Mechanical Ventilation In Patients Research Articles

Early antibiotic therapy is associated with a lower probability of successful liberation from mechanical ventilation in patients with severe acute exacerbation of chronic obstructive pulmonary disease

BackgroundWhile antibiotic therapy is advocated to improve outcomes in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) whenever mechanical ventilation is required, the evidence relies on small studies carried out before the era of widespread antibiotic resistance. Furthermore, the impact of systematic antibiotic therapy on successful weaning from mechanical ventilation was never investigated accounting for the competitive risk of death. The aim of the study was to assess whether early antibiotic therapy (eABT) increases successful mechanical ventilation weaning probability as compared to no eABT, in patients with AECOPD without pneumoniae, using multivariate competitive risk regression.MethodsRetrospective analysis of patients admitted in 2 intensive care units (ICU) from 2012 to 2020 for AECOPD without pneumonia and requiring mechanical ventilation. eABT was defined as any anti-bacterial chemotherapy introduced during the first 24 h after ICU admission. The primary outcomes were the adjusted subdistribution hazard ratio (SHR) of the probability of being successfully weaned from mechanical ventilation (i.e. non-invasive and invasive ventilation) according to eABT status and accounting for the competitive risk of death.ResultsThree hundred and ninety-one patients were included, of whom 66% received eABT. eABT was associated with a lower probability of successful liberation from mechanical ventilation when accounting for the competing risk of death in multivariate analyses (SHR 0.71 [95% confidence interval, 0.57–0.89], p < 0.01), after adjustment with covariates of disease severity. This association was present in all subgroups except in patients under invasive mechanical ventilation on ICU day-1, in patients with ICU day-1 worst PaCO2 > 74 torr (median value) and in patients with a documented bacterial bronchitis at ICU admission. Ventilator-free days at day 28, ICU-free days at day 28 and invasive mechanical ventilation-free days at day 28, were significantly lower in the eABT group, while there was no significant difference in mortality at day 28 between patients who received eABT and those who did not.ConclusionseABT was independently associated with a lower probability of being successfully weaned from mechanical ventilation, suggesting that the clinician decision to overrule systematic administration of eABT was not associated with a detectable harm in AECOPD ICU patients without pneumonia.

Corrected flow time and respirophasic variation in blood flow peak velocity of radial artery predict fluid responsiveness in gynecological surgical patients with mechanical ventilation

BackgroundRecent evidence suggests that ultrasound measurements of carotid and brachial artery corrected flow time (FTc) and respirophasic variation in blood flow peak velocity (ΔVpeak) are valuable for predicting fluid responsiveness in mechanical ventilated patients. We performed the study to reveal the performance of ultrasonic measurements of radial artery FTc and ΔVpeak for predicting fluid responsiveness in mechanical ventilated patients undergoing gynecological surgery.MethodsA total of eighty mechanical ventilated patients were enrolled. Radial artery FTc and ΔVpeak, and non-invasive pulse pressure variation (PPV) were measured before and after fluid challenge. Fluid responsiveness was defined as an increase in stroke volume index (SVI) of 15% or more after the fluid challenge. Multivariate logistic regression analyses and receiver operating characteristic (ROC) curve were used to screen multivariate predictors of fluid responsiveness and identify the predictive abilitie of non-invasive PPV, ΔVpeak and FTc on fluid responsiveness.ResultsForty-four (55%) patients were fluid responders. Multivariate logistic regression analysis showed that radial artery FTc, ΔVpeak, and non-invasive PPV were the independent predictors of fluid responsiveness, with odds ratios of 1.152 [95% confidence interval (CI) 1.045 to 1.270], 0.581 (95% CI 0.403 to 0.839), and 0.361 (95% CI, 0.193 to 0.676), respectively. The area under the ROC curve of fluid responsiveness predicted by FTC was 0.802 (95% CI, 0.706–0.898), and ΔVpeak was 0.812 (95% CI, 0.091–0.286), which were comparable with non-invasive PPV (0.846, 95%CI, 0.070–0.238). The optimal cut-off values of FTc for fluid responsiveness was 336.6 ms (sensitivity of 75.3%; specificity of 75.9%), ΔVpeak was 14.2% (sensitivity of 88.2%; specificity of 67.9%). The grey zone for FTc was 313.5–336.6 ms and included 40 (50%) of the patients, ΔVpeak was 12.2–16.5% and included 37(46%) of the patients.ConclusionsUltrasound measurement of radial artery FTc and ΔVpeak are the feasible and reliable methods for predicting fluid responsiveness in mechanically ventilated patients.Trial registrationThe trial was registered at the Chinese Clinical Trial Registry (ChiCTR)(www.chictr.org), registration number ChiCTR2000040941.

Efficacy of COVID-19 Convalescent Plasma Based on Antibody Concentration.

Background Convalescent plasma obtained from individuals who have recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contains neutralizing antibodies to the virus and has been frequently used as a treatment in hospitalized patients with severe COVID-19. Methods We conducted a retrospective, observational cohort study involving 96 hospitalized patients with severe COVID-19 who were allocated in a 1 : 1 ratio to having received either high antibody concentration convalescent plasma or low antibody concentration convalescent plasma. Quantitative measurements of IgG to the receptor-binding domain (RBD), the S1 subunit of the spike protein, and the SARS-CoV-2 nucleocapsid (N) protein were determined from donor plasma samples. The primary outcome was all-cause mortality within 30 days following convalescent plasma administration in regard to each of the three antibody domains. Results Within the nucleocapsid antibody domain, death occurred in 22.2% of patients in the low antibody concentration group versus 23.5% in the high antibody concentration group (p=0.88). Within the RBD antibody domain, death occurred in 22.9% of patients in both the low and the high antibody concentration groups (p=1.0). Within the S1 subunit antibody domain, death occurred in 27.1% of patients in the low antibody concentration group versus 18.8% in the high antibody concentration group (p=0.33). Conclusions No significant differences were observed between low and high concentration convalescent plasma in regard to overall mortality at 30 days, hospital length of stay, number of ventilator days, and subsequent receipt of invasive mechanical ventilation in patients who were previously not receiving mechanical ventilation. Trial Registration. This study was not associated with a clinical trial due to the retrospective nature of study design.

A Randomized Trial of Mesenchymal Stromal Cells for Moderate to Severe ARDS From COVID-19.

There are limited therapeutic options for patients with COVID-19-related acute respiratory distress syndrome (ARDS) with inflammation-mediated lung injury. Mesenchymal stromal cells offer promise as immunomodulatory agents. Evaluation of efficacy and safety of allogeneic mesenchymal cells in mechanically-ventilated patients with moderate or severe COVID-induced respiratory failure. Patients were randomized to two infusions of 2 million cells/kg or sham infusions, in addition to standard of care. We hypothesized that cell therapy would be superior to sham-control for the primary endpoint of 30-day mortality. The key secondary endpoint was ventilator-free survival within 60 days, accounting for deaths and withdrawals in a ranked analysis. At the third interim analysis, the Data and Safety Monitoring Board recommended that the trial halt enrollment as the pre-specified mortality reduction from 40% to 23% was unlikely to be achieved (n=222 out of planned 300). Thirty-day mortality was 37.5% (42/112) in cell recipients versus 42.7% (47/110) in control patients (RR 0.88;95% CI 0.64,1.21;p=0.43). There were no significant differences in days alive off ventilation within 60 days (median rank 117.3 [IQR:60.0,169.5] in cell patients and 102.0 [IQR:54.0,162.5] in controls; higher is better). Resolution or improvement of ARDS at 30-days was observed in 51/104 (49.0%) cell recipients and 46/106 (43.4%) of control patients (OR 1.36;95% CI 0.57, 3.21). There were no infusion-related toxicities and overall serious adverse events over 30 days were similar. Mesenchymal cells, while safe, did not improve 30-day survival or 60-day ventilator-free days in patients with moderate/severe COVID-related acute respiratory distress syndrome. Clinical trial registration available at www. gov, ID:NCT04371393. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Determinants of the health care service choices of long-term mechanical ventilation patients: Applying andersen's behavioral model.

AimsThe number of ventilator-dependent patients is rapidly increasing globally. As a result, long-term mechanical ventilation (LTMV) patients face the choice of receiving health care in respiratory care wards (RCWs) rather than at home. In this study, we applied Andersen’s behavioral theoretical model (ABM) to investigate the determinants of the health care service decisions of patients receiving LTMV.MethodsA cross-sectional research design and cluster random sampling were used to select 365 participants from nine RCWs and eight home care facilities in northern Taiwan. Data were collected in face-to-face interviews using a structured questionnaire.ResultsOf the predisposing factors, advanced age and an education level of at least junior high school influenced the choice to use RCW services. Being married, living with extended family, and medium or higher socioeconomic status were associated with the decision to use home care services. Of the enabling factors, patients with more caregivers, those whose family caregivers held strong beliefs about providing care, and those who perceived greater social support from health care providers were more likely to choose home care services. Of the need factors examined, poor cognitive function and higher dependence on assistance for activities of daily living (ADL) increased the probability of patients choosing RCW services. Hierarchical logistic regression analysis indicated that our final model accounted for 44.8% of the observed variance in health care service choice.ConclusionsABM enables an improved understanding of the health care service choices of LTMV patients. Our findings also highlight the importance of rigorously assessing patient needs and helping patients choose the most appropriate health care service.

Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different?

Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.

Adjunctive corticosteroid therapy in patients with pulmonary tuberculosis.

SUMMARYOBJECTIVES:In tuberculosis treatment, corticosteroids are used as adjuvants, especially in meningeal/pericardial tuberculosis. In other forms of the disease, especially in severe tuberculosis requiring mechanical ventilation, its use is controversial. The aim of the present study is to assess whether the use of corticosteroids in the treatment of pulmonary tuberculosis patients in mechanical ventilation is associated with in-hospital mortality.METHODS:This is a retrospective cohort study. Tuberculosis patients >18 years requiring mechanical ventilation, admitted to the emergency department or intensive care unit, were included. Data on corticosteroid use and mortality were collected.RESULTS:In total, 467 patients were included in the analysis; 399 used corticosteroids and 68 were noncorticosteroid users. The mortality rate was higher among corticosteroid users (59.9%) than in noncorticosteroid users (41.2%) (p=0.010). The total dose of corticosteroid in prednisone equivalents was not different between survivors and nonsurvivors (median [interquartile range]: 80 mg [5–56.6 mg] vs. 80 mg [50–135 mg]; p=0.881).CONCLUSIONS:Tuberculosis patients in mechanical ventilation who used corticosteroids had a higher mortality rate than those who did not use corticosteroids. The role of corticosteroids in pulmonary tuberculosis, especially in critically ill patients, remains unclear and needs further evaluation in prospective studies.

Predictive value of combined assessment of diaphragmatic and pulmonary ultrasound for weaning outcomes in mechanical ventilated patients with acute respiratory failure

To investigate the clinical predictive value of combined diaphragmatic and pulmonary ultrasound in acute respiratory failure patients with mechanical ventilation (MV). From January 2020 to August 2022, patients with acute respiratory failure admitted to People's Hospital Affiliated to Ningbo University who underwent invasive MV and weaning were enrolled. After meeting the weaning standards, spontaneous breathing test (SBT) was performed using T-tube. Right diaphragm excursion (DE), diaphragm thickness and lung ultrasound score (LUS) were collected by bedside ultrasound at 30 minutes of SBT, and rapid shallow respiratory index (RSBI), diaphragmatic-shallow respiratory index (D-RSBI) and diaphragmatic thickening rate (DTF) were calculated. According to the weaning outcome, the patients were divided into successful weaning group and failed weaning group. The clinical data of all patients were collected, and the ultrasound parameters and clinical indicators were compared between the two groups. Receiver operator characteristic curve (ROC curve) was used to evaluate the predictive value of D-RSBI, RSBI, DE combined with LUS score and DTF combined with LUS score for weaning failure patients. A total of 77 patients were enrolled, including 54 cases in the successful weaning group and 23 cases in the failed weaning group. The right DE and DTF of patients in successful weaning group were significantly higher than those in failed weaning group [right DE (cm): 1.28±0.39 vs. 0.88±0.41, DTF: (32.64±18.27)% vs. (26.43±15.23)%, both P < 0.05], LUS score, RSBI and D-RSBI were significantly lower than those in failed weaning group [LUS score: 11.45±2.67 vs. 18.33±3.62, RSBI (times×min-1×L-1): 72.21±19.67 vs. 107.35±21.32, D-RSBI (times×min-1×mm-1): 0.97±0.19 vs. 1.78±0.59, all P < 0.05]. ROC curve analysis showed that when the cut-off value of D-RSBI and RSBI was 1.41 times×min-1×mm-1 and 56.46 times×min-1×L-1, the area under the ROC curve (AUC) for predicting weaning failure was 0.972 and 0.988; and the sensitivity was 95.7% and 87.0%, respectively; the specificity was 81.0% and 100.0%, respectively. The AUC of right DE combined with LUS score and DTF combined with LUS score in predicting weaning failure were 0.974 and 0.985, respectively, with a sensitivity of 91.3% and a specificity of 98.1%. Combined assessment of diaphragmatic and pulmonary ultrasound is a good parameter to effectively predict weaning failure in MV patients, which has high application value in guiding weaning in MV patients, and is worthy of clinical application.

Seronegative immunity to SARS-CoV-2: a case study

BackgroundCOVID-19 presents with a variable clinical course from asymptomatic to severe respiratory distress with nearly 25% mortality in mechanically-ventilated patients. As such, there is uncertainty regarding how host factors modulate the disease course.Case PresentationThis report examines these factors in two geriatric patients with multiple comorbid conditions who were residents of the long-term care facility in West Virginia that was the epicenter of COVID-19 in the state. Each patient had substantial, unprotected exposure to SARS-CoV-2 with subsequent negative PCR and antibody testing.ConclusionsThese cases could represent an important step in understanding host factors that modulate the disease course and susceptibility of patients exposed to SARS-CoV-2, and illustrate the need for further research into host resistance relating to this pandemic.

Comparison of liver biomarkers with N/L ratio, CRP, d-dimer in Covid 19 pneumonia and its effect on mortality

Coronavirus Disease-2019 (Covid-19) is the cause of a pandemic that has high mortality and global effects. The liver damage in Covid-19 cases in mechanical ventilation was investigated in this study. A total of 60 patients (the Study Group) who were diagnosed with Covid-19 pneumonia, and 65 individuals (the Control Group) were included prospectively in the study. The cases were divided into 3 groups as those who were intubated (severe), those who were not intubated (mild), and the healthy Control Group. The lung tomography results of those who were diagnosed with Covid-19 were examined in the study. The cases with positive RT-PCR (Real Time Polymerized Chain Reaction) test results were recorded from the system. The liver tests of the patients were compared with those of the Control Group. The two groups with and without intubation were also compared. The results were evaluated and analyzed statistically. When all the data were evaluated, it was found that LDH, GGT, AST, and aPTT levels were significantly higher in the mild and severe patient group compared to the Control Group, and the T. Protein and albumin levels were low (p&lt;0.01). The N/L Ratio, and the CRP levels, which are the other acute phase reactants, were significantly higher (p&lt;0.05). No statistically significant differences were detected when all parameters of the groups with and without intubation were compared (p&gt;0.05). Increased D-dimer, GGT, D. Bil, LDH, NLR, and AST levels in Covid-19 patients in invasive mechanical ventilation are associated with mortality.

Effect of preoperative pulse oximeter oxygen saturation on postoperative prolonged mechanical ventilation in patients with tetralogy of Fallot.

BackgroundAs an easily accessible and intervened clinical indicator, preoperative pulse oximeter oxygen saturation (SpO2) is an important factor affecting the prognosis of patients with tetralogy of Fallot (TOF). However, whether SpO2 is associated with postoperative mechanical ventilation (MV) time remains unknown. Therefore, this study aimed to investigate the impact of preoperative SpO2 on postoperative prolonged mechanical ventilation (PMV) in children with TOF.Materials and methodsThe study included children younger than 18 years who underwent corrective operations for TOF between January 2016 and December 2018 in Fuwai Hospital, China. Univariate and multivariate logistic regression analyses were used to evaluate the influence of preoperative SpO2 on postoperative PMV. After identifying SpO2 as an independent risk factor for PMV, patients were further divided into two groups according to the cutoff value of SpO2, and propensity score matching (PSM) analysis was used to eliminate the effect of confounding factors. The logistic regression was used to compare the outcomes between the two groups after PSM.ResultsA total of 617 patients were finally enrolled in this study. By the univariable and multivariate logistic analysis, four independent risk factors for PMV were determined, namely, SpO2, surgical technique, aortic cross-clamp time, and intraoperative minimum temperature. According to the outcomes of 219 paired patients after PSM, the incidence of PMV was significantly higher in patients with lower preoperative SpO2 (P = 0.022). Also, there was significant increase in mechanical ventilation time (P = 0.019), length of intensive care unit stay (P = 0.044), postoperative hospital stay (P = 0.006), hospital stay (P = 0.039), and hospitalization cost (P = 0.019) at the lower preoperative SpO2 level.ConclusionLow preoperative SpO2 represents an independent risk factor of postoperative PMV in children with TOF.

Comparison between the persistence of post COVID-19 symptoms on critical patients requiring invasive mechanical ventilation and non-critical patients.

During follow-up, patients severely affected by coronavirus disease 2019 (COVID-19) requiring invasive mechanical ventilation (IMV), show symptoms of Post-Intensive Care Syndrome (PICS) such as cognitive impairment, psychological disability, and neuromuscular deconditioning. In COVID-19 pandemic, it is a priority to develop multidisciplinary post-acute care services to address the long-term multisystemic impact of COVID-19. Which are the most relevant multisystemic sequelae in severe post-COVID-19 patients? Observational chart review study that included adult patients discharged from a referral hospital for respiratory diseases in Mexico after recovering from severe COVID-19 disease from December 23, 2020, to April 24, 2021. Data were collected from 280 of 612 potentially eligible patients to evaluate persistent symptoms and compare sequelae in patients who required intubation, using a standardized questionnaire of symptoms, in addition to findings reported during the face-to-face health assessment. Univariable and multivariate analyses were performed for the association among the requirement of IMV and the long-term persistence of symptoms. 280 patients were included. The median age was 55 (range, 19 to 86) years, and 152 (54.3%) were men. The mean length of hospital stay was 19 (SD, 14.1) days. During hospitalization 168 (60%) participants received IMV. A large proportion of these patients reported fatigue (38.7%), paresthesia (35.1%), dyspnea (32.7%) and headache (28%); meanwhile only 3 (1.8%) of them were asymptomatic. Patients who required intubation were more likely to have neuropsychiatric (67.3% vs 55.4%; OR, 1.79 [95% CI, 1.08 to 2.97]) and musculoskeletal involvement (38.7% vs. 25.9%; OR, 1.92 [95% CI, 1.12 to 3.27]), adjusted for age,sex and hospitalization time. The proportion of patients requiring intubation was 60%, reporting persistent symptoms in 98% of them. Neuropsychiatric and musculoskeletal symptoms were the most predominant symptoms in these patients, with a significant difference. Post-COVID-19 syndrome is a frequent problem in patients who required IVM. Physicians in ICU and in care of COVID-19 patients should be aware of this syndrome in order to avoid more complications.

Association between Glucocorticoids and Mortality in Patients with Severe Pneumonia: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials.

Objective To explore the associations between glucocorticoid use and the clinical outcome of patients with severe pneumonia. Methods Medical databases including PubMed, EMBASE, and ScienceDirect were searched for relevant literature. Two independent researchers extracted the primary endpoint from the included literature. The Cochrane Q test and I2 statistics were used to evaluate the interstudy heterogeneity. The combined risk estimates were calculated by random effect model, and the source of heterogeneity was evaluated by subgroup analysis. Funnel plot and Egger's test were used to assess publication bias. P < 0.05 denoted statistical significance. Results A total of 12 literature, including 8171 patients with 1083 deaths, were included in this study for meta-analysis. The use of glucocorticoids significantly increased the mortality (RR = 1.44, 95% CI: 1.13, 1.84, P < 0.001), the risk of requiring mechanical ventilation (RR = 1.62, 95% CI: 1.30, 2.02, P < 0.001), and the incidence of nosocomial infection (RR = 1.36, 95% CI: 1.01, 1.82, P = 0.04) in patients with severe pneumonia as compared with the control group. In addition, the use of glucocorticoids did not seem to be associated with length of treatment in the intensive care unit (mean difference = 1.47, 95% CI: -1.04, 3.96, P = 0.25) and the length of hospital stay (mean difference = 0.55, 95% CI: -3.90, 4.99, P = 0.81). Conclusion The use of glucocorticoids may increase the mortality, the incidence of hospital-acquired pneumonia, and the need for mechanical ventilation in patients with severe pneumonia.

Manual vs. mechanical ventilation in patients with advanced airway during CPR

Early chest compressions and rapid defibrillation are important components of cardiopulmonary resuscitation (CPR). American heart association (AHA) recommends two breaths to be delivered for every 30 compressions for an adult cardiac arrest victim. Patient with an advanced airway like endotracheal tube (ETT) should be given one breath every 6 s without interruptions in chest compression (10 breaths per minute). All of the modern mechanical ventilators have option to generate spontaneous breaths by the patient if the patient has spontaneous respiratory efforts. During CPR, the mechanical ventilator is fallaciously sensing the chest compressions as patient's spontaneous trigger and thereby it delivers higher respiratory rates. Avoiding excessive ventilation is one of the components of high quality CPR as excessive ventilation decreases venous return thereby decreasing the cardiac output and also it affects intra-thoracic pressure thereby adversely affects intra-arterial pressure. As modern ventilators have trigger for spontaneous breaths and they will be erroneously triggered by chest compressions, it would be prudent to use volume marked resuscitation bags or manual breathing devices (manual self-inflating resuscitation bag, Bain's circuit) for delivering breaths which can be synchronised with compression phase of CPR at RR of 10 breaths per min with advanced airway in place. If any patient who is on mechanical ventilation develops cardiac arrest, patient should be disconnected from the mechanical ventilator and should be ventilated manually. Manual ventilation with aforementioned breathing devices should be used in a patient without and with advanced airway devices during CPR.

Effect of controlled sedation based on Richmond scale on the duration of mechanical ventilation in patients admitted to ICU

Background &amp; objective: Patients treated with mechanical ventilation may need sedatives and analgesics due to discomfort, pain, lack of coordination with the device, immunity maintenance, and oxygenation elevation. The use of sedation scoring protocols and systems reduces the duration of mechanical ventilation and hospitalization. Therefore, this study aimed to investigate the effect of controlled sedation based on the Richmond model on the duration of mechanical ventilation in patients admitted to the ICU. Methodology: This experimental study was performed on 60 patients admitted to ICU, who had been selected by simple random sampling and divided in two intervention and control groups. The data collection tools included the Richmond Agitation Sedation Scale (RASS), and Berne separation program checklist. In the intervention group, intervention was performed according to the standard Richmond protocol, but the control group received only the routine care. After the intervention, data were collected at 24 hours, 48 ​​hours and 72 hours after the intervention by SPSS-21 statistical software, and then were analyzed by descriptive statistics (mean, standard deviation) and inferential statistics (paired t-test, independent t-test and repeated measure).

Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury.

Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.

A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit.

Sepsis leads to left and/or right ventricular systolic and/or diastolic dysfunction resulting in adverse outcomes. Myocardial dysfunction can be diagnosed by echocardiography (ECHO) and early intervention can be planned. There are lacunae in Indian literature regarding the true incidence of septic cardiomyopathy and its influence on the outcome of patients admitted to intensive care unit (ICU). This prospective observational study was conducted on patients consecutively admitted with sepsis to the ICU of a tertiary care hospital in North India. In these patients, ECHO was performed after 48-72 hours to establish left ventricular (LV) dysfunction, in whom the ICU outcome was analyzed. The incidence of LV dysfunction was 14%. About 42.86% of patients had isolated systolic dysfunction, 7.14% of patients had isolated diastolic dysfunction, and 50.00% of patients had combined LV systolic and diastolic dysfunctions. The average days of mechanical ventilation in patients without LV dysfunction group (group I) was 2.41 ± 3.82 days as compared to 4.43 ± 4.27 days in patients with LV dysfunction (group II) (p = 0.034). Incidence of all-cause ICU mortality was 11 (12.79%) in group I and 3 (21.43%) in group II (p = 0.409). The mean duration of stay in ICU was 8.26 ± 4.41 days in group I as compared to 13.21 ± 6.83 days in group II. We concluded that sepsis-induced cardiomyopathy (SICM) in ICU is quite prevalent and clinically significant. All-cause ICU mortality and length of ICU stay are prolonged in patients with SICM. Bansal S, Varshney S, Shrivastava A. A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit. Indian J Crit Care Med 2022;26(7):798-803.

Effect of Ketamine on Vasopressor Needs in Mechanically Ventilated Patients: A Retrospective Study

Background: Ketamine has many recognized effects that may be beneficial in patients undergoing mechanical ventilation. While ketamine provides sedation and analgesia, it has additional sympathomimetic properties that may help support critically ill patients in shock. We hypothesized patients undergoing mechanical ventilation with continuous ketamine infusion as an adjunct to sedation agents would be associated with a lower vasopressor requirement. Methods: We performed a retrospective cohort study on 200 mechanically-ventilated patients (205 hospital encounters) in two academic hospitals between 2015 to 2019. Patients on ketamine as an adjunct (K-G) to another sedative were utilized as the intervention group. Patients on both propofol and fentanyl (PF-G), a common sedation regimen, were used as the control group. The primary outcome was vasopressor requirements before and after initiation of ketamine or propofol and fentanyl. Secondary outcomes included all-cause mortality, 30-day mortality, ICU length-of-stay (LOS), hospital LOS, and ventilator-free days. Results: The overall proportion of males was 63.4% (p-value =0.5016). The norepinephrine average dose (up to 48 hours after initiating sedatives) was lower in K-G (8.7 mcg/kg/min) when compared with PF-G (14.2 mcg/kg/min), p-value&lt;0.0001. The ICU, 30-day or any time all-cause mortality was similar in both groups (22.0, 21.5 and 32.2%, p-value=0.8952, 0.9709, 0.8019, respectively). The average ICU and hospital stay overall were 8.8 (p-value=0.5174) and 16.6 (p-value=0.9280) days, respectively. The average ventilator-free days for K-G was 22.8 days compared to 23.2 days in PF-G (p-value=0.5567). Conclusions: In our study, ketamine as an adjunct sedation agent was associated with decreased vasopressor requirements in patients on mechanical ventilation when compared to the standard use of propofol and fentanyl. Further prospective research is necessary before ketamine can be broadly recommended as an adjunct to sedation in critically ill patients with shock.

Prolonged mechanical ventilation in patients with severe COVID-19 is associated with serial modified-lung ultrasound scores: A single-centre cohort study.

Lung ultrasound (LUS), a rapid, bedside, goal-oriented diagnostic test, can be quantitatively assessed, and the scores can be used to evaluate disease progression. However, little data exists on predicting prolonged mechanical ventilation (PMV) and successful extubation using serial LUS scores. We examined the relationship of PMV with successful extubation in patients with severe coronavirus disease (COVID-19) by using two types of serial LUS scores. One LUS score evaluated both the pleura and lung fields, while the other assessed each separately (modified-LUS score). Both LUS scores were determined for 20 consecutive patients with severe COVID-19 at three timepoints: admission (day-1), after 48 h (day-3), and on the seventh follow-up day (day-7). We compared LUS scores with the radiographic assessment of the lung oedema (RALE) scores and laboratory test results, at the three timepoints. The PMV and successful extubation groups showed no significant differences in mortality, but significant differences occurred on day-3 and day-7 both LUS scores, day-7 RALE score, and day-7 PaO2/FiO2 ratio, in the PMV group (p<0.05); and day-3 and day-7 modified-LUS scores, day-7 C-reactive protein levels, and day-7 PaO2/FiO2 ratio, in the successful extubation group (p<0.05). The area under the curves (AUC) of LUS scores on day-3 and day-7, modified-LUS scores on day-3 and day-7,RALE score on day-7, and PaO2/FiO2 ratio on day-7 in the PMV group were 0.98, 0.85, 0.88, 0.98, 0.77, and 0.80, respectively. The AUC of modified-LUS scores on day-3 and day-7, C-reactive protein levels on day-7, and PaO2/FiO2 ratio on day-7 in the successful extubation group were 0.79, 0.90, 0.82, and 0.79, respectively. The modified-LUS score on day 7 was significantly higher than that on day 1 in PMV group (p<0.05). While the LUS score did not exhibit significant differences. The serial modified-LUS score of patients with severe COVID-19 could predict PMV.

Abnormal Echocardiographic Findings in Hospitalized Patients with Covid-19: A Systematic Review and Meta-analysis.

ResumoFundamentos A doença do coronavírus 2019 (Covid-19) pode levar à insuficiência respiratória grave e lesão cardíaca aguda, mas não está claro com que frequência ela pode causar disfunção cardíaca.Objetivos Nesta revisão sistemática, nosso objetivo foi resumir os principais achados ecocardiográficos em pacientes com Covid-19.Métodos Conduzimos uma busca sistemática nos bancos de dados PUBMED, EMBASE, LILACS e Cochrane, além de artigos não pulicados ( preprints ) no MedRxiv e Scielo desde o início até 21 de julho de 2021. Foram incluídos estudos que apresentaram dados ecocardiográficos de pacientes com Covid-19. Características demográficas, doença cardiovascular (DCV) prévia, e achados ecocardiográficos foram extraídos dos estudos. Realizamos uma metanálise de proporções para estimar os principais achados ecocardiográficos. O nível de significância foi p<0,05.Resultados Do total de 11 233 estudos, 38 preencheram os critérios de inclusão e foram incluídos na metanálise. A proporção estimada de disfunção sistólica do ventrículo esquerdo (VE) foi 25% (IC95%: 19, 31; I2 93%), strain longitudinal global anormal 34% (IC95% 23, 45; I2 90%), disfunção sistólica do ventrículo direito (VD) 17% (IC95% 13, 21; I2 90%), derrame pericárdico 17% (IC95%: 9, 26; I2 97%), e hipertensão pulmonar 23% (IC95%: 15, 33, I2 96%). Disfunção sistólica do VE foi diretamente associada com prevalência de ecocardiograma anormal prévio nos estudos (p<0,001). A proporção de pacientes em ventilação mecânica, indicando gravidade da doença, não explicou a heterogeneidade nas proporções de disfunção do VE (p=0,37).Conclusão Entre os pacientes internados com Covid-19, a disfunção ventricular esquerda foi descrita em um quarto dos pacientes, com menores proporções de disfunção do ventrículo direito, derrame pericárdico e hipertensão pulmonar. No entanto, houve uma proporção mais alta de disfunção do VE nos estudos que relataram presença de doença cardíaca prévia, sugerindo que a disfunção cardíaca era predominantemente pré-existente.