Number Of Ventilator-free Days Research Articles

Delirium as detected by the CAM-ICU predicts restraint use among mechanically ventilated medical patients*

The first goal of this investigation was to identify individuals with delirium defined by the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) among medical patients with respiratory failure. Our second goal was to compare clinical interventions including use of continuous sedation infusions, the number of ventilator-free days, ICU length of stay, hospital mortality, and use of physical restraints in mechanically ventilated patients with and without delirium. A prospective, single-center, observational cohort study. The medical intensive care unit (19 beds) of an urban teaching hospital. Adult, intubated, and mechanically ventilated patients. Daily evaluation with the CAM-ICU, outcomes assessment, and prospective data collection. Among 93 patients evaluated using the CAM-ICU, 44 patients (47%) developed delirium (CAM-ICU+) for >/=1 day while in the intensive care unit. Twenty-two patients (24%) had no episodes of delirium recorded (CAM-ICU-), and 27 (29%) remained comatose until extubation or death. A statistically greater number of patients with delirium (CAM-ICU+) received continuous infusions of midazolam (59% vs. 32%, p < .05) or fentanyl (57% vs. 32%, p < .05) and physical soft-limb restraints (77% vs. 50%, p < .05) compared with patients without delirium (CAM-ICU-). The identification of delirium using the CAM-ICU was associated with greater use of continuous sedation infusions and physical restraints. Additional studies are required to determine how the use of these specific interventions influences the occurrence and the natural history of delirium among critically ill patients.

Partial liquid ventilation

Partial liquid ventilation (PLV) is a relatively new therapeutic approach to acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS). The idea of combining the intrapulmonary application of an oxygen-carrying substance and positive pressure ventilation was introduced by Fuhrman in 1991 and originally called perfluorocarbon-associated gas exchange (PAGE). Nowadays, the technique is mostly known as partial liquid ventilation (PLV). The efficacy of PVL treatment has been demonstrated in numerous animal studies in different models of lung injury. The results of those studies led to multicenter phase I-II studies in patients of all age groups in the United States and Canada. Recently, the first randomized, controlled study in 90 adult patients suffering from ALI and ARDS was completed and first results have been published. Comparison of overall mortality and number of ventilator-free days (VFD's) in a 28-day period showed no differences between PLV and conventionally treated patients. A post-hoc stratification by age (< 55 years) demonstrated a tendency to lower mortality (PLV 25.6%; CMV 36.8%) and a significant increase of VFD (PLV 8.95 days; CMV 4.11 days; p = 0.03) in PLV when compared to conventionally treated patients. Perfluorocarbons (PFCs) are chemically stable and inert. They are mostly eliminated via exhalation (> 99%). The unique physicochemical properties of PFCs permit access to atelectatic, non-ventilated lung areas, enhance gas exchange and decrease inflammation. The dense PFCs prevent the endexpiratory collapse of alveoli and reestablish functional residual capacity (FRC). Comparable to positive endexpiratory pressure (PEEP), these effects have been described as "liquid or fluid PEEP". These properties offer a new approach to the underlying pathophysiology of ALI and ARDS. In addition, the combination with other therapeutic approaches to ALI and ARDS like high-frequency oscillations (HFO), inhaled nitric oxide (NO) therapy, and surfactant replacement can be considered and is already the subject of recent publications. However, combination therapy is still experimental and further investigation is necessary to evaluate efficacy and potential risks. Many questions still exist which need to be answered by experimental as well as human pilot studies. Based on these studies, the results of ongoing human trials can be assessed properly and new multicenter trials can be planned effectively.