Length Of Intubation Research Articles

Implications of COVID-19 in Airway and Swallowing Function.

The acute treatment and complications of the novel COVID-19 virus have been well studied, but the implications of this novel virus for swallowing function continue to be investigated. The goal of this study is to retrospectively assess airway and swallowing outcomes for those patients who requiredintensive care unit(ICU)-level care for COVID-19 infection. Comparison of swallowing outcomes through diet change in COVID-19 patients in the Ochsner-Louisiana State University (LSU) Hospital ICU. Ochsner-LSU Hospital (Shreveport, Louisiana). A retrospective chart review was performed from March 2020 to May 2022 to identify patients with a primary diagnosis of COVID-19. Variables analyzed include age, gender, length of intubation, length of ventilation, airway interventions, use of extracorporeal membrane oxygenation, and diet prior to, during, and after hospitalization for COVID-19 infection. Two hundred and seven patients fit the inclusion criteria. There was a significant difference in discharge diet between those patients who were intubated and those who were not (P = .007). Thirty percent of patients were discharged on a different diet than their baseline with patients on a nonregular diet significantly more likely to discharge to a facility (P = .043). Negative vaccine status was associated with prolonged ICU stay, prolonged duration of intubation, and prolonged duration of ventilation. COVID-19 continues to present novel challenges with new implications and outcomes being discovered in the third year of the pandemic. Further research is necessary to determine the most effective treatment approaches with respect to optimized speech and swallow outcomes.

712 Added Effect, Injuries, And Complications Of Blast Injuries Among Burn Patients On Resuscitation And Outcomes

Abstract Introduction Major burn injuries present as complex cases due to the hemodynamic and cardiodynamic changes that occur following the injury which can lead to the development of sepsis, multiple organ failure, and death[1]. Complexity of these cases increase furthermore with the inclusion of explosion induced injuries. Concussive explosive forces can be particularly devastating for air containing organs like the lung, bowel and middle ear [8]. In explosion-related cases, “the mortality correlated significantly with higher burned total body surface area (TBSA), higher abbreviated burn severity index (ABSI) score, accompanying inhalation injuries, and lung contusions” [2]. Cardiac blast traumas may occasionally result directly from blast energy but are more often presented as indirect coronary emboli [4]. Explosive energies have been observed to induce bradycardia, hypotension, and apnea [5]. Although more common in underwater blasts, small bowel perforations can result directly from an explosion or indirectly up to 2 weeks following the explosion [4]. A longer ICU length of stay is also associated with patients suffering from an explosion event [7]. Methods Through a hypothesis-driven retrospective study, we isolated a group of 68 burn patients, ages 18-85, from 2010-2017 that fit our criteria. Inclusion to the test group required the presence of an injury related to an explosion that resulted in a TBSA% greater than 10%. We then collected data and compared that to the outcomes of patients who had burn injuries not caused by an explosion. The control group had statistically similar age, TBSA percentage, and comorbidities. We compared major outcomes such as length of stay, length of time on a ventilator, and mortality rates. Results When controlled for age, TBSA %, presence of inhalation injuries and comorbidities, the explosion group had significantly higher mortality rates (p< 0.001). The length of stay and length of intubation were not significantly different for the explosion group. The incidence of sepsis in the explosion group was nearly significant with a p-value of 0.051. Conclusions After analyzing the data, we conclude that patients experiencing an explosion experience higher mortality rates than burn patients of similar age, TBSA%, and comorbidities. The shockwave present in explosion cases likely causes additional injuries to patients that decrease survivability. There was indication that sepsis or infection events may be more likely in patients experiencing an explosion, but results nearly missed the standard of significance. Due to the relatively small sample size of 68 patients, some of the data might be limited in its generalizability. A larger study could provide more insight into the outcomes of patients experiencing explosions. Applicability of Research to Practice The effect of explosions on mortality provides an opportunity for quality improvement research and development of improved methods for treating explosion involved burn injuries.

Aerosolized Plus Intravenous Polymyxin B Versus Colistin in the Treatment of Pandrug-Resistant Klebsiella Pneumonia-mediated Ventilator-Associated Pneumonia: A Retrospective Cohort Study in Bangladesh.

Pandrug-resistant Klebsiella pneumoniae ventilator associated pneumonia (VAP) is associated with high rate of mortality in intensive care unit (ICU) and has been recognized as a difficult-to-treat infection worldwide. Polymyxin B or colistin-based combination therapies are frequently used worldwide though microbial eradication rate is not promising. The aim of this study is to compare the clinical outcome of intravenous with aerosolized polymyxin B versus colistin in the treatment of pandrug-resistant K. pneumoniae VAP. This retrospective cohort study was conducted on 222 mechanically ventilated patients admitted from May 11, 2019 to October 19, 2020. K. pneumoniae isolates were resistant to all available antibiotics, including polymyxins in culture sensitivity tests. As treatment, polymyxin B and colistin was administered in intravenous and aerosolized form concurrently twice daily in 106 patients and 116 patients in PMB and CLN group, respectively for 14 days. Survival rate, safety, and clinical outcomes were compared among the groups. The Cox proportional-hazard model was performed to calculate hazard ratio (HR) with 95% confidence intervals (CI). Patients in PMB group showed more microbial eradication than the patients CLN group [68.1% (n=116)/83% (n=106), respectively; P <0.05). The median day of intubation and ICU stay in PMB group was shorter than that in CLN group [10 (IQR: 9-12.25) vs. 14 (IQR: 11-19), P <0.05; 12 (IQR: 10-14) vs. 15 (IQR: 9-18.5), P=0.072, respectively] with reduced 60-day all-cause mortality rate [15% (n=106) vs. 21.55% (n=116)]. Polymyxin B improved survival compared to colistin (multivariate HR: 0.662; 95% CI=0.359-1.222, P=0.195). Concurrent administration of intravenous and aerosolized polymyxin B in patients with pandrug-resistant K. pneumoniae-associated VAP revealed better microbial eradication, reduced the length of intubation and ICU stay, and improved survival rate compared to colistin.

Glycemic Stress Index: Does It Correlate with the Intensive Care Length of Stay?

A retrospective chart review of 85 infants ≤ 6 months undergoing elective open heart surgery was performed. GSI values ≥ 3.9 and 4.5 were tested to determine whether they carried a higher incidence of postoperative complications (metabolic uncoupling, kidney injury, ECMO, and death). The correlation between GSI and the length of intubation, PICU stay, and duration of fasting were also investigated. Perioperative factors such as age, weight, blood gas analysis, use of inotropes, and risk adjustment for congenital heart surgery were also analyzed as possible predictors. GSI correlated with the duration of intubation and PICU stay. A GSI ≥ 4.5, but not 3.9, was associated with a higher incidence of metabolic uncoupling. GSI was not influenced by preoperative fasting. None of the preoperative patient factors analyzed was associated with prolonged intubation, PICU stay, or PICU complications. An abnormal creatinine before surgery increased the risk of developing acute kidney injury postoperatively. GSI may be valuable to predict prolonged intubation, PICU stay, and metabolic derangement in infants undergoing cardiac surgery. Fasting does not appear to affect GSI.

The Effect of Oxygenation on Mortality in Patients With Head Injury.

Introduction In this study, we planned to investigate the effect of hyperoxygenation on mortality and morbidity in patients with head trauma who were followed and treated in the intensive care unit (ICU). Methods Head trauma cases (n = 119) that were followed in the mixed ICU of a 50-bed tertiary care center in Istanbul between January 2018 and December 2019 were retrospectively analyzed for the negative effects of hyperoxia. Age, gender, height/weight, additional diseases, medications used, ICU indication, Glasgow Coma Scale score recorded during ICU follow-up, Acute Physiology and Chronic Health Evaluation (APACHE) II score, length of hospital/ICU stay, the presence of complications, number of reoperations, length of intubation, and the patient's discharge or death status were evaluated. The patients were divided into three groups according to the highest partial pressure of oxygen (PaO2) value (200 mmHg) in the arterial blood gas (ABG) taken on the first day of admission to the ICU, and ABGs on the day of ICU admission and discharge were compared. Results In comparison, the first arterial oxygen saturation and initial PaO2 mean values were found to be statistically significantly different. There was a statistically significant difference in mortality and reoperation rates between groups. The mortality was higher in groups 2 and 3, and the rate of reoperation was higher in group 1. Conclusion In our study, mortality was found to be high in groups 2 and 3, which we considered hyperoxic. In this study, we tried to draw attention to the negative effects of common and easily administered oxygen therapy on mortality and morbidity in ICU patients.

High-dose Steroids Versus Standard Treatment for Myasthenic Crisis

Background: Previous literature revealed the possible benefit of high-dose steroids in myasthenic crises. Steroids are more economical than standard therapy, especially in resource-poor settings. More data are therefore needed about the utility of steroids for the myasthenic crisis. Objective: The outcomes were compared between standard therapy (intravenous immunoglobulin [IVIg] or plasmapheresis [PLEX]) and high-dose steroid (intravenous methylprednisolone) for the myasthenic crisis. The primary outcome was the length of hospital stay. The secondary outcomes were the length of intubation, intensive care unit stay, readmission rate due to crisis, posttreatment muscle score, and mortality. Methodology: This study was a single-center, longitudinal, 12-year retrospective study. Sixty-five patients were analyzed. A comparison of means was made between the outcomes of the two groups. Regression analysis was done for hospital stay and intubation outcomes. Side effects of treatment were determined. Results: Shorter hospital stay (P = 0.001), shorter intubation length (P = 0.000), and shorter intensive care (P = 0.000) were observed in the steroid group. Mortality (P = 0.187) and muscle score (P = 0.281) were comparable between the two groups. There was a trend toward lesser readmission (P = 0.097) and longer time to readmission (P = 0.069) in the standard therapy group. The IVIg group had arrhythmias, hypotension, headache, renal impairment, and hypomagnesemia. The PLEX group had hypotension and lower limb pain. The steroid group had hyperglycemia, insomnia, infection, stomach upset, facial flushing, myopathy, and sudden death. No acute worsening of the myasthenia crisis was seen in all patients in the steroid arm. Conclusion: Data on hospital stay, intensive care days, and intubation length were better with high-dose steroids. Mortality and motor outcomes were comparable between the two groups. Readmission rates due to crisis were lower in the standard therapy group.

Non-invasive positive pressure ventilation can reduce perioperative mortality in acute aortic dissection patients with hypoxemia.

Hypoxemia is a common critical respiratory complication in patients with acute aortic dissection (AAD) before operation and results in adverse outcomes. This study aimed to identify the optimal oxygenation treatment for AAD patients with hypoxemia in the emergency department (ED). This was a retrospective, observational, cohort study. We retrospectively collected data from 187 adult patients with AAD and hypoxemia who had been admitted to our ED. All patients were divided into nasal cannula group (n=91), Venturi mask group (n=60), and non-invasive positive pressure ventilation (NIPPV) group (n=36). The primary outcome was overall mortality in ED; the secondary outcomes were preoperative intubation rate and postoperative mortality, length of intensive care unit (ICU) stay, length of hospital stay, and length of intubation. Among all patients, those who received NIPPV treatment showed the lowest ED intubation rate (2.78%, P=0.004), shortest postoperative length of ICU stay (median 2.31, P<0.001), postoperative length of intubation (median 25.10, P<0.001), and post-operative length of hospital stay (median 21.00, P<0.001). Kaplan-Meier analysis showed the highest 3-day survival (log-rank 7.387, P=0.03) and 5-day survival (log-rank 14.710, P=0.001) in the NIPPV group. After adjustment, NIPPV therapy was independently associated with the reduced 3-day [adjusted hazard ratio (HR) 0.102, 95% confidence interval (CI): 0.013-0.791, P=0.03] and 5-day (adjusted HR 0.057, 95% CI: 0.008-0.427, P=0.005) mortality in ED. Early utilization of NIPPV in AAD patients with hypoxemia in the ED can effectively decrease pre-operative intubation rate and perioperative mortality, and improve postoperative outcomes.

337: DIFFERENCES IN D-DIMER LEVELS IN COVID-19 PATIENTS WITH VERSUS WITHOUT VENOUS THROMBOEMBOLISMS (VTE)

Introduction: Coronavirus disease 2019 (COVID19) is known to cause coagulopathy as multiple systemic coagulation and inflammatory responses are activated during infectious complications. In COVID19 patients, hypercoagulopathy usually presents with an elevated D-dimer level. Methods: All patients ≥ 18 years old who were admitted to NYU Langone Hospital—Long Island with a primary diagnosis of COVID-19 or with a flagged admission of COVID19 during April 1, 2020 to June 30, 2020 were included. IRB approval was acquired prior to data collection and upon permission, the clinical pharmacy IT department ran a report to identify patients. Most patients had a positive reverse-transcription polymerase chain reaction (RT-PCR) test during their admission, while a small number of patients were diagnosed before admission. Admissions included ICU patients or general ward patients. Series of D dimers were recorded. Results: There were 350 patients enrolled in the study, 331 had no VTE, 19 had VTE. Peak D dimer was 4876 (range 1509 to 15,872) in VTE group vs. 680 in non VTE group (range: 257 to 2723). 47.4% of VTE group had peak D dimer greater than 5000 vs. 16% of non VTE group. Surprisingly, there was no difference in mortality between the two groups: 26.3% for VTE group; 19.9% in non VTE group, (p=0.556). However, VTE group had higher ICU admission rate 42.1% vs. 20.2% of non VTE group, p=0.039. Length of intubation was also significantly higher in VTE group (27 days) comparing to non VTE group (6 days), p=0.007. Conclusions: Covid 19 patients with VTE have much higher D dimer than non VTE Covid 19 patients. Although there is no difference in mortality in the two groups in our study, VTE group is associated with higher ICU admission as well as longer length of intubation days.

986: HOW ARE WE OVERSEDATING OUR MECHANICALLY VENTILATED PATIENTS IN THE MICU AT A TERTIARY CARE CENTER?

Introduction: Endotracheal intubation and invasive mechanical ventilation are distressing interventions in the Medical Intensive care Unit (MICU). Mechanically ventilated patients often receive analgesic and sedative medications to reduce agitation and pain. According to recommendations in the Society of Critical Care (SCC) PADIS guidelines, sedatives should be used only when pain and delirium have been addressed with specific pharmacologic and non-pharmacologic strategies. Despite this, we observe that many mechanically ventilated MICU patients are sedated on a routine basis without any clear indication. Methods: We performed a retrospective medical chart review of patients above 18 years of age who were intubated for more than 24 hours between January 2020 till October 2021. We analyzed indications for intubation and excluded patients requiring a deep level of sedation from the final study sample. We analyzed the type and number of sedatives initiated in the first 24 hours of intubation, associated RASS parameters set for sedation titration and its monitoring frequency by nurses, and the effect of our practices on intubation and hospitalization outcomes. Statistical analysis was performed using SPSS and SAS. Results: Of the 281 patients, 83% received fentanyl, 66% received propofol or dexmedetomidine, and 33% received midazolam in the first 24 hours. About 53% and 11% of patients were simultaneously started on a 2- and 3-agents sedative regimen in the first 24 hours, respectively. The most common upper and lower RASS limits for sedation titration were set at 0 and -3, respectively. The average frequency of nurses’ RASS documentation was once every 10 hours. There was a positive correlation between the number of sedative agents used in the first 24 hours and the associated length of intubation, hospitalization, and extubation failure. Furthermore, the use of benzodiazepine led to a higher rate of extubation failure, length of intubation, and hospitalization. Conclusions: In the absence of clear medical indication for deep sedation and appropriate sedation administration and titration parameter protocol, the indiscriminate use of sedatives leads to poor patient outcomes. There is a dire need to implement sedation protocols in institutions to standardize practices and improve sedation performance metric.

Management of MACROGLOSSIA: Case Series and Suggested Algorithm

Idiopathic macroglossia is a rare entity of true tongue enlargement without an underlying etiology. There are only a few case reports on the diagnosis and management of idiopathic macroglossia. This study's purpose was to present a series of patients with idiopathic macroglossia and suggest a treatment algorithm. This was a retrospective case series of a cohort of patients with macroglossia who were treated by the Oral and Maxillofacial Surgery service at the University of Texas Health Science Center at Houston (UTHealth)and Emory University. The patient's medical comorbidities, history of present illness, clinical presentation, radiographic findings, and disease management were studied. The outcome variables include normalization of the tongue size, dependence on parenteral nutrition, and tolerating tracheostomy decannulation. Five patients with a mean age of 45years were included in the study. All of the patients (n=5, 100%) in our cohort developed macroglossia following prolonged oral intubation, with 3.5weeks being the average length of intubation. All patients presented with difficulty feeding orally and breathing. The average tongue dimension was 12.20 x 6.25cm. All tongue enlargements were located in the anterior 2/3 of the tongue, and all patients had displaced anterior dentition. In addition, 60% of the patients (n=3) experienced altered tongue sensation (pain and/or decreased taste). These patients were surgically managed with tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement followed by partial glossectomy (n=5, 100%). We defined successful outcomes as 1) modifying the tongue to a functional, nonprotruding form, 2) tracheostomy decannulation and 3) PEG tube removal. Tracheostomy decannulation and PEG tube removal were achieved in 80% of the patients (n=4). In this patient cohort, we were unable to identify the cause of the pathology based on existing clinical data. When the etiology is unclear or irreversible, management should involve tracheostomy and surgical feeding access for the initial stabilization, followed by modified glossectomy to improve form, function, and cosmesis thereby improving the overall quality of life.

Invasive brain tissue oxygen and intracranial pressure (ICP) monitoring versus ICP-only monitoring in pediatric severe traumatic brain injury.

Severe traumatic brain injury (TBI) is a leading cause of disability and death in the pediatric population. While intracranial pressure (ICP) monitoring is the gold standard in acute neurocritical care following pediatric severe TBI, brain tissue oxygen tension (PbtO2) monitoring may also help limit secondary brain injury and improve outcomes. The authors hypothesized that pediatric patients with severe TBI and ICP + PbtO2 monitoring and treatment would have better outcomes than those who underwent ICP-only monitoring and treatment. Patients ≤ 18 years of age with severe TBI who received ICP ± PbtO2 monitoring at a quaternary children's hospital between 1998 and 2021 were retrospectively reviewed. The relationships between conventional measurements of TBI were evaluated, i.e., ICP, cerebral perfusion pressure (CPP), and PbtO2. Differences were analyzed between patients with ICP + PbtO2 versus ICP-only monitoring on hospital and pediatric intensive care unit (PICU) length of stay (LOS), length of intubation, Pediatric Intensity Level of Therapy scale score, and functional outcome using the Glasgow Outcome Score-Extended (GOS-E) scale at 6 months postinjury. Forty-nine patients, including 19 with ICP + PbtO2 and 30 with ICP only, were analyzed. There was a weak negative association between ICP and PbtO2 (β = -0.04). Conversely, there was a strong positive correlation between CPP ≥ 40 mm Hg and PbtO2 ≥ 15 and ≥ 20 mm Hg (β = 0.30 and β = 0.29, p < 0.001, respectively). An increased number of events of cerebral PbtO2 < 15 mm Hg or < 20 mm Hg were associated with longer hospital (p = 0.01 and p = 0.022, respectively) and PICU (p = 0.015 and p = 0.007, respectively) LOS, increased duration of mechanical ventilation (p = 0.015 when PbtO2 < 15 mm Hg), and an unfavorable 6-month GOS-E score (p = 0.045 and p = 0.022, respectively). An increased number of intracranial hypertension episodes (ICP ≥ 20 mm Hg) were associated with longer hospital (p = 0.007) and PICU (p < 0.001) LOS and longer duration of mechanical ventilation (p < 0.001). Lower minimum hourly and average daily ICP values predicted favorable GOS-E scores (p < 0.001 for both). Patients with ICP + PbtO2 monitoring experienced longer PICU LOS (p = 0.018) compared to patients with ICP-only monitoring, with no significant GOS-E score difference between groups (p = 0.733). An increased number of cerebral hypoxic episodes and an increased number of intracranial hypertension episodes resulted in longer hospital LOS and longer duration of mechanical ventilator support. An increased number of cerebral hypoxic episodes also correlated with less favorable functional outcomes. In contrast, lower minimum hourly and average daily ICP values, but not the number of intracranial hypertension episodes, were associated with more favorable functional outcomes. There was a weak correlation between ICP and PbtO2, supporting the importance of multimodal invasive neuromonitoring in pediatric severe TBI.

Barotrauma in COVID 19: Incidence, pathophysiology, and effect on prognosis

ObjectivesTo investigate the incidence, risk factors, and outcomes of barotrauma (pneumomediastinum and subcutaneous emphysema) in mechanically ventilated COVID-19 patients. To describe the chest radiography patterns of barotrauma and understand the development in relation to mechanical ventilation and patient mortality. MethodsWe performed a retrospective study of 363 patients with COVID-19 from March 1 to April 8, 2020. Primary outcomes were pneumomediastinum or subcutaneous emphysema with or without pneumothorax, pneumoperitoneum, or pneumoretroperitoneum. The secondary outcomes were length of intubation and death. In patients with pneumomediastinum and/or subcutaneous emphysema, we conducted an imaging review to determine the timeline of barotrauma development. ResultsForty three out of 363 (12%) patients developed barotrauma radiographically. The median time to development of either pneumomediastinum or subcutaneous emphysema was 2 days (IQR 1.0–4.5) after intubation and the median time to pneumothorax was 7 days (IQR 2.0–10.0). The overall incidence of pneumothorax was 28/363 (8%) with an incidence of 17/43 (40%) in the barotrauma cohort and 11/320 (3%) in those without barotrauma (p ≤ 0.001). In total, 257/363 (71%) patients died with an increase in mortality in those with barotrauma 33/43 (77%) vs. 224/320 (70%). When adjusting for covariates, barotrauma was associated with increased odds of death (OR 2.99, 95% CI 1.25–7.17). ConclusionBarotrauma is a frequent complication of mechanically ventilated COVID-19 patients. In comparison to intubated COVID-19 patients without barotrauma, there is a higher rate of pneumothorax and an increased risk of death.

Evaluating the effect of Edaravone on clinical outcome of patients with severe COVID-19 admitted to ICU: a randomized clinical trial.

Cytokine storm is the most prominent hallmark in patients with coronavirus disease 2019 (COVID-19) that stimulates the free radical storm, both of which induce an overactive immune response during viral infection. We hypothesized that owning to its radical-scavenging and anti-inflammatory properties, Edaravone could reduce multi-organ injury, clinical complications, and mortality in severe COVID-19 cases. This single-center randomized clinical trial was accompanied in the intensive care units (ICUs) of the teaching hospital of Tabriz University of Medical Sciences to evaluate the effect of Edaravone on the outcome of patients with severe COVID-19. Thirty-eight patients admitted to ICU were included and randomized into two control and intervention arms. Patients in the intervention group received 30 mg Edaravone by slow intravenous infusion for three days in addition to receiving national therapy. The primary outcome was the need for intubation, the intubation length, and mortality rate. Secondary endpoints were clinical improvement. Edaravone administration improved the primary outcomes; it decreased the need for endotracheal intubation and mechanical ventilation [10.52% (n = 2) versus 42.1% (n = 8); p = 0.03] and intubation length [3 (1–7) versus 28 (4–28), p = 0.04] compared to control group. Baseline characteristics and laboratory tests were similar between the studied groups. No marked differences were observed in secondary endpoints (p > 0.05). Administration of Edaravone could decrease the need for mechanical ventilation and length of intubation in severe COVID-19 patients admitted to ICU.

Use of Propofol and Dexmedetomidine in Neuro Critical Care: Impact on Delirium Rate and Length of Intubation

Use of Propofol and Dexmedetomidine in Neuro Critical Care: Impact on Delirium Rate and Length of Intubation

Open Bedside Tracheostomy: Safe and Cost Saving but Underutilized Nationally.

To evaluate open bedside tracheostomy (OBT) and compare it with open operating room (OR) tracheostomy and bedside percutaneous dilatational tracheostomy (PDT) in complications and cost. To determine the tracheostomy practice patterns of academic otolaryngology programs. Retrospective cohort study and cross-sectional study. Public hospital and tertiary care hospital. Otolaryngology program directors were surveyed to determine their institutions' tracheostomy practice patterns and the factors preventing the implementation of open bedside tracheostomies. A retrospective chart review was done of tracheostomies performed at our institutions from 2009 to 2019 for prolonged mechanical ventilation. Complications, length of intubation, comorbidities, body mass index, demographics, mortality rates, and decannulation rates were recorded. A cost analysis between OBT and PDT was conducted. Data from 802 patients were analyzed for 449 OBTs, 206 PDTs, and 147 open OR tracheostomies. Complication rates were low. PDTs were more likely to have perioperative tracheal bleeding (P = .028) and mucus plugging (P = .006). OBTs were performed on sicker patients with a higher Charlson Comorbidity Index than PDT and OR tracheostomies. The cost of OBT was less than that of PDT. The survey response rate of tracheostomy practice patterns was 46%. The otolaryngologists at the responding programs all conducted OR tracheostomies, while 52.7% did OBTs and 30.9% PDTs. OBT can be done safely in patients with multiple comorbidities and has a cost that can be less than PDT. Despite these benefits, only 50% of academic institutions routinely performed OBT.

Complications of Intraoperative ECMO During Lung Transplantation

<h3>Purpose</h3> Routine intraoperative (IO) ECMO has been proposed as the preferred strategy for lung transplantation (LTX). We reviewed the clinical outcomes and complications of patients who underwent LTX with IO ECMO support at a low-volume center. <h3>Methods</h3> All consecutive patients who underwent LTX between 2008 and 2020 were included in the study. Demographics, the type and duration of supports, and patient outcomes were retrospectively reviewed. Uni-and multivariate analysis was performed as appropriate. <h3>Results</h3> Out of 201 lung transplants, 95 (47.2%) were performed on intraoperative support, of which 55 (27,3%) with IO ECMO. The indications for support were switch from preoperative in 28 cases (50.9%) and IO respiratory or hemodynamic instability in 24 (43.6%). The predominant baseline disease was IPF (45.4%). IO support was VA in 41 (74,5%), VV in 13 (23.6%), VAV in 1 (1.8%). ECMO configuration was peripheral in 49 cases (89%). Most supports were placed with a cut-down approach (69.1%). The average duration of support was 472 min±32,2. In 23 patients (41.8%) the IO support was extended postoperatively. The median ICU and hospital LOS were 12 (2-137) and 42 days (2-204) respectively and were significantly longer compared to patients who did not receive IO support. At least one complication occurred in 22 patients (40%), while 7 (10.9%) had more than one. The most frequent complications were postoperative hemothorax (23%), limb ischemia (9%), lymphocele (5.1%), IO harlequin syndrome (3.6%). Complications required surgical revision in 79.3% of cases. 1-yr (77.1% vs 83.3%) but not 5-yr (66.9% vs 70.1%) Kaplan-Meier survival of patients supported with IO ECMO was less favourable compared to non-supported patients, with borderline statistical significance (p=0.05%). On univariate analysis, no pre-operative or IO parameter was significantly associated with the development of complications. On multivariate analysis, the development of at least one complication was significantly associated with hospital stay (p=003), ICU stay (=.0002), duration of postoperative intubation (p=0.03). <h3>Conclusion</h3> IO ECMO during LTX has a relevant impact on the development of early complications after LTX at a small volume Institution, increases the length of intubation and hospital stay, and decreases 1-yr survival. These results may support the local policy to attempt transplantation off support if tolerated.

Long-term upper aerodigestive sequelae as a result of infection with COVID-19.

ObjectivesRespiratory, voice, and swallowing difficulties after severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) may result secondary to upper airway disease from prolonged intubation or mechanisms related to the virus itself. We examined a cohort who presented with new laryngeal complaints following documented SARS‐CoV‐2 infection. We characterized their voice, airway, and/or swallowing symptoms and reviewed the clinical course of their complaints to understand how the natural history of these symptoms relates to COVID‐19 infections.MethodsRetrospective review of patients who presented to our department with upper aerodigestive complaints as sequelae of prior infection with, and management of, SARS‐CoV‐2.ResultsEighty‐one patients met the inclusion criteria. Median age was 54.23 years (±17.36). Most common presenting symptoms were dysphonia (n = 58, 71.6%), dysphagia/odynophagia (n = 16, 19.75%), and sore throat (n = 9, 11.11%). Thirty‐one patients (38.27%) presented after intubation. Mean length of intubation was 16.85 days (range 1–35). Eighteen patients underwent tracheostomy and were decannulated after an average of 70.69 days (range 23–160). Patients with history of intubation were significantly more likely than nonintubated patients to be diagnosed with a granuloma (8 vs. 0, respectively, p < .01). Fifty patients (61.73%) were treated for SARS‐CoV‐2 without requiring intubation and were significantly more likely to be diagnosed with muscle tension dysphonia (19 vs. 1, p < .01) and laryngopharyngeal reflux (18 vs. 1, p < .01).ConclusionIn patients with persistent dyspnea, dysphonia, or dysphagia after recovering from SARS‐CoV‐2, early otolaryngology consultation should be considered. Accurate diagnosis and prompt management of these common underlying etiologies may improve long‐term patient outcomes.Level of evidence4

Rate of Successful Extubation in Mechanically Ventilated Patients with Cirrhosis and Hepatic Coma.

The prognosis of critically ill patients with cirrhosis who require mechanical ventilation is guarded. Data are lacking for the optimal therapeutic approach to hepatic encephalopathy (HE) in the ventilated patient. Retrospective cohort analysis of 314 encounters (298 patients) with cirrhosis who underwent mechanical ventilation in a medical ICU and were ordered at least 1 dose of lactulose. Hazard of extubation alive was determined using a competing risk model. Primary exposures were HE therapy (lactulose and rifaximin) which were adjusted for the indication for ventilation (HE, procedures, respiratory failure), age, MELD-Na, and compensation status. Indications for ventilation were 22.3% for grade 4 HE, 29.9% for procedures, and 47.8% for respiratory or cardiovascular failure. Median length of intubation was 2.63days; death rate on ventilator was 31.2%. Relative to intubation for procedure, hazard of extubation for intubation for HE was 0.34 (95% confidence interval (CI): 0.22-0.52) and 0.33 (CI: 0.23-0.47) for respiratory failure. Hazard of extubation for rifaximin administration within 24-h after intubation was significant at 1.74 (1.21-2.50). Lactulose dosing was not significant for hazard of extubation. Mortality is high for all patients with cirrhosis requiring mechanical ventilation, including those intubated for grade 4 HE. Efforts to optimize the odds of successful extubation are urgently needed. Our findings suggest improved incidence of extubation associated with rifaximin administration in the first 24-h after intubation. Prospective, multi-center data to confirm these findings in this vulnerable population are warranted.

Lung recruitment improves the efficacy of intubation-surfactant-extubation treatment for respiratory distress syndrome in preterm neonates, a randomized controlled trial

BackgroundLung recruitment is a maneuver used to decrease the length of intubation in preterm neonates. This study aimed to compare the therapeutic efficacy of lung recruitment plus intubation-surfactant-extubation (INSURE) procedure and INSURE alone for the preterm neonates with respiratory distress syndrome.MethodsFrom 2017 to 2019, 184 preterm neonates (gestational age 24–32 weeks) with respiratory distress syndrome were enrolled and randomized into the lung recruitment group receiving lung recruitment (25 cm H2O, 15 s) plus INSURE and the control group receiving INSURE only. The primary outcome was the need for mechanical ventilation (MV) within 72 h after extubation. The secondary outcomes included duration of MV, noninvasive ventilation, total oxygen therapy, hospitalization time, and complications.ResultsCompared to the control group, the lung recruitment group had a significantly lower proportion of preterm neonates requiring MV within 72 h after extubation (23% vs. 38%, P = 0.025) and pulmonary surfactant administration, as well as a shorter MV duration. There was no significant difference in the incidences of complications (all P > 0.05) and in-hospital mortality (2% vs. 4%, P = 0.4) between the lung recruitment group and control group. Multivariate logistic regression analysis demonstrated that the control group had a 2.17-time higher risk of requiring MV than the lung recruitment group (AOR: 2.17, 95% CI: 1.13–4.18; P = 0.021). Compared with infants with a normotensive mother, infants with a hypertensive mother have a 2.41-time higher risk of requiring MV (AOR: 2.41, 95% CI: 1.15–5.05; P = 0.020).ConclusionLung recruitment plus INSURE can reduce the need for MV within 72 h after extubation and did not increase the incidence of complications and mortality.Trial registrationChinese Clinical Trial Registry ChiCTR1800020125, retrospectively registered on December 15, 2018.

The effect of BIS usage on anaesthetic agent consumption in high-risk patients for coronary artery bypass grafting off-pump surgery

Background: In patients undergoing coronary artery bypass grafting off-pump (CABG-OP) surgery with limited haemodynamic reserve, achieving the ideal anaesthesia depth is challenging. The risk of awareness during surgery increases with light anaesthesia, too deep anaesthesia can cause hypotension, delayed awakening, and increased morbidity and mortality. Aims and Objectives: In this study, we aimed to compare whether the use of the Bispectral Index (BIS) reduces the consumption of the anaesthetic drug and improves recovery time in CABG-OP surgery without awareness during surgery (ADS). Materials and Methods: This was a prospective, single-centre, randomised and double-blind comparative research performed on the American Society of Anaesthesiologists (PS) III patients booked for elective CABG-OP surgery under general anaesthesia. Patients received either propofol or isoflurane anaesthesia, and their consumption was calculated and compared. The conventional groups conventional propofol infusion group (CPG)-1 and conventional isoflurane group (CIG-3) received propofol and isoflurane, and haemodynamic parameters (±20% of initial values) were used to check the depth of anaesthesia. The groups BIS-guided propofol infusion group (BPG-2) and BIS-guided isoflurane group (BIG-4) received propofol and isoflurane, and BIS (value 50 ± 5) were used to check the depth of anaesthesia. In addition, haemodynamic parameters, awakening conditions, length of intubation, hospital stay and drug utilisation were recorded. To explicit ADS, patients were interviewed 24 h after extubation. Results: The quantity of propofol used was 178 ± 11 ml in CPG-1 and 117 ± 6 ml in BPG-2, with a 34.26% reduction with BIS. The isoflurane used was 39 ± 8 ml in CIG-3 and 25 ± 6 ml in BIG-4, with a 35.89% reduction in isoflurane requirement. This difference was statistically significantly low with BIS monitored anaesthesia compared to conventional anaesthesia. The length of intubation was 2.2 ± 1.27 and 2.3 ± 1.49 h in groups BPG-2 and BIG-4, respectively (P < 0.05). Conclusion: BIS monitoring aids CABG-OP surgeries by monitoring the depth of anaesthesia (BIS value 50 ± 5), preventing ADS (0%), reducing the anaesthetic agent requirement (propofol 34.26% and isoflurane 35.89%), reducing myocardial depression (mean arterial pressure maintained >74 mmHg) and aiding ultra-fast-track extubation (37% and 50% reduction in the duration of intubation in propofol and isoflurane with BIS).