Fewer Days Of Mechanical Ventilation Research Articles

Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia

Hospital-acquired pneumonia (HAP) is the most common and morbid health care-associated infection, but limited data on effective prevention strategies are available. To determine whether daily toothbrushing is associated with lower rates of HAP and other patient-relevant outcomes. A search of PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and 3 trial registries was performed from inception through March 9, 2023. Randomized clinical trials of hospitalized adults comparing daily oral care with toothbrushing vs regimens without toothbrushing. Data extraction and risk of bias assessments were performed in duplicate. Meta-analysis was performed using random-effects models. The primary outcome of this systematic review and meta-analysis was HAP. Secondary outcomes included hospital and intensive care unit (ICU) mortality, duration of mechanical ventilation, ICU and hospital lengths of stay, and use of antibiotics. Subgroups included patients who received invasive mechanical ventilation vs those who did not, toothbrushing twice daily vs more frequently, toothbrushing provided by dental professionals vs general nursing staff, electric vs manual toothbrushing, and studies at low vs high risk of bias. A total of 15 trials met inclusion criteria, including 10 742 patients (2033 in the ICU and 8709 in non-ICU departments; effective population size was 2786 after shrinking the population to account for 1 cluster randomized trial in non-ICU patients). Toothbrushing was associated with significantly lower risk for HAP (risk ratio [RR], 0.67 [95% CI, 0.56-0.81]) and ICU mortality (RR, 0.81 [95% CI, 0.69-0.95]). Reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR, 0.68 [95% CI, 0.57-0.82) but not for patients who were not receiving invasive mechanical ventilation (RR, 0.32 [95% CI, 0.05-2.02]). Toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation (mean difference, -1.24 [95% CI, -2.42 to -0.06] days) and a shorter ICU length of stay (mean difference, -1.78 [95% CI, -2.85 to -0.70] days). Brushing twice a day vs more frequent intervals was associated with similar effect estimates. Results were consistent in a sensitivity analysis restricted to 7 studies at low risk of bias (1367 patients). Non-ICU hospital length of stay and use of antibiotics were not associated with toothbrushing. The findings of this systematic review and meta-analysis suggest that daily toothbrushing may be associated with significantly lower rates of HAP, particularly in patients receiving mechanical ventilation, lower rates of ICU mortality, shorter duration of mechanical ventilation, and shorter ICU length of stay. Policies and programs encouraging more widespread and consistent toothbrushing are warranted.

Comparison of In-Hospital Outcomes of Surgical Stabilization of Rib Fractures with Nonsurgical Management: A Multicenter, Prospective, Cohort Study.

Evidence for the efficacy of surgical stabilization of rib fractures in patients with rib fractures is controversial. We aim to compare the clinical outcomes of surgical rib fixation for rib fracture with non-operative treatment. Our institutional database from three general hospitals (Viet Duc Hospital, Viet Tiep Friendship Hospital & Cho Ray Hospital) was queried to identify patients with flail chest treated with locked plate fixation between December 2021 and February 2023. A medical record review for demographic, injury, hospital, and surgical data was also retrospectively performed for all patients. Characteristics and outcomes of the patients receiving the surgical rib fixation for rib fracture were compared with those without surgery. A total of 166 patients with thoracic trauma were included. The majority of patients were male, and the age range was from 18 to 80 years old, with a mean age of 51.6 years. 52 (31.3%) underwent surgical stabilization of rib fractures (SSRF). The highest combined injuries were limb injuries, followed by traumatic brain injury, and maxillofacial trauma. While 1 patient died in the non-surgical group, there was no significant difference in the mortality between the two groups. The surgical group had a slightly shorter hospital stay than the non-surgical group (8.6 days vs. 10.0 days, p-value: 0.038). SSRF group tended toward a lower incidence of pneumonia compared to the non-surgical group (SSRF: 3.8% vs. non-surgical: 7%), but this difference was not statistically significant (p-value: 0.426). SSRF group also had a lower incidence of tracheostomy than the non-operative group (SSRF: 0% vs. non-surgical: 1.8%, p-value: 0.337). Operative fixation of a rib fracture in trauma patients resulted in a lower incidence of pneumonia, fewer days of mechanical ventilation, and a shorter hospital stay compared to non-operative treatment group.

HIV exposure and its association with paediatric ICU outcomes in children admitted with severe pneumonia at Chris Hani Baragwanath Academic Hospital, South Africa

Background. Pneumonia is one of the leading causes of under-5 death in South Africa and accounts for a substantial burden of paediatric intensive care unit (PICU) admissions. However, little is known about PICU outcomes in HIV-exposed uninfected (HIV-EU) children with pneumonia, despite the growing size of this vulnerable population.Objectives. To determine whether HIV exposure without infection is an independent risk factor for mortality and morbidity in childrenadmitted to PICU with pneumonia.Methods. This retrospective review included all patients with pneumonia admitted to the PICU at Chris Hani Baragwanath AcademicHospital between 1 January 2013 and 31 December 2014. Patients were classified as HIV-unexposed (HIV-U), HIV-EU and HIV-infected.Medical records were reviewed to determine survival to PICU discharge, duration of PICU admission and duration of mechanicalventilation. Survival analysis was used to determine the association between HIV infection/exposure with mortality, and linear regression was used to examine the association with length of stay and duration of mechanical ventilation. This study included 107 patients: 54 were HIV-U; 28 were HIV-EU; 23 HIV-positive; and 2 had an unknown HIV status.Results. Overall, 84% (n=90) survived to PICU discharge, with no difference in survival based on HIV infection or exposure. Both HIV-EUand HIV-U children had significantly shorter PICU admissions and fewer days of mechanical ventilation compared with HIV-infectedchildren (p=0.011 and p=0.004, respectively).Conclusion. HIV-EU children behaved similarly to HIV-U children in terms of mortality, duration of PICU admission and length ofmechanical ventilation. HIV infection was associated with prolonged length of mechanical ventilation and ICU stay but not increasedmortality

Early tracheostomy and active exercise programmes in adult intensive care patients with severe burns

BackgroundTracheostomy is a strategy often employed in patients requiring prolonged intubation in ICU settings. Evidence suggests that earlier tracheostomy and early active exercise are associated with better patient centered outcomes. Severe burn patients often require prolonged ventilatory support due to their critical condition, complex sedation management and multiple operating room visits. It is still unclear the optimal timing for tracheostomy in this population. MethodsWe conducted a service evaluation where we compared Early Tracheostomy (≤10 days) with Late Tracheostomy (>10 days) in 41 severely burned patients that required prolonged respiratory support. ResultsEarly Tracheostomy cohort was associated with fewer days of mechanical ventilation (16 vs 33, p = 0.001), shorter hospital length of stay (65 vs 88 days, p = 0.018), earlier first day of active exercise (day 8 vs day 25, p < 0.0001) and higher Functional Assessment for Burns scores upon discharge (32 vs 28, p = 0.016). ConclusionEarly tracheostomy in patients with severe burns is associated with earlier active exercise, fewer days of ventilation, shorter length of hospital stay and better physical functional independence upon discharge from hospital.

Outcomes and Timing of Bedside Percutaneous Tracheostomy of COVID-19 Patients over a Year in the Intensive Care Unit.

Background: The benefits and timing of percutaneous dilatational tracheostomy (PDT) in Intensive Care Unit (ICU) COVID-19 patients are still controversial. PDT is considered a high-risk procedure for the transmission of SARS-CoV-2 to healthcare workers (HCWs). The present study analyzed the optimal timing of PDT, the clinical outcomes of patients undergoing PDT, and the safety of HCWs performing PDT. Methods: Of the 133 COVID-19 patients who underwent PDT in our ICU from 1 April 2020 to 31 March 2021, 13 patients were excluded, and 120 patients were enrolled. A trained medical team was dedicated to the PDT procedure. Demographic, clinical history, and outcome data were collected. Patients who underwent PDT were stratified into two groups: an early group (PDT ≤ 12 days after orotracheal intubation (OTI) and a late group (>12 days after OTI). An HCW surveillance program was also performed. Results: The early group included 61 patients and the late group included 59 patients. The early group patients had a shorter ICU length of stay and fewer days of mechanical ventilation than the late group (p < 0.001). On day 7 after tracheostomy, early group patients required fewer intravenous anesthetic drugs and experienced an improvement of the ventilation parameters PaO2/FiO2 ratio, PEEP, and FiO2 (p < 0.001). No difference in the case fatality ratio between the two groups was observed. No SARS-CoV-2 infections were reported in the HCWs performing the PDTs. Conclusions: PDT was safe and effective for COVID-19 patients since it improved respiratory support parameters, reduced ICU length of stay and duration of mechanical ventilation, and optimized the weaning process. The procedure was safe for all HCWs involved in the dedicated medical team. The development of standardized early PDT protocols should be implemented, and PDT could be considered a first-line approach in ICU COVID-19 patients requiring prolonged mechanical ventilation.

Changes in Use of Respiratory Support for Preterm Infants in the US, 2008-2018

In preterm infants, mechanical ventilation (MV) is associated with adverse pulmonary and neurodevelopmental outcomes. Multiple randomized clinical trials over the past 2 decades have shown the effectiveness of early noninvasive ventilation (NIV) in decreasing the use of MV in preterm infants. The epidemiologic factors associated with respiratory support in US preterm infants and any temporal changes after these trials is unknown. To evaluate temporal changes in MV and noninvasive respiratory support in US preterm infants. In a cohort design, 2 large national data sets (Pediatrix Clinical Data Warehouse for the clinical cohort and National Inpatient Sample for the national cohort) were used to collect data on preterm infants (<35 weeks' gestation) without congenital anomalies who received active intensive care and were discharged home or died in the birth hospital from January 1, 2008, to December 31, 2018. Data analysis was conducted from December 10, 2019, to December 16, 2020. Discharge year. In the clinical cohort, detailed respiratory support data were generated, including days of MV and NIV modalities, and temporal trends were evaluated using multivariable modified Poisson or negative binomial regression models with discharge year as a continuous variable. In the national cohort, observed and expected national MV use were calculated. Among 259 311 infants (47.2% female) in 359 neonatal intensive care units in the clinical cohort, decreases were noted in the use (from 29.4% of infants in 2008 to 18.5% in 2018, relative risk for annual change, 0.96; 95% CI, 0.95-0.96) and duration (mean days, from 10.3 in 2008 to 9.7 in 2018; rate ratio for annual change, 0.98; 95% CI, 0.97-0.98) of MV. Noninvasive ventilation use increased from 57.9% of infants in 2008 to 67.4% in 2018 (adjusted relative risk for annual change, 1.02; 95% CI, 1.02-1.03), and mean NIV duration increased by 3.2 days (95% CI, 2.9-3.6 days). With increased use of continuous positive airway pressure and nasal intermittent positive-pressure ventilation as the main factors in the increase, the mean duration of respiratory support increased from 13.8 to 15.4 days (adjusted rate ratio for annual change, 1.03; 95% CI, 1.02-1.04) from 2008 to 2018. Among 1 169 441 infants in the national cohort, MV use decreased from 22.0% in 2008 to 18.5% in 2018, with an estimated 29 700 fewer ventilated infants and 142 000 fewer days of MV than expected during this period. These findings suggest that preterm respiratory support changed significantly from 2008 to 2018, with decreased use and duration of MV, increased use and duration of NIV, and an overall increase in respiratory support duration.

Less invasive surfactant administration reduces incidence of severe intraventricular haemorrage in preterms with respiratory distress syndrome: a cohort study.

Less invasive surfactant administration (LISA) has proved to safely improve morbidity in extreme preterms with respiratory distress syndrome (RDS). Its effect regarding intraventricular hemorrhage (IVH) remains controversial between most recent systematic reviews. We aimed to evaluate its effect over incidence of severe IVH in this population. We compared the incidence of IVH in a prospective cohort of consecutively born preterm infants <34 weeks' gestation receiving LISA (n = 108) with a historical cohort receiving surfactant delivery via tracheal tube and managed with mechanical ventilation (n = 100). No significant differences regarding perinatal characteristics were observed between both groups. There was a significant reduction in the incidence of severe IVH in LISA group as compared with the historical group [OR = 0.054 (95% CI 0.01-0.2) p = 0.000. NNT 5]. In addition, a significant trend towards decreased mortality was also observed in the study group [OR = 0.2 (95% CI 0.04-0.9) p = 0.027, NNT 9]. Intervention group infants also showed lower oxygenation requirements during the first 72 h post surfactant administration and a reduced incidence of pneumothorax. They were less frequently intubated [31 infants (28.4%) vs. 100 [100%]; P < 0.001] and required fewer days of mechanical ventilation. However, no significant difference in bronchopulmonary dysplasia incidence was observed between both groups. LISA approach effectively reduces severe IVH in very low and low birth weight (BW) preterms with RDS. In addition we observe a significant trend towards reduction in both need and duration of MV support, air leak, and overall mortality in the intervention group.

Early mobilization of trauma patients admitted to intensive care units: A systematic review and meta-analyses

ObjectiveTo determine the effect of early mobilization (EM) in trauma patients admitted to the ICU. Outcomes of interest included mortality, hospital and ICU length of stay (LOS), and duration of mechanical ventilation. MethodsWe performed a systematic review of 4 electronic databases (Ovid MEDLINE, Embase, CINAHL, Cochrane Library) and the grey literature. Eligible study designs included randomized control trials, prospective cohorts, or retrospective cohorts. Studies must have compared EM to usual care (i.e., delayed or no mobilization) in trauma patients admitted to ICU. Overall, there were 2982 articles screened and 9 were included in the analysis. Two authors independently performed data extraction using a standardized form. Pertinent study design and population characteristics were recorded, as were prespecified outcome measures. Meta-analyses were performed using random effects models. Study quality was assessed using the Newcastle-Ottawa Scale. ResultsStudy cohorts ranged from 15 to 1132 patients (median 63) and varied in their inclusion criteria. Most studies utilized a progressive mobility protocol as their intervention. Mortality was reported in 5 studies, of which 3 observed a lower rate with EM; however, meta-analysis showed no difference in mortality between patients mobilized early and those receiving usual care. Eight studies reported on LOS (in-hospital and ICU); although all 8 studies found EM reduced LOS, the difference in LOS was not significant on meta-analysis. Finally, 3 studies reported on ventilator days, all of which observed a reduction in the EM group. On meta-analysis, duration of mechanical ventilation was significantly lower with EM (mean difference −1.18 days, 95% CI, −2.17 – −0.19). ConclusionsFew studies have investigated the effects of EM in trauma ICU patients. The available evidence suggests that patients who receive EM require fewer days of mechanical ventilation, but have similar mortality and LOS compared to those receiving usual care.

No Time for Early Mobility?

We know that early mobility has many benefits. Nurse-facilitated early mobility reduces incidence of delirium, improves muscle strength, increases independent functional status after discharge, and improves overall quality of life.1 Early mobility also decreases health care costs with fewer days of mechanical ventilation and shorter stays in the intensive care unit.1 The question then becomes, how do I fit one more task into my shift?That is the question that Young et al and Colwell et al seek to answer in their respective studies “Identifying Barriers to Nurse-Facilitated Patient Mobility in the Intensive Care Unit” and “Mobilization Therapy in the Pediatric Intensive Care Unit: A Multidisciplinary Quality Improvement Initiative.” Although early mobility is an interprofessional responsibility, nurses have the unique distinction of being present with the patient more than any other member of the health care team. Thus nurses have the opportunity to assist patients with passive range of motion exercises, dangling legs at the bedside, or other types of early mobility at times that are convenient to both the patient and the nurse.

Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery

ObjectiveNeonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. MethodsWe retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. ResultsOf 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. ConclusionsAdmission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery.

VP149 Sustained Low Efficiency Dialysis (SLED): A Rapid Review

INTRODUCTION:This rapid review aimed to determine the effectiveness of Sustained Low Efficiency Dialysis (SLED) when compared to Continuous Renal Replacement Therapy (CRRT) and Continuous Veno-Venous Hemofiltration (CVVH) in the treatment of acute renal failure (ARF) with a view to implementing SLED in a tertiary hospital in 2014.METHODS:A rapid review was performed on the effect of SLED for patients with ARF compared with CRRT or CVVH. The outcomes of interest were mortality, hemodynamic stability, reduced utilization of intensive care unit (ICU) and cost-effectiveness. The search terms ("sustained low-efficiency dialysis[MESH]”) were used to search PubMed, the Cochrane Library, UK NHS Centre for Reviews and Dissemination databases and the US National Guidelines Clearinghouse for relevant articles until 2014.RESULTS:Four observational and two randomized controlled trial (RCT) studies were found. The results showed that 90-day mortality, was similar between groups (SLED: 49.6 percent versus CVVH: 55.6 percent, p = .43). Hemodynamic stability did not differ between SLED and CVVH and between SLED and CRRT. Patients in the SLED group had significantly fewer days of mechanical ventilation (17.7 ± 19.4 versus 20.9 ± 19.8, p = .047) and fewer days in the ICU (19.6 ± 20.1 versus 23.7 ± 21.9, p = .04). Patients treated with SLED needed fewer blood transfusions (1,375 ± 2,573 ml versus 1,976 ± 3,316 ml, p = .02) and had a substantial reduction in nursing time (p &lt; .001). The hospital weekly costs were CAD1,431 for SLED, CAD2,607 for CRRT with heparin, and CAD 3,089 for CRRT with citrate. Dialysis using SLED was associated with higher first post-dialysis mean arterial pressure (p = .003) than those treated with CVVH, which led to lower mortality.CONCLUSIONS:The evidence suggests that SLED can be used as an alternative to CRRT, as the outcomes were similar. SLED provides solute removal equivalent to CRRT at significantly lower cost.

Prolonged Glucocorticoid Treatment in ARDS: Impact on Intensive Care Unit-Acquired Weakness.

Systemic inflammation and duration of immobilization are strong independent risk factors for the development of intensive care unit-acquired weakness (ICUAW). Activation of the pro-inflammatory transcription factor nuclear factor-κB (NF-κB) results in muscle wasting during disuse-induced skeletal muscle atrophy (ICU bed rest) and septic shock. In addition, NF-κB-mediated signaling plays a significant role in mechanical ventilation-induced diaphragmatic atrophy and contractile dysfunction. Older trials investigating high dose glucocorticoid treatment reported a lack of a sustained anti-inflammatory effects and an association with ICUAW. However, prolonged low-to-moderate dose glucocorticoid treatment of sepsis and ARDS is associated with a reduction in NF-κB DNA-binding, decreased transcription of inflammatory cytokines, enhanced resolution of systemic and pulmonary inflammation, leading to fewer days of mechanical ventilation, and lower mortality. Importantly, meta-analyses of a large number of randomized controlled trials investigating low-to-moderate glucocorticoid treatment in severe sepsis and ARDS found no increase in ICUAW. Furthermore, while the ARDS network trial investigating methylprednisolone treatment in persistent ARDS is frequently cited to support an association with ICUAW, a reanalysis of the data showed a similar incidence with the control group. Our review concludes that in patients with sepsis and ARDS, any potential direct harmful neuromuscular effect of glucocorticoids appears outweighed by the overall clinical improvement and reduced duration of organ failure, in particular ventilator dependency and associated immobilization, which are key risk factors for ICUAW.

Preoperative education on postoperative delirium, anxiety, and knowledge in pulmonary thromboendarterectomy patients.

Delirium is the most common postoperative psychiatric condition in intensive care settings and can lead to increased complications and costs. To evaluate the impact of multifaceted preoperative patient education on postoperative delirium, anxiety, and knowledge and to explore predictors of postoperative delirium, days of mechanical ventilation, and days in the intensive care unit (ICU) in patients undergoing pulmonary thromboendarterectomy. A prospective, randomized controlled trial was conducted on consented patients from October 2011 to April 2013. Patients were randomized in a 1 to 1 ratio to receive either an individualized 45-minute multifaceted preoperative education (experimental group, n = 63) or standard education (control group, n = 66). Participants completed the State-Trait Anxiety Inventory and Knowledge Test before and after the education. Data on incidence of delirium, days of mechanical ventilation, ICU days, and cardiopulmonary parameters were collected. The experimental group had significantly more knowledge about postoperative care (P< .001) and fewer days of mechanical ventilation (P = .04) than the control group. The 2 groups did not differ significantly in anxiety, incidence of delirium, or ICU days. In exploratory multivariate analyses, hearing impairment was a positive predictor for days of delirium (P = .009), days of mechanical ventilation (P< .001), and ICU days (P= .049), whereas the posttest knowledge was a negative predictor for days of mechanical ventilation (P = .02). The patient education appeared to be effective in improving knowledge and reducing days of mechanical ventilation. Hearing impairment was an unexpected predictor of adverse outcomes for patients but may be amenable to nursing intervention.

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

Protocolized sedation improves clinical outcomes in critically ill adults, but its effect in children is unknown. To determine whether critically ill children managed with a nurse-implemented, goal-directed sedation protocol experience fewer days of mechanical ventilation than patients receiving usual care. Cluster randomized trial conducted in 31 US pediatric intensive care units (PICUs). A total of 2449 children (mean age, 4.7 years; range, 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled in 2009-2013 and followed up until 72 hours after opioids were discontinued, 28 days, or hospital discharge. Intervention PICUs (17 sites; n = 1225 patients) used a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites; n = 1224 patients) managed sedation per usual care. The primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, measures of sedative exposure (wakefulness, pain, and agitation), and occurrence of iatrogenic withdrawal. Duration of mechanical ventilation was not different between the 2 groups (intervention: median, 6.5 [IQR, 4.1-11.2] days; control: median, 6.5 [IQR, 3.7-12.1] days). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not significantly different between the 2 groups. Intervention patients experienced more postextubation stridor (7% vs 4%; P = .03) and fewer stage 2 or worse immobility-related pressure ulcers (<1% vs 2%; P = .001). In exploratory analyses, intervention patients had fewer days of opioid administration (median, 9 [IQR, 5-15] days vs 10 [IQR, 4-21] days; P = .01), were exposed to fewer sedative classes (median, 2 [IQR, 2-3] classes vs 3 [IQR, 2-4] classes; P < .001), and were more often awake and calm while intubated (median, 86% [IQR, 67%-100%] of days vs 75% [IQR, 50%-100%] of days; P = .004) than control patients, respectively; however, intervention patients had more days with any report of a pain score ≥ 4 (median, 50% [IQR, 27%-67%] of days vs 23% [IQR, 0%-46%] of days; P < .001) and any report of agitation (median, 60% [IQR, 33%-80%] vs 40% [IQR, 13%-67%]; P = .003), respectively. Among children undergoing mechanical ventilation for acute respiratory failure, the use of a sedation protocol compared with usual care did not reduce the duration of mechanical ventilation. Exploratory analyses of secondary outcomes suggest a complex relationship among wakefulness, pain, and agitation. clinicaltrials.gov Identifier: NCT00814099.

Standardized application of laxatives and physical measures in neurosurgical intensive care patients improves defecation pattern but is not associated with lower intracranial pressure.

Background. Inadequate bowel movements might be associated with an increase in intracranial pressure in neurosurgical patients. In this study we investigated the influence of a structured application of laxatives and physical measures following a strict standard operating procedure (SOP) on bowel movement, intracranial pressure (ICP), and length of hospital stay in patients with a serious acute cerebral disorder. Methods. After the implementation of the SOP patients suffering from a neurosurgical disorder received pharmacological and nonpharmacological measures to improve bowel movements in a standardized manner within the first 5 days after admission to the intensive care unit (ICU) starting on day of admission. We compared mean ICP levels, length of ICU stay, and mechanical ventilation to a historical control group. Results. Patients of the intervention group showed an adequate defecation pattern significantly more often than the patients of the control group. However, this was not associated with lower ICP values, fewer days of mechanical ventilation, or earlier discharge from ICU. Conclusions. The implementation of a SOP for bowel movement increases the frequency of adequate bowel movements in neurosurgical critical care patients. However, this seems not to be associated with reduced ICP values.

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Introduction: The purpose of this study was to evaluate the impact of multifaceted preoperative patient education and to explore the predictors of delirium, mechanical ventilation, and intensive care unit length of stay (LOS) in patients who received preoperative education regarding what to expect of their ICU stay. Methods: A prospective, randomized controlled trial was conducted on consented patients undergoing pulmonary thromboendarterectomy from October 2011 to April 2013. Patients were randomized in 1:1 ratio to receive either an individualized 45-minute multifaceted preoperative education (experimental group, n=63) or standard of care preoperative education (control group, n=66). Participants completed a knowledge test and the State-Trait Anxiety Inventory before and after the education. Patient satisfaction, delirium assessment, days of mechanical ventilation, ICU LOS, and cardiopulmonary parameters were collected postoperatively. Results: The experimental group had significant improvement in postoperative care knowledge (p<0.001) and fewer days of mechanical ventilation (p=0.038) compared to the control group. No statistically significant differences were observed in anxiety, satisfaction, ICU LOS, and incidence of delirium. In exploratory multivariate analyses, hearing impairment was a statistically significant positive predictor for days of delirium (p=0.009), days of mechanical ventilation (p<0.001), and ICU LOS (p=0.049); whereas the posttest knowledge was a statistically significant negative predictor for days of mechanical ventilation (p=.018). Conclusions: The multifaceted preoperative patient education appeared to be effective in improving knowledge and reducing days of mechanical ventilation. Hearing impairment was an unexpected negative predictor of patient outcomes.

Effect of Aerosolized Colistin as Adjunctive Treatment on the Outcomes of Microbiologically Documented Ventilator-Associated Pneumonia Caused by Colistin-Only Susceptible Gram-Negative Bacteria

The increasing frequency of ventilator-associated pneumonia (VAP) caused by colistin-only susceptible (COS) gram-negative bacteria (GNB) is of great concern. Adjunctive aerosolized (AS) colistin can reportedly increase alveolar levels of the drug without increasing systemic toxicity. Good clinical results have been obtained in patients with cystic fibrosis, but conflicting data have been reported in patients with VAP. We conducted a retrospective, 1:1 matched case-control study to evaluate the efficacy and safety of AS plus IV colistin vs IV colistin alone in 208 patients in the ICU with VAP caused by COS Acinetobacter baumannii, Pseudomonas aeruginosa, or Klebsiella pneumoniae. Compared with the IV colistin cohort, the AS-IV colistin cohort had a higher clinical cure rate (69.2% vs 54.8%, P = .03) and required fewer days of mechanical ventilation after VAP onset (8 days vs 12 days, P = .001). In the 166 patients with posttreatment cultures, eradication of the causative organism was also more common in the AS-IV colistin group (63.4% vs 50%, P = .08). No between-cohort differences were observed in all-cause ICU mortality, length of ICU stay after VAP onset, or rates of acute kidney injury (AKI) during colistin therapy. Independent predictors of clinical cure were trauma-related ICU admission (P = .01) and combined AS-IV colistin therapy (P = .009). Higher mean Simplified Acute Physiology Score II (P = .002) and Sequential Organ Failure Assessment (P = .05) scores, septic shock (P &lt; .001), and AKI onset during colistin treatment (P = .04) were independently associated with clinical failure. Our results suggest that AS colistin might be a beneficial adjunct to IV colistin in the management of VAP caused by COS GNB.

Prophylactic sequential bronchoscopy after inhalation injury: results from a three-year prospective randomized trial.

That the prophylactic, sequential use of bronchoscopy after inhalation injury as a therapeutic tool to remove secretions and carbonaceous material and to screen for the early detection of pneumonia will improve outcome. A three-year prospective randomized trial at a regional burn center. Thirty-three patients with inhalation injury requiring mechanical ventilation were admitted over threeyears. The bronchoscopy group had a higher initial carboxyhemoglobin level at 11.9% (95% CI±9.6%) versus the control group at 9.9% (95% CI±5.7%, p=0.7). There was no difference in the incidence of pneumonia between groups (p=0.6). There was a trend toward fewer days of antibiotic use in the bronchoscopy group, at 4.5days (95% CI±4.5days) versus 9.3days (95% CI±7.1days, p=0.3). Fewer patients were treated with antibiotics in the bronchoscopy group (4/13, 31%) versus the control group (9/15, 60%, p=0.1). There was a statistically significant difference in the morbidity that favored the bronchoscopy group (3/13, 23%) over the control group (9/15, 60%, p=0.04). There was no statistically significant difference between the two groups in days of mechanical ventilation (bronchoscopy 5.1days, 95% CI±3.6days, control 6.7days, 95% CI±6.3days, p=0.7), ICU days (bronchoscopy 10days, 95% CI±10days, control 18days, 95% CI±12days, p=0.4), and hospital days (bronchoscopy 21days, 95% CI±12days, control 26days, 95% CI±12days, p=0.5), although the trends favored the bronchoscopy group for all of the endpoints. In conclusion, this program of scheduled, sequential bronchoscopy after inhalation injury showed several strong trends towards less morbidity, fewer days of mechanical ventilation, and a shorter length of stay. There was also a strong trend towards less antibiotic use and a shorter duration of treatment. This data is promising and should promote a larger, multi-institutional trial in the future.

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Introduction: Limited studies supporting a hypocaloric feeding approach in critically ill obese patients have suggested differences in clinical outcomes, including decreased length of mechanical ventilation and intensive care unit (ICU) length of stay. Hypothesis: Hypocaloric parenteral feeding is associated with improvements in clinical outcomes, including reduced ICU length of stay and fewer days of mechanical ventilation. Methods: This retrospective chart review screened all obese (BMI > 30 kg/m2) adult patients receiving parenteral nutrition at goal rate for > 48 hours in three ICUs at our academic medical center over a 33 month period. The nutritional content of parenteral nutrition was quantified and patients were stratified by compliance with the guidelines ±10 percent on the basis of kcal/kg/day (actual and ideal body weights). Primary outcomes included net changes in albumin and prealbumin, ICU and hospital length of stay, and duration of mechanical ventilation. Statistical significance was tested using the Student’s t-test. Results: Twenty four patients were fed hypocalorically per the guidelines while 27 patients were fed with a modified hypocaloric approach that provided more kcal/kg per day than current guideline recommendations (13.79 ± 3.12 vs. 19.81 ± 2.78, p < 0.001). There were no statistically significant differences between the two feeding strategies in surrogate markers of nutrition support (except for prealbumin (p = 0.027)) and clinical outcomes, including days of mechanical ventilation, ICU length of stay, hospital length of stay, and in-hospital mortality. Subgroup analyses stratified by compliance to the protein recommendations and by kcal/kg adjusted body weight also failed to show an association between feeding strategy and outcomes. Conclusions: There was no association between parenteral hypocaloric feeding per the guidelines and a modified hypocaloric approach with regard to clinical outcomes in critically ill obese patients. Although well designed prospective studies are required to confirm, these results raise the possibility that a less strict hypocaloric feeding approach in this patient population does not impact meaningful clinical and nutritional outcomes.

Rescue corticosteroids in twin pregnancies and short‐term neonatal outcomes

To estimate the efficacy of a rescue course of antenatal corticosteroids in twin pregnancies. Retrospective cohort study. Tertiary-care centre. Twins born from 24 to <34 weeks of gestation in a single maternal and fetal medicine practice from 2006 to 2011. We compared neonatal outcomes in 88 twins exposed to a single course of corticosteroids with outcomes in 42 twins exposed to two courses of corticosteroids: the initial course and a single rescue course. Analyses were adjusted to control for correlation between twins born to the same mother. Short-term neonatal respiratory morbidity. Rescue corticosteroids were associated with fewer days of mechanical ventilation (7.3 ± 3.3 versus 33.9 ± 25.3 days, P = 0.003), fewer days with a fraction of inspired oxygen of >21% (6.3 ± 4.3 versus 33.3 ± 25.8 days, P = 0.003), a lower incidence of mechanical ventilation >14 days or death while on mechanical ventilation (0 versus 12.5%, P = 0.016), and a lower incidence of retinopathy of prematurity (0 versus 12.5%, P = 0.016). The proportion of neonates with respiratory distress syndrome did not differ between the groups (adjusted odds ratio 1.28, 95% confidence interval 0.50-3.26). There were no differences found for birthweight, head circumference and length. In twins born before 34 weeks of gestation, exposure to rescue corticosteroids may be associated with improved neonatal outcomes. Further studies are warranted to assess the effect of rescue corticosteroids in twin pregnancies.