Number Of Ventilator-free Days Research Articles

Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial

There is no proven specific pharmacological treatment for patients with the acute respiratory distress syndrome (ARDS). The efficacy of corticosteroids in ARDS remains controversial. We aimed to assess the effects of dexamethasone in ARDS, which might change pulmonary and systemic inflammation and result in a decrease in duration of mechanical ventilation and mortality. We did a multicentre, randomised controlled trial in a network of 17 intensive care units (ICUs) in teaching hospitals across Spain in patients with established moderate-to-severe ARDS (defined by a ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen of 200 mm Hg or less assessed with a positive end-expiratory pressure of 10 cm H2O or more and FiO2 of 0·5 or more at 24 h after ARDS onset). Patients with brain death, terminal-stage disease, or receiving corticosteroids or immunosuppressive drugs were excluded. Eligible patients were randomly assigned based on balanced treatment assignments with a computerised randomisation allocation sequence using blocks of 10 opaque, sealed envelopes to receive immediate treatment with dexamethasone or continued routine intensive care (control group). Patients in the dexamethasone group received an intravenous dose of 20 mg once daily from day 1 to day 5, which was reduced to 10 mg once daily from day 6 to day 10. Patients in both groups were ventilated with lung-protective mechanical ventilation. Allocation concealment was maintained at all sites during the trial. Primary outcome was the number of ventilator-free days at 28 days, defined as the number of days alive and free from mechanical ventilation from day of randomisation to day 28. Secondary outcome was all-cause mortality 60 days after randomisation. All analyses were done according to the intention-to-treat principle. This study is registered with ClinicalTrials.gov, NCT01731795. Between March 28, 2013, and Dec 31, 2018, we enrolled 277 patients and randomly assigned 139 patients to the dexamethasone group and 138 to the control group. The trial was stopped by the data safety monitoring board due to low enrolment rate after enrolling more than 88% (277/314) of the planned sample size. The mean number of ventilator-free days was higher in the dexamethasone group than in the control group (between-group difference 4·8 days [95% CI 2·57 to 7·03]; p<0·0001). At 60 days, 29 (21%) patients in the dexamethasone group and 50 (36%) patients in the control group had died (between-group difference -15·3% [-25·9 to -4·9]; p=0·0047). The proportion of adverse events did not differ significantly between the dexamethasone group and control group. The most common adverse events were hyperglycaemia in the ICU (105 [76%] patients in the dexamethasone group vs 97 [70%] patients in the control group), new infections in the ICU (eg, pneumonia or sepsis; 33 [24%] vs 35 [25%]), and barotrauma (14 [10%] vs 10 [7%]). Early administration of dexamethasone could reduce duration of mechanical ventilation and overall mortality in patients with established moderate-to-severe ARDS. Fundación Mutua Madrileña, Instituto de Salud Carlos III, The European Regional Development's Funds, Asociación Científica Pulmón y Ventilación Mecánica.

Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: A retrospective pre-post study.

Prolonged immobility has detrimental consequences for critically ill patients admitted to the intensive care unit (ICU). Previous work has shown that early mobilization of ICU patients is a safe, feasible and effective strategy to improve outcomes; however, few of these studies focused on trauma ICU patients. Our objective was to assess the impact of implementing an ICU early mobilization protocol (EMP) on trauma outcomes. We conducted a retrospective pre-post study of adult trauma patients (>18 years old) admitted to ICU at a Level I trauma center over a 2-year period prior to and following EMP implementation, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared outcomes (mortality, length of stay [LOS], ventilator-free days) between patients admitted during pre-EMP and post-EMP periods, and assessed for factors associated with outcomes using binary logistic regression and generalized linear models. Overall, 526 patients were included in the analysis (292 pre-EMP, 234 post-EMP). Ages ranged from 18 years to 92 years (mean, 49.0 ± 20.4 years) and 74.3% were men. The post-EMP group had lower ICU mortality (21.6% vs. 12.8%; p = 0.009) and in-hospital mortality (25.3% vs. 17.5%; p = 0.031). After controlling for confounders, patients in the post-EMP group were less likely to die in the ICU (odds ratio, 0.43; 95% confidence interval, 0.24-0.79; p = 0.006) or in-hospital (odds ratio, 0.55; 95% confidence interval; 0.32-0.94; p = 0.03). In-hospital LOS, ICU LOS, ICU-free days, and number of ventilator-free days were similar between the two groups. Trauma patients admitted to ICU during the post-EMP period had decreased odds of ICU mortality and in-hospital mortality. This is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol. Therapeutic, level III.

Incidence, risk factors, and outcomes for sepsis-associated delirium in patients with mechanical ventilation: A sub-analysis of a multicenter randomized controlled trial

PurposeThis study aimed to investigate incidence, risk factors, and outcomes for sepsis-associated delirium (SAD) in mechanically ventilated patients. Materials and methodsWe performed a retrospective post-hoc analysis of the DExmedetomidine for Sepsis in Intensive care unit Randomized Evaluation (DESIRE) trial. Outcomes included 28-day mortality, ventilator-free days, length of ICU stay, self-extubation, and re-intubation. Multivariable analysis was performed to identify variables independently associated with SAD. ResultsWe retrospectively divided the patients into two groups: delirium group (n = 89) and non-delirium group (n = 98). There were no significant differences between the groups in 28-day mortality, self-extubation, and re-intubation. The number of ventilator-free days was significantly less in the delirium vs. non-delirium group (17 vs. 22 days, p = .006), and the length of ICU stay was significantly longer in the delirium group (10 vs. 5 days, p = .04). Multivariable analyses revealed that emergency surgery, more doses of midazolam, and fentanyl were independent predictors for SAD. ConclusionsSAD was associated with a less number of ventilator-free days and longer length of ICU stay. Emergency surgery, more doses of midazolam, and fentanyl may be independent risk factors for SAD in mechanically ventilated patients with sepsis.

Acyclovir for Mechanically Ventilated Patients With Herpes Simplex Virus Oropharyngeal Reactivation

The role of herpes simplex virus (HSV) reactivation on morbidity and mortality in patients in the intensive care unit requiring mechanical ventilation remains unknown. To determine whether preemptive treatment with intravenous acyclovir reduces the duration of mechanical ventilation in patients with HSV oropharyngeal reactivation. A double-blind, placebo-controlled randomized clinical trial was conducted in 16 intensive care units in France. Participants included 239 adults (age, >18 years) who received mechanical ventilation for at least 96 hours and continued to receive mechanical ventilation for 48 hours or more, with HSV oropharyngeal reactivation. Patients were enrolled between February 2, 2014, and February 22, 2018. Participants were randomized to receive intravenous acyclovir, 5 mg/kg, 3 times daily for 14 days or a matching placebo. The primary end point was ventilator-free days from randomization to day 60. Prespecified secondary outcomes included mortality at 60 days. Main analyses were conducted on an intention-to-treat basis. Of 239 patients enrolled and randomized, 1 patient withdrew consent, leaving 238 patients, with 119 patients in both the acyclovir and placebo (control) groups (median [IQR] age, 61 [50-70] years; 76 [32%] women) available for primary outcome measurement. On day 60, the median (IQR) numbers of ventilator-free days were 35 (0-53) for acyclovir recipients and 36 (0-50]) for controls (P = .17 for between-group comparison). Among secondary outcomes, 26 patients (22%) and 39 patients (33%) had died at day 60 (risk difference, 0.11, 95% CI, -0.004 to 0.22, P = .06). The adverse event frequency was similar for both groups (28% in the acyclovir group and 23% in the placebo group, P = .40), particularly acute renal failure post randomization affecting 3 acyclovir recipients (3%) and 2 controls (2%). Four patients (3%) in the acyclovir group vs none in the placebo group stopped the study drug for treatment-related adverse events. In patients receiving mechanical ventilation for 96 hours or more with HSV reactivation in the throat, use of acyclovir, 5 mg/kg, 3 times daily for 14 days, did not increase the number of ventilator-free days at day 60, compared with placebo. These findings do not appear to support routine preemptive use of acyclovir in this setting. ClinicalTrials.gov identifier: NCT02152358.

Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest

BackgroundPatients who are treated with targeted temperature management after out-of-hospital cardiac arrest with shockable rhythm are at increased risk for ventilator-associated pneumonia. The benefit of preventive short-term antibiotic therapy has not been shown.MethodsWe conducted a multicenter, double-blind, randomized, placebo-controlled trial involving adult patients (>18 years of age) in intensive care units (ICUs) who were being mechanically ventilated after out-of-hospital cardiac arrest related to initial shockable rhythm and treated with targeted temperature management at 32 to 34°C. Patients with ongoing antibiotic therapy, chronic colonization with multidrug-resistant bacteria, or moribund status were excluded. Either intravenous amoxicillin–clavulanate (at doses of 1 g and 200 mg, respectively) or placebo was administered three times a day for 2 days, starting less than 6 hours after the cardiac arrest. The primary outcome was early ventilator-associated pneumonia (during the first 7 days of hospitalization). An independent adjudication committee determined diagnoses of ventilator-associated pneumonia.ResultsA total of 198 patients underwent randomization, and 194 were included in the analysis. After adjudication, 60 cases of ventilator-associated pneumonia were confirmed, including 51 of early ventilator-associated pneumonia. The incidence of early ventilator-associated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P=0.03). No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respectively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%). At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups.ConclusionsA 2-day course of antibiotic therapy with amoxicillin–clavulanate in patients receiving a 32-to-34°C targeted temperature management strategy after out-of-hospital cardiac arrest with initial shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia than placebo. No significant between-group differences were observed for other key clinical variables, such as ventilator-free days and mortality at day 28. (Funded by the French Ministry of Health; ANTHARTIC ClinicalTrials.gov number, NCT02186951.)

Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis.

BackgroundPhysical therapy can prevent functional impairments and improve the quality of life of patients after hospital discharge. However, the effect of early mobilization on patients with a critical illness remains unclear. This study was performed to assess the evidence available regarding the effect of early mobilization on critically ill patients in the intensive care unit (ICU).MethodsElectronic databases were searched from their inception to March 21, 2019. Randomized controlled trials (RCTs) comprising critically ill patients who received early mobilization were included. The methodological quality and risk of bias of each eligible trial were assessed using the Cochrane Collaboration tool. Data were extracted using a standard collection form each included study, and processed using the Mantel-Haenszel (M-H) or inverse-variance (I-V) test in the STATA v12.0 statistical software.ResultsA total of 1,898 records were screened. Twenty-three RCTs comprising 2,308 critically ill patients were ultimately included. Early mobilization decreased the incidence of ICU-acquired weakness (ICU-AW) at hospital discharge (three studies, 190 patients, relative risk (RR): 0.60, 95% confidence interval (CI) [0.40, 0.90]; p = 0.013, I2 = 0.0%), increased the number of patients who were able to stand (one study, 50 patients, 90% vs. 62%, p = 0.02), increased the number of ventilator-free days (six studies, 745 patients, standardized mean difference (SMD): 0.17, 95% CI [0.02, 0.31]; p = 0.023, I2 = 35.5%) during hospitalization, increased the distance the patient was able to walk unassisted (one study, 104 patients, 33.4 (0–91.4) meters vs. 0 (0–30.4) meters, p = 0.004) at hospital discharge, and increased the discharged-to-home rate (seven studies, 793 patients, RR: 1.16, 95% CI [1.00, 1.34]; p = 0.046). The mortality (28-day, ICU and hospital) and adverse event rates were moderately increased by early mobilization, but the differences were statistically non-significant. However, due to the substantial heterogeneity among the included studies, and the low quality of the evidence, the results of this study should be interpreted with caution. Publication bias was not identified.ConclusionsEarly mobilization appears to decrease the incidence of ICU-AW, improve the functional capacity, and increase the number of ventilator-free days and the discharged-to-home rate for patients with a critical illness in the ICU setting.

¿Cuál es el volumen tidal ideal en pacientes ingresados en UCI sin SDRA que requieren ventilación mecánica más de 24 horas?

La protección pulmonar en los pacientes críticos sometidos a ventilación mecánica, es uno de los objetivos que persiguen los facultativos cuando utilizan esta herramienta terapéutica; que, pese a todos sus beneficios y su uso extendido, no está exenta de efectos adversos. El apoyo ventilatorio en el Síndrome de Distrés Respiratorio Agudo (SDRA) consta de una serie de medidas, entre las que se incluye el volumen tidal (VT) bajo. Pero, ¿qué ocurre con aquellos pacientes que precisan más de 24 horas de ventilación mecánica sin criterios de SDRA? ¿Cuál es su VT recomendado? La evidencia científica apoya que la ventilación con VT bajo se asocia a la disminución del número de complicaciones respiratorias en comparación con VT alto (si bien, los ensayos clínicos preexistentes comparaban volúmenes bajos de 6 ml/kg vs volúmenes muy altos, de más de 10 ml/kg) (1)(2). Por contra, los VT bajos pueden incrementar la necesidad de sedación, aumentan la tasa de asincronía entre el paciente y el ventilador e incluso algunos trabajos hablan de que podría aumentar el riesgo de delirio.(3) El objetivo principal del estudio fue determinar si una estrategia de ventilación con VT bajo es más efectiva que una estrategia de VT intermedio en función del número de días libres de ventilación en el día 28 en los pacientes vivos tras la aleatorización. ABSTRACT Which is the ideal tidal volume for patients in ICU without ARDS who need mechanical ventilation more than 24h? Invasive ventilation, one of the most frequently applied strategies in the intensive care unit (ICU), is increasingly recognized as a potentially harmful intervention. There is evidence that lung-protective ventilation using low tidal volumes improves survival in patients with acute respiratory distress syndrome (ARDS), but it is less certain whether tidal volume restriction benefits patients without ARDS. Two randomized clinical trials found tidal volume reduction to be associated with a lower number of pulmonary complications in patients without ARDS, and 2 individual patient data meta-analyses suggested that tidal volume reduction may shorten the time spent on the ventilator and duration of stay in the ICU and hospital. However, the use of low tidal volumes could lead to an in- creased need for sedation because of higher respiratory rate or patient-ventilator asynchrony and, possibly, self- inflicted lung injury due to compensatory injurious inspiratory efforts. In addition, it has been suggested that low tidal volumes may increase the risk of delirium. The Protective Ventilation in Patients Without ARDS (PReVENT) trial was conducted to test whether a ventilation strategy using low tidal volumes is superior to a ventilation strategy using intermediate tidal volumes with respect to the number of ventilator-free days and alive at day.

Bag-Valve-Mask Ventilation After Induction for Intubation: PreVenting Hypoxemia?: July 2019 Annals of Emergency Medicine Journal Club

Bag-Valve-Mask Ventilation After Induction for Intubation: PreVenting Hypoxemia?: July 2019 Annals of Emergency Medicine Journal Club

Airway pressure release ventilation during acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials

BackgroundAirway pressure release ventilation (APRV) has been considered a tempting mode of ventilation during acute respiratory failure within the concept of open lung ventilation. We performed a systematic review and meta-analysis to verify whether adult patients with hypoxemic respiratory failure have a higher number of ventilator-free days at day 28 when ventilated in APRV compared to conventional ventilation strategy. Secondary outcomes were difference in PaO2/FiO2 at day 3, ICU length of stay (LOS), ICU and hospital mortality, mean arterial pressure (MAP), risk of barotrauma and level of sedation. We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials database until December 2018.ResultsWe considered five RCTs for the analysis enrolling a total of 330 patients. For ventilatory-free day at day 28, the overall mean difference (MD) between APRV and conventional ventilation was 6.04 days (95%CI 2.12, 9.96, p = 0.003; I2 = 65%, p = 0.02). Patients treated with APRV had a lower ICU LOS than patients treated with conventional ventilation (MD 3.94 days [95%CI 1.44, 6.45, p = 0.002; I2 = 37%, p = 0.19]) and a lower hospital mortality (RD 0.16 [95%CI 0.02, 0.29, p = 0.03; I2 = 0, p = 0.5]). PaO2/FiO2 at day 3 was not different between the two groups (MD 40.48 mmHg [95%CI − 25.78, 106.73, p = 0.23; I2 = 92%, p < 0.001]). MAP was significantly higher during APRV (MD 5 mmHg [95%CI 1.43, 8.58, p = 0.006; I2 = 0%, p = 0.92]). Then, there was no difference regarding the onset of pneumothorax under the two ventilation strategies (RR 1.94 [95%CI 0.54, 6.94, p = 0.31; I2 = 0%, p = 0.74]). ICU mortality and sedation level were not included into quantitative analysis.ConclusionThis study showed a higher number of ventilator-free days at 28 day and a lower hospital mortality in acute hypoxemic patients treated with APRV than conventional ventilation, without any negative hemodynamic impact or higher risk of barotrauma. However, these results need to be interpreted with caution because of the low-quality evidence supporting them and the moderate heterogeneity found. Other well-designed RCTs need to be conducted to confirm our findings.

Neutrophil Extracellular Traps Are Elevated in Patients with Pneumonia-related Acute Respiratory Distress Syndrome.

Neutrophil extracellular traps have been associated with tissue damage. Whether these are involved in the pathogenesis of human acute respiratory distress syndrome (ARDS) and could be a potential therapeutic target is unknown. The authors quantified bronchoalveolar and blood neutrophil extracellular traps in patients with pneumonia-related ARDS and assessed their relationship with ventilator-free days. Immunocompetent patients with pneumonia and moderate or severe ARDS (n = 35) and controls (n = 4) were included in a prospective monocentric study. Neutrophil extracellular trap concentrations were quantified (as DNA-myeloperoxidase complexes) in bronchoalveolar lavage fluid and serum by enzyme-linked immunosorbent assay. The relationship between bronchoalveolar lavage neutrophil extracellular trap concentrations and the primary clinical endpoint (i.e., the number of live ventilator-free days at day 28) was assessed using linear regression analyses. There was no significant relationship between bronchoalveolar lavage neutrophil extracellular trap concentrations and ventilator-free days by multiple regression analysis (β coefficient = 2.40; 95% CI, -2.13 to 6.92; P = 0.288). Neutrophil extracellular trap concentrations were significantly higher in bronchoalveolar lavage than in blood of ARDS patients (median [first to third quartiles]:154 [74 to 1,000] vs. 26 [4 to 68] arbitrary units, difference: -94; 95% CI, -341 to -57; P < 0.0001). Bronchoalveolar concentrations of patients were higher than those of controls (154 [74 to 1,000] vs. 4 [4 to 4] arbitrary units, difference: -150; 95% CI, -996 to -64; P < 0.001) and associated with bronchoalveolar interleukin-8 (Spearman's ρ = 0.42; P = 0.012) and neutrophil concentrations (ρ = 0.57; P < 0.0001). Intensive care unit mortality (12%, n = 2 of 17 vs. 17%, n = 3 of 18; P > 0.99) and the number of ventilator-free days at day 28 (22 [14 to 25] vs. 14 [0 to 21] days; difference: -5; 95% CI, -15 to 0; P = 0.066) did not significantly differ between patients with higher (n = 17) versus lower (n = 18) bronchoalveolar neutrophil extracellular trap concentrations. Bronchoalveolar neutrophil extracellular trap concentration was not significantly associated with mechanical ventilation duration in pneumonia-related ARDS.

Acyclovir for Mechanically Ventilated Patients with Herpes Simplex Virus Oropharyngeal Reactivation

Background: The role of herpes simplex virus (HSV) reactivation on morbidity/mortality in intensive care unit patients requiring mechanical ventilation remains controversial. Methods: In this multicentre study, non-immunosuppressed adults >18 years old, mechanically ventilated for at least 96 hours and expected to remain on mechanical ventilation for ≥48 hours, with HSV oropharyngeal reactivation, were double-blindly randomized to receive intravenous acyclovir (5 mg/kg tid, for 14 days) or a matching placebo (controls). Randomisation (1:1) was stratified by study site, pre-randomisation mechanical ventilation duration and number of organ failure, and performed using a secure web-based system. The primary endpoint was ventilator-free days from randomisation to day 60. Findings: The 16 participating centres randomised 238 patients: 119 to receive acyclovir and 119 the placebo. On day 60, for acyclovir recipients and controls, respectively, the median (IQR) numbers of ventilator-free days were 35 (0-53) and 36 (0-50) (p=0.17 for between-group comparison); 26 (22%) and 39 (33%) patients had died (risk difference, 0.11, 95% CI, - 0.004 to 0.22, p=0.059). The adverse-event frequency was similar for both groups (28% in the acyclovir group and 23% in the placebo group, p= 0.4), particularly with acute renal failure post-randomisation affecting three acyclovir recipients and two controls. Four patients in the acyclovir group (vs. none in the placebo group) stopped the study drug for treatment-related adverse event. Interpretation: In non-immunosuppressed patients mechanically ventilated for ≥96 hours with HSV reactivation in the throat, intravenous acyclovir use (5 mg/kg tid) did not increase the number of ventilator-free days on day 60, compared to a placebo. Trial Registration: The trial is registered on ClinicalTrials.gov, number NCT02152358. Funding Statement: Direction de la Recherche Clinique et du Developpement and the French Ministry of Health (Programme Hospitalier de Recherche Clinique 2011). Declaration of Interests: No potential conflict of interest relevant to this article was reported. The following conflicts of interest are outside the area of the article. Dr Luyt reports receiving lecture fees from ThermoFischer Brahms, Biomerieux, Merck Sharp & Dohme and Aerogen, and consulting fees from Bayer Healthcare, Carmat and Faron. Dr Jaber reports receiving consulting fees from Drager, Fisher-Paykel, Xenios-Fresenius Medical and Medtronic. Dr Rimmele reports receiving consulting or lecture fees from Fresenius Medical Care, Baxter, Medtronic, Biomerieux, BBraun. Dr Lu reports receiving lectures fees from Aerogen. Dr Combes reports receiving grant support and lectures fees from Maquet and Baxter and consulting fees from Hemovent. Dr Wolff reports receiving consulting fees from Merck Sharp & Dohme, Inotrem, Correvio, Menarini and Pfizer. Dr Chastre reports receiving lecture and consulting fees from Bayer Healthcare, Pfizer, Merck Sharp & Dohme, Aridis, the Medicines Company, Astra Zenecca, Tigenix, Accelerate Diagnotics, Inotrem and Glaxo Smith Kline Ethics Approval Statement: An independent Ethics Committee (Comite de Protection des Personnes Sud Mediterranee 5) approved its protocol.

Impact of Continuous Ketamine Infusion Versus Alternative Regimens on Mortality Among Burn Intensive Care Unit Patients: Implications for Prolonged Field Care.

The military is rapidly moving into a battlespace in which prolonged holding times in the field are probable. Ketamine provides hemodynamic support and has analgesic properties, but the safety of prolonged infusions is unclear. We compare in-hospital mortality between intubated burn intensive care unit (ICU) patients receiving prolonged ketamine infusion lasting =7 days or until death versus controls. We conducted a before/after cohort study of patients undergoing admission to a burn ICU with intubation within the first 24 hours as part of treatment for thermal burns. In January 2012, this ICU implemented a novel continuous ketamine infusions protocol. We performed a preintervention and postintervention cohort analysis. We identified 2394 patients meeting our inclusion criteria-475 in the ketamine group and 1919 in the control group. Regarding burn total body surface area (TBSA) involvement, there were 1533 in the <10% group, 586 in the 11-30% group, and 281 in the >31% group. The median number of ventilator-free days within the first 30 days did not vary significantly between the ketamine group and the control group: 8.5 days (interquartile range [IQR] 1-16 days) versus 8 days (IQR 3-13 days, p = .442). Subjects receiving ketamine had higher mortality rates: 59.4% (n = 117) versus 40.6% (n = 80, p < .001), with an odds ratio for in-hospital mortality of 7.51 (95% CI 5.53-10.20, p < .001). When controlling for TBSA category, ventilator days and vasopressor administration, there was no association between ketamine and in-hospital mortality (0.66, 0.41-1.05, p = .08). When controlling for confounders, we found no difference in in-hospital mortality between the prolonged ketamine infusion recipients versus non-recipients.

Lung-protective Ventilation for Acute Respiratory Distress Syndrome.

Lung-protective Ventilation for Acute Respiratory Distress Syndrome.

Interventions for preventing intensive care unit delirium in adults.

Interventions for preventing intensive care unit delirium in adults.

Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS

It remains uncertain whether invasive ventilation should use low tidal volumes in critically ill patients without acute respiratory distress syndrome (ARDS). To determine whether a low tidal volume ventilation strategy is more effective than an intermediate tidal volume strategy. A randomized clinical trial, conducted from September 1, 2014, through August 20, 2017, including patients without ARDS expected to not be extubated within 24 hours after start of ventilation from 6 intensive care units in the Netherlands. Invasive ventilation using low tidal volumes (n = 477) or intermediate tidal volumes (n = 484). The primary outcome was the number of ventilator-free days and alive at day 28. Secondary outcomes included length of ICU and hospital stay; ICU, hospital, and 28- and 90-day mortality; and development of ARDS, pneumonia, severe atelectasis, or pneumothorax. In total, 961 patients (65% male), with a median age of 68 years (interquartile range [IQR], 59-76), were enrolled. At day 28, 475 patients in the low tidal volume group had a median of 21 ventilator-free days (IQR, 0-26), and 480 patients in the intermediate tidal volume group had a median of 21 ventilator-free days (IQR, 0-26) (mean difference, -0.27 [95% CI, -1.74 to 1.19]; P = .71). There was no significant difference in ICU (median, 6 vs 6 days; 0.39 [-1.09 to 1.89]; P = .58) and hospital (median, 14 vs 15 days; -0.60 [-3.52 to 2.31]; P = .68) length of stay or 28-day (34.9% vs 32.1%; hazard ratio [HR], 1.12 [0.90 to 1.40]; P = .30) and 90-day (39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54) mortality. There was no significant difference in the percentage of patients developing the following adverse events: ARDS (3.8% vs 5.0%; risk ratio [RR], 0.86 [0.59 to 1.24]; P = .38), pneumonia (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67), severe atelectasis (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94), and pneumothorax (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55). In patients in the ICU without ARDS who were expected not to be extubated within 24 hours of randomization, a low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy. ClinicalTrials.gov Identifier: NCT02153294.

Incidence and outcome of weaning from mechanical ventilation in medical wards at Thammasat University Hospital.

BackgroundWeaning from mechanical ventilation is classified as simple, difficult, or prolonged according to weaning process. Theoretically, simple weaning group usually has better clinical outcomes than non-simple group; however, the results of previous studies were still inconsistent.ObjectivesThe purpose of the study was to determine the incidence, predictors, and outcomes of ventilator weaning and causes of weaning failure.MethodsA prospective observational study was performed between June and December 2013 in all patients (n = 164) who required mechanical ventilation with endotracheal intubation in medical wards at Thammasat University Hospital, Thailand. Duration of weaning, causes of weaning failure, extubation, reintubation, tracheostomy, number of ventilator-free days within 28 days, length of hospital stay, and hospital mortality were measured.Results103 patients were eligible for final analysis. Mean ± SD age was 65.1±17.5 years and 55.3% were males. The incidences of simple, difficult and prolonged weaning were 46.6%, 36.9% and 16.5%, respectively. The mortality rates for simple, difficult, and prolonged weaning were 0%, 10.5% and 23.5% (p = 0.006), respectively. The 3 causes of weaning failure in non-simple weaning were bronchospasm, pneumonia, and malnutrition.ConclusionsNon-simple weaning increased mortality. Bronchospasm, pneumonia, and malnutrition were key risk factors for weaning failure. Strategies are needed to minimize their effects.

Prevention of early ventilation-acquired pneumonia (VAP) in comatose brain-injured patients by a single dose of ceftriaxone: PROPHY-VAP study protocol, a multicentre, randomised, double-blind, placebo-controlled trial

IntroductionVentilator-associated pneumonia (VAP) is the first cause of healthcare-associated infections in intensive care units (ICUs) and brain injury is one of the main risk factors for early-onset VAP. Antibiotic prophylaxis...

P(v-a)CO2/C(a-v)O2-directed resuscitation does not improve prognosis compared with SvO2 in severe sepsis and septic shock: A prospective multicenter randomized controlled clinical study

PurposesThe present study examined the value of P(v-a)CO2/C(a-v)O2 compared with ScvO2 as a target for clinical resuscitation of severe sepsis/septic shock. Materials and methods228 patients were randomly divided into a P(v-a)CO2/C(a-v)O2-targeted and a ScvO2-targeted therapy group. The effects on hemodynamics, interventional intensity, and outcome were recorded and analyzed. ResultsThe mean arterial pressure (MAP) of the P(v-a)CO2/C(a-v)O2-targeted therapy group was significantly higher at 3 h, 12 h, 24 h, and 3 days (P < .05). The P(v-a)CO2/C(a-v)O2 of the ScvO2-targeted therapy group was significantly higher at each time point after resuscitation (P < .05). However, the CVP, lactate, urine output, ScvO2, and P(v-a)CO2 were not significantly improved. The P(v-a)CO2/C(a-v)O2-targeted therapy group used a smaller fluid volume and required fewer red blood cell transfusions and vasoactive drugs, but these results were also not significant. There were no differences between 28-day and 60-day mortality, APACHEII and SOFA scores, ICU length of stay, residence length of stay, number of days free of vasoactive drugs, or number of ventilator-free days. Post hoc tests revealed no significant differences between these two groups in 28-day survival. ConclusionP(v-a)CO2/C(a-v)O2-directed resuscitation did not improve prognosis compared with ScvO2 in severe sepsis and septic shock.ClinicalTrials.gov Identifier NCT01877798

Comparison of high flow nasal cannula oxygen and conventional oxygen therapy on ventilatory support duration during acute-on-chronic respiratory failure: study protocol of a multicentre, randomised, controlled trial. The ‘HIGH-FLOW ACRF’ study

IntroductionThis study protocol describes a trial designed to investigate whether high-flow heated and humidified nasal oxygen (HFHO) therapy in patients with hypercapnic acute respiratory failure (ARF) reduces the need of...

Effect of In-Bed Leg Cycling and Electrical Stimulation of the Quadriceps on Global Muscle Strength in Critically Ill Adults

Early in-bed cycling and electrical muscle stimulation may improve the benefits of rehabilitation in patients in the intensive care unit (ICU). To investigate whether early in-bed leg cycling plus electrical stimulation of the quadriceps muscles added to standardized early rehabilitation would result in greater muscle strength at discharge from the ICU. Single-center, randomized clinical trial enrolling critically ill adult patients at 1 ICU within an 1100-bed hospital in France. Enrollment lasted from July 2014 to June 2016 and there was a 6-month follow-up, which ended on November 24, 2016. Patients were randomized to early in-bed leg cycling plus electrical stimulation of the quadriceps muscles added to standardized early rehabilitation (n = 159) or standardized early rehabilitation alone (usual care) (n = 155). The primary outcome was muscle strength at discharge from the ICU assessed by physiotherapists blinded to treatment group using the Medical Research Council grading system (score range, 0-60 points; a higher score reflects better muscle strength; minimal clinically important difference of 4 points). Secondary outcomes at ICU discharge included the number of ventilator-free days and ICU Mobility Scale score (range, 0-10; a higher score reflects better walking capability). Functional autonomy and health-related quality of life were assessed at 6 months. Among 314 randomized patients, 312 (mean age, 66 years; women, 36%; receiving mechanical ventilation at study inclusion, 78%) completed the study and were included in the analysis. The median global Medical Research Council score at ICU discharge was 48 (interquartile range [IQR], 29 to 58) in the intervention group and 51 (IQR, 37 to 58) in the usual care group (median difference, -3.0 [95% CI, -7.0 to 2.8]; P = .28). The ICU Mobility Scale score at ICU discharge was 6 (IQR, 3 to 9) in both groups (median difference, 0 [95% CI, -1 to 2]; P = .52). The median number of ventilator-free days at day 28 was 21 (IQR, 6 to 25) in the intervention group and 22 (IQR, 10 to 25) in the usual care group (median difference, 1 [95% CI, -2 to 3]; P = .24). Clinically significant events occurred during mobilization sessions in 7 patients (4.4%) in the intervention group and in 9 patients (5.8%) in the usual care group. There were no significant between-group differences in the outcomes assessed at 6 months. In this single-center randomized clinical trial involving patients admitted to the ICU, adding early in-bed leg cycling exercises and electrical stimulation of the quadriceps muscles to a standardized early rehabilitation program did not improve global muscle strength at discharge from the ICU. ClinicalTrials.gov Identifier: NCT02185989.