Need For Mechanical Ventilation Research Articles

Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study.

Patients with paraquat poisoning (PP) have a mortality rate comparable to that of advanced malignancies, yet palliative care is seldom considered in these patients. This audit aimed to identify triggers for early palliative care referral in critically ill patients with PP. Medical records of patients with PP were audited. Predictors of mortality within 48 hours of hospitalization and 24 hours of intensive care unit (ICU) admission were considered as triggers for palliative care referral. Among 108 patients, 84 complete records were analyzed, and 53 out of 84 (63.1%) expired. Within 48 hours after hospitalization, the lowest oxygen partial pressure in arterial blood to a fraction of inspired oxygen [the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (PaO2/FiO2)] was the independent predictor of mortality, cut-off ≤ 197; the area under the curve (AUC), 0.924; sensitivity, 97%; specificity, 78%; p <0.001; and 95% confidence interval (CI): 0.878-0.978. Kaplan-Meier survival plot showed that the mean survival time of patients with the lowest PaO2/FiO2, ≤197, was 4.64 days vs 17.20 days with PaO2/FiO2 >197 (log-rank p < 0.001). Sequential organ failure assessment (SOFA) score within 24 hours of ICU admission had a cut-off ≥9; AUC, 0.980; p < 0.001; 95% CI: 0.955-1.000; 91% sensitivity; and 90% specificity for mortality prediction. Out of the total of 84 patients with PP analyzed, there were 11 patients admitted to the high dependency units (13.1%) and 73 patients admitted to the ICU (86.9%). Out of the total of 84 patients of PP in whom data was analyzed, 53 (63.1%) patients required ventilator support. All the 53 patients who required ventilator support due to worsening hypoxemia, eventually expired. The lowest PaO2/FiO2 ≤ 197 within 48 hours of hospitalization, SOFA score ≥9 within 24 hours of ICU admission or need for mechanical ventilation are predictors of mortality in PP patients, who might benefit from early palliative care. Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, et al. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024;28(5):453-460.

Factors associated with severe respiratory syncytial virus infection among hospitalized children in Thammasat University Hospital

Background Respiratory syncytial virus (RSV) is one of the most significant respiratory pathogens that causes acute lower respiratory tract infections (LRTI) early in life. Most children have a history of RSV infection within 24 months of age, and recurrent infections are common throughout life. Methods Children under five years of age were identified through a review of medical records with a diagnosis of RSV-LRTI between 2016 and 2020. Severe RSV-LRTI was defined as a prolonged length of stay (&gt; 7 days), admission to the intensive care unit, need for mechanical ventilation, non-invasive positive pressure ventilation, or in-hospital mortality. Factors associated with severe RSV-LRTI were investigated using univariate and multivariate analyses. Results During the study period, 620 patients were diagnosed with RSV-LRTI and 249 (40.16%) patients had severe RSV-LRTI. In the multivariable logistic regression analysis, the factors for severe RSV-LRTI were being under 3 months (aOR 2.18 CI 1.39-3.43, p0.001), cardiovascular disease (aOR 3.55 CI 1.56-8.06, p0.002), gastrointestinal disease (aOR 5.91 CI 1.90-18.46, p0.002), genetic disease (aOR 7.33 CI 1.43-37.54, p0.017), and pulmonary disease (aOR 9.50, CI 4.56-19.80, p&lt;0.001). Additionally, the presence of ≥ 2 co-morbidities (aOR 6.23 CI 2.81-14.81, p&lt;0.016), experiencing illness for more than 5 days (aOR 3.33 CI 2.19-5.06, p&lt;0.001), co-detection of influenza (aOR 8.62 CI 1.49-38.21, p0.015), and nosocomial RSV infection (aOR 9.13 CI 1.98-41.30, p0.012), markedly increased the risk of severe RSV-LTRI. The severe RSV-LRTI group demonstrated higher hospitalization expenses (median, US $720.77 vs $278.00, respectively; p&lt;0.001), and three infants died in-hospital. Conclusion Children at high risk for RSV-LRTI due to underlying genetic and gastrointestinal diseases are at an increased risk for severe RSV-LRTI. Further studies to determine the cost-effectiveness of RSV immunization in these potential co-morbidities should be initiated to prioritize RSV immunization, especially in resource-constrained regions with limited availability of nirsevimab.

THE CHALLENGING SCENARIO OF DYSPNEA IN THE ELDERLY: DUE MORE TO CONGESTION OR INFLAMMATION?

Abstract Introduction Elderly patients hospitalized due to acute heart failure often have a concomitant acute lung disease. Establishing the role of each disease in a clinical picture of acute cardiopulmonary syndrome can be challenging. A common thread of these diseases is inflammation; a hyperinflammatory response determines more serious symptoms and a worse prognosis. Purpose We evaluated the effectiveness of a treatment with dexamethasone in patients with acute cardiopulmonary syndrome and strong inflammatory response. Materials and Methods We evaluated 302 consecutive HFPEF (heart failure with preserved ejection fraction) patients ≥80 years of age, with concomitant symptoms attributable to acute bronchitis, pneumonia, or COPD exacerbation, hospitalized due to worsening dyspnoea, with an NT–proBNP ≥3,000 pg/ml, and a finding X–ray of lung congestion with or without a consolidation. Reactive C Protein (CRP) was measured. Patients with SARS–CoV–2, indication to corticosteroids for other clinical conditions or need for mechanical ventilation were excluded. The 112 patients with CRP&amp;gt;20 mg/dl were randomized into 2 groups: 56 patients were treated open–label with dexamethasone at a dose of 8 mg iv/day for a maximun of ten days, in addition to the usual therapies, while the same number of patients were treated with the usual therapy. In both groups antibiotics were administered based on procalcitonin guided protocl. Clinical recovery time, length of hospitalization, in–hospital mortality, need for a new hospitalization and mortality at one month were evaluated. Results The mean age of patients was 89±5 years in the dexamethasone group and 88±5 in the usual therapy group. The results are shown in Table 1. Patients treated with dexamethasone experienced a faster clinical recovery and a shorter length of hospitalization. No significant differences were found regarding either in–hospital mortality or need for rehospitalization and mortality at 30 days. Notably, PCT guided treatment led to an average reduction in duration of antibiotic therapy from 8 to 5 days. Conclusions Very elderly patients with acute cardiopulmonary syndrome and hyperinflammatory state have a favorable response to dexamethasone therapy added to the usual therapy in terms of clinical improvement and length of hospitalization. Our case history is small to evaluate a possible improvement in mortality. These findings need to be consolidated from double–blind randomized controlled trials.

The Role of Obesity in the Poor Prognosis of COVID-19 Infection: A Review of 192 Patients.

We performed a retrospective study on all patients having COVID-19 infection and admitted to our institution between March 2020 and June 2021. Inclusion criteria included any patient over the age of 18 admitted to our institution's COVID-19 unit, or intensive care unit, with a positive COVID-19 PCR or positive COVID-19 serology (IgM). 192 patients met the inclusion criteria, with an average age of 62.68 years and a slight male predominance (64.58%). 76.04% of hospitalized patients and 80% of those admitted to the ICU were either overweight or obese. No statistically significant difference was found regarding the risk of in-hospital mortality and invasive ventilation. The same applies to the length of stay, admission to intensive care, O2 needs, and for the various complications (all p values were >0.05). Patients with obesity type II and III have an increased risk of cardiac arrests and need for intubation and mechanical ventilation. Obesity tends to be a major risk factor for a pejorative evolution in the COVID-19 infection.

Pulmonary vein thrombosis: Clinical presentation and outcomes

BackgroundPulmonary vein thrombosis (PVT) is a rare thromboembolic disease with potential high-risk complications related to arterial embolization, but little is known regarding risk factors and outcomes. ObjectiveTo describe the etiology, management, and clinical course of PVT. MethodsInstitutional health records were queried (1/1/2001–12/30/2023) to identify patients ≥18 years of age diagnosed with PVT. Thrombosis, bleeding, respiratory failure, and all-cause mortality were analyzed. Suspected tumor thrombus cases were excluded. Results72 patients with PVT were identified (median age 62 years, 50 % female), and PVT was overall rare at 3.1 diagnosed cases per year at our institution. PVT primarily affected a single vein (89 %), most commonly the left upper PV (40 %). Of these, 37 % occurred while on therapeutic anticoagulation. The most common risk factors included cancer (55 %) and related surgical lobectomy (21 %). Extrinsic vein compression (17 %) and recent surgery (19 %) were also common; 19 % were deemed idiopathic. Most patients (76 %) were treated with anticoagulation and frequently indefinite duration (80 %). During a median follow-up of 11.7 months (IQR 39.5 months), serial imaging (available for 68 %) revealed PVT resolution in 64 %. Four-year Kaplan-Meier probability of outcome included: left atrial thrombus (21 %), need for mechanical ventilation (14 %), pneumonia (9 %), and ischemic stroke (9 %). The mortality rate was 46 % with median survival 14 months after PVT diagnosis. ConclusionPVT is often associated with active malignancy, lobectomy, recent surgery, and extrinsic vein compression; 1 in 5 cases were idiopathic. Notable complications include left atrial thrombus with arterial embolism including stroke. With anticoagulation, most thrombi resolve over time. Mortality rates are high, reflecting the high the prevalence of cancer.

Temporal and regional trends of case-fatality in patients hospitalized with acute respiratory distress syndrome in Germany

Abstract Funding Acknowledgements None. Aims Significant progress has been made in understanding the pathophysiology of acute respiratory distress syndrome (ARDS). However, ARDS it is still a life-threatening medical condition with a high mortality rate. Little is known about temporal trends and regional variations in Germany. Methods We analyzed data on the characteristics, comorbidities and in-hospital outcomes for all hospitalized patients with ARDS in Germany between 2005 and 2019. Diagnoses were coded according to the International Classification of Diseases and Related Health Problems, 10th Revision with German Modification (ICD-10-GM), and diagnostic, surgical or interventional procedures according to the German Procedure Classification (OPS, surgery and procedures codes. The computed study analyses were performed on our behalf by the Research Data Center of the Federal Statistical Office and the Statistical Offices of the federal states in Wiesbaden, Germany. Results Overall, 8,369,723 inpatients aged ≥18 years were included in this analysis; among these, 155,872 (1.9%) were codes with the diagnosis of ARDS. The annual number of ARDS cases increased from 7,286 in 2005 to 13,722 in 2019 in parallel with a significant decrease of in-hospital mortality. Overall, 74,751 (48.0%) patients with ARDS died during the in-hospital stay and in-hospital case-fatality grew exponentially with age. Independent predictors of in-hospital fatality with an OR &amp;gt;2 were age ≥70 years, necessity of ECMO, severe liver disease, acute renal failure, dialysis, shock and cardio-pulmonary resuscitation. Most patients with ARDS were treated in hospitals in urban areas (n=56,582) with a high case-fatality rate (49.7%), but also with concomitant high proportion rate of mechanical ventilation (23.7%) compared to hospitals in suburban or rural areas. Conclusion The number of patients with ARDS increased markedly in Germany between 2005 and 2019, in parallel with a decrease of in-hospital fatality. Our findings may suggest that general management of ARDS have improved over time and might draw more attention to predictors for in-hospital fatality in patients hospitalized with ARDS. The need for mechanical ventilation and a poor outcome was more likely in urban areas – this might be accentuated by patient transfer to specialized high care centers usually located in urban settings.

Influence of tricuspid regurgitation on the prognosis of patients with cardiogenic shock

Objective Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations. However, data regarding the prognostic impact in patients with cardiogenic shock (CS) is limited. The study investigates the prognostic impact of pre-existing TR in patients with CS. Methods Consecutive patients with CS from 2019 to 2021 were included in a monocentric registry. Every patient's medical history, including echocardiographic data, was recorded. The influence of pre-existing TR on prognosis was investigated. Furthermore, Kaplan-Meier analyses based on TR severity were conducted. Statistical analyses comprised univariable t-test, Spearman´s correlation, Kaplan-Meier analyses, as well as multivariable Cox proportional regression models. Analyses were stratified by the underlying cause of CS such as acute myocardial infarction (AMI), or the need for mechanical ventilation. Results 105 patients with CS and pre-existing TR were included. In Kaplan Meier analyses, it could be demonstrated that patients with severe TR (TR III°) had the highest 30-day all-cause mortality compared to mild (TR I°) and moderate TR (TR II°) (44% vs. 52% vs. 77%; log rank p = 0.054). In the subgroup analyses of CS-patients without AMI, TR II°/TR III° showed a higher all-cause mortality after 30 days compared to TR I° (39% vs. 64%; log rank p = 0.027). In multivariable Cox regression TR II°/TR III° was associated with 30-day all-cause mortality in CS-patients without AMI (HR = 2.193; 95% CI 1.007–4.774; p = 0.048). No significant difference could be found in the AMI group. Furthermore, TR II°/III° was linked to an increased 30-day all-cause mortality in non-ventilated CS-patients (6% vs. 50%, log rank p = 0.005), which, however, could not be confirmed in multivariable Cox regression. Conclusion The occurrence of pre-existing TR II°/III° was independently related with 30-day all-cause mortality in CS-patients without AMI. However, no prognostic influence was observed in CS-patients with AMI.

The role of cardiac rehabilitation in patients following acute coronary syndrome

Abstract Funding Acknowledgements None. Introduction The benefits of cardiac rehabilitation in patients with acute coronary syndrome (ACS) are well established. Although there are limited centres with cardiac rehabilitation and patients, especially from peripheral hospitals, wait a long time to enter the programme and many of them don’t even enter these programmes. Purpose Characterize the patient population that go to cardiac rehabilitation and evaluate short- and long-term outcomes. Methods Multicenter retrospective study, patients with the diagnosis of ACS and data collected from 1/01/2015 to 31/12/2021. Patients were divided into 2 groups (G). G1 – Patients with cardiac rehabilitation programmed and/or planned; G2 – Patients not referenced for cardiac rehabilitation. We further analyse patients according to MACE events, group A without MACE; group B with MACE. Results 11992 patients were enrolled, only 3162 (26.4%) patients were referenced for cardiac rehabilitation. G1 was younger 63.5 ± 12.4 (p&amp;lt;0.001), had more males 76.7% (p&amp;lt;0.001) and more smokers 38.0% vs 25.3% (p&amp;lt;0.001), but less patients with arterial hypertension (AH) 65.1% vs 70.9% (p&amp;lt;0.001), diabetes mellitus (DM) 29.5% vs 32.8% (p&amp;lt;0.001), dyslipidemia 57.0% vs 61.2% (p&amp;lt;0.001), previous heart failure 4.8% vs 7.9% (p&amp;lt;0.001) and chronic kidney disease (CKD) 3.8% vs 7.3% (p&amp;lt;0.001). G1 had although more patients with symptoms of angina 29.2% vs 23.3% (p&amp;lt;0.001) and previous MI 20.5% vs 17.6% (p&amp;lt;0.001). Regarding MACE events G1 had better outcomes 1.3% vs 6.1% (p&amp;lt;0.001). Considering MACE events, group B was older 74±12 years (p&amp;lt;0.001), male gender was predominant (62.5%) and had more patients with AH 76.9% vs 68.8% (p&amp;lt;0.001), DM 45.1% vs 31.1% (p&amp;lt;0.001), CKD 14.6% vs 5.6% (p&amp;lt;0.001) and pacemaker (PM) or ICD devices 3.8% vs 1.7% (p&amp;lt;0.001). Independent predictors of MACE achieved through logistic regression analysis are gender p&amp;lt;0.001, OR 0.325, CI (95%) 0.158-0.672; CKD p= 0.042, OR 4.027, CI 1.019-15.911; time from symptoms to 1st contact ≥ 120min p=0.032, OR 2.088, CI 1.067-4.087; usage of inotropic medications p&amp;lt;0.001, OR 6.383, CI 2.995-13.602; left ventricular ejection fraction &amp;lt;30% vs ≥30% p=0.002, OR 4.172, CI 1.722-10.108; need of invasive mechanical ventilation p&amp;lt;0.001, OR 6.593, CI 2.812-15.457 and need of temporary PM p&amp;lt;0.001, OR 12.372, CI 4.025-38.031. Conclusion In these study population, patients with less cardiovascular (CV) risk factors and comorbidities were more often assigned to cardiac rehabilitation programmes. Not unpredictable patients with more comorbidities suffered more from MACE events. Survival analysis also showed that CV mortality and re-admission at 1 year were higher in patients not assigned for cardiac rehabilitation.

Perfusion index: could it be a new tool for early identification of pulmonary embolism severity?

Perfusion index (PI) is a promising indicator for monitoring peripheral perfusion. The present study aimed to compare the efficiency of PI and PESI score in estimating the 30-day mortality and treatment needs of patients diagnosed with pulmonary embolism in the emergency department. This study was prospective and observational. The demographic features of the patients, comorbidities, vital signs, PESI score, PI, treatment applied to the patient and airway management, right ventricular diameter/left ventricular diameter ratio, length of hospital stay, outcome, and 30-day mortality were recorded. A total of 94 patients were included. All patients' vital signs and PI values were recorded on admission. The mean pulse rate (p = 0.001) and shock index (p = 0.017) values of deceased patients were statistically significantly higher, while the mean PI (p = 0.034) was statistically significantly lower. PESI score and PI were statistically significant to predict the need for mechanical ventilation (PI, p = 0.004; PESI score, p < 0.001), inotropic treatment (PI, p = 0.047; PESI score p = 0.005), and thrombolytic therapy (PI, p = 0.035; PESI score p = 0.003). According to the ROC curve, the mortality prediction power of both PESI (AUC: 0.787, 95% CI 0.688-0.886, cutoff: 109.5, p < 0.001) and PI index (AUC: 0.668, 95% CI 0.543-0.793, cutoff: 1, p = 0.011) were determined as statistically significant. PI might be helpful in clinical practice as a tool that can be applied to predict mortality and treatment needs in PE.

The impact of different corticosteroids in hospitalised patients with severe COVID-19 pneumonia: a retrospective observational study

Background: The COVID-19 pandemic created havoc on health care systems and economies worldwide. Corticosteroids have been shown to be effective in the management of COVID-19. Methods: A retrospective observational study was conducted on 311 patients meeting the inclusion criteria at the Augustus Long Hospital, Trinidad and Tobago between July-December 2021. Data was classified into three treatment groups: low dose dexamethasone, high dose dexamethasone and methylprednisolone pulse therapy. The primary outcomes were the 28-day mortality and need for invasive mechanical ventilation and the secondary outcome was the length of hospital stay. The patient cohort was also classified into simple oxygen and high flow oxygen groups and a subgroup analysis was also performed. Results: There were no significant statistical differences between age, gender, vaccination status and co-morbidities between the treatment groups. However, there were significant differences in the ethnic ratios amongst the high dose dexamethasone and methylprednisolone treatment groups (East Indians to Africans; 61.7%vs. 37%; 72.9% vs.25.4% respectively; p=0.02). In patients receiving simple oxygen on admission, those who were treated with low dose dexamethasone when compared to high dose dexamethasone and methylprednisolone, had the lowest 28-day mortality (15.3% vs. 40.9% vs. 40% respectively; p&lt; 0.001), lowest need for IMV (0.7% vs. 9.1% vs. 40% respectively; p&lt; 0.001) and the shortest length of hospital stay (median [IQR] days; 7[12-5], 11[22-7], 16[27-14] respectively; p&lt; 0.001). In patients receiving high flow oxygen, those treated with methylprednisolone had the lowest 28-day mortality (45.8%), when compared to the high dose dexamethasone (59.5%) and low dose dexamethasone (81%) groups; however, these results were not statistically significant (p = 0.053). Conclusion: In our study, patients receiving simple oxygen had better clinical outcomes when treated with low dose dexamethasone compared to higher dose corticosteroids. Methylprednisolone pulse therapy may be beneficial in patients requiring high flow oxygen; but further studies are needed.

Evaluation of Clinical and Laboratory Features of Rhinovirus Infections in Children

Abstract Objective Our aim in this study was to evaluate the clinical characteristics of patients afflicted with rhinovirus (RV) infections, compare their laboratory findings with a healthy population, determine the features of the clinical course of the illness in individuals with a chronic disease, and set out the risk factors involved in the need for mechanical ventilation (MV). Methods The study was conducted on 318 pediatric patients aged 0 to 18 years diagnosed with RV infection. Patients were divided into two main groups, those with and without a chronic disease. The group with chronic disease was divided into four subgroups. Children with RV were compared with a control group of 231 healthy children. Results The most common symptoms and signs were wheeze (65.4%), cough (65.1%), and tachypnea (50.3%). Compared with the healthy population, RV-positive patients showed significant increases in their white blood cell (WBC), neutrophil, and platelet counts, and in their delta neutrophil index and C-reactive protein values (all p &lt; 0.001). The most important risk factors in terms of the need for MV were elevated WBC (odds ratio [OR] = 1.404, 95% confidence interval [CI]: 1.059–1.862), chronic lung disease (CLD) (OR = 5.196, 95% CI: 2.296–11.762), reticular involvement (OR = 3.132, 95% CI: 1.259–7.793), and lobar involvement (OR = 10.575, 95% CI: 13.434–32.564). Conclusion It is of vital importance that individuals with asthma and CLD are closely monitored and protected during RV seasonal periods as they are most at risk of severe infection, which can require high-flow nasal cannula and MV.

Non-invasive high-frequency ventilation in newborn infants with respiratory distress.

Non-invasive high-frequency ventilation in newborn infants with respiratory distress.

Impact of breastfeeding on ICU admissions and need for mechanical ventilation in infants younger than 6 months with RSV+ bronchiolitis. An observational study.

This work aimed to analyze whether breastfeeding is a predictive factor for admission to ICU or needing mechanical ventilation in children under 6 months with RSV+ respiratory infection. A retrospective cohort study was performed in three hospitals. Binary and multiple logistic regression analyses were performed to evaluate the association of variables with admission to the ICU or receiving mechanical ventilation. We analyzed 414 admissions, of which 293 (70.8%) had received breastfeeding, 43 (8.1%) were admitted to the ICU, and 26 (5.4%) required mechanical ventilation. Bivariate analysis showed that breastfeeding for at least 15 days and a longer duration of breastfeeding were associated with a lower risk of admission to the ICU and requiring mechanical ventilation. Multivariate analysis showed that not having been breastfed for at least 1 month was predictive of ICU admission; not having been breastfed for at least 2 months was predictive of needing mechanical ventilation. Breastfeeding for as little as 15-28 days could be associated with a lower risk of ICU admission and requiring mechanical ventilation in infants younger than 6 months admitted for RSV+ bronchiolitis. Since breastfeeding is one of the few protective factors that can be promoted, this finding is relevant for current clinical practice and the development of health promotion programs. Future studies can compare their results to ours.

Critical Care in Guillain–Barré Syndrome

AbstractGuillain–Barré syndrome (GBS) is an autoimmune polyneuropathy characterized by hyporeflexic neuromuscular paralysis and albuminocytologic dissociation in the cerebrospinal fluid. It is a postinfectious disorder. The most common antecedent illnesses are respiratory tract infection and Campylobacter jejuni infection. After the antecedent infection, specific antibodies are generated that cross-react with gangliosides in the host culminating in demyelination of the peripheral nerves or nerve roots. Complement activation also contributes to nerve degeneration. Bilateral symmetrical progression of the limb weakness occurs over a period of a few days followed by a plateau phase, after which a recovery phase follows. Generalized hypotonia and hyporeflexia characterize the limb weakness. Cerebrospinal fluid analysis shows albuminocytologic dissociation. About one-third of patients develop respiratory failure. Neuropathic pain is a disturbing symptom in GBS. Dysautonomia is very characteristic of GBS. Erasmus GBS respiratory insufficiency score predicts the need for mechanical ventilation. The weaning process from mechanical ventilation mainly depends on the recovery of vital capacity and inspiratory force. The definitive treatment for GBS consists of plasma exchange or intravenous immunoglobulin therapy both of which are equally efficacious. Seasonal variation has been observed in the occurrence and recovery of GBS. Prognosis of GBS varies widely. Erasmus GBS outcome scale scoring system predicts the ability of the patient to walk independently after 6 months. Several GBS cases have been reported globally during recent pandemic of coronavirus disease 2019. Though GBS is a self-limiting disease, there are quite a few research questions that still remain to be answered.

F-37 | In patients with acute cardiogenic pulmonary edema without cardiogenic shock, rapid administration of repeated buccal nitroglycerin ointment prevents the need for intubation and mechanical ventilation

F-37 | In patients with acute cardiogenic pulmonary edema without cardiogenic shock, rapid administration of repeated buccal nitroglycerin ointment prevents the need for intubation and mechanical ventilation

Study of acute kidney injury in children with nephrotic syndrome in a rural tertiary care hospital

Background: Acute kidney injury (AKI) is a common comorbidity in critically ill children and is associated with an increased risk of morbidity and mortality in children with nephrotic syndrome. The etiology of AKI in nephrotic syndrome is complex and multifactorial. Aims and Objectives: To determine the proportion, risk factors, and outcomes of patients with AKI in children hospitalized with nephrotic syndrome. Materials and Methods: This cross-sectional study was done on children between 1 month and 14 years of age attending the pediatric department for 1 year from October 2020 to June 15, 2022. Detailed history, physical examination, and investigations were done in children with nephrotic syndrome as per pro forma. Information was collected on demographic variables, vital signs, anthropometry, diagnosis, comorbidities, therapies, presence of hypovolemia, sepsis or shock, use of diuretics or nephrotoxic medications, need for oxygen, mechanical ventilation, vasopressors or renal replacement therapy, length of hospital stay, and outcome at discharge. For those children having AKI, clinical outcomes were measured in terms of duration of hospital stay, recovery of S.creatinine, and urine output. Results: A total of 64 patients with nephrotic syndrome were enrolled in this study. Fifteen patients had AKI (23.4%) among children with nephrotic syndrome. The most common etiology being sepsis accounting for 4 out of 15 (26.7%) of total cases followed by acute respiratory distress syndrome (13.3%), nephrotoxic medications (13.3%), renal parenchymal disease (13.3%), Post-streptococcal glomerulonephritis (13.3% each) and Sickle cell disease with nephritis and acute fulminant hepatitis (6.7%). There was significantly more mortality among subjects with stage 2 (14.3%) and 3 (14.3%) kidney disease. Conclusion: AKI is common in our children with nephrotic syndrome and the main risk factors of AKI include sepsis, gross hematuria, urinary tract infections, peritonitis, and exposure to potentially nephrotoxic medications. There is a need to identify the patients with nephrotic syndrome at risk of AKI and apply strategies to prevent AKI in focused at-risk groups.

Factors Associated with Adverse Outcomes among SARS-CoV-2 Positive Children in a Tertiary Government COVID-19 Referral Hospital in the Philippines

Background and Objective. Pediatric COVID-19 epidemiology and factors associated with adverse outcomes –mortality, need for invasive mechanical ventilation, and ICU admission, are largely unstudied. We described the clinicodemographic characteristics of Filipino pediatric COVID-19 patients and determined the factors associated with adverse outcomes. Methods. This is a retrospective cohort study of 180 hospitalized SARS-CoV-2-confirmed cases 0-18 years oldfrom April 2020 to August 2021 in a tertiary COVID-19 referral hospital in Manila, National Capital Region. Crudeassociations were determined using chi-squared or Fisher’s exact tests; and medians were compared using the Mann-Whitney test. Factors predictive of mortality were determined using Cox proportional hazards regression analysis. The survivor functions were depicted in graphs. Results. About 41.67% had mild disease, 58.33% were males, 39.4% aged 0-4 years, and 69.44% had at least onecomorbidity. About 9.44% died (adjusted 9.2 persons per 1000 patient-days, 95% CI 5.5%-15.2%), 17.78% needed invasive mechanical ventilation, and 20% needed ICU admission. Independently, severe-critical COVID-19 (HRc 11.51, 95% CI 3.23, 41.06), retractions (HRc 10.30, 95% CI 3.27, 32.47), alar flaring (HRc 4.39, 95% CI 1.53, 12.58), cyanosis (HRc 4.39, 95% CI 1.72, 14.11), difficulty of breathing (HRc 7.99, 95% CI 2.25, 28.71), poor suck/appetite (HRc 4.46, 95% CI 1.59, 12.40), ferritin (HRc 1.01, 95% CI 1.00, 1.01), IL-6 (HRc 1.01, 95% CI 1.00, 1.01), aPTT (HRc 1.05, 95% CI 1.01, 1.10), IVIg (HRc 4.00, 95% CI 1.07, 14.92) and corticosteroid (HRc 6.01, 95% CI 2.04, 17.67) were significant hazards for mortality. In adjusted Cox analysis, only retractions (HRa 34.96, 95% CI 3.36, 363.79), seizure (HRa 9.98, 95% CI 1.76, 56.55), and corticosteroids (HRa 8.21, 95% CI 1.12, 60.38) weresignificantly associated with mortality while alar flaring appeared to be protective (HRa 0.10, 95% CI 0.01,0.95). Several clinical characteristics were consistently associated with adverse outcomes. Conclusions. Majority of hospitalized pediatric COVID-19 patients were very young, males, had milddisease, and had at least one comorbidity. Mortality, invasive mechanical ventilation, and ICU admission wererelatively low. Except for alar flaring which appeared to be protective, retractions, seizure, and use ofcorticosteroids were associated with adverse outcomes.

Impact of interhospital transfer status on outcomes of variceal and nonvariceal upper gastrointestinal bleeding: insights from the National Inpatient Sample analysis, 2017 to 2020

Background Variceal and nonvariceal upper gastrointestinal bleeding (VUGIB and NVUGIB, respectively) require prompt intervention. Existing studies offer limited insight into the impact of interhospital transfers on patients with VUGIB and NVUGIB. Methods We conducted a retrospective study using the US National Inpatient Sample database from 2017 to 2020. The outcomes included in-hospital mortality, incidence of complications, procedural performance, and resource utilization. Results A total of 28,275 VUGIB and 781,370 NVUGIB adult patients were included. Transferred VUGIB and NVUGIB patients, when compared to nontransferred ones, demonstrated higher inpatient mortality (adjusted odds ratio [AOR] 1.49 and 1.86, P < 0.05). Patients with VUGIB and NVUGIB had a higher likelihood of acute kidney injury requiring dialysis (AOR 3.79 and 1.76, respectively, P = 0.01), vasopressor requirement (AOR 2.13 and 2.37, respectively, P < 0.01), need for mechanical ventilation (AOR 1.73 and 2.02, respectively, P < 0.01), and intensive care unit admission (AOR 1.76 and 2.01, respectively, P < 0.01). Compared to their nontransferred counterparts, transferred VUGIB patients had a higher rate of undergoing transjugular intrahepatic portosystemic shunt (AOR 3.26, 95% CI 1.92–5.54, P < 0.01), while transferred NVUGIB patients had a higher rate of interventional radiology-guided embolization (AOR 2.01, 95% CI 1.73–2.34, P < 0.01) and endoscopic hemostasis (AOR 1.10, 95% CI 1.05–1.15, P < 0.01). Conclusion Interhospital transfer is associated with worse clinical outcomes and higher resource utilization for VUGIB and NVUGIB patients.

Lactate level is an independent predictor of mortality in patients with hematologic malignancy receiving urgent chemotherapy in intensive care unit

BackgroundIntensive care unit (ICU) survival of cancer patients has improved. Urgent chemotherapy has become feasible in critically ill patients with specific organ dysfunction due to hematological malignancies. ObjectiveThe aim of the study was to assess ICU mortality rates and the factors associated with mortality in patients with hematologic malignancies receiving urgent chemotherapy in the ICU. MethodsWe retrospectively included all patients admitted to the ICU who received chemotherapy due to hematologic malignancy in 2012–2022. ResultsOf the 129 patients undergoing chemotherapy in the ICU, 50 (38.7 %) died during the ICU follow-up. The following conditions were significantly more common among nonsurvivors: presence of infection at the time of ICU admission (p < 0.001), the requirement for mechanical ventilation during ICU stay (p < 0.001), the need for noninvasive mechanical ventilation during ICU stay (p = 0.014), vasopressor support (p < 0.001), and sepsis (p < 0.001). Logistic regression analysis revealed that among laboratory parameters on ICU admission, lactate (p = 0.008), albumin (p = 0.022), C-reactive protein (p = 0.046), baseline sequential organ failure assessment (SOFA) score (p < 0.001), newly developed heart failure (p = 0.006), and the requirement for vasopressor agents during ICU stay (p < 0.001) significantly influenced the risk of mortality in the univariate analysis. The multivariate analysis revealed lactate levels (p = 0.047) on ICU admission as an independent predictor of mortality. ConclusionThe development of heart failure and lactate levels on admission were the main predictors of mortality. Additionally, higher SOFA scores revealed that illness severity was closely associated with mortality. Future studies should focus on strategies to further reduce these risks and achieve the best outcomes for these patients.

Comparison between high-flow nasal oxygen (HFNO) alternated with non-invasive ventilation (NIV) and HFNO and NIV alone in patients with COVID-19: a retrospective cohort study

BackgroundNon-invasive respiratory support (conventional oxygen therapy [COT], non-invasive ventilation [NIV], high-flow nasal oxygen [HFNO], and NIV alternated with HFNO [NIV + HFNO] may reduce the need for invasive mechanical ventilation (IMV) in patients with COVID-19. The outcome of patients treated non-invasively depends on clinical severity at admission. We assessed the need for IMV according to NIV, HFNO, and NIV + HFNO in patients with COVID-19 according to disease severity and evaluated in-hospital survival rates and hospital and intensive care unit (ICU) lengths of stay.MethodsThis cohort study was conducted using data collected between March 2020 and July 2021. Patients ≥ 18 years admitted to the ICU with a diagnosis of COVID-19 were included. Patients hospitalized for < 3 days, receiving therapy (COT, NIV, HFNO, or NIV + HFNO) for < 48 h, pregnant, and with no primary outcome data were excluded. The COT group was used as reference for multivariate Cox regression model adjustment.ResultsOf 1371 patients screened, 958 were eligible: 692 (72.2%) on COT, 92 (9.6%) on NIV, 31 (3.2%) on HFNO, and 143 (14.9%) on NIV + HFNO. The results for the patients in each group were as follows: median age (interquartile range): NIV (64 [49–79] years), HFNO (62 [55–70] years), NIV + HFNO (62 [48–72] years) (p = 0.615); heart failure: NIV (54.5%), HFNO (36.3%), NIV + HFNO (9%) (p = 0.003); diabetes mellitus: HFNO (17.6%), NIV + HFNO (44.7%) (p = 0.048). > 50% lung damage on chest computed tomography (CT): NIV (13.3%), HFNO (15%), NIV + HFNO (71.6%) (p = 0.038); SpO2/FiO2: NIV (271 [118–365] mmHg), HFNO (317 [254–420] mmHg), NIV + HFNO (229 [102–317] mmHg) (p = 0.001); rate of IMV: NIV (26.1%, p = 0.002), HFNO (22.6%, p = 0.023), NIV + HFNO (46.8%); survival rate: HFNO (83.9%), NIV + HFNO (63.6%) (p = 0.027); ICU length of stay: NIV (8.5 [5–14] days), NIV + HFNO (15 [10–25] days (p < 0.001); hospital length of stay: NIV (13 [10–21] days), NIV + HFNO (20 [15–30] days) (p < 0.001). After adjusting for comorbidities, chest CT score and SpO2/FiO2, the risk of IMV in patients on NIV + HFNO remained high (hazard ratio, 1.88; 95% confidence interval, 1.17–3.04).ConclusionsIn patients with COVID-19, NIV alternating with HFNO was associated with a higher rate of IMV independent of the presence of comorbidities, chest CT score and SpO2/FiO2.Trial registration ClinicalTrials.gov identifier: NCT05579080.