Need For Ventilatory Support Research Articles

Clinical profile of neonatal candidiasis in newborn nursery

Background: Candidiasis refers to infection with fungi of the genus candida. Candida infections are frequent and major causes of septicemia in neonatal intensive care units and are associated with high morbidity and mortality. Low birth weight preterm infants are especially vulnerable to these devastating infections. Candida infections are a major cause of septicemia in neonatal ICUs and may affect 1.6% to 12.9% of very low birth weight infants. The smaller the infant is, the greater is the likelihood for systemic fungal infection to develop.Methods: 40 Newborns with culture proven candidiasis admitted in new-born nursery of Government T. D Medical College, Alappuzha, were selected for the study. The significance of different parameters such as gender, gestational age, birth weight, Apgar score, duration of hospital stays, central venous catheter and use of third generation cephalosporins were analysed. Clinical profile like apnoea, feed intolerance, requirement of ventilator support, temperature instability, thrombocytopenia, hyperglycemia etc. were analyzed.Results: Out of 40 newborns 39 were preterms, 42% of study population were having a birth weight of 1-1.5 kg, 33% with a birth weight of 1.5-2 kg and 20% with a birth weight of <1 kg.75% of the study population were hospitalized for >1 week. In the study group 58% had feed intolerance, 52.5% needed ventilator support, 52.5% had temperature instability, 70% had thrombocytopenia 50% had apnea and 4% had hyperglycemia. The overall survival was 60%.Conclusions: Prematurity, low birth weight and prolonged hospital stay were associated with increased risk of candidiasis. Feed intolerance, increased need for ventilator support, apnea, temperature instability and thrombocytopenia were significant clinical parameters.

Hypoalbuminemia as a marker of adverse outcome in children admitted to pediatric intensive care unit

Background: Research on critically ill adult patients has shown the usefulness of albumin as a predictor of increased morbidity and mortality. There is a paucity of similar data in pediatric age group. Objective: The objective of the study was to know the incidence of hypoalbuminemia in children admitted to pediatric intensive care unit (PICU) and its correlation to disease severity and clinical outcome. Materials and Methods: This was a prospective observational study conducted at the PICU of a tertiary care hospital. Children of age group 1 month – 18 years admitted to the PICU were included in the study. Serum albumin levels were estimated at the time of admission to PICU. Pediatric index of mortality 2 (PIM2) scoring system was used to assess the severity of illness at admission and to calculate the predicted death rate (PDR). The independent sample t-test and Fisher’s exact test were used to compare the albumin levels with PDR and duration of hospital or PICU stay. Mortality risk was computed using Pearson’s Chi-square test. Multivariate regression analysis was performed to evaluate whether hypoalbuminemia is an independent predictor of mortality. Results: Mean serum albumin level in this study was 3.38±0.89 g/dL. The incidence of hypoalbuminemia was 44.1%. The PDR (calculated using PIM2 score) was increased in children with hypoalbuminemia compared with the normal albumin level group (p=0.004). As compared to children with normal albumin levels, children with hypoalbuminemia had longer duration of PICU stay (95% confidence interval (CI) for difference 0.86–3.03; p=0.05), higher need for ventilator support (odds ratio (OR) 4.2, p=0.003) and higher mortality (OR 0.16, p=0.002). The association of serum albumin levels with mortality remained significant even after adjusting for age and PDR by PIM2 score (OR=3.68; 95% CI, 1.76–7.74; p<0.001). Conclusion: Hypoalbuminemia is a significant predictor of mortality and morbidity in critically ill children.

Analysis of emergency laboratory parameters of various poisonings in tertiary care teaching hospital

Aim: India is predominantly an agricultural country; pesticides and insecticides are abundantly used during cultivation. The adult mortality rate due to mixed drug poisoning in rural south India is 0.97/1000 persons/year. Only 70%–80% of patients admitted to hospitals survive. The present study is undertaken to identifying the association of laboratory parameters with different poisoning etiologies which may help in predicting the need for ventilator support to reduce the mortality by timely entry into emergency department (ED). Materials and Methods: A prospective study on the mixed poisoning of 964 cases was done in the ED at Narayana Medical College Hospital, Nellore, Andhra Pradesh, for 8 years (from 2009 to Jan 2016). Clinical and laboratory data were recorded for all patients on admission (time 0) and 24 h later (time 24). The severity of patients graded according to the Glasgow Coma Scale (GCS) classification. Results: Among 964 patients, in the present study, the majority of the patients in the study group were males, and higher age group affected was 40–50 years. Agricultural farmers and rural residents were highly consumed pesticides. In the study, ingestion poisoning 95% had common occurrences than inhalation poisoning 5%. In severity categorization, we observed that 28.4% of patients were in mild condition, 55.6% in moderate, and 16% in severe. Mean, GCS scoring system was statistically significant between time 0 and time 24 in the survivors. Low GCS at admission was vulnerable for ventilator support. Cholinesterase activity was measured significantly depressed in the Grade 1, 2, and 3. Conclusions: The present study concludes that the need for ventilatory support in organophosphoros poisoning was significantly more in patients who consumed chlorpyrifos methyl parathion compounds, airway edema secondary to hair dye poisoning, presence of cholinergic crisis, GCS score of

Evaluation of the Severity of Organophosphorus Compound Poisoning and Forecasting the Need for Ventilatory Support

Evaluation of the Severity of Organophosphorus Compound Poisoning and Forecasting the Need for Ventilatory Support

A study of serum magnesium level in critically ill patients

Background: It is considered that Hypomagnesemia is one of the underdiagnosed electrolyte abnormalities in patients who are critically ill. Many studies have been done to find the hypomagnesemia prevalence and its effects on patients regarding mortality and morbidity. So we have undertaken this study to know the effects of Hypomagnesemia in critically ill patients admitted in medical critical ward. And it is an observational study. Aims and Objectives: To study the level of serum magnesium in critically ill patients and to correlate its effects with patient outcome in terms of length of stay in ICU, need for ventilator support, duration of ventilator support, APACHE II score. To detect any electrolyte abnormalities associated with hypomagnesemia. Results: In our study, on admission in ICU, 55.3% patients had hypomagnesemia, and patients with hypomagnesemia have mean duration of stay in ICU was 8.2 days, longer duration on mechanical ventilator i.e. 6.3 day and APACHE II Score of 15.7 and more frequently patients were in sepsis (25.9%), 15.3 % had cardiovascular abnormality. Patients with hypomagnesemia were more frequently associated with Diabetes Mellitus (34%) and they were having higher mortality rate (48.9%). Conclusion: In the critically ill patients Hypomagnesemia was prevalent in higher rate. And it was associated with a higher mortality rate in them. And the requirement of ventilator support and duration on ventilator was significantly higher in hypomagnesemic patients. Hypomagnesemia was more commonly associated with sepsis, diabetes mellitus. And also it was associated with higher mortality rates and APACHE II Score.

Shifting the boundaries for early caffeine initiation in neonatal practice: Results of a prospective, multicenter study on very preterm infants with respiratory distress syndrome.

BackgroundThere is growing evidence that supports the benefits of early use of caffeine in preterm neonates with RDS; however, no formal recommendations specifying the exact timing of therapy initiation have been provided.ObjectivesWe compared neonatal outcomes in infants receiving early (initial dose on the 1st day of life) and late (initial dose on day 2+ of life) caffeine therapy.MethodsUsing data from a prospective, cohort study, we identified 986 infants ≤32 weeks’ gestation with RDS and assessed the timing of caffeine therapy initiation, need for ventilatory support, mortality and incidence of typical complications of prematurity. To adjust for baseline severity, the early and late caffeine groups were propensity score (PS) matched to 286 infants (1:1). Clinical outcomes were compared between the PS-matched groups.ResultsEarly treatment with caffeine citrate was associated with a significantly reduced need for invasive ventilation (71.3% vs 83.2%; P = 0.0165) and total duration of mechanical ventilation (mean 5 ± 11.1 days vs 10.8 ± 14.6 days; P = 0.0000) and significantly lower odds of intraventricular hemorrhage (IVH) (OR 0.4827; 95% CI 0.2999–0.7787) and patent ductus arteriosus (PDA) (OR 0.5686; 95% CI 0.3395–0.9523). The incidence of bronchopulmonary dysplasia (BPD) (36.4% vs 45.8%) and rates of moderate and severe BPD were not significantly different between the two groups. The mortality rates were comparable between the two groups (8.6% vs 8.5%, P = ns)ConclusionEarly caffeine initiation was associated with a decreased need for invasive ventilatory support and lower incidence of IVH and PDA.

Adherence to Mediterranean Diet and All-Cause Mortality After an Episode of Acute Heart Failure: Results of the MEDIT-AHF Study

ObjectivesThe authors sought to evaluate clinical outcomes of patients after an episode of acute heart failure (AHF) according to their adherence to the Mediterranean diet (MedDiet). BackgroundIt has been proved that MedDiet is a useful tool in primary prevention of cardiovascular diseases. However, it is unknown whether adherence to MedDiet is associated with better outcomes in patients who have already experienced an episode of AHF. MethodsWe designed a prospective study that included consecutive patients diagnosed with AHF in 7 Spanish emergency departments (EDs). Patients were included if they or their relatives were able to answer a 14-point score of adherence to the MedDiet, which classified patients as adherents (≥9 points) or nonadherents (≤8 points). The primary endpoint was all-cause mortality at the end of follow-up, and secondary endpoints were 1-year ED revisit without hospitalization, rehospitalization, death, and a combined endpoint of all these variables for patients discharged after the index episode. Unadjusted and adjusted hazard ratios (HRs) were calculated. ResultsWe included 991 patients (mean age of 80 ± 10 years, 57.8% women); 523 (52.9%) of whom were adherent to the MedDiet. After a mean follow-up period of 2.1 ± 1.3 years, no differences were observed in survival between adherent and nonadherent patients (HR of adherents [HRadh] = 0.86; 95% confidence interval [CI]: 0.73 to 1.02). The 1-year cumulative ED revisit for the whole cohort was 24.5% (HRadh = 1.10; 95% CI: 0.84 to 1.42), hospitalization 43.7% (HRadh = 0.74; 95% CI: 0.61 to 0.90), death 22.7% (HRadh = 1.05; 95% CI: 0.8 to 1.38), and combined endpoint 66.8% (HRadh = 0.89; 95% CI: 0.76 to 1.04). Adjustment by age, hypertension, peripheral arterial disease, previous episodes of AHF, treatment with statins, air-room pulsioxymetry, and need for ventilation support in the ED rendered similar results, with no statistically significant differences in mortality (HRadh = 0.94; 95% CI: 0.80 to 1.13) and persistence of lower 1-year hospitalization for adherents (HRadh = 0.76; 95% CI: 0.62 to 0.93). ConclusionsAdherence to the MedDiet did not influence long-term mortality after an episode of AHF, but it was associated with decreased rates of rehospitalization during the next year.

Risk Trajectories of Readmission and Death in the First Year after Hospitalization for Chronic Obstructive Pulmonary Disease.

Characterization of the dynamic nature of posthospital risk in chronic obstructive pulmonary disease (COPD) is needed to provide counseling and plan clinical services. To analyze risk of readmission and death after discharge for COPD among Medicare beneficiaries aged 65 years and older and to determine the association between ventilator support and risk trajectory. We computed daily absolute risks of hospital readmission and death for 1 year after discharge for COPD, stratified by ventilator support. We determined the time required for risks to decline by 50% from maximum daily values after discharge and for daily risks to plateau. We compared risks with those found in the general elderly population. Among 2,340,637 hospitalizations, the readmission rate at 1 year was 64.2%, including 63.5%, 66.0%, and 64.1% among those receiving invasive, noninvasive, and no ventilation, respectively. Among 1,283,069 hospitalizations, mortality at 1 year was 26.2%, including 45.7%, 41.8%, and 24.4% among those same respective groups. Daily risk of readmission declined by 50% within 28, 39, and 43 days and plateaued at 46, 54, and 61 days among those receiving invasive, noninvasive, and no ventilation, respectively. Risk of death declined by 50% by 3, 4, and 17 days and plateaued by 21, 18, and 24 days in the same respective groups. Risks of hospitalization and death were significantly higher after discharge for COPD than among the general Medicare population. Discharge from the hospital is associated with prolonged risks of readmission and death that vary with need for ventilator support. Interventions limited to the first month after discharge may be insufficient to improve longitudinal outcomes.

Un cas atypique de pneumopathie nécrosante staphylococcique !

Some strains of Staphylococcus aureus produce a toxin known as Panton-Valentine leukocidin. These strains notably cause a necrotizing pneumonia which is associated with a high mortality. A 70-year-old woman presented with sub-acute onset dyspnea, low-grade fever, and hemoptysis after a trip to Dubai and New Zealand. Computed tomography showed bilateral necrotizing pneumonia, suggesting the diagnosis of pneumonia caused by S.aureus producing Panton-Valentine toxin. It was confirmed by microbiological investigation. The rapid initiation of adequate antimicrobial therapy including an effective antitoxin was essential for successful treatment, without the need for ventilatory support. Necrotizing pneumonia caused by S.aureus producing Panton-Valentine leukocidin usually occurs in young subjects without comorbidities. Typical symptoms are a combination of hypoxemia, high fever, hemoptysis, leukopenia, and a rapidly worsening condition. Panton-Valentine leukocidin should not be discarded if not all the symptoms are typical. Antibiotic therapy including an antitoxin drug such as linezolid or clindamycin should be initiated promptly.

Should delivery timing for repeat cesarean be reconsidered based on dating criteria?

Purpose: We sought to examine if the method of pregnancy dating at five increasing term gestational ages is associated with increasing neonatal morbidity.Materials and methods: A cohort of women who underwent elective repeat cesarean delivery at ≥37 weeks’ gestation were identified from the NICHD MFMU Network registry. We excluded women who were in labor, those carrying a fetus with a congenital anomaly, those with a non-reassuring fetal heart tracing, and those with preeclampsia, preexisting chronic hypertension or diabetes. Composite neonatal morbidity was defined for our study as any of the following: NICU admission, hypotonia, meconium aspiration, seizures, need for ventilator support, NEC, RDS, TTN, hypoglycemia, or neonatal death. We compared composite neonatal morbidity rates among infants born at five different gestational age cutoffs according to their method of pregnancy dating.Results: At 39 and 40 weeks’ gestation, the lowest rate of neonatal complications was seen in pregnancies dated by first trimester ultrasound (5.8% and 5.5%, respectively), while those with the highest neonatal morbidity rates were seen when dated by a second or third trimester ultrasound (8.1% and 6.0%, respectively); p < .001. Additionally within each pregnancy dating category, the neonatal morbidity rates declined from 37 to 40 weeks’ gestation and then significantly increased at 41 + 0 weeks’ gestation.Conclusion: Even with suboptimal dating methods, amongst women undergoing elective repeat cesarean delivery, neonatal morbidity was lowest when delivery occurred between 40 and 40 + 6 weeks gestation.

Effects of somatostatin/octreotide treatment in neonates with congenital chylothorax.

The influence of somatostatin/octreotide treatment on outcomes of neonates with congenital chylothorax remains controversial. We retrospectively reviewed our experience with somatostatin/octreotide therapy in neonates with this very rare disease.Fourteen neonates with congenital chylothorax who were treated with somatostatin (3.5–7 μg/kg/h, before 2016) or octreotide (1–6 μg/kg/h, after January 2016), along with traditional management between 2013 and 2016, were retrospectively reviewed in this observational study. Their daily volumes of pleural drainage and parameters of respiratory support were recorded, and the potential side effects of somatostatin/octreotide were screened.Four patients (28.6%) had a unilateral presentation of pleural effusion, whereas 10 patients (71.4%) had a bilateral presentation. Twelve patients (85.7%) survived until discharge without later recurrence or death, whereas 2 patients (14.3%) died within the first 3 days after birth. Somatostatin/octreotide treatment was maintained for a median period of 6 days (range 1–16 days). The chest tube was removed after a median duration of 14 days (range 2–51 days), and no patient needed pleurodesis or thoracic duct ligation surgery. The average daily drain output within 3 days post-treatment (median 62 mL, range 10–651 mL) was significantly lower than that before treatment (median 133 mL, range 70–620 mL) (P = .002). The need for ventilation support was reduced in most patients (85.7%) after the initiation of somatostatin/octreotide therapy. No serious side effects were identified.Somatostatin/octreotide treatment reduced pleural drainage and respiratory support without significant side effects. Further randomized controlled studies with more patients are necessary to ascertain the benefits of somatostatin/octreotide in neonates with congenital chylothorax.

Trauma-Induced Acute X Chromosome Skewing in White Blood Cells Represents an Immuno-Modulatory Mechanism Unique to Females and a Likely Contributor to Sex-Based Outcome Differences.

Sex-related outcome disparities following severe trauma have been demonstrated in human and animal studies; however, sex hormone status could not fully account for the differences. This study tested whether X-linked cellular mosaicism, which is unique to females, could represent a genetically based mechanism contributing to sex-related immuno-modulation following trauma. Serial blood samples collected for routine laboratory tests were analyzed for ChrX inactivation (XCI) ratios in white blood cells. Thirty-nine severely injured (mean ISS 19) female trauma patients on mixed racial and ethnic background were tested for initial (baseline) and trauma-induced changes in XCI ratios and their associations with severity of injury and clinical outcome. At admission, two-thirds of the patients showed XCI-ratio values between one and three, about a third presented skewed XCI ratios (3-7 range) and three patients displayed extremely skewed XCI ratios (8-30 range). Serial blood samples during the clinical course showed additional changes in XCI ratios ranging between 20% and 900% over initial. Increasing XCI ratios during the injury course correlated with the severity of trauma, subsequent need for ventilator support and pneumonia. In contrast, initial XCI ratios did not show correlations with injury severity or clinical complications. Initial XCI ratios showed a positive correlation with age but older patients retained the ability to mount trauma-induced secondary XCI changes. These data show that trauma results in X-linked cell selection in females, which is likely to be driven by polymorphic differences between the parental ChrXs. X-linked white blood cell skewing correlates with injury severity and a complicated postinjury clinical course. Female X-linked cellular mosaicism and its capacity to change dynamically during the injury course compared with the lack of this machinery in males may represent a novel immuno-modulatory mechanism contributing to sex-based outcome differences after injury and infection.

A study on serum cholinesterase levels as a prognostic marker in organophosphorus poisoning

Background: Organophosphorus compound poisoning is the most common medico toxic emergency in India. Respiratory failure is the most common complication of OP poisoning leading to death. Materials and methods: Cross sectional study was done in Cases with history of exposure to organophosphorus compound within previous 24 hours was chosen after applying inclusion and exclusion criteria. Patients were evaluated for Peradeniya OP poisoning scale and serum cholinesterase levels for assessment of severity of poisoning. Serum cholinesterase levels and Peradeniya OP poisoning scale were studied to predict the complications and prognosis. Results: In our study ventilatory support required in 27.5% of patients. Mortality in our study was 17.5%. Only 15% of patients with mild grade of poisoning according to Peradeniya OP poisoning scale required ventilatory support, where as 85% did not require ventilatory support. Most of patients with moderate (45%) and severe poisoning (57%) according to Peradeniya OP poisoning scale required ventilatory support. 91% of patients with serum cholinesterase levels more than 50% did not require ventilatory support. Only 34% of patients with serum cholinesterase levels less than 50% required ventilatory support. In our study there was no significant correlation between initial serum cholinesterase levels and the need for ventilator support. Conclusion: No significant increase in serum cholinesterase levels with treatment in patients with poor prognosis and correlated with mortality. Serial measurement of PChE levels useful in predicting outcome and incidence of neurological complications.

Impact of maternal obesity on very preterm infants

Infants born at less than 34 weeks' gestational age are at higher risk for morbidity and mortality. Data are limited on the impact of maternal obesity on the very preterm infant. This study reviewed whether maternal obesity further increases the intensive care needs of very preterm infants of less than 34 weeks' gestation. Maternal and neonatal data for live-born singleton births of 23 0/7 to 33 6/7 weeks' gestation delivering in upstate New York were reviewed. BMI categorization followed the National Institutes of Health BMI classification that subdivides obesity into three ascending BMI groups. Records were obtained on 1,224 women, of whom 31.6% were classified with obesity. Despite similar mean gestational age (31 to 31.6 weeks, P = 0.57) and birth weight (1,488 to 1,569 g, P = 0.51) of the infants in the BMI categories, delivery room (DR) resuscitation was more common for infants of women with level III obesity (63.2%, P = 0.04) with a trend toward the continued need for assisted ventilation (54.7%, P = 0.06). Preterm infants of women with level III obesity were more likely to require DR resuscitation with a trend to continued need for ventilatory support beyond 6 hours of age. This could impact utilization of DR resources at delivering hospitals.

Incidence and risk factors for delirium development in ICU patients - a prospective observational study.

Delirium is an acute brain dysfunction and a frequent complication in critically ill patients. When present it significantly worsens the prognosis of patients. The aim of this study was to evaluate the incidence of delirium and risk factors for delirium in a mixed group of trauma, medical and surgical ICU patients. A prospective observational study was conducted in one of the six-bed Intensive Care Units of the University Hospital Ostrava in the Czech Republic during a 12-month period. We evaluated the incidence of delirium and its predisposing and precipitating risk factors. All patients were assessed daily using the Confusion Assessment Method for the ICU (CAM-ICU). Of the total of 332 patients with a median APACHE II (the Acute Physiology and Chronic Health Evaluation) score of 12, who were evaluated for delirium, 48 could not be assessed using CAM-ICU (47 due to prolonged coma, 1 due to language barriers). The incidence of delirium was 26.1%, with trauma and medical patients being more likely to develop delirium than surgical patients. Risk of delirium was significantly associated with age ≥ 65 years, and alcohol abuse in their anamnesis, with APACHE II score on admission, and with the use of sedatives and/or vasopressors. Delirious patients who remained in the ICU for a prolonged period showed a greater need for ventilator support and had a greater ICU-mortality.

Does Hypomagnesemia Impact on the Outcome of Patients Admitted to the Intensive Care Unit? A Systematic Review and Meta-Analysis.

Hypomagnesemia is commonly seen but frequently overlooked in critically ill patients in intensive care unit (ICU). However, the strength and consistency of the effect of hypomagnesemia on outcomes in critically ill patients remain controversial. In this report, we performed a systematic review and meta-analysis to evaluate the association of serum magnesium level with prognosis of critically ill patients upon admission to the ICU. A comprehensive search for clinical trials was performed, and 10 studies comprising 1,122 cases and 630 controls were finally selected for analysis. The patients with hypomagnesemia had higher mortality rate (risk ratio [RR] 1.76; 95% confidence interval [CI] 1.54-2.00; P <0.00001), more frequently had sepsis (RR 2.04; 95% CI 1.21-3.42; P = 0.0007) and more frequent need for ventilatory support (RR 1.36; 95% CI 1.21 to 1.53; P <0.00001). Length of ICU stay was also higher in the hypomagnesemia group (RR 1.85; 95% CI 0.43- 3.26; P = 0.01). Collectively, our data indicated that hypomagnesemia appears associated with greater risk of mortality, sepsis, mechanical ventilation, and the length of ICU stay in patients admitted to ICU. The role of magnesium therapy for improving outcomes in critically ill patients is needed to further study.

Elective delivery versus expectant management for pre-eclampsia: a meta-analysis of RCTs

PurposeTo evaluate the effectiveness and safety of elective delivery versus expectant management for women with pre-eclampsia (PE) and to assess neonatal outcomes before and after 34 weeks gestation.MethodsWe searched Biomed Central, CINAHL, Cochrane Library, Embase, HMIC, Medline, and WHO trial registry, British Nursing Index, ClinicalTrials.gov, Current Controlled Trials, and Web of Science on 16 March, 2016. 1704 citations were identified. Randomised controlled trials comparing elective delivery with expectant management for women with PE were included. Seven studies were included (n = 1501). There were no maternal deaths.ResultsElective delivery lowered incidence of complications in women with PE or hypertension greater than 34 weeks gestation (n = 756; RR, 0.64; 95% CI 0.51–0.80). For women with severe PE less than 34 weeks gestation, elective delivery lowered the incidence of placental abruption (n = 483, 5 RCTs; RR, 0.43; 95% CI 0.19–0.98). For women with PE or hypertension greater than 34 weeks gestation, elective delivery also reduced the need for antihypertensive drug therapy. The need for ventilatory support and the risk of developing neonatal intraventricular hemorrhage or hypoxic ischemic encephalopathy may be increased in infants whose mothers undergo elective delivery for severe PE at less than 34 weeks gestation. However, there was no relevant evidence for women with severe PE over 34 weeks.ConclusionsIn women with PE or gestational hypertension beyond 34 weeks gestation, elective delivery can decrease the incidence of complications, severe hypertension and the need for antihypertensive drug therapy. Elective delivery can also lower the risk of placental abruption in women before 34 weeks gestation with severe PE, however, may be associated with increased risk of neonatal complications.

Successful tracheostomy decannulation after complete or sensory incomplete cervical spinal cord injury.

Retrospective study. To report the successful tracheostomy decannulation/extubation in cervical spinal cord injury (C-SCI) patients. Tertiary university hospital, pulmonary rehabilitation center. Complete or sensory incomplete C-SCI patients who had received invasive acute phase respiratory management, and succeeded in decannulation/extubation became candidates of this study. Retrospective review was conducted on the transitions of the respiratory status. Sixty-two patients (M: 55, F: 7) were identified. Traumatic etiologies accounted for 93.5%, and mean onset age was 47.6±15.8 years. Sixty patients (96.8%) had undergone tracheostomy and the other two received endotracheal intubation during acute phase. All patients succeeded in decannulation/extubation after employing mechanically assisted coughing and noninvasive mechanical ventilation (NIV). Mean time since tracheostomy to decannulation was 7.0±14.5 months. Of the 60 tracheostomized patients, 12 succeeded in decannulation without applying long-term NIV, 31 switched to continuous NIV after decannulation. Fifteen patients totally weaned off from ventilators after NIV. Two patients who once succeeded in decannulation were re-tracheostomized. For the 31 patients with continuous NIV, mean hours of daily need for ventilatory support had reduced from 15.3±8.0 to 5.7±5.7 h at final follow-ups. Complete or sensory incomplete C-SCI patients, even with high neurological level can be successfully decannulated through NIV and aggressive use of mechanically assisted coughing. Undesirable tracheostomy can be avoided by employing the noninvasive respiratory management.

Analyzing intra-abdominal pressures and outcomes in patients undergoing laparotomy

Background: Despite the abundance of knowledge, IAH still remains strangely under-diagnosed. A national postal questionnaire in United Kingdom reported that despite widespread awareness of IAH and the ACS, many intensive care units never measure the IAP. The aim was to evaluate the effects of intra-abdominal hypertension and to assess whether intra-abdominal pressure is a predictor of morbidity and mortality in patients undergoing laparotomy. Methods: This was a prospective observational study conducted in Department of General Surgery, Kamineni Hospitals, L. B. Nagar, Hyderabad, India on patients undergoing emergency and elective laparotomy, over a period of 2 years from October 2012 to October 2014. The study included 51 patients who underwent laparotomy. IAP was measured preoperatively and then post-operatively at 0, 6, 24, 48 and 72 hours. If IAP remained below 12 mmHg, measurement was discontinued after 24 hours. Duration of ICU and hospital stay, occurrence of burst abdomen, new organ function damage, need for ventilatory support and mortality in patients undergoing laparotomy were noted as outcomes. Results: At admission, an overall 65% incidence of intra-abdominal hypertension (IAH) was observed. In this group of 33 patients, CVS dysfunction was seen in 11 patients (33.3%), Respiratory dysfunction was seen in 9 patients (27.2%) and renal dysfunction was seen in 11 patients (33.3%). At 24 hours improvement was seen in all organ dysfunctions. Number of patients with CVS, respiratory and renal dysfunction in this group of 33 patients at 24 hours was 5 (15%), 4 (12%) and 6 (18%) respectively. This signifies that along with decrease in incidence of IAH, there is concomitant decrease in incidence of organ dysfunctions and morbidity. Conclusions: Raised intra-abdominal pressure (IAP) is associated with higher morbidity and mortality in patients undergoing laparotomy. Intra-abdominal hypertension (IAH) has detrimental effect on various organ systems and decompression leads to improvement in all the parameters.

Mechanical Ventilation in the Intensive Care Unit: A Prospective Study of Indications and Factors that Affect Outcome in a Tertiary Hospital in Nigeria

The need for ventilatory support is one of the commonest indications for admission into the intensive care unit (ICU). Despite the usefulness of mechanical ventilation, its damaging effect on the lungs has also been widely recognized. The study was a prospective, case-controlled survey of all mechanically ventilated patients admitted in our ICU from November 2013 to April 2014. For every ventilated patient, a non-ventilated similar patient served as a control. A total of 128 patients were admitted into the ICU over the six month period and 44 patients constituting 34.4% were mechanically ventilated. The average duration of mechanical ventilation was 12.30 ± 10.10 days. Duration of mechanical ventilation, use of arterial blood gas measurement and ionotropic support had significant effect on weaning from ventilation with p values of 0.005, 0.05 and 4 times chance of death than non-ventilated patients. Mechanical ventilation though a useful therapeutic intervention in the ICU is associated with increased mortality. Duration of ventilation, use of arterial blood gas (ABG) and need for ionotropic support influenced successful weaning off ventilator. It may be expedient therefore to weigh the risk: benefit assessment of mechanical ventilation before commencement in the ICU.