Removal Of Mechanical Ventilation Research Articles

The Effect of Comprehensive Medical Care on the Long-Term Outcomes of Children Discharged from the NICU with Tracheostomy.

Background:Survival of infants with complex care has led to a growing population of technology-dependent children. Medical technology introduces additional complexity to patient care. Outcomes after NICU discharge comparing Usual Care (UC) with Comprehensive Care (CC) remain elusive.Objective:To compare the outcomes of technology-dependent infants discharged from NICU with tracheostomy following UC versus CC.Methods:A single site retrospective study evaluated forty-three (N=43) technology-dependent infants discharged from NICU with tracheostomy over 5½ years (2011-2017). CC provided 24-hour accessible healthcare-providers using an enhanced medical home. Mortality, total hospital admissions, 30-days readmission rate, time-to-mechanical ventilation liberation, and time-to-decannulation were compared between groups.Results:CC group showed significantly lower mortality (3.4%) versus UC (35.7%), RR, 0.09 [95%CI, 0.12-0.75], P=0.025. CC reduced total hospital admissions to 78 per 100 child-years versus 162 for UC; RR, 0.48 [95% CI, 0.25-0.93], P=0.03. The 30-day readmission rate was 21% compared to 36% in UC; RR, 0.58 [95% CI, 0.21-1.58], P=0.29). In competing-risk regression analysis (treating death as a competing-risk), hazard of having mechanical ventilation removal in CC was two times higher than UC; SHR, 2.19 [95% CI, 0.70-6.84]. There was no difference in time-to-decannulation between groups; SHR, 1.09 [95% CI, 0.37-3.15].Conclusion:CC significantly decreased mortality, total number of hospital admissions and length of time-to-mechanical ventilation liberation.

Our great forgotten, chronic respiratory sufferers

Lung’s own properties make that nutritional support, besides covering the requirements can modulate its infl ammatory response. Lung tissue has a low glucose stock. Fatty acids are the main energy producer of type II pneumocytes, which use them in order to form phospholipids, essential for surfactant whose creation and release decrease in acute lung injury (ALI). Glutamine is a good substratum for endocrine cells and type II pneumocytes. Due to high nutritional risk, it is important its assessments in disorders as COPD and acute respiratory distress syndrome (ADRS). Indirect calorimetry values the effect of ventilation and nutritional support, avoiding overfeeding. Hypophosphatemia and refeeding syndrome are frequent and need to be avoided because of their morbidity. In critically ill patients, malnutrition can lead to respiratory failure and increasing mechanical ventilation time. To avoid hypercapnia in weaning, glucose levels should be controlled. High lipids/carbohydrates ratio do not show usefulness in COPD neither mechanical ventilation removal. ALI patients beneficiate from an early start and the volume administered. Enteral nutrition with high fatty acids ratio (EPA, DHA and γ-linolenic acid) and antioxidants do not show any superiority. Omega-3 fatty acid in parenteral nutrition could modulate infl ammation and immunosuppression in a positive manner. The use of glutamine, vitamins or antioxidants in these patients could be justified.

When to Say When: Helping the Team and Family Recognize when Death is Inevitable After Pediatric Bone Marrow Transplant (TH356)

Describe ways to support family and staff during and after the extubation. Compassionate extubation or the removal of mechanical ventilation in the home requires the involvement of the entire hospice team to ensure both patient and family comfort. With the assistance of the hospice physician, nurse, social worker and chaplain, patients and families should not have to leave their home to come off ventilatory support. We will present four cases of home discontinuation of support: two elderly female patients and two children. We did not have IV access in any of the cases but were able to anticipate and manage their symptoms using subcutaneous medications administered via a pump or medications administered via a gastric tube in one of the pediatric patients. The process involved the whole team (ie, hospice physician, nurse case manager, social worker, and spiritual counselor) making visits to the home prior to and during the extubation. Also, the pharmacy department was essential in providing assistance in symptom management. These were emotionally difficult experiences for staff, as well as for families. We will describe ways to provide effective bereavement support for families as well as support for staff. Our hospice team was able to provide what these patients and families needed in a compassionate way and in an appropriate setting. Review of the literature reveals little information on home extubation. We hope to provide information on positive experiences for patients, their families, and staff.

Correlations between hemodynamic, oxygenation and tissue perfusion parameters during asphyxial cardiac arrest and resuscitation in a pediatric animal model

Aim To analyze the correlations between hemodynamic, oxygenation and tissue perfusion values in an infant animal model of asphyctic cardiac arrest (ACA). Methods A prospective observational animal study was performed in seventy one, two month-old piglets. CA was induced by removal of mechanical ventilation and was followed by advanced life support after at least 10 min. Correlations between hemodynamic [heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), stroke volume index (SVI) and intrathoracic blood index (ITBI) measured by PiCCO method], blood gas values (arterial and central venous saturation), and tissue perfusion values [intramucosal gastric pH (pHi), and tissue oxygenation (cerebral and renal saturation)] were analyzed during asphyxia, resuscitation and after return of spontaneous circulation (ROSC). Results Among global hemodynamic parameters, the only moderate significant correlation observed was between CI and ITBI ( r = .551). Among tissue oxygenation/perfusion values, a moderate to good significant correlation ( r = .460–.763) between arterial oxygen saturation, central venous, renal and cerebral oxygen saturation was observed. Lactic acid, potassium (K) and pHi were correlated ( r = .561–.639), but no correlation was found between them and tissue oxygenation parameters. Global hemodynamic parameters (CI, HR, MAP) did not correlate with renal and cerebral saturations and tissue perfusion parameters. Conclusions During ACA and after ROSC global hemodynamic parameters do not correlate with oxygenation and tissue perfusion values. Additional studies which assess the potential usefulness of tissue oxygenation/perfusion parameters during cardiac arrest and ROSC are needed.

Hemodynamic, respiratory, and perfusion parameters during asphyxia, resuscitation, and post-resuscitation in a pediatric model of cardiac arrest

To analyze the evolution of hemodynamic, respiratory, and tissue perfusion parameters in an infant animal model of asphyxial cardiac arrest (CA). This was a secondary analysis of a prospective observational study conducted at a laboratory research department of a university hospital. Seventy-one, 2-month-old piglets were studied. CA was induced by removal of mechanical ventilation. Cardiopulmonary resuscitation (CPR) was performed by means of manual external chest compressions, mechanical ventilation, epinephrine and/or terlipressin intravenous administration. The evolution of hemodynamic (heart rate, blood pressure, cardiac index), respiratory (end-tidal CO(2), blood gas analysis), and tissue perfusion (intramucosal gastric pH, central, cerebral, and renal hemoglobin saturation) parameters was analyzed during three periods: asphyxia, CPR, and after return of spontaneous circulation (ROSC). During asphyxia, a severe arterial and tissue hypoxia with hypercapnia and lactic acidosis quickly developed. Bradycardia, hypotension, and increasing of systemic vascular resistances and pulmonary arterial pressure were also observed. During CPR, arterial, cerebral, and tissue oxygenation were low in spite of ventilation with oxygen 100%. After ROSC a rapid restoration of hemodynamic and respiratory parameters was observed. However, 30min after ROSC, lactic acidosis and low intramucosal gastric pH persisted. Asphyxia leads to sudden hypoxia and hypercapnia with tissue hypoxia and progressive bradycardia. Standard CPR is not able to maintain an adequate tissue oxygenation during CPR in this animal model. When ROSC is achieved, a rapid restoration of the normal values of general hemodynamic and respiratory parameters is observed, although lactic acidosis and splanchnic hypoperfusion persist in time.

Terlipressin versus adrenaline in an infant animal model of asphyxial cardiac arrest

The objective of this study was to compare the efficacy of terlipressin versus adrenaline in an experimental infant animal model of asphyxial cardiac arrest (ACA). Prospective randomised animal study. Laboratory research department of a university hospital. Seventy-one, 2-month-old, mechanically ventilated piglets were investigated. ACA was induced by removal of mechanical ventilation. Resuscitation was performed by means of manual external chest compressions and mechanical ventilation (CC + V). After 3 min of CC + V, return of spontaneous circulation (ROSC) was observed in 11 animals. The 60 piglets without ROSC were then randomised to the four study groups: adrenaline standard dose (Asd): 0.01 mg/kg/3 min; adrenaline high dose (Ahd): first dose (0.01 mg/kg) and subsequent doses (0.1 mg/kg/3 min); terlipressin (T): 20 microg/kg/6 min; and adrenaline standard dose plus terlipressin (Asd + T). The relationship between haemodynamic (heart rate, blood pressure, ECG rhythm, cardiac index), respiratory (end-tidal CO(2), blood gas analysis) and tissue perfusion (gastric intramucosal pH, central, cerebral and renal saturation) parameters and ROSC was analysed. ROSC was achieved in three piglets treated with Asd (20%), four treated with Ahd (26.7%), one treated with T (6.7%) and seven treated with Asd + T (46.7%) (P = 0.099). ROSC was achieved in 43.1% of animals with pulseless electrical activity, 30.4% with asystole and none with ventricular fibrillation (P = 0.0001). In this infant animal model of cardiac arrest, there was a non-significant trend towards better outcome when terlipressin was combined with adrenaline compared with the use of adrenaline or terlipressin alone.

Euthanasia and the Administration of Neuromuscular Blockers without Ventilation: Should Physicians Fear Prosecution?

A common dilemma among physicians who treat the dying is whether pharmacological paralysis should be reversed prior to removal of mechanical ventilation. But what if a physician were to administer a neuromuscular blocker without ever ventilating the patient in the first place? While there is evidence that euthanasia does occur in the United States, few physicians have been prosecuted. Could these infrequent prosecutions reflect a conscious desire by prosecutors not to pursue such matters? In an effort to explore this question, chief prosecutors in four U.S. states were presented with a vignette based on an actual event involving the administration of Succinylcholine to a dying patient. Response rates in this study were very acceptable (76.36% overall), and results indicated that not only was the likelihood of criminal prosecution low, almost half of the prosecutors believed that a physicianadministered lethal injection may be morally justified in some circumstances even though illegal.

Evaluation of the dead space to tidal volume ratio (Vd/Vt) as a predictor of successful removal of mechanical ventilation in critically ill children

Evaluation of the dead space to tidal volume ratio (Vd/Vt) as a predictor of successful removal of mechanical ventilation in critically ill children