Mean Duration Of Intubation Research Articles

Percutaneous Tracheostomy Via Grigg's Technique in Children: Does Age and Size Matter?

Percutaneous tracheostomy is rarely performed in children, especially in infants. In the present study, we aimed to evaluate the complications and outcomes of PT via the Griggs technique according to the age and size of pediatric patients. This study included 110 PICU patients who underwent PT using the Griggs technique between 2012 and 2020. The patients were divided into six groups according to their age, demographic data, primary disease, mean duration of intubation before PT, mean duration of PICU and hospitalization after PT, complications, and decannulation outcomes were compared between these groups. The mean age and mean weight of the patients were 43.6 ± 58.9 months (1 month-207 months) and 14.6 ± 14.9 kg (2.6-65 kg), respectively. Mean intubation times before the procedures were 64.6 ± 40 days and 38.6 ± 37.9. Thirty-seven (33.6%) infants were under 6 months of age(Group 1). There were no intraoperative complications. Tracheostomy site stenosis was significantly greater in Group 1 than in the other age groups (p = 0.032). Granuloma formation and dermatitis incidence were similar in all age groups. PT is a safe and feasible procedure even in small infants. The accidental decannulation risk is lower than standard tracheostomy. Interacting with rigid bronchoscopy guidance is essential to perform a safer procedure. The first tracheostomy change after PT in small infants under 6 months of age, the possibility of tracheostomy site (stoma) stenosis should be considered. Level III Laryngoscope, 2024.

Dysphagia in COVID-19 Patients on Extracorporeal Membrane Oxygenation.

Patients on extracorporeal membrane oxygenation (ECMO) are infrequently nourished via oral feeding due to aspiration risks. Patients with COVID-19 and on ECMO represent a subpopulation that has additional factors that may affect their swallow function. This study aimed to describe the swallow function and ability to maintain oral feeding in patients with COVID-19 while on ECMO. A retrospective study of patients with COVID-19 who started veno-venous ECMO at the beginning of the COVID-19 pandemic (March 2020 and August 2020) was conducted at a tertiary care hospital. Clinical swallow evaluations and videofluoroscopic swallow studies (VFSS) were analyzed using standardized measurement scales. Pearson's correlation coefficient (r) identified relationships between ECMO and swallowing function at different time points. 19 patients were included; all underwent clinical swallow evaluation and 4 underwent VFSS while on ECMO. Mean age was 43.2 years (standard deviation: 9.2), mean duration of ECMO was 65.7 days (58.7), and mean duration of intubation was 14.4 days (8.6). All patients were able to undergo swallow function evaluation, regain swallow function, and resume oral feeding while cannulated. Duration of ECMO and time to feeding tube removal was positively correlated (r = 0.747, p < 0.001) with patients demonstrating less functional swallowing independence and requiring a more modified diet upon oral diet initiation. Clinical swallow evaluation and videofluoroscopic swallowing evaluation are possible for COVID-19 patients actively on ECMO. Patient swallow function can improve, and oral diet can be achieved while on ECMO, demonstrating benefit of SLP surveillance and swallowing assessment prior to ECMO decannulation.

Nonmalignant tracheal stenosis: presentation, management and outcome in limited resources setting

BackgroundNonmalignant tracheal stenosis is a potentially life threatening conditions that develops as fibrotic healing from intubation, tracheostomy, caustic injury or chronic infection processes like tuberculosis. This is a report of our experience of its management with tracheostomy, rigid bronchoscopic dilation and surgery.MethodsRetrospective study design was used. 60 patients treated over five years period were included.ResultsMean age was 26.9 ± 10.0 with a range of 10–55 years. Majority (56 patients (93.3%)) had previous intubation as a cause for tracheal stenosis. Mean duration of intubation was 13.8 days (range from 2 to 27 days). All patients were evaluated with neck and chest CT (Computed Tomography) scan. Majority of the stenosis was in the upper third trachea − 81.7%. Mean internal diameter of narrowest part was 5.5 ± 2.5 mm, and mean length of stenosed segment was 16.9 ± 8 mm. Tracheal resection and end to end anastomosis (REEA) was the most common initial modality of treatment followed by bronchoscopic dilation (BD) and primary tracheostomy (PT). The narrowest internal diameter of the tracheal stenosis (TS) for each initial treatment category group was 4.4 ± 4.3 mm, 5.1 ± 1.9 mm and 6.7 ± 1.6 mm for PT, tracheal REEA and BD respectively, and the mean difference achieved statistical significance, F (10,49) = 2.25, p = 0.03. Surgery resulted in better outcome than bronchoscopic dilation (89.1% vs. 75.0%).Discussion and conclusionNonmalignant tracheal stenosis mostly develops after previous prolonged intubation. Surgical resection and anastomosis offers the best outcome.

Prevalence of Post-extubation Airway Penetration and Aspiration among Critically Ill Patients Assessed by an Eight-point Penetration-Aspiration Scale Using Flexible Endoscopy: A Cross-sectional Study.

Prolonged endotracheal intubation was found to be a risk factor for pulmonary aspiration following the extubation. In this study, we have tried to analyze the prevalence of airway penetration and aspiration among mechanically ventilated patient who received mechanical ventilation for a period of 48 hours or more. This cross-sectional study was done among non-neurologic critically ill patients who had an endotracheal tube for more than 48 hours and who got extubated subsequently. Such patients were taken for a fiberoptic endoscopic swallow study after the initial assessment by a speech pathologist. Airway penetration and aspiration was assessed by an eight-point penetration-aspiration scale after giving a test feed. Data of 99 patients were analyzed. Mean duration of intubation was 5.9 days. 1% of the patients had aspiration and 20% of the patients had varying degrees of penetration. Duration of endotracheal intubation, age, sex, comorbidities, admission diagnosis, and size of the endotracheal tube were found to have no association with penetration and aspiration. Prevalence of post-extubation aspiration was low among non-neurologic critically ill patients on short-term ventilation. Duration of endotracheal intubation, age, sex, comorbidities, and endotracheal tube size were not found to be significantly associated with the development of airway penetration. Contrary to previous studies, this study has shown that among non-neurologic critically ill patients who had an endotracheal tube for a shorter period before extubation, the prevalence of airway penetration and aspiration was low when assessed by an eight-point penetration-aspiration scale using flexible fiberoptic endoscopy. Hence, in such a cohort of patients, a routine swallowing evaluation by flexible endoscopy is not recommended. Vijayan D, Suresh Kumar VK, Harikrishnanan, Menon J, Ragitha, Jacob M, et al. Prevalence of Post-extubation Airway Penetration and Aspiration among Critically Ill Patients Assessed by an Eight-point Penetration-Aspiration Scale Using Flexible Endoscopy: A Cross-sectional Study. Indian J Crit Care Med 2023;27(9):651-654.

The effect of prolonged intubation on ventilator associated pneumonia: endotracheal tube cuff is really steril or not?

Aims: Endotracheal tube (ETT) design, size, cuff material, cuff pressure, and intubation duration are critical in preventing nosocomial pneumonia. We aimed to evaluate the possible infection focus potential of ETT cuff and pilot balloon, particularly in prolonged intubated patients. Methods: A total number of 66 patients who underwent orotracheal intubation and received conventional mechanical ventilation more than 48 hours in the intensive care unit (ICU), were included in this prospective cohort study. Results:The mean duration of intubation was 10.36±4.82 days. Bacteriologically confirmed positive tracheal aspirate culture was 18.2% (n=12). The most frequent positive culture was detected inside of ETT lumen with a percentage of 83.3% (n=55) and followed by cuff (27.3%, n=18), pilot balloon (13.6%, n=9), respectively. It was documented that rates of lung infections were significantly increased after 14 days (p = 0.017) and rates of cuff positive cultures were significantly increased after 10 and 14 days of incubation (p= 0.001, p=0.004). The same type of bacteriological strains was identified from both pilot balloon (n=9) and ETT cuff (n=9), simultaneously. In the remaining 9-cuff positive patients pilot balloons were sterile and ETT lumens were positive culture with the same strains as identified from the cuff. There was a statistically significant positive correlation between the intubation duration and the number of infected ETT parts (p&lt;0.001). Conclusion: ETT cuff was demonstrated to be a potential infection focus in the present study. In addition, it was observed that ETT cuff colonization increased in proportion to the intubation duration. We suggest changing ETT at appropriate time intervals in order to reduce ventilator-associated pneumonia in intubated patients.

Non-channeled Video Laryngoscopy as an Alternative to Conventional Laryngoscopy for Intubating Adult Patients in the Intensive Care Unit.

Background Endotracheal intubation in the intensive care unit (ICU) is often a risky procedure due to the emergency situation, unstable condition of the patient, and technical problems such as inadequate positioning. Several new techniques, such as video laryngoscopy, have been developed recently to improve the success rate of first-pass intubations and reduce complications. We conducted this study to compare a non-channeled reusable video laryngoscope BPL VL-02 (manufactured by BPL Medical Technologies, Bangalore, India) with a conventional laryngoscope for intubation of adult patients in the ICU. Methodology A total of 72 ICU patients were randomly allocated to be intubated with either conventional direct laryngoscopy via Macintosh blade (group A) or video laryngoscopy with BPL VL-02 (group B). All patients were intubated by the primary investigator and the assistant noted the following parameters: the total number of intubation attempts, total duration of intubation, assistance or alternative technique required, Cormack Lehane grading, and any complications. Results There was no significant difference in the Cormack Lehane grading, number of attempts, or complications between the two groups. On comparing the assistance required during intubation in patients, it was observed that four (11.11%) patients in group A and seven (19.44%) patients in group B needed backward, upward, and rightward pressure on the larynx assistance during intubation. In five (13.89%) patients in group B, Stylet was required during intubation. The difference was statisticallysignificant (p = 0.0308). The video laryngoscopy group (group B) had a longer mean duration of intubation (64.36 ± 6.28 seconds) compared to group A (45.72 ± 11.45 seconds), and the difference was statistically significant (p < 0.0001). Conclusions Non-channeled video laryngoscope (BPL VL-02) is not a suitable alternative to conventional direct laryngoscopy with a Macintosh blade in terms of successful first-pass intubation, total duration of intubation, and assistance required.

Comparative Study of Percutaneous Dilatational Tracheostomy and Conventional Surgical Tracheostomy in Critically Ill Adult Patients.

The present study was aimed to compare percutaneous dilatational tracheostomy (PDT) with that of conventional surgical tracheostomy (ST) in critically ill adult patients requiring tracheostomy for respiratory management. For this purpose 32 critically ill patients, admitted to the ICU between July 2016 and June 2018, were subjected to tracheostomy and randomly divided into two groups (PDT and ST) of 16 patients each. Mean duration of intubation was similar between the two procedures while the mean size of the tracheostomy tube was smaller in percutaneous technique. In comparison, post-operative infection after 7days seem to be statistically lowered and the length of scar tend to be smaller in PDT patients. Although early and late post-operative complication rates are not statistically significant in the PDT groups, yet investigations of the long-term outcome following PDT are, therefore, necessary. Generally, PDT has lower acute complications than ST, although this may vary by the specific PDT technique. Patient factor may also influence complications. In view of the benefit versus risks in tracheostomy, PDT may be considered the "procedure of choice" for performing elective tracheostomies in critically ill adult patients.

The Clinical Features and Risk Factors of Subglottic Cysts in Children: A Clinical Experience Using the Spontaneous Respiration Technique.

Subglottic cysts (SGCs) are a rare cause of respiratory distress resulting from upper airway obstruction in infants and young children. Risk factors other than prematurity with a history of endotracheal intubation have not yet been well elucidated. Therefore, we aimed to describe the clinical features and analyze the risk factors of SGCs. We conducted a retrospective review of medical records of pediatric patients who underwent marsupialization for SGCs between January 2017 and March 2022. These records were then compared with those of controls with a history of neonatal intubation, with a case-to-control ratio of 1:3. Eleven patients (eight boys and three girls) diagnosed with SGCs and 33 control patients (26 boys and seven girls) were included. All patients had a history of premature birth and neonatal intubation. Symptoms of SGCs appeared at a mean age of 8.2 months (range, 1-14 months) after extubation. The mean duration of intubation was 21.5 days (range, 2-90 days), and the intubation period was longer in patients with SGCs than in controls (21.5±24.8 days vs. 5.3±7.1 days; P<0.001). Furthermore, gestational age (28.3±4.2 weeks vs. 33.8±4.4 weeks; P=0.001) and birth weight (1,134.1±515.1 g vs. 2,178.2±910.1 g; P=0.001) were significantly lower in patients with SGCs than in controls. Multivariable analysis identified the intubation period as an independent risk factor. This study showed that gestational age, birth weight, and the intubation period were significantly associated with the development of SGCs. Pediatric patients presenting with progressive dyspnea who have the corresponding risk factors should undergo early laryngoscopy for the differential diagnosis of SGC.

1284: OUTCOMES FROM THE GIFT OF LIFE INTERNATIONAL SURGERY REGISTRY

Introduction: Of the 1.3 million children born with congenital heart disease annually, over 90% do not have access to cardiac care. Since 2020, Gift of Life International (GOLI) has collaborated with CEDIMAT Hospital in the Dominican Republic to perform pediatric cardiac surgery. With limited access to care and delayed surgical repair, this population is data rich in epidemiology, natural history, and clinical management strategies. There is limited research evaluating the outcomes of pediatric cardiac surgery in this middle-income country. Prior studies have raised concerns of limited published data and the need for an international database with better accountability and communication between charities being imperative for patient safety. Since 2021, GOLI has been collecting data for internal quality review. We hope this study will serve as a beacon for charitable organizations to provide quality cardiac surgery to children with limited access. Methods: Combined retrospective and prospective observational analysis of the GOLI Surgical Registry was performed. The registry was developed by GOLI team members, using definitions shared by the PC4 and STS databases for generalizability. All patients who underwent cardiac surgery with the GOLI team at CEDIMAT Hospital since March 2021 to date were included. Results: 55 subjects were identified. They were predominantly Hispanic females (55%) with a mean age at diagnosis of 1.9 years, and mean age at repair of 3.5 years. Primary diagnosis included ASD (9%), VSD (32%), PDA (11%), AV Canal (9%), Tetralogy of Fallot (16%), Single Ventricle (13%), and Coarctation (7%). Most common intraoperative complications were bleeding requiring transfusion (14%) and multiple CPB runs (7%). ICU complications included arrhythmias (17%), cardiac arrest (7%), LCOS (5%), and effusions requiring chest tube (5%). Mean duration of intubation was 17.8 hours with 2 reintubations. Mortality was 7.1%. Conclusions: Globally, there is limited access to cardiac care for children with CHD. While many organizations have tried to close this gap, there is little published data on the surgical outcomes in low/middle-income countries. This study demonstrates that emerging countries can safely perform cardiac surgery and track quality metrics in children with congenital heart disease.

Outcome of Tracheostomy in COVID-19 Patients.

Since the start of the COVID-19 pandemic 2019, quite a few patients became critical and needed ICU admission with ventilator assistance. Tracheostomy, which was initially performed late during the course of patient on ventilator, has now been considered a procedure that can be performed relatively early as this leads to early weaning of patients and overcomes the shortage of critical beds. This study aims to focus on the outcomes of tracheotomised COVID-19 patients in terms of survival and any tracheostomy related morbidity. A prospective study was performed on COVID-19 patients undergoing tracheostomy at this tertiary care teaching hospital, which also was a dedicated centre for treating COVID-19 patients. The duration of this study was from April 2020 to September 2021. Following tracheostomy, all patients were followed up regularly and clinical changes were recorded. Points that were specifically noted were timing of the tracheostomy, change in ventilator settings, tracheostomy related complications, requirement of oxygen, days needed to wean the patient, decanulation, and, if death, the cause of death. A total of 136 surgical open tracheostomies were performed on COVID-19 patients over the study period. The mean duration of intubation (timing of tracheostomy) was 12 days. A total of 73 out of 136 (53.6%) patients survived. 51 patients (37.5%) got decannulated during the course of the hospital stay. 9 patients were decanulated during the follow up visits and 13 patients were lost to follow up. 63 out of 136 (46.3%) patients died due to COVID pneumonia. Most of the patients who died had gone into multi-organ failure. Air leak syndromes (pneumothorax and pneumomediastinum) were common findings. 10 patients already had surgical emphysema before taking up for tracheostomy and 6 developed 2-3 days after tracheostomy. The most common complication was bleeding, which was seen in 28 out of 136 patients. The Median weaning of period of patients who survived was 5 days. Performing tracheostomy early in COVID-19 patients helps in early weaning of the patient from the ventilator and makes nursing care easier and increases the availability of ICU beds. The mortality rate was 46% amongst the 136 tracheostomies done in COVID-19 patients. Local site bleeding was the most common complication and surgical emphysema was also seen more than routine tracheostomies. The online version contains supplementary material available at 10.1007/s12070-022-03248-1.

First-pass Success Rate and Number of Attempts Required for Intubation in Anticipated Difficult Airway: Comparison between Macintosh and Channeled King Vision Video Laryngoscopes.

Video laryngoscopy has been shown to improvise Cormack-Lehane grading and rate of successful tracheal intubation and is now incorporated in most of the difficult airway guidelines. Since there is scarce literature regarding the use of channeled blade of King Vision video laryngoscope (KVVL) in anticipated difficult intubation, we planned to undertake this randomized control trial to assess the performance of channeled blade of KVVL and Macintosh laryngoscope in patients with anticipated difficult intubation. This prospective randomized study was conducted in a tertiary care hospital. Patients fulfilling the inclusion criteria were randomly assigned equally to the KVVL group or Macintosh group. The primary outcome of the study was intubation success in the first attempt and number of attempts required for intubation, and the secondary outcomes were Cormack-Lehane grading and time required to intubate in both the groups. The first-pass success of intubation was 88.6% in the KVVL group and 76.5% in the Macintosh group (P = 0.035). The second attempt of intubation was required in 11.4% and 20.6% of patients in the KVVL and Macintosh groups, respectively. Cormack Lehane Grade I was achieved in 100% of patients of the KVVL group as compared to 29.4% of patients in the Macintosh group. Moreover, the difference was statistically significant (P = 0.035). The mean duration of intubation was prolonged in the KVVL group as compared to the Macintosh group, and the difference was statistically significant (P = 0.04). The channeled blade of KVVL had a higher first-pass success rate and required fewer attempts to intubate when used in patients with anticipated difficult intubation. Further, the KVVL was found to be significantly better than the Macintosh laryngoscope in terms of Cormack-Lehane grading, but the time taken to intubate the trachea was more in the KVVL group.

EFFECTS OF DONEPEZIL AND MEDROXYPROGESTERONE VS PLACEBO ON WEANING IN ADULT PATIENTS RECEIVING INVASIVE MECHANICAL VENTILATION: A TRIPLE-BLIND RANDOMIZED CLINICAL TRIAL

TYPE: Late Breaking Abstract TOPIC: Critical Care PURPOSE: The aim of the current study was to evaluate the effects of donepezil or medroxyprogesterone compared to the placebo in improvement in respiratory status and weaning facilitation in critically ill adult patients receiving mechanical ventilation METHODS: Patients were randomized to receive 5mg donepezil, 5mg medroxyprogesterone, or placebo twice a day until weaning. The primary endpoints were weaning duration and duration of invasive MV. Secondary endpoints included rate of successful weaning, changes in ABG parameters, GCS, SOFA score, hemoglobin, ICU mortality, and duration of ICU stay. RESULTS: Of 78 studied patients who were randomized, 59 weaned successfully. 87% patients in donepezil and 88.5% patients in medroxyprogesterone groups were successfully weaned compared to 66.7% patients in the placebo group. However, this difference was not statistically significant (P-Value=0.111). Changes in pH, mean duration of intubation, and weaning duration were statistically different in donepezil compared with the control group (P-value < 0.05). No significant difference in ABG, Hgb, GCS and SOFA score, and duration of intubation were seen in the medroxyprogesterone group, but weaning duration was significantly reduced to 1.429 days compared with the control group (P-Value =0.038). CONCLUSIONS: Medroxyprogesterone and donepezil could be effective in the facilitation of weaning from MV. Our results in the hospital setting show that pH, mean intubation and weaning duration were the main endpoints during weaning that could be valuable predictors for a positive response to these interventions. However, the effect size of this finding has had uncertain clinical importance. CLINICAL IMPLICATIONS: Donepezil and medroxyprogesterone effects on weaning in adult patients receiving invasive mechanical ventilation DISCLOSURE: Nothing to declare. KEYWORD: Weaning, Donepezil, Medroxyprogesterone

Clinical Predictors of Postintubation Bilateral Vocal Fold Immobility.

Introduction Iatrogenic bilateral vocal fold immobility (BVFI) often arises from posterior glottic stenosis (PGS) after endotracheal intubation, whereby posterior commissure mucosal disruption leads to fibrosis and ankylosis of the cricoarytenoid joints. Sequelae can be devastating, resulting in dyspnea, stridor, and death due to asphyxiation. Objectives We sought to review features associated with PGS to better understand how to prevent this condition. A secondary aim is to analyze factors correlating to tracheostomy dependence. Methods Charts from January 2010 to November 2020 were retrospectively reviewed, and adult patients with the diagnosis of BVFI after intubation were included. Data on comorbidities, duration of intubation, laryngoscopy, and decannulation status was analyzed. Results Out of the 68 patients included in the present study, 60.3% were male, and the mean duration of intubation 14.3 ± 8.5 days. A total of 94% of the patients were intubated for at least 7 days, diabetic, and/or obese. Although association with prolonged intubation >7 days was not significant ( p = 0.064), complete BVFI on fiberoptic exam ( n = 47) was significantly associated with tracheostomy dependence both in the entire cohort ( p = 0.036) and in the 56 patients with tracheostomy ( p = 0.0086). Patients without cardiovascular disease (CVD) were less likely to be tracheostomy dependent compared with those with CVD (odds ratio [OR]: 0.23 [0.053-0.79]; p = 0.028). Conclusions We identified duration of intubation, DM, and obesity as potential risk factors for PGS. Complete immobility and CVD were significantly associated with tracheostomy dependence. Our findings may have important implications for earlier tracheostomy in high-risk intubated patients, as well as for closer monitoring of disease progression and earlier intervention in those predisposed to tracheostomy dependence.

A COMPARATIVE STUDY TO ASSESS EASE OF INTUBATION WITH C-MAC VS DIRECT LARYNGOSCOPE, WHEN USED FOR INTUBATION WITH CLEAR PLASTIC DRAPES OVER MAYO STAND FOR IN COVID NEGATIVE PATIENTS DURING A PANDEMIC IN RESOURCE LIMITED SETTING

The aim of the study was to assess the time to endotracheal intubation, First-pass success when intubating with C-MAC and Direct laryngoscope with clear plastic drapes over a mayo stand. Standard anaesthesia machine and monitors Drugs for pre-medication &amp; general anaesthesia Anatomical face masks, video laryngoscope with blades 3 &amp; 4 Macintosh blade 3 &amp; 4, endotracheal cuffed tubes, Bougie, Clear plastic sheets, Mayo stand. Mayo stands containment setup is suspended over the patient’s head, neck and chest. The necessary Anaesthesia equipment required for intubation will be kept inside the containment setup. General anaesthesia induced with fentanyl, Propofol &amp; Succinylcholine. C- Mac laryngoscope with appropriate size blade will be kept with Group A patients, while Direct laryngoscope with appropriate size blade will be kept with Group B patients. The mean duration of intubation in secs was longer in Group B compared to group A ( 27.47 sec vs 21.4 sec). Based on the intubation difficulty scale score, Group B had more second attempts needed (26.67%) than Group A 6.67%) and also the second operator required in (16.67% vs 3.33%) Group B compared to Group A (p&lt;0.05). Based on CL grades among Group B vs Group A a statistically significant association was observed in relation to grade 1 (63.33%vs93.34%), Grade2a ( 23.34% vs 3.33%) and grade 2b ( 13.33%vs3.33%). We conclude that intubation with a C-MAC laryngoscope has a better glottis view, takes a lesser duration, and lesser number of attempts required for successful intubation when compared to that of the Macintosh laryngoscopy with a plastic drape on a mayo trolley.

Survival Rate of Critically Ill Coronavirus Disease 2019 Patients on Tracheostomy in Indonesia

Introduction. During COVID-19 global pandemic, tracheostomy is often performed on critically ill COVID-19 patients. There is no available data on the survival rate of critically ill COVID-19 patients on tracheostomy in Indonesia. This study aimed to find the survival rate of critically ill COVID-19 patients on tracheostomy in Indonesia. Methods. A descriptive survival analysis study enrolled critically ill COVID-19 patients in RSUI who underwent a tracheostomy procedure. Baseline data, including clinical characteristics and laboratory findings before tracheostomy, were recorded. Survival analysis was conducted using the Kaplan-Meier plot. Results. Forty-two subjects were enrolled in the study: 25 males (59.5%) and 17 females (40.5%). The median age was 57 (26 – 72) years. Subjects with diabetes mellitus or hypertension were 78.6% and 78.6% with BMI >25 kg/m2. The mean duration of intubation was 16.24 ±7.62 days, the median duration of tracheostomy before the outcome was 8 (0 – 53) days. There were 9.5% of subjects survived and were discharged. The median survival time was 8 (0 – 53). In the first 15 days after tracheostomy procedures, those who were deceased were 75% of the subjects. Conclusion. In this study, the survival rate of critically ill COVID-19 patients on tracheostomy remains low. Another study to evaluate the cause of the low survival rate of critically ill patients with COVID-19 on tracheostomy is required.

Effects of Donepezil and Medroxyprogesterone Versus Placebo on Weaning in Adult Patients With Non-Pulmonary Etiologies Receiving Invasive Mechanical Ventilation: A triple-blind Randomized Clinical Trial.

Background: Medroxyprogesterone and donepezil could be used as respiratory stimulants in ventilated patients. However, no randomized placebo-controlled trial is available to confirm this approach and compare these drugs. The aim of the current study was to evaluate the effects of donepezil or medroxyprogesterone compared to the placebo in improvement in respiratory status and weaning facilitation in critically ill adult patients receiving mechanical ventilation. Material and Methods: This randomized, triple-blind trial was conducted on 78 ventilated patients in intensive care units (ICU). Patients who were intubated due to pulmonary disorders were ruled out. Patients were randomized in a 1:1:1 ratio to receive 5 mg donepezil (n = 23) or 5 mg medroxyprogesterone (n = 26), or placebo (n = 24) twice a day until weaning (maximum 10 days). The primary endpoints were weaning duration, and duration of invasive mechanical ventilation. Secondary endpoints included rate of successful weaning, changes in arterial blood gas (ABG) parameters, GCS and sequential organ failure assessment (SOFA) score, hemoglobin (Hgb), ICU-mortality, and duration of ICU stay, were measured before and after the intervention and if successful weaning was recorded. Results: Of 78 studied patients who were randomized, 59 weaned successfully. 87% patients in donepezil and 88.5% patients in medroxyprogesterone groups were successfully weaned compared to 66.7% patients in the placebo group. However, this difference was not statistically significant (p-Value = 0.111). Changes in pH, mean duration of intubation, and weaning duration were statistically different in donepezil compared with the control group (p-Value < 0.05). No significant difference in ABG, Hgb, GCS and SOFA score, and duration of intubation were seen in the medroxyprogesterone group, but weaning duration was significantly reduced to 1.429 days compared with the control group (p-Value = 0.038). Conclusion: The results of this clinical trial have demonstrated that the administered dose of medroxyprogesterone and donepezil can expedite the weaning process by reducing the weaning duration compared to placebo. Furthermore, the total duration of invasive ventilation was significantly lower in the donepezil group compared to the control group. Future clinical trials with a larger sample size will determine the exact role of medroxyprogesterone and donepezil in mechanically ventilated patients. Clinical Trial Registration: https://irct.ir/IRCT20190810044500N2 (April 1, 2020).

Extended duration of faecal diversion is associated with increased ileus upon loop ileostomy reversal.

The timing of ileostomy reversal has been the subject of controversy, with researchers investigating the safety of early versus late stoma closure. Anecdotally, a longer duration of faecal diversion is associated with a greater incidence of postoperative ileus. We sought to investigate the association between duration of diversion and postoperative ileus. We conducted an institutional retrospective cohort study on 173 patients undergoing ileostomy closure between 2012 and 2018. Our primary outcome was ileus; secondary outcomes included postoperative complications and descriptive factors. We investigated the association between duration of diversion and ileus using several analyses to ensure that time was treated appropriately as a continuous, nonlinear variable. In all, 20.2% of patients had an ileus. Multivariate analysis did not identify a significant association between any independent predictors and ileus, although there was a trend towards increased risk of ileus with increasing duration of diversion. When treated as a categorical variable, a duration of diversion >328days independently increased the odds of ileus (OR=3.25, P=0.033). Duration of diversion was associated with days to first flatus and to first diet (P=0.025 and P=0.004, respectively). When patients received nasogastric intubation, the mean duration of intubation was 3.2days. Greater duration of diversion was associated with a trend towards increased risk of ileus; this risk tripled when diversion lasted more than 328days.

Determination of Antibiotic Resistance Pattern of Organisms Isolated from Endotracheal Tube Cultures of Patients Admitted to Intensive Care Unit

Background: It is widely accepted that increased prevalence of antibiotic resistance of pathogens grown in the respiratory system in intensive care unit (ICU) patients is a very serious problem causing expansion of mortality. The most important strategy to prevent the occurrence and appropriate solution to control the antibiotic resistance is to thoroughly investigate the pattern of resistance in the studied ward. Therefore, the purpose of this study was to determine the antibiotic resistance pattern of organisms isolated from endotracheal tube secretions of patients admitted to ICU of Khatam-Al-Anbia Hospital at Zahedan in Iran. Methods: In the present retrospective and descriptive cross-sectional study, the medical records of patients hospitalized during 2013-2018 were included by census method and then selected based on inclusion criteria (n=1387). The required data, including age, gender, type of microorganism isolated from endotracheal tube cultures, antibiotic resistance and sensitivity, duration of intubation and cause of hospitalization, were recorded for each patient. Finally, the data were analyzed by descriptive statistics using SPSS 16 software. Results: Mean age of patients was 44.66 ± 21.39 years and mean duration of intubation was 17.96 ± 10.99 days. Stroke was the most common cause of hospitalization with a prevalence of 553 patients (49%). The prevalence of positive culture of endotracheal tube secretions was 1128 (81.3%) of which 71.5% were male (n=807) and 28.5% were female (n=321). The cultures of endotracheal tube secretions resulted in 933 (82.7%) gram-negative bacteria, 191 (16.9%) grampositive bacteria and 4 (0.4%) mixed isolates. The most prevalent gram-negative bacterium was Acinetobacter baumannii (37.2%) with the highest and lowest antibiotic resistance to Meropenem (95.1% resistance) and colistin (99.5% sensitivity), respectively. In addition, the most prevalent gram-positive bacterium was Staphylococcus epidermidis (50.3%) with the highest and lowest antibiotic resistance to Meropenem (85.7% resistance) and Vancomycin (92.2% sensitivity). Conclusion: The findings of the present study illustrate that there was widespread bacterial resistance to respiratory tract infections in our ICU patients. Due to the high sensitivity of gram-negative bacteria to colistin, the use of antibiotic combination with colistin in the control of pulmonary infections caused by these organisms can be a good choice. In addition, in the case of gram-positive bacteria, the highest sensitivity was to vancomycin; therefore, it can be the selective antibiotic to control infections caused by these bacteria.

Impact of Inhalation of Nitric Oxide and Extubation on Hemodynamics of Right Heart in Acute Phase after Left Ventricular Assist Device Implantation

Right ventricular failure (RVF) is one of the major complications after LVAD implantation. In acute phase after LVAD implantation, inhalation of nitric oxide (NO) and mechanical respiratory support and extubation causes hemodynamic changes on right heart dramatically. Although perioperative management is crucial to prevent RVF, there was no study which analyzed the impact of NO, mechanical respiratory support and extubation on hemodynamics of right heart in detail. Between December 2014 and September 2018, consecutive 102 patients underwent LVADs implantation in Osaka University Hospital. Patients below 18 years were excluded. Patients with right ventricular assist device support, and/or tracheostomy without trying of extubation after LVAD implantation were also excluded. Finally, 75 patients were included in this study (mean age, 45 ± 14 years; 30% were women). We used 5 different types of LVADs. We assessed the perioperative course of central venous pressure (CVP), pulmonary vascular resistance (PVR), and cardiac index (CI) before and after discontinuation of NO and extubation. Mean duration of NO inhalation was 2.0(0-3.3) days and final concentration of NO was 5ppm. The changes of CVP and CI before and after discontinuation of NO were not significantly (CVP: 10.0±2.7 to 10±2.7 mmHg, p=0.436, CI: 2.8±0.6 to 2.6±0.4 l/min/m2, p=0.999). Mean duration of intubation was 2.7(1.8-6.2) days. Just before extubation, respiratory rate was 17±4rpm and PaO2/FiO2 ratio was 341±71 under 5 cmH20 of positive end-expiratory pressure. The changes of CVP, PVR and CI before and after extubation were significantly (CVP: 9.1±2.9 to 8.2±3.0 mmHg, p=0.001, PVR: 1.1±0.4 to 1.2±0.5 wood, p=0.014, CI: 2.8±0.6 to 3.0±0.6 l/min/m2, p=0.004). Furthermore, patients with elevated CVP(≧10mmHg, n=31) also increased their CI significantly after extubation (CI:2.9±0.5 to 3.1±0.6 l/min/m2, p=0.007). Among adult patients with LVAD, discontinuation of NO inhalation caused minor decrease of CI but not significant. Extubation improves CI even patients with elevated CVP, who are higher risk for suffering from RVF. These analysis of hemodynamic changes imply that after respiratory condition become stable, extubation could be one important choice to improve hemodynamics even in patients with higher risk for RVF.

Incidence of Biofilm Formation in ET Tube and Correlation with Occurrence of VAP in a Tertiary Care ICU

Introduction: VAP is one of the most frequent hospital-acquired infections occurring in mechanically ventilated patients and is associated with increased mortality, morbidity, and health-related costs. Bacterial biofilm has been observed universally on the surface of endotracheal tubes in mechanically ventilated patients. Some data show a good concordance between bacterial colonization of the airway and microbial findings in the biofilm. Even the same microorganisms causing VAP could be found in the ETT biofilm leading to the potential implication of biofilm in the genesis of VAP. Aims and Objectives: The objective was to investigate the involvement of ETT biofilm in VAP pathogenesis. Materials and Methods: This observational descriptive study was conducted in Department of Pulmonary Medicine, D.Y Patil Hospital, Nerul, Navi Mumbai. Approval of Institutional Ethics Committee was taken before start of the study. A written signed informed consent was taken prior to enrolling the subjects in the study. Patients requiring mechanical ventilation for at least 24 hours were included in the study. The following data were recorded in a standardized form: age and sex of the patient, cause of mechanical ventilation, duration of ventilation, manoeuvres to prevent VAP, the occurrence or not of nosocomial pneumonia, together with data of pathogen isolated in respiratory samples and/or ETT biofilm, antibiotic therapy and sensitivity patterns. Statistical Method: Descriptive and analytical statistics was done. The data was analyzed using statistical software (IBM SPSS V20.1, IBM Corporation, Armonk, NY, USA). The results are expressed as mean ± standard deviation and proportions. Categorical variables were compared using chi-square tests. The statistical significance was determined at p<0.05.Results: A total of 55 subjects fulfilling the inclusion criteria were participated in the study. The mean age of the study population was 46.56 19.79 with a range of 18 to 87 years. There were 23 (41.8%) males and 32 (58.2%) female’s subjects in the study population. The patients were intubated for mainly three reasons – AHF, ARF and CVA. The diagnosis of the ventilated patients was as follows – pneumonia (25.4%), ARDS (18.2%), cerebral stroke (16.4%), septic shock (16.4%), hemorrhagic shock (9.1%), cardiac arrest (7.3%), cardiopulmonary failure (5.4%) and interstitial lung disease (1.8%). The mean duration of intubation was 10.23 1.55, ICU days was 13.45 1.34 and hospital days was 19.72 2.84. Out of the 55 ventilated patients, 9 (16.3%) patients developed VAP. Biofilm was found positive in 30 (54.5%) patients. In the present study the three most common organisms found in ET tube were Acinetobacter (23.6%), klebsiella (18.2%), E.Coli (7.3%). The other organisms found were Pseudomonas (7.3%), Candida Albicans (3.6%) and staphylococcus (1.8%). The incidence of VAP development in biofilm positive cases was 30%. Conclusion: Biofilms are highly organized microbial communities which in vivo play an important part in evading the defence mechanism and obstinate the antimicrobial therapy. The precise link between biofilm productions in mechanically ventilated patients is still obscure apart from some limited studies which have described role of a specific pathogen or virulence factor. The present study, thus, showed that majority of the pathogens isolated possessed capability to produce biofilm.