Need For Ventilatory Support Research Articles

Acute myocardial infarction in older adult patients

OBJECTIVES: To assess clinical and coronary angiographic characteristics, previous medical history, and clinical course, by age group, in older adults after myocardial infarction who underwent primary percutaneous coronary intervention (pPCI). METHODS: Single-center, cohort study that enrolled all patients with ST-segment elevation myocardial infarction who underwent pPCI at a specialized cardiology reference center in the South of Brazil. Older adults were defined as age ≥ 60 years, as set out in Brazilian legislation. Patients in the following age groups were compared: 60 to 64 years, 65 to 69 years, 70 to 74 years, 75 to 79 years, and ≥ 80 years. Patients’ clinical course was assessed at initial hospital admissions and after 2 years of clinical follow-up. Data were analyzed using SPSS 19, and significance was established at p < 0.05. RESULTS: From December 2015 to December 2018, a total of 636 patients were enrolled consecutively. Angiographic success rates were around 90% in all age groups. There were no differences in medications used, except for glycoprotein IIb/IIIa inhibitors, which were more frequently used in patients of lower age groups. Older patients had more in-hospital acute renal failure and higher in-hospital mortality. Predictors of mortality were age over 75, chronic renal failure, need for ventilatory support, severe arrhythmia, and sepsis. CONCLUSIONS: pPCI in older adult patients is a safe procedure with a high success rate.

Predictive Factors for Severe Disease in Patients Hospitalised with COVID-19 in London, England: A Retrospective Cohort Study

Background: In April 2020, deaths directly attributable to COVID-19 in the United Kingdom (UK) exceeded 40,000. Although a number of studies have examined the association between demographic and morbidity variables and outcomes of COVID-19, few have evaluated the additional predictive value of admission blood results and clinical observations. Methods: Adults admitted to Northwick Park Hospital (London, UK) between 12th March and 15th April 2020 with laboratory-confirmed COVID-19 were retrospectively identified. Demographic descriptors, comorbidities, blood tests and clinical observations were collected. The primary outcome was death. Secondary outcomes were the need for ventilatory support. Time-dependent associations were explored using Cox proportional hazards modelling. Censoring was performed on 13th May 2020, ensuring a minimum of 28 days follow-up. Findings: The study cohort consisted of 981 patients. During the study period, 354 (36.0%) patients died. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), higher respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Score Interpretation: Mortality rates from COVID-19 are high among hospitalised patients. This study identifies a number of characteristics associated with a higher risk of mortality. These important data will aid clinical risk stratification and provide direction for further research. Funding: This project did not receive funding. ​Declaration of Interests: The authors declare no competing interests.Ethics Approval Statement: This study had National Research Ethics approval (REC 20/NW/0218, IRAS 282630).

Exacerbaciones agudas en pacientes con fibrosis pulmonar idiopática

Classically we understand as an exacerbation of Idiopathic Pulmonary Fibrosis (IPF) to a clinically significant respiratory deterioration, without obvious cause. At present, the concept of “acute triggered exacerbations” is preferred to refer to those that are generated in the context of infection, aspiration, drug toxicity, pulmonary thromboembolism, heart failure or after invasive procedures. While the term “idiopathic acute exacerbations” is reserved for those in which we do not find a trigger. The prognosis is ominous and the mortality is high, with figures that fluctuate between 50 to 90% depending on the need for ventilatory support. Many times an acute exacerbation can be the final event of a patient with IPF. The treatment is not entirely clear, there is no robust evidence of the benefit of therapies, historically corticosteroids have been used as standard therapy, however current evidence questions the benefits of such a treatment.

Lung ultrasound for early diagnosis of postoperative need for ventilatory support: a prospective observational study.

Pulmonary complications have a significant impact on morbidity and mortality in patients after major surgery. Lung ultrasound can be used at the bed-side, and has gained widespread acceptance in the intensive care unit. We conducted a prospective study to evaluate whether lung ultrasound could be used as a predictive marker for postoperative ventilatory support in high-risk surgical patients. We included 109 patients admitted to the intensive care unit while having mechanical ventilation of the lungs following major surgery. The PaO2 /FI O2 ratio was calculated on admission and an ultrasound examination performed, including: lung ('lung ultrasound score', number of consolidated lung areas); cardiac (mitral flow); and inferior vena cava imaging (diameter and respiratory variation). Respiratory outcomes included: the need for ventilation support (mechanical ventilation, non-invasive ventilation or high-flow nasal cannula oxygen therapy); acute respiratory distress syndrome; cardiogenic pulmonary oedema; and early or late pulmonary infection. Patients with a lung ultrasound score ≥ 10 had a lower PaO2 /FI O2 ratio, and needed more postoperative ventilatory support, than patients with lung ultrasound score < 10. Twenty patients had acute respiratory distress syndrome, and 14 had cardiogenic pulmonary oedema. The presence of ≥ 2 areas of consolidated lung was associated with a lower PaO2 /FI O2 ratio, postoperative ventilatory support, longer intensive care stay and episodes of ventilator-associated pneumonia requiring antibiotics. Our results suggest that at intensive care unit admission, lung ultrasound scoring and detection of atelectasis can predict postoperative pulmonary outcomes after major visceral surgery, and could enhance bed-side decision making.

Early post-operative vasoplegia in lung transplantation

Introduction Lung transplantation (LTx) is the main treatment for end-stage respiratory failure. The post-operative development of pulmonary and systemic inflammation represents a severe limitation leading to Primary Graft Dysfunction (PGD) and multi-organ failure with great impact on survival and clinical outcomes. We hypothesise that LTx is associated with a high incidence of vasoplegia and that this is associated with a profound inflammatory response and high mortality and organ dysfunction. To test our hypotheses, we have identified patients who developed vasoplegia in the first 48 hours after LTx, described the impact of the vasoplegia on the clinical impact and explored the role of neutrophil degranulation products, such as Myeloperoxidase (MPO) and Heparin Binding Protein (HBP). Methods We recruited 40 patients who underwent LTx in 2013-15 at Harefield Hospital. Clinical data were recorded. Vasoplegia was defined according to Tsiouris et al (1). PGD was diagnosed and scored according to ISHLT criteria 2005, Acute Kidney Injury (AKI) to KDIGO criteria. Blood samples were collected before surgery and at different time-points after the arrival in ITU and analysed for MPO and HBP levels (Axis-Shield Heparin Binding Protein EIA, Abcam MPO ELISA kit). Data were analysed and reported as appropriate. Results 13 patients developed post-operative vasoplegia (32%). Within this group, 6 patients also developed PGD 3 (46%, p 0.284) and 9 AKI (69%, p 0.312), 7 requiring haemofiltration (54%, p 0.032). Vasoplegic patients showed lower P/F ratios on day 1 (23.1 [17.3, 35.7] vs. 31.4 [24.4, 41.4], p 0.151), day 2 936.0 [29.0, 44.6] vs. 46.7 [41.4, 50.5], p 0.011), and day 3 939.6 [29.7, 46.9] vs. 48.3 [43.4, 53.2], p 0.004). They also had longer ventilation duration (159 [59, 971] hours vs. 29 [15, 114] hours, p 0.012) and longer ITU stay (22 [5, 43] days vs. 5 [3, 9] days, p 0.029). Overall survival was not significantly affected by vasoplegia (log rank 1.005 p 0.316). Vasoplegic patients exhibit a tendency for higher levels of MPO early after surgery (232 [140, 406] ng/ml vs. 170 [110, 336] ng/ml before surgery (p 0.247), 566 [84, 1246] ng/ml vs. 312 [121, 658] ng/ml at the arrival in ITU (p 0.504), 441 [231, 753] ng/ml vs. 300 [142, 518] ng/ml at 6 hours (p 0.353), 160 [52, 447] ng/ml vs. 139 [112, 744] ng/ml at 12 hours (p 0.200)), but similar levels of HBP. Discussion These results identify high incidence of vasoplegia in the LTx population. One third of our patients developed vasoplegia in the early post-operative period with significant impact on the early post-operative function in terms of gas exchange and need for ventilatory support and level 3 care. Moreover, the data may suggest potential involvement of neutrophil-derived myeloperoxidase and, therefore oxidative stress, in the early postoperative period events.

The relation between positive screening results and MRSA infections in burn patients

IntroductionMethicillin-resistant Staphylococcus aureus (MRSA) is a key pathogen in burn patients. Several factors put them at increased risk of MRSA infection: partial loss of the skin barrier, the immune-compromising effects of burns, prolonged hospital stays, and invasive procedures. This study aims to find the relation between MRSA screening swab cultures taken within 48 h of admission, weekly surveillance cultures, and MRSA infection secondary to colonization. MethodsThe data of all burns patients admitted to the referral centre for burns from 2012 to 2016 were reviewed. MRSA cultures taken at admission and on weekly surveillance screening, including nasal, perianal, and wound swabs, were reviewed. To determine associations between MRSA colonization and infection rates, both MRSA-positive and MRSA-negative swab cultures were included in the analysis. Several risk factors were considered: age, gender, ethnicity, %TBSA, BAUX index, inhalational injury, ICU admission and days, need for ventilator support and days, length of stay (LOS) in hospital, and complications. Univariate and multiple logistic regression analyses were used to predict correlations between positive swab cultures and risk factors. ResultsData from 396 patients were reviewed. The median age at admission for the burn patients was 46 (IQR: 31–59) years. On admission, 2.5% of patients were MRSA positive, whereas 17.9% were found to be MRSA positive on weekly surveillance screening. At surveillance, 60.6% developed an infection secondary to MRSA colonization. An MRSA infection was not identified for any patient who did not have at least one positive admission or surveillance swab. A statistically significant association was found between any positive swab and MRSA infection (P < 0.001).The median number of complications reported in the MRSA-positive group was 2 (IQR: 1–3) versus 0 (IQR: 0–1) in the MRSA-negative group and the median length of hospital stay in the MRSA-positive group was 34.5 (IQR: 20.25–56.25) days versus 7 (IQR: 3–16) days in the MRSA-negative group (P < 0.001). ConclusionNosocomial MRSA colonization rates are high, and patients incurring infections experience a greater than average LOS in hospital and complications. Over 60% of patients who had a positive swab culture at surveillance developed an infection, whereas, no patient with a negative MRSA swab status developed an infection. Hence, pragmatic prevention strategies have to be implemented.

Feasibility of predicting improvements in motor function following SCI using the SCAR outcome measure: a retrospective study.

A retrospective study. To assess improvement in volitional motor function after SCI, using The Spinal Cord Ability Ruler (SCAR) as a metric and investigate participant characteristics and recovery of motor functioning. A highly-specialized SCI rehabilitation unit (Spinal Cord Injury Centre of Western Denmark, SCIWDK). Retrospectively, data on all SCI patients admitted to SCIWDK between 1 January 1997 and 1 November 2018 were extracted from a database. The SCAR score (range: 0-100) was calculated by combining items from ISNCSCI and SCIM. Mean (95%CI) improvement in volitional motor function was of 17.2 (CI: 14.5-19.9) equal to an improvement of 43% from baseline after median 155 days in-hospital rehabilitation. Individuals with tetraplegia exerted larger improvement (mean difference of 8.9 (CI: 3.6-14.2) points) as compared to paraplegia. Male gender predicted better improvement (p < 0.03), as did no need for mechanical ventilation with a gain of 8.5 (CI: 1.8-15.3) points as compared to those in need. Overall mean improvement of 43% in volitional motor function was found in 84 in-hospitalized patients using SCAR as a metric at a highly-specialized SCI unit. Following factors; level-of-injury, gender, age, need of ventilation support predicted improvement in volitional motor function after a rehabilitation period. Results should be cautiously interpreted as a majority of hospitalized patients did not fulfill criteria for SCAR scoring. Prospectively designed studies with better internal validation and external validations are needed to confirm these findings.

Preoperative cardiopulmonary evaluation in specific neonatal surgery

Preoperative assessment of surgical neonates often relates to issues of prematurity, low birth weight, or associated malformations. This review explores the preoperative cardiopulmonary evaluation in specific newborn surgical populations, the role of echocardiography in congenital diaphragmatic hernia perioperative management, the impact of bronchopulmonary dysplasia in the ex-preterm surgical neonate and a brief discussion on the risk of general anesthesia and specific anesthetic considerations for any surgical neonate.Newborns with congenital anomalies requiring early general surgical intervention should have an assessment for congenital heart disease. In the asymptomatic neonate, a thorough physical exam may be sufficient preoperatively. Neonates born with esophageal atresia or anorectal malformations should have a full evaluation for VACTERL associations. Initial echocardiography in congenital diaphragmatic hernia is used to evaluate anatomy, but there is emerging evidence to suggest the use of echocardiography in the ongoing surveillance of CDH to influence the timing of surgical intervention. Bronchopulmonary dysplasia is present in up to 40% of ex-premature neonates and increases the risk of postoperative apneas and need for ventilatory support. However, all surgical neonates have an increased risk of post-operative apneas, and the need for surgical intervention should be balanced with the risk of general anesthesia.

Clinical and demographic characteristics of geriatric patients with acute poisoning in the state of Uttarakhand.

Background:Acute poisoning in geriatric age group is a clinical challenge due to multiple comorbidities and complications in this age group. There are very few studies done in the past, which have addressed this issue.Materials and Methods:This retrospective observational study was a carried out in the Department of Emergency Medicine of a tertiary care hospital of Uttarakhand over a period of 1 year from November 2017 to October 2018. Detailed demographic data and clinical history of patients with alleged history of acute poisoning was obtained from the hospital record section.Results:During the period of 1 year, 156 patients of acute poisoning attended the medical emergency department, of which 53 (33.9%) patients belonged to geriatric age group (>60 years). Maximum number of patients belonged to the age group of 71–80 years (n = 26, 16.6%). Males outnumbered female patients. The most common toxidrome in geriatric age group was alcohol intoxication followed by pesticide (organophosphorus) poisoning. Unintentional exposure of toxin in the form of drug over dosage encompassed more than one-third of poisonings in geriatric population. Nine (16.9%) geriatric patients succumbed to poisoning. Complications such as acute renal failure, shock, respiratory distress, acute liver injury, and need for ventilator support were more common in nonsurvivors as compared with survivors.Conclusion:The study demonstrated mortality of 16.9% (n = 9) among geriatric patients with alleged history of acute poisoning. The risk factors attributing to mortality were shock, aspiration pneumonia, and acute liver injury. Although cases of suicidal exposure outnumbered cases of unintentional exposure, the latter group comprised of a considerable number. Clearly, more attention is needed while managing a case of acute poisoning of geriatric age group as their pattern of presentation and complications differ from that of younger age group.

Prediction of outcomes in chest trauma patients using chest trauma scoring system: A prospective observational study.

Background and Aims:Prognostication of chest trauma patients by scoring systems is of vital importance to predict morbidity and mortality. We aimed to predict outcomes in chest trauma patients using chest trauma scoring system (CTS) in Indian patients.Methods:This was a prospective observational study done in a trauma care centre at a tertiary care teaching public hospital. CTS was calculated by scores of age, severity of pulmonary contusion, number of rib fractures and presence of bilateral rib fractures. Final CTS ranges from 2 to 12. We evaluated CTS to predict outcome that is mortality as primary objective and development of complications like pneumonia and need for ventilator support as secondary objective in Indian population.Results:Data were collected from 30 patients and they were divided into two groups, CTS <5 (15) and CTS ≥5 (15). High CTS ≥5 was statistically significantly associated with high incidence of pneumonia (P = 0.046), increased requirement of mechanical ventilation (P = 0.025) and mortality (P = 0.035) in chest trauma. Area under the ROC for mortality shows that the test is acceptable (0.75) and at CTS score 5.5 maximum sensitivity is 87.5% and specificity is 68%.Conclusion:This study concludes that a CTS ≥5 is associated with poor outcomes. This scoring system may be used to identify patients at risk of complications and institute early intensive focussed care.

Guillain–Barre syndrome in pregnancy and its association with maternal and perinatal outcome

Background: Guillain–Barre syndrome or acute inflammatory demyelinating proliferative syndrome is rare in pregnancy. It affects the nervous system, presenting as an acute onset of symmetric ascending weakness resulting in respiratory failure and autonomic dysfunction. Aims: This study aims to study the incidence of GBS in pregnant women and its association with maternal and perinatal outcome. Settings and Design: Retrospective observational study conducted at a tertiary care hospital. Materials and Methods: Records of all women diagnosed as GBS in pregnancy and postpartum period were analyzed. Maternal and perinatal outcomes were studied based on the pattern of involvement of limbs, need for ventilator support, treatment with plasmapheresis and intravenous immunoglobulin (IVIG), intrauterine fetal demise (IUFD), and neonatal deaths. Results: During the study of 3 years, there were 11,484 deliveries, of which 8 women had GBS. The incidence of GBS was 0.06%. Lower limb weakness developed in 6 (75%) of women, bifacial weakness in 2 (25%), IVIG received by 3 (37.5%), and (62.5%) underwent plasmapheresis. Four (50%) required ventilator support and maternal mortality was recorded in 2 (25%) due to respiratory failure and IUFD in 2 (25%) of women. Conclusions: GBS is associated with high maternal and perinatal morbidity. Timely diagnosis by obstetricians and management in women complaining of muscular weakness and respiratory difficulty in pregnancy and early postpartum period will help in improving the maternal and perinatal outcome.

Fetal pulmonary artery acceleration/ejection time prognostic accuracy for respiratory complications in preterm prelabor rupture of membranes

Objective: To determine the prognostic accuracy of the fetal pulmonary artery acceleration time/ejection time (PATET) for the prediction of neonatal respiratory complications (NRCs) in pregnancies with preterm premature rupture of membranes (PPROM).Methods: This is a prospective cohort of singleton pregnancies complicated by PPROM managed in our institution from October 2015 to April 2018. Inclusion criteria included mothers from 13 to 46 years of age and singleton pregnancies with PATET measurements <7 days prior to delivery. PATET was obtained by placing the Doppler caliper in the main pulmonary artery proximal to the bifurcation of this vessel. NRC was defined as: need for ventilatory support, respiratory distress syndrome (RDS), or lung hypoplasia. Logistic regression models and area under the receiver operating characteristic curves (ROC) were utilized to determine the prognostic accuracy of PATET and gestational age for NRC and RDS.Results: Of 95 patients included, 46 had NRC (RDS = 33). PATET was a significant predictor of NRC (AUC 0.74; 95%CI: 0.61–0.83; p < .001) and RDS (AUC 0.69; 95%CI: 0.57–0.80; p = .021) in PPROM. Gestational age at delivery and gestational age at PPROM were also significantly associated with NRC and RDS. Their predictive accuracy for NRC was 0.87 and 0.84, and for RDS 0.85 and 0.86, respectively.Conclusions: PATET is a statistically significant predictor for NRC in pregnancies with PPROM; however, its clinical use may be limited as gestational age is a better predictor of these outcomes.Rationale: NRCs are common in pregnancies complicated by preterm prelabor rupture of membranes (PPROM). We aim to determine the prognostic accuracy of the fetal PATET for the prediction of neonatal NRC in these pregnancies. Our results indicate that PATET is a statistically significant predictor for NRC in pregnancies with PPROM; however, its clinical use may be limited, as gestational age is a better predictor of these outcomes.

Intravenous magnesium sulphate infusion as first-line therapy in the control of spasms and muscular rigidity in childhood tetanus

ABSTRACTBackground: Reports suggest that, in tetanus, magnesium sulphate (MgSO4) alone may control muscle spasms, thereby avoiding sedation and mechanical ventilation.Aim: To study the efficacy and safety of intravenous MgSO4 in controlling spasms and rigidity in children with tetanus.Methods: All children with tetanus consecutively admitted over a 2-year period in a tertiary-care teaching hospital were recruited. In addition to human tetanus immunoglobulin and parenteral metronidazole, patients received MgSO4 100 mg/kg intravenously followed by infusion at 40 mg/kg/hr. The infusion rate was increased by 5 mg/kg/hr every 6 h until cessation of spasms or abolition of the patellar tendon reflex. Efficacy was determined by control of spasms. Time to commencement of feeds, frequency of autonomic instability, the need for ventilatory support, duration of hospitalisation and mortality were also recorded.Results: Twenty-seven children with tetanus aged between 18 months and 10 years were recruited. A contaminated wound was the most common portal of entry of tetanus spores. The incidences of severity were: grade I, 3; grade II, 7; grades IIIa and b, 17. Rigidity and spasms were controlled by magnesium therapy alone in 14 patients. Additional sedation was required for 13 patients (grade II, 1; grade III, 12). Feeding could be commenced early in five patients. Mechanical ventilation was required in eight patients. The mean (SD) duration of hospitalisation was 26.5 (12.0) days. Five patients died (18.5%). Asymptomatic hypocalcaemia was a universal finding and was treated with calcium supplements.Conclusion: MgSO4 alone is effective in mild-to-moderate tetanus but not when it is severe.

Risk Factors in Predicting Prognosis of Neonatal Bacterial Meningitis-A Systematic Review.

Background: Neonatal bacterial meningitis is a severe infection with high mortality and morbidity. It is necessary to identify factors associated with a high risk of a poor prognosis so that we can prevent them with more appropriate treatments. This study was performed to summarize the prognostic factors known to predict adverse outcomes in neonatal bacterial meningitis.Methods: The Medline/PubMed, Cochrane Library and Embase databases were searched for studies of prognostic risk factors in neonates with bacterial meningitis. Studies published from the initiation of the database to April 30th, 2017 were included. The quality of cohort studies was assessed by the Newcastle-Ottawa Scale (NOS). The quality of cross-section studies was assessed by the Agency for Healthcare Research and Quality (AHRQ) scale. Each prognostic factor known to cause adverse outcomes is summarized.Results: Sixteen studies were identified, including 7 cohort studies and 9 cross section studies. Seizure and high protein levels in the cerebrospinal fluid (CSF) predict a poor prognosis in this disease. Coma, the need for ventilation support, and leukopenia also had some value for predicting poor prognoses. A bulging anterior fontanelle was valuable for predicting mortality. Low CSF glucose levels, thrombocytopenia, gestational age (GA) < 37 weeks and an altered sensorium were correlated with a poor prognosis. A birth weight < 2500 g, early onset meningitis and positive CSF cultures were correlated with mortality.Conclusions: This study provides a preliminary exploration of prognostic factors in neonatal bacterial meningitis and thereby fills some of the gaps in the study of prognoses in this disease. These prognostic factors can be used to predict and estimate outcomes in neonatal bacterial meningitis. Without a meta-analysis, the reliability of these factors cannot be assured. In addition, these results emphasize that there is an urgent need for a standardized protocol for follow-up and well-designed prognostic studies in neonatal bacterial meningitis.

A Quality Improvement Initiative for Early Initiation of Emergency Management for Sick Neonates

To determine efficacy of Point-of-care Quality improvement (POCQI) in early initiation (within 30 minutes) of emergency treatment among sick neonates. Quality improvement project over a period of twenty weeks. Special Newborn Care Unit (SNCU) of a tertiary care center of Eastern India. All consecutive sick neonates (≥ 28 wk gestation) who presented at triage during morning shift (8 am to 2 pm). We used a stepwise Plan-do-study-act (PDSA) approach to initiate treatment within 30 min of receiving sick newborns. After baseline phase of one month, a quality improvement (QI) team was formed and conducted three PDSA cycles (PDSA I , PDSA II and PDSA III) of 10 d each, followed by a post-intervention phase over 3 months. Percentage of sick babies getting early emergency management at SNCU triage. 309 neonates were enrolled in the study (56 in baseline phase, 88 in implementation phase and 212 in post- intervention phase). Demographic characteristics including birthweight and gestational age were comparable among baseline and post intervention cohorts. During implementation phase, successful early initiation of management was noted among 47%, 69% and 80% neonates following PDSA I, PDSA II and PDSA III, respectively. In comparison to baseline phase, the percentage of neonates receiving treatment within 30 minutes of arrival at triage increased from 20% to 76% (P<0.001) and the mean (SD) time of initiation of treatment decreased from 80.8 (21.0) to 19.8 (5.6) min (P<0.001) during post-implementation phase. Hospital mortality (33% vs 15%, P=0.004) and need for ventilator support (44% vs 18%, P<0.001) were also significantly lower among post intervention cohort in comparison to baseline cohort. Stepwise implementation of PDSA cycles significantly increased the percentage of sick newborns receiving early emergency management at the SNCU triage, thereby resulting in better survival.

Predictores de Mortalidad en Infecciones de Pacientes Neutropénicos Febriles Críticos.

Introducción: La mortalidad relacionada a la neutropenia febril puede ser muy alta en ciertas poblaciones de alto riesgo. El objetivo del presente estudio fue identificar factores predictores tempranos de mortalidad en una cohorte de pacientes oncológicos con neutropenia febril admitidosen una unidad de cuidados intensivos (UCI).&#x0D; Métodos: Estudio observacional retrospectivo en pacientes con neutropenia febril mayores de 18 años ingresados en la UCI del Hospital Oncológico Solón Espinosa Ayala de Quito. Se recogieron variables sociodemográficas, clínicas, de laboratorio y microbiológicas de los registros clínicos al ingreso. Con dichas variables se construyeron modelos predictivos de mortalidad mediante análisis de regresión logística para identificar predictores de muerte.&#x0D; Resultados: Se registraron 107 pacientes con episodios de neutropenia febril, el 53.3 % de los casos presentaron neutropenia severa y en un 29.9 % de los casos la neutropenia duró más de 10 días. La prevalencia de bacteriemia fue del 34.6 %. El 34.6 % de los pacientes murieron (n=37), de estos el 22.4 % falleció en la UCI. Edad superior de 40 años, valores de procalcitonina superiores a 4 ng/ml, puntuaciones altas en APACHE II y la necesidad de apoyo ventilatorio se asociaron con mayor riesgo de muerte en el modelo multivariado; el valor predictivo en la validación interna tuvo una precisión de 81.3 %; sensibilidad de 63.6 %; especificidad de 90.5 %; valor predictivo positivo de 77.8 %; valor predictivo negativo de 82.6 %; área bajo la curva de 0.87.&#x0D; Conclusión: Factores como la edad mayor de 40 años, procalcitonina &gt; 4 ug/ml al ingreso, valores de APACHE II y necesidad de ventilación mecánica están asociados con mayor riesgo de muerte.

Adultos con influenza, evolución clínica, costos y grupos relacionados por el diagnóstico, resultados de 4 años. Clínica Dávila. Santiago de Chile

Introduction: In 2009 Influenza A H1N1pdm09 caused in Chile 12,258 cases and 155 deaths. Objective: To analyze ventilatory support, cost of hospitalization, Diagnosis Related Groups (DRG) and lethality in adults patients with influenza discharged from our institution, during 2009, 2010, 2012 and 2014. Patients and Method: Retrospective descriptive study using electronic medical records. Results: 115,673 adults were discharged, 338 (0.29%) with diagnosis of Influenza, age 56.5 ± 22 yr.o., 59% women, lethality 4%. There were 3 groups, Group 1: without any ventilatory support, 295 patients, age 63 ± 20, stay 6.6 ± 6.9 days, average cost of hospitalization 2,885,261 clp, medium weight DRG 0.41 (p25 = 0.38) andp75 = 0.62), lethality 1.01% (3 patients). Group 2: Non-invasive mechanical ventilation (NIMV), 23 cases, age 77.1 ± 13, lethality 22% (5 cases), stay 16.8 ± 12.4, cost 9,245,242 clp, DRG 0.79 (p25 = 0.62 and p75 = 1.03). Group 3: Intubation and invasive mechanical ventilation (IMV), 20 patients, age 56.4 ± 15, stay 36.9 ± 41.4, cost 38.681.099 clp, DRG 5.86 (p25 = 5.82 and p75 = 5,86) and lethality 30% (6 patients). The DRG group VMI versus group VMNI and no support were different (p < 0.0001 and p < 0.0001 respectively). The lethality for influenza in 2014 was 8.5%, while in 2012, 2010 and 2009 it was 1.5%, 3% and 2.5% respectively. The median age in 2009 was 37.5 yr.o significantly minor, than the other years (p < 0.0001). Conclusions: In 2009 the patients were younger, the need for ventilatory support led to a higher DRG weight, stay, cost and lethality than those who did not require it.

Safety and Efficacy of Bedside Percutaneous Endoscopic Gastrostomy Placement in the Neonatal Intensive Care Unit.

The aim of the study is to describe the safety and efficacy of bedside percutaneous endoscopic gastrostomy (PEG) placement in a level 3 neonatal intensive care unit (NICU). A retrospective chart review was performed on 106 infants with a birthweight ≤6 kg receiving bedside PEG placement at Johns Hopkins All Children's Hospital between 2007 and 2013. Preprocedure, postprocedure, and demographic data were collected. The main safety outcome was postprocedure complication rate and the main efficacy outcome was time to initiate feeds and time on respiratory support. The mean birth weight and mean gestational age of our population at the time of procedure were 2.2 kg and 33 weeks, respectively. There were 9 total complications (8.5%) with major complications being only 2 (1.8%). There were no instances of blood stream infections. The mean length of time to initiate feeds was 1.2 days (standard deviation [SD] = 1.2). Ninety-three percent of patients were extubated within 24 hours. Bedside PEG placement is safe with minimal complications. It is associated with little need for ventilator support and allows for early re-initiation of feeds and early success at reaching goal feedings.

Organophosphorus Compound Induced 'Intermediate Syndrome'

Background: Organophosphate compound (OPC) poisoning with suicidal intent is common in Indian ICUs. These compounds are the organic derivatives of phosphorous containing acids and their effect on neuromuscular junction and autonomic synapses is clinically important. Organophosphate poisoning can present as acute cholinergic syndrome, intermediate syndrome and delayed neuropathy. Case Presentation: Intermediate syndrome secondary to organophosphate poisoning is a serious health problem leading to increased morbidity and mortality. The incidence of problem varies and ranges from 8%-84% of OPC poisoning cases. After initial recovery from cholinergic crisis, some patients have resurgence of respiratory muscle paralysis requiring continued ventilatory support. This is termed intermediate syndrome (IMS). The factors accounting for this difference is the nature of organophosphate compound, severity of poisoning and inadequate oxime therapy. The recognition of this syndrome is important as if this entity is overlooked it can have disastrous effects. Discussion: Our patient had developed respiratory muscle weakness as evidenced by inadequate respiratory efforts, drop in oxygen saturation, retention of CO2 and need for ventilatory support. There was no evidence of weakness in ocular, neck, bulbar muscles but he had weakness in all 4 limbs more pronounced in proximal muscles. Conclusion: We presented this case of OPC poisoning with intermediate syndrome, which remained for a prolonged time and required mechanical ventilation for 16 days. This case highlights how the timely intervention can save the patient’s life.

The National Institutes of Health Stroke Scale score—a valuable stroke scale used in emergency in predicting the need for mechanical ventilation and outcome in patients of acute ischemic stroke

Background: Stroke is the third leading cause of death in developed countries and the leading cause of long term disability. Up to 10% of patients with acute stroke need mechanical ventilation (MV) due to different reasons. Identification of early markers associated with poor outcome appears to be of major importance in helping to provide the most appropriate management in stroke patients. The present study has the objective of determining the predictor accuracy of the National Institutes of Health Stroke Scale (NIHSS) score for the requirement of support of MV in patients with acute stroke and evaluating the outcome of patients who require ventilator support. Methods: The aim of the study was to determine the predictor accuracy of NIHSS score in determining the requirement for MV and outcome of patients of acute ischemic stroke. This prospective cohort study was carried out in Max Superspeciality Hospital Saket in New Delhi over a period of one and half years. Patients with acute stroke, defined as the presence of sudden onset of focal neurological deficit and admitted within 24 h of onset of symptoms, with age ≥18 years were included in the study. The patients who were already on ventilator support at the time of admission were excluded from the study. Results: Out of 139 patients of acute ischemic stroke and venous stroke, 32 patients were put on the mechanical ventilator. In case of ischemic stroke patients who required MV 21 (65.6%) were having NIHSS score between 6 and 13, 10 (31.3%) patients were having NIHSS score of ≥14 and only one (3.1%) was having NIHSS score of ≤5. We found the predictor accuracy of NIHSS score of about 82.7% in determining the need for ventilation support. Conclusions: NIHSS score was found to have predictor accuracy of 82.7% in determining the need for MV. Mortality rate was shown to be increased with increase in the NIHSS score. Keywords: The National Institutes of Health Stroke Scale (NIHSS) score; mechanical ventilation (MV); predictor accuracy; favorable; Modified Rankin Scale (MRS); mortality