning from mechanical ventilation was improved oxygenation that is probably flow-dependent. Respiratory effort, lung aeration, neuroventilatory drive, and ventilation were similar for HFTO and conventional O2 therapy. Future studies on HFTO should be performed early in the weaning process and should evaluate its effect on sputum clearance and patient-centered outcomes like dyspnea.

Protracted fibrinolysis resistance following cardiac surgery with cardiopulmonary bypass: A prospective observational study of clinical associations and patient outcomes.

Surgery on cardiopulmonary bypass (CPB) elicits a pleiomorphic systemic host response which, when severe, requires prolonged intensive care support. Given the substantial cross-talk between inflammation, coagulation, and fibrinolysis, the aim of this hypothesis-generating observational study was to document the kinetics of fibrinolysis recovery post-CPB using ClotPro® point-of-care viscoelastometry. Tissue plasminogen activator-induced clot lysis time (TPA LT, s) was correlated with surgical risk, disease severity, organ dysfunction and intensive care length of stay (ICU LOS). In 52 patients following CPB, TPA LT measured on the first post-operative day (D1) correlated with surgical risk (EuroScore II, Spearman's rho .39, p < .01), time on CPB (rho = .35, p = .04), disease severity (APACHE II, rho = .52, p < .001) and organ dysfunction (SOFA, rho = .51, p < .001) scores, duration of invasive ventilation (rho = .46, p < .01), and renal function (eGFR, rho = -.65, p < .001). In a generalized linear regression model containing TPA LT, CPB run time and markers of organ function, only TPA LT was independently associated with the ICU LOS (odds ratio 1.03 [95% CI 1.01-1.05], p = .01). In a latent variables analysis, the association between TPA LT and the ICU LOS was not mediated by renal function and thus, by inference, variation in the clearance of intraoperative tranexamic acid. This observational hypothesis-generating study in patients undergoing cardiac surgery with cardiopulmonary bypass demonstrated an association between the severity of fibrinolysis resistance, measured on the first post-operative day, and the need for extended postoperative ICU level support. Further examination of the role of persistent fibrinolysis resistance on the clinical outcomes in this patient cohort is warranted through large-scale, well-designed clinical studies.

Longitudinal plasma proteomics reveals biomarkers of alveolar-capillary barrier disruption in critically ill COVID-19 patients

The pathobiology of respiratory failure in COVID-19 consists of a complex interplay between viral cytopathic effects and a dysregulated host immune response. In critically ill patients, imatinib treatment demonstrated potential for reducing invasive ventilation duration and mortality. Here, we perform longitudinal profiling of 6385 plasma proteins in 318 hospitalised patients to investigate the biological processes involved in critical COVID-19, and assess the effects of imatinib treatment. Nine proteins measured at hospital admission accurately predict critical illness development. Next to dysregulation of inflammation, critical illness is characterised by pathways involving cellular adhesion, extracellular matrix turnover and tissue remodelling. Imatinib treatment attenuates protein perturbations associated with inflammation and extracellular matrix turnover. These proteomic alterations are contextualised using external pulmonary RNA-sequencing data of deceased COVID-19 patients and imatinib-treated Syrian hamsters. Together, we show that alveolar capillary barrier disruption in critical COVID-19 is reflected in the plasma proteome, and is attenuated with imatinib treatment. This study comprises a secondary analysis of both clinical data and plasma samples derived from a clinical trial that was registered with the EU Clinical Trials Register (EudraCT 2020–001236–10, https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-001236-10/NL) and Netherlands Trial Register (NL8491, https://www.trialregister.nl/trial/8491).

Association between Weight for Length and the Severity of Respiratory Morbidity in Preterm Infants.

To determine whether higher weight-to-length z-scores after 32 weeks of gestation are associated with higher pulmonary scores (PSs) in preterm infants requiring respiratory support using a prospective observational study. Infants born at <30 weeks, with a post-menstrual age (PMA) of 30-33 weeks, were enrolled. The infant's weight, length, and head circumference were measured weekly. Data on calories/kg/d, protein g/kg/d, weight-for-length percentiles, z-scores, and BMI at 33 through 40 weeks PMA were collected. The PS was calculated. We analyzed 91 infants. The mean gestational age was 26.9 ± 1.7 weeks. The mean birthweight was 0.898 ± 0.238 kgs. They were predominantly African American (81.3%) and girls (56%). Postnatal steroids were administered in 26.4% of the infants. The mean duration of invasive ventilation was 19.23 days ± 28.30 days. There was a significant association between the PS and W/L z-score (p < 0.0001). For every one-unit increase in W/L z-score, the PS increased by 0.063. There was a significant association between the PS and W/L percentile (p = 0.0017), as well as BMI (p ≤ 0.0001). For every unit increase in W/L percentile, the PS increased by 0.002, and for a unit increase in BMI, the PS increased by 0.04. The association remained significant after postnatal steroid use, sex, and corrected and birth gestational ages were included in the regression analysis. Nutrition did not affect the anthropometric measurements. Our study is the first to demonstrate that a higher BMI and W/L may adversely affect the respiratory severity in preterm infants. Studies with larger sample sizes are needed to confirm our findings.

Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis

PurposeThe ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada. Material and methodsWe conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record. Results44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18–0.50%, p < 0.01) from 33.48% (95%CI 29.64–37.31%) in 2017 to 28.74% (95%CI 25.22–32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00–11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events. ConclusionsAn ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.

Effects of diaphragm electrical stimulation in treating respiratory dysfunction on mechanical ventilation after intracerebral hemorrhage: A single-center retrospective study.

Intracerebral hemorrhage (ICH) is a major cause of death and disability worldwide. The benefits of electrical stimulation in the treatment of respiratory dysfunction in patients on mechanical ventilation is unknown. Nevertheless, there is a dearth of evidence-based medical research concerning its clinical efficacy. From January 2019 to January 2023, every enrolled patients experienced respiratory dysfunction after ICH while being supported by mechanical ventilation. A total of 205 eligible patients were enrolled and then allocated into 2 groups: control group and observation group. 133 patients was selected and administered standard treatment as control group. Based on conventional treatment, other 72 patients were administered diaphragm electrical stimulation (DES) treatment. We examined information from current medical records, encompassing all initial data and predictive follow-up data, such as the weaning success rate, occurrence of ventilator-associated pneumonia (VAP), duration of stay in the intensive care unit (ICU) and hospital, expenses related to hospitalization, and mortality within 30 days. The baseline clinical data of the 2 groups did not exhibit any statistically significant disparities (all P > .05). The rate of successful weaning showed a significant increase in the DES group when compared to the control group (P = .025). In patients with respiratory dysfunction due to ICH, treatment with DES resulted in a significant reduction in the duration of invasive ventilation (9.8 ± 2.1 vs 11.2 ± 2.6, P < .01) and total ventilation time (9.8 ± 2.1 vs 11.2 ± 2.6, P < .01). It also led to a decrease in the length of stay in the ICU (15.67 ± 3.76 vs 17.53 ± 4.28, P = .002) and hospitalization cost (11500 vs 13600, P = .001). Additionally, DES treatment resulted in a lower incidence of VAP (73.61% vs 86.46%, P = .022) and improved 30-day mortality (P < .05), without any significant adverse effects. The findings of this research indicate that DESs have a positive impact on enhancing the rate of successful weaning and reducing the incidence of VAP. It decreases the duration of invasive ventilation and total ventilation time while also improving the mortality rate within 30 days. This therapy could offer a fresh alternative for respiratory impairment in patients undergoing mechanical ventilation.

Clinical Profile and Predictors of Intensive Care Admission in Neonicotinoid Poisoning in a Tertiary Care Hospital in South India.

Neonicotinoids are a newer class of pesticides that are believed to cause predominantly mild toxicity in humans. This study aimed to describe the clinical features of neonicotinoid poisoning and identify predictors of severe toxicity. This retrospective study included all patients with neonicotinoid poisoning admitted to a Tertiary Care Center in India over an 18-year period. Clinical and laboratory features were compared against outcomes to identify predictors of the need for intensive care admission. Twenty-eight patients were included in the study of which 28.6% had severe disease requiring ICU admission. A higher respiratory rate, blood lactate level, SOFA, and qSOFA scores as well as a lower Glasgow coma score at presentation predicted ICU admission. First-generation compounds and imidacloprid consumption were associated with longer ICU stays and a longer duration of invasive ventilation. Neonicotinoid compounds can cause significant toxicity with oral ingestion. Imidacloprid and other first-generation compounds were associated with more severe toxicity requiring intensive care. Simple clinical parameters assessed at presentation can be used to predict severe disease and the need for ICU care. Larger, prospective studies are required to confirm these findings. Sanga L, Jacob A, Jayakaran JAJ, Iyadurai R. Clinical Profile and Predictors of Intensive Care Admission in Neonicotinoid Poisoning in a Tertiary Care Hospital in South India. Indian J Crit Care Med 2024;28(1):66-69.

Sex differences in preterm respiratory morbidity: A recent whole-population study.

To determine whether there were differences between male and female infants in respiratory morbidity in a whole population of extremely preterm infants, including infants born below 24 weeks of gestation. Retrospective whole-population study of all infants <28 weeks of gestation admitted to a neonatal unit in England from 2014 to 2019. Bronchopulmonary dysplasia (BPD) development was defined as any respiratory support at 36 weeks postmenstrual age. The 11 844 infants had a median (IQR) gestational age of 26.0 (24.9-27.1) weeks and a birth weight of 0.81 (0.67-0.96) kg. The duration of invasive ventilation was longer in male compared to female infants who were born at 24-27 completed weeks of gestation (p < 0.001), but not significantly different between male and female infants born at 22 and 23 weeks of gestation (p = 0.446). The incidence of BPD was higher in male compared to female infants born at 24-27 weeks of gestation (p < 0.001) but not different between male and female infants born at 22 and 23 weeks of gestation (p = 0.148). Respiratory morbidity was more pronounced in male compared to female extremely preterms, only in gestations 24-27 completed weeks. Male predominance was absent in infants born below 24 weeks of gestation.

Prediction of Postnatal Growth Failure in Very Low Birth Weight Infants Using a Machine Learning Model.

Accurate prediction of postnatal growth failure (PGF) can be beneficial for early intervention and prevention. We aimed to develop a machine learning model to predict PGF at discharge among very low birth weight (VLBW) infants using extreme gradient boosting. A total of 729 VLBW infants, born between 2013 and 2017 in four hospitals, were included. PGF was defined as a decrease in z-score between birth and discharge that was greater than 1.28. Feature selection and addition were performed to improve the accuracy of prediction at four different time points, including 0, 7, 14, and 28 days after birth. A total of 12 features with high contribution at all time points by feature importance were decided upon, and good performance was shown as an area under the receiver operating characteristic curve (AUROC) of 0.78 at 7 days. After adding weight change to the 12 features-which included sex, gestational age, birth weight, small for gestational age, maternal hypertension, respiratory distress syndrome, duration of invasive ventilation, duration of non-invasive ventilation, patent ductus arteriosus, sepsis, use of parenteral nutrition, and reach at full enteral nutrition-the AUROC at 7 days after birth was shown as 0.84. Our prediction model for PGF performed well at early detection. Its potential clinical application as a supplemental tool could be helpful for reducing PGF and improving child health.

Long-Term Outcomes of Pulmonary Embolism Requiring Intensive Care Unit (ICU) Admission

Introduction:Pulmonary embolism (PE) requiring intensive care unit (ICU) admission is associated with high in-hospital mortality, however data on long-term survival outcomes and associated contributors remains limited. We sought to further investigate this using a large binational dataset. Methods:Retrospective cohort study of adults aged &amp;gt;16 years admitted to an Australian or New Zealand (NZ) ICU between January 1, 2018 and December 31, 2022 with a primary admission diagnosis of PE using the Australian and NZ Intensive Care Society (ANZICS) Adult Patient Database (APD). Data were available on baseline characteristics - specifically age, gender, admission co-morbidities (active malignancy, chronic cardiovascular, respiratory, renal and liver disease and illness severity as per the Acute Physiology and Chronic Health Evaluation (APACHE) III scoring system. The need for ICU-specific supports (vasopressors or inotropes, invasive and non-invasive ventilation [NIV], extracorporeal membrane oxygenation [ECMO]) was also recorded. All-cause mortality from 30 days to 48 months after ICU admission was obtained. Descriptive analyses, Kaplan-Meier and Cox proportional hazards models were used to describe survival during this time period. Ethical approval was granted by the Alfred Hospital Human Research Ethics Committee (HREC). Results:6447 patients with PE who had been admitted to 193 ICUs across Australia and NZ were identified, representing 9136 patient-years of follow-up. Median age was 66.5 years (interquartile range [IQR], 53-75). 24.5% were admitted to a rural or regional ICU. Median ICU length of stay was 46.6 hours (IQR, 27-79). Median APACHE III score was 42 (IQR, 31-56). Admission co-morbidities included active malignancy (8.1%), chronic respiratory (7.0%), renal (1.4%) and liver (0.4%) disease. Systolic blood pressure was was ≤90 mmHg at time of ICU admission in 1482 patients (23.9% of those in whom this data was available). Vasopressors or inotropes were required in 986 patients (17.6%), NIV was used in 713 (12.6%), invasive ventilation in 453 (8.0%) and 24 patients (0.43%) received ECMO. The mean duration of invasive ventilation where this was required was 14.9 hours. Kaplan-Meier survival analysis is shown in Figure 1. Overall survival was 92.3% at 30 days (95% CI, 91.6-93.0%), 87.5% at 6 months (95% CI, 86.5-88.3%), 84.4% at 12 months (95% CI 83.4%-85.4%) and 73.0% at 48 months (95% CI, 71.0-74.9%). Active malignancy was the strongest independent predictor of mortality (hazard ratio [HR] 3.3, 95% CI 2.8-4.0). Other independent predictors were chronic liver (HR 2.8), renal (HR 1.7) and respiratory (HR 1.6) disease, immunosuppressive therapy (HR 1.5), and the need for NIV (HR 1.4) or vasopressor and inotropic support (HR 1.3). No significant difference in mortality was observed between rural/regional and tertiary/metropolitan ICUs, however improved survival was observed in patients admitted to Australian ICUs (n = 6032) compared to those in NZ (n = 415) (HR 0.5 [95% CI 0.4-0.8]). Conclusions:Nearly three-quarters of patients admitted to ICU due to PE remain alive 2 years later. The largest risk factor for late mortality is malignancy, along with other chronic diseases, which is similar to previous studies reporting long-term follow-up of PE survivors outside ICU, however patients who need advanced life supports (NIV, ECMO) were also at greater risk. Limitations of this study include retrospective design, broad heterogeneity in admission criteria across different ICUs due to variation in resources across both countries and lack of data therapies such as intravenous thrombolysis and anticoagulation. Further work is needed to understand if changes to acute management of at-risk patients might improve long-term survival outcomes.

Related factors of viral nucleic acid change in critically ill patients with SARS-CoV-2 infection after treatment with Nirmatrelvir/Ritonavir: a single center retrospective cohort study

To describe negative conversion and rebound of patients with severe and critical acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection after treatment with Nirmatrelvir/Ritonavir, and to analyze related factors associating with failure of SARS-CoV-2 negative conversion and relapse and prognosis. A single center retrospective cohort study was conducted. Patients aged ≥ 16 years old who were diagnosed with severe or critical SARS-CoV-2 infection and took Nirmatrelvir/Ritonavir for 5 days in Peking University First Hospital from December 7, 2022 to January 27, 2023, were included. General characteristics and clinical data were collected from electronic medical record system. The Kaplan-Meier curve of SARS-CoV-2 negative conversion was drawn. Factors with P < 0.10 were incorporated into multivariate Logistic regression model to analyze the relationship between the factors and persistent nucleic acid positive and rebound. A total of 31 severe and 37 critical SARS-CoV-2 infection patients were included. The median duration from initiation of Nirmatrelvir/Ritonavir to negative conversion of SARS-CoV-2 for both was 6.0 days, and the negative conversion rate on day 15 was 93.5% and 86.5%, respectively. SARS-CoV-2 rebound was observed in 7 patients (11.3%), among whom were 1 severe patient and 6 critical patients. The above 7 patients with SARS-CoV-2 rebound and 6 patients with failure of SARS-CoV-2 negative conversion were compared with 55 patients with persistent negative conversion. Factors with P < 0.10, including the lowest lymphocyte count (LYM), the highest D-dimer, the highest procalcitonin (PCT), the lowest Ct value, cardiovascular diseases other than hypertension and coronary heart disease, were incorporated into multivariate Logistic regression analysis. The decreased LYM [odds ratio (OR) = 0.146, 95% confidence interval (95%CI) was 0.031-0.689, P = 0.015] and the increased PCT (OR = 2.008, 95%CI was 1.042-3.868, P = 0.037) were revealed to be independent risk factors of the failure of SARS-CoV-2 negative conversion or rebound. The proportion of mechanical ventilation and invasive ventilation were significantly higher in patients with persistent SARS-CoV-2 infection or rebound than those in patients with SARS-CoV-2 negative conversion (84.6% vs. 38.2%, 69.2% vs. 25.5%, both P < 0.01), but no significant difference in mechanical ventilation and invasive ventilation duration was observed. Compared with the patients with SARS-CoV-2 negative conversion, more patients with persistent SARS-CoV-2 infection or rebound were admitted to intensive care unit (ICU, 76.9% vs. 50.9%), and length of ICU stay in patients with persistent SARS-CoV-2 infection or rebound tended to be longer [days: 13.0 (10.3, 24.3) vs. 11.0 (5.3, 23.0), P > 0.05]. The decreased LYM and increased PCT are independent risk factors for the failure of SARS-CoV-2 negative conversion or rebound in patients with severe and critical SARS-CoV-2 infection. Attention should be paid to these patients for their poor prognosis.

Adrenomedullin as a marker of severity in community acquired pneumonia

Background: Stratification of the risk of mortality as well as identifying those patients most susceptible to complications due to pneumonia in the short and long-term, are key in establishing preventive strategies and optimizing treatment. Methods: Cross Sectional Observational Study. Participants: 72 children of 1month to &lt;18 years of suspected cases of community acquired pneumonia (CAP) were included according to World health organisation (WHO) criteria of pneumonia. Samples were taken at the outset for pro-Adrenomedullin (Pro-ADM) level estimation. Correlations between final clinical outcomes (viz. ICU Stay, mortality, length of hospital stay) with Serum Pro-ADM levels were noted. Results: Significant positive correlation was seen between Pro-ADM levels (picomol/l) with duration of ICU stay (days), duration of invasive ventilation (days), duration of hospital stay (days) with correlation coefficient of 0.783, 0.778, 0.808 respectively. Pro-ADM levels at cut off point of &gt;5.7 (picomol/l) with area under curve of 0.866 with diagnostic accuracy of 84.72% for correctly predicting severe CAP. Conclusions: We concluded that pro-ADM levels found to be high in severe/very severe pneumonia patients as per WHO criteria. Also, in our study higher levels of pro-ADM at the outset suggests need of ICU, Ventilator or longer hospital stays.

Analysis of trends in retinopathy of prematurity over 5 years in a tertiary neonatal intensive care unit.

The aim of the study was to look at the incidence and trend of retinopathy of prematurity (ROP) between 2017 and 2021 in a tertiary neonatal intensive care unit (NICU) in Australia and to compare potential modifiable risk factors of ROP between preterm infants who required treatment for ROP and who did not need treatment. This retrospective study used the data of newborn infants who were <31 weeks gestational age (GA) or birth weight (BW) of <1250 g born between 2017 and 2021 at a tertiary NICU in Australia (n = 261). Univariate analysis using t test for continuous data, Fischer exact test for categorical data and multiple logistic regression analysis were undertaken to identify any significant differences between two groups. A total number of 261 infants were studied. 55.9% of infants developed any type of ROP (146 infants out of 261 infants), type 1 ROP was 5.4% (14 out of 261) and aggressive ROP (AROP) was 3% (8 out of 261). Out of 146 infants who were diagnosed with ROP, 22 (15%) of them required treatment. Mean GA for those who underwent ROP treatment was 25.6 (±1.47) weeks and for those who did not require treatment was 27.6 (±1.95) weeks. The mean BWs for those who needed treatment was 764 (±189.32) g and for those who did not need treatment was 1039 (±306.06) g. The mean duration of invasive ventilation for infants with ROP requiring treatment and those who did not require treatment were 23.95 (±22.41) days and 9.89 (±17.2) days. The total duration of oxygen requirement was 235.54 (±160.5) days and 121.11 (±117.34) days for those who needed treatment and those who did not need treatment respectively. Among infants who required treatment for ROP, 68.18% required blood transfusion whereas among those who did not need treatment, 24.19% required blood transfusion. Lower GA, lower BW, longer duration of invasive ventilation, longer total duration of oxygen requirement and blood transfusion in first 2 weeks of life were significant in preterm infants who required treatment for ROP compared with those who did not.

Mechanical Power Density Predicts Prolonged Ventilation Following Double Lung Transplantation.

Prolonged mechanical ventilation (PMV) after lung transplantation poses several risks, including higher tracheostomy rates and increased in-hospital mortality. Mechanical power (MP) of artificial ventilation unifies the ventilatory variables that determine gas exchange and may be related to allograft function following transplant, affecting ventilator weaning. We retrospectively analyzed consecutive double lung transplant recipients at a national transplant center, ventilated through endotracheal tubes upon ICU admission, excluding those receiving extracorporeal support. MP and derived indexes assessed up to 36h after transplant were correlated with invasive ventilation duration using Spearman's coefficient, and we conducted receiver operating characteristic (ROC) curve analysis to evaluate the accuracy in predicting PMV (>72h), expressed as area under the ROC curve (AUROC). PMV occurred in 82 (35%) out of 237 cases. MP was significantly correlated with invasive ventilation duration (Spearman's ρ = 0.252 [95% CI 0.129-0.369], p < 0.01), with power density (MP normalized to lung-thorax compliance) demonstrating the strongest correlation (ρ = 0.452 [0.345-0.548], p < 0.01) and enhancing PMV prediction (AUROC 0.78 [95% CI 0.72-0.83], p < 0.01) compared to MP (AUROC 0.66 [0.60-0.72], p < 0.01). Mechanical power density may help identify patients at risk for PMV after double lung transplantation.

Study protocol for TARGET protein: The effect of augmented administration of enteral protein to critically ill adults on clinical outcomes: A cluster randomised, cross-sectional, double cross-over, clinical trial

BackgroundIt is unknown whether increasing dietary protein to 1.2–2.0 g/kg/day as recommended in international guidelines compared to current practice improves outcomes in intensive care unit (ICU) patients. The TARGET Protein trial will evaluate this. ObjectiveTo describe the study protocol for the TARGET Protein trial. Design, setting, and participantsTARGET Protein is a cluster randomised, cross-sectional, double cross-over, pragmatic clinical trial undertaken in eight ICUs in Australia and New Zealand. Each ICU will be randomised to use one of two trial enteral formulae for three months before crossing over to the other formula, which is then repeated, with enrolment continuing at each ICU for 12 months. All patients aged ≥16 years in their index ICU admission commencing enteral nutrition will be eligible for inclusion. Eligible patients will receive the trial enteral formula to which their ICU is allocated. The two trial enteral formulae are isocaloric with a difference in protein dose: intervention 100g/1000 ml and comparator 63g/1000 ml. Staggered recruitment commenced in May 2022. Main outcomes measuresThe primary outcome is days free of the index hospital and alive at day 90. Secondary outcomes include days free of the index hospital at day 90 in survivors, alive at day 90, duration of invasive ventilation, ICU and hospital length of stay, incidence of tracheostomy insertion, renal replacement therapy, and discharge destination. ConclusionTARGET Protein aims to determine whether augmented enteral protein delivery reduces days free of the index hospital and alive at day 90. Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12621001484831).

Hypothermia and adverse outcomes during the transfer of extremely low birth weight infants.

We aimed to explore whether hypothermia during the transfer of extremely low birth weight (ELBW) infants was associated with increased morbidity and mortality. Retrospective cohort study of transfers of ELBW infants by the London Neonatal Transfer Service between April 2015 and January 2017. Hypothermia was defined as an axillary temperature below 36.5°C. Hypothermia was recorded in 36-47% of the 146 transfers depending on the time point of measurement from admission at the referring unit to admission at the receiving unit. Infants with hypothermia had a lower gestational age [25.1 (24.1-26.6) versus 26.0 (25.3-27.0) weeks, p < 0.001], birth weight [750 (600-830) versus 800 (730-885) gr, p = 0.004) and age at referral [1 (0.8-3) versus 1.5 (1-4) hours, p = 0.049] compared to infants without hypothermia. Infants with hypothermia had a longer median (IQR) duration of invasive ventilation [22(6-44) days] compared to infants without hypothermia [10 (4-21) days, p = 0.002]. Infants with hypothermia had a higher incidence of a patent ductus arteriosus and mortality before discharge from neonatal care compared to infants without hypothermia (79% vs. 27%, p = 0.043 and 29% vs. 13%, p = 0.025, respectively). Among ELBW infants, hypothermia during transfer was common, particularly in infants of lower gestational age. Hypothermia was associated with a longer duration of ventilation and increased mortality before discharge from neonatal care.

Bronchopulmonary Dysplasia: A Five-Year Retrospective Cohort Study on Differences in Clinical Characteristics and Morbidities According to Severity Grading.

Bronchopulmonary dysplasia (BPD) is the most common complication associated with extreme prematurity. Although several criteria defining severity were developed over time, there are a few studies describing the differences in BPD phenotype and neonatal morbidities and complications between severity groups. We aimed to describe these differences in BPD patients of a neonatal intensive care unit (NICU). We conducted an observational retrospective cohort study through a medical record review over a five-year period. Participants were newborns admitted to an NICU who were diagnosed with BPD. We performed a descriptive statistical analysis of gestational complications and the use of antenatal corticosteroid therapy, birth-related data, and complications throughout the NICU stay, as well as the respiratory support used. We also compared different severity groups across these variables. The patients were divided into severe and non-severe BPD using the severity criteria of the 2001 NICHD/NHLBI/ORD consensus workshop. A total of 101 newborns with BPD participated in the study and 73 had data on BPD severity. The median gestational age was 27 weeks, ranging from 23 to 32 weeks. Of these 73 newborns, 36 had mild BPD (49.3%), 10 had moderate BPD (13.7%), and 27 had severe BPD (37.0%). When comparing severe and non-severe BPD, we found that extreme prematurity, extremely low birth weight, and small size for gestational age were more frequent in the severe BPD group (p-value=0.012, p-value<0.001, and p-value=0.012, respectively). Infants with severe BPD had a longer duration of invasive ventilation than those with mild or moderate BPD (p-value<0.001). Late sepsis, necrotizing enterocolitis, severe brain injury, and retinopathy of prematurity were more frequent in severe BPD (p-value=0.017, p-value=0.045, p-value=0.033, p-value=0.003, respectively). Previously published evidence describing causal links between BPD development and comorbidities exists but data on their impact on BPD severity are scarce. In our study, severe BPD seemed to be associated with a higher frequency of comorbidities and complications. Further studies are needed to ascertain the impact of each morbidity on the severity of BPD and if measures to prevent them could lead to potentially milder BPD disease.

A Study of Hypomagnesemia in Patients Admitted to the ICU.

Introduction After potassium, magnesium (Mg2+) is the most prevalent cation found intracellularly in the human body. The maintenance of excitability by Mg2+ and other cations is crucial for the neuromuscular junction to operate normally. Magnesium shortages are frequently overlooked compared to other electrolyte disorders such as hyponatremia, hypokalemia, and hypocalcemia. The present study aimed to study the factors and effects of hypomagnesemia amongintensive care unit (ICU) patients who are critically ill at atertiary care hospital. Methods This is a prospective observational study done among the patients who got admittedto the Medical ICUat Maharajahs Institute of Medical Sciences (MIMS), Nellimarla, Vizianagaram, from January 2020 to June 2021. A total of 100 patients were included in the study, of which 50 were cases and 50 were controls. The cases are those patients admitted to the medical ICU with critical illness and hypomagnesemia, and the controls are selected from those patients admitted with critical illness to the medical ICU with normal magnesium levels. Patients with severe infections, including sepsis, respiratory failure, cardiac failure,renal failure, cerebrovascular accidents (CVA), poisonings, and diabetic ketoacidosis (DKA), were included in the study. Patients who were treated with magnesium before admission to our ICU were excluded from this study. Serum magnesium was tested within24 hours of admission and is correlated with the outcomes of the patients in terms of APACHE II score, length of ICU stay, and requirementand duration ofventilatory support. Results Out of a total of 50 cases, 29 (58%) are of males. The mean age of cases was57.6 ∓ 8.2 years. Most cases were admitted due to organ failure (30%), followed by sepsis (26%) and poisoning (22%). The mean magnesium levels were 1.19 mg/dL among the cases, which was significantly lower when compared to the control group (2.16 mg/dL) (p-value= 0.01). The mean length of stay in the ICU was 6.12∓5.16 days in cases, whereas it was 5.28∓3.37 days in the control group (p-value = 0.33). 12% of cases needed non-invasive ventilation (NIV) when compared to 8% of controls (p-value= 0.50). 48% of the cases needed invasive ventilator support when compared to 28% in the control group (p-value= 0.03). The duration of invasive ventilation was higher among the cases (mean = 10 ∓3-17 days) compared to the controls(mean = 3 ∓2-4 days);p-value = 0.001.Mortality was higher in the case groupat 28% (14) and was 10% (5) in the control group (p-value = 0.02). Conclusion The need for invasive ventilation and duration of invasive ventilation were significantly higher among thepatients with hypomagnesemia compared to the patients with normal magnesium levels (p-value<0.05).Mortality was higher in the cases than in the controls (p-value<0.05).

Application of lung ultrasound in monitoring bronchopulmonary dysplasia and pulmonary arterial pressure in preterm infants.

The aim of this study was to evaluate the application value of lung ultrasound in monitoring bronchopulmonary dysplasia (BPD) and pulmonary artery pressure in premature infants. A total of 98 preterm infants diagnosed with BPD in the Fourth Hospital in Shijiazhuang were recruited, and their disease severity was classified as mild (n=32), moderate (n=33), or severe BPD (n=33) based on gestational age and oxygen concentration. Lung ultrasonography of the children was performed. The correlation between lung ventilation scores and disease severity was statistically analyzed, and the discrete optimization results were documented. The pulmonary hypertension indexes of the three groups of children were compared. Aberrant alterations of the pleural line were observed in all included children, and the B-line rose as the disease progressed. The duration of invasive ventilation, medication, and hospital stay increased with disease exacerbation (p<0.05). The three groups significantly differed in terms of ultrasound pulmonary ventilation scores and clinical severity (p<0.05). Only mild BDP was identified by lung ultrasound on the first day of birth (T1), and severe BDP was detectable during the first and second week (T2-T3) as well as the third and fourth week (T4-T5). Severe BPD was associated with significantly higher levels of pulmonary hypertension indices vs. mild and moderate BPD (p<0.05). Pulmonary ultrasonography demonstrates great potential to predict pulmonary hypertension in children and assesses the disease severity. Pulmonary ultrasound allows for dynamical real-time observation of the pulmonary lesions in children with pulmonary hypertension, thereby revealing the severity of pulmonary hypertension in premature children.

Pressure support versus continuous positive airway pressure for predicting successful liberation from invasive ventilation in children: an open label, randomized non-inferiority trial.

Pressure support (PS) as a spontaneous breathing trial (SBT) was considered inferior to continuous positive airway pressure (CPAP) and T-piece because PS underestimated post-extubation work of breathing in physiologic studies. We aimed to compare PS and CPAP as SBT methods for assessing clinical outcomes in children. This was an open label randomized non-inferiority trial conducted between December 2019 and August 2021 among children aged 1 month to 12 years deemed ready for weaning after at least 48h of invasive ventilation in PICU. Children were randomized to undergo a 2-h SBT with PS of 8cmH2O in addition to PEEP 5-6cm H2O or CPAP (5-6cm H2O). The primary outcome was successful liberation from invasive ventilation for 72h after first SBT. Secondary outcomes included first SBT pass rate, need for post-extubation respiratory support (high flow oxygen and/or non-invasive ventilation), and length of PICU stay. Of the 247 enrolled children, 244 completed the trial (121 in PS and 123 in CPAP group). Median (IQR) age was 24 (9, 84) months. Median (IQR) duration of invasive ventilation before randomization was 4.5 (3, 6.5) days. Successful liberation from invasive ventilation after first SBT occurred in 97 (80.2%) children in PS and 93 (75.6%) children in CPAP group [difference 4.6; 95% CI (-5.8, 15); p=0.39]. First SBT pass rate between PS and CPAP [111 (91.7%) versus 105 (85.4%); difference 6.3; 95% CI (-1.6, 14.3); p=0.12] was similar. Need for post-extubation respiratory support [52 (43%) versus 49 (40%)], rate of reintubation within 72h [14 (11.6%) versus 12 (9.8%)] and median (IQR) length of PICU stay [9 (6, 15) versus 8 (5.5, 13) days] were comparable. Four (1.6%) children, all in CPAP group had unfavourable outcome (1 died, 3 discontinued care). In invasively ventilated children, 2-h SBT with pressure support was non-inferior to CPAP in predicting successful liberation from invasive ventilation. None.