Prolonged Ventilation Research Articles

A clinical study on the outcomes of tracheostomy in a tertiary care center: a prospective observational study

Background: Tracheostomy is most commonly performed in patients who have difficulty in weaning off a ventilator. This surgical procedure is associated with complications. The present study was aimed to evaluate the outcomes of tracheostomy with primary and secondary objectives. Methods: This study was done in department of ENT, KIMS Health, Trivandrum, Kerala. Based on the inclusion and exclusion criteria 81 patients were included in the study. Study procedure was explained and informed consent was obtained from close relatives or kin of patients. Demographic, clinical and complication data was collected from the patients and analysed with Statistical Package for Social Sciences (20.0 version) software. Correlation was done between complications and period of decanulation. Results: The study was done in 81 patients under gone tracheostomy. Maximum number of patients had age between 61-80 years. Males were more number than females. Portex type of tube used in maximum patients. 70 patients underwent elective and 11 underwent emergency tracheostomy. 74 patients underwent surgery in operation theatre and 5 in an ICU. Prolonged ventilation is the major indication for tracheostomy. Out of 81 patients 55 did not show any complications. 9 patients developed granulations. Significant correlation was observed between complications with period of decanulation. Conclusions: Postoperative care, regular follow up and proper nursing home care is essential for the patients who require prolonged tracheostomy and also to prevent complications with speedy recovery.

Distribution of thrombus predicts severe reperfusion pulmonary edema after pulmonary endarterectomy

ObjectivesPatients underwent pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to investigate the effect of thrombus distribution on the occurrence of severe reperfusion pulmonary edema (RPE) and identify specific parameters for predicting severe RPE. MethodsPatients with CTEPH who underwent PEA surgery were retrospectively analyzed. The thrombus in pulmonary arteries were evaluated through computed tomography pulmonary angiography. Based on presence of prolonged artificial ventilation, extracorporeal membrane oxygenation required, or perioperative death due to RPE, the patients were divided into the severe RPE and without severe RPE groups. Main resultsAmong the 77 patients (29 women), 16 (20.8%) patients developed severe RPE. The right major pulmonary artery (RPA) (0.64[0.58, 0.73] vs 0.58[0.49, 0.64]; p = 0.008) and pulmonary artery trunk (PAT) thrombus ratios (0.48[0.44, 0.61] vs 0.42[0.39, 0.50]; p = 0.009) (the PAT ratio is expressed as the sum of the right middle lobe clot burden and right lower lobe clot burden divided by the total clot burden multiplied by 100) of the severe RPE group was significantly higher than that of the without severe RPE group. Receiver operator characteristics curve identified a PAT ratio of 43.4% as the threshold with areas under the curve = 0.71(95%CI 0.582; 0.841) for the development of severe RPE (sensitivity 0.875, specificity 0.541). The logistic regression analysis demonstrated that age, period from symptom onset to PEA, NT-pro BNP, preoperative mPAP, preoperative PVR, RPA ratio, and PAT ratio were associated with the development of severe RPE. Multivariable logistic regression analysis revealed PAT ratio (odds ratio = 10.2; 95% confidence interval 1.87, 55.53, P = 0.007) and period from symptom onset to PEA (OR = 1.01; 95% CI = 1.00–1.02, P = 0.015) as independent risk factors for the development of severe RPE. ConclusionsThe thrombus distribution could be a key factor in the severity of RPE. PAT ratio and medical history could predict the development of severe RPE.

Ultrasonography of Diaphragm to Predict Extubation Outcome.

Background and objectives An intensivist's decision, when it comes to weaning off a patient from mechanical ventilationand extubation, is based on many criteria.Problems can be associated with both prolonged ventilation and early extubation. Therefore, for optimal functioning of the diaphragm, the primary inspiratory muscle, it is important to resume spontaneous ventilation after extubation irrespective of the cause of respiratory failure. Thus, diaphragmatic parameters can prove useful in predicting the rate of success of extubation. However, till date in our institute, extubation has been done using only the standard parameters; hence, in this study, diaphragmatic parameters obtained by ultrasonography-diaphragmatic thickening fraction (dTF) and diaphragmatic excursion (DE) have been studied to predict extubation outcome. The objectives of this study are to (1) measure the diaphragmatic thickening fraction (dTF) in % and diaphragmatic excursion (DE) in cm before and after the spontaneous breathing trial (SBT) and (2) compare dTF and DE with standard extubation parameters in order to predict extubation outcome. Materials and methods This is a prospective, double-blind, observational study. The number of patients involved was 41. After obtaining ethical committee clearance, informed consent was taken from the patients' attendants. In this study, we divided doctors into the treating team and the research team. The treating team comprised the primary doctors working in the intensive care unit (ICU), and they evaluated the patients' readiness for pressure support ventilation. The research team performed diaphragmatic ultrasonography on those patients who met the inclusion criteria. The treating team was blinded to the dTF and DE results obtained by the research team. Prior to extubation, all the patients had to satisfy the standard extubation criteria followed at R. L. Jalappa Hospital and Research Centre (RLJH), Kolar Results We observed that 68.29 (%) of the patients with normal dTF and DE values and 21.95(%) with slightly lower dTF and DE values were extubated successfully, and 7.31 (%) with normal dTF and DE values were reintubated; 2.43 (%) were extubated onto non-invasive ventilation (NIV). Conclusion From our study, we have concluded that bedside ultrasonography of the diaphragm, that is the measurement of diaphragm for dTF and DE always compliments the standard criteria for extubation and can be used for weaning the patients from mechanical ventilation, as bedside ultrasonography is not only easy and convenient but also a reliable parameter in predicting the outcome of weaning,however, it cannot be used as a sole criteria.

Early Outcome of Coronary Artery Bypass Grafting in Obese and Non Obese Patients

Objective: To determine the impact of body mass index (BMI) on short-term outcomes like; renal failure, prolonged ventilation and mortality after CABG surgery. Methodology: This prospective comparative study was conducted at the Cardiac Surgery Department, Pervaiz Elahi Institute of Cardiology, Bahawalpur from February to December 2021. A total of 148 patients were enrolled after taking written consent and data was collected through predesign proforma sheets, including; clinical history, investigation and early outcomes in term of (renal failure, prolonged ventilation, and mortality). SPSS 23 was used to analyze data with statistically significant p-value < 0.05. Results: The findings showed that average age of research participants were 57.14 ± 3.07 (age range 30-73 years) and 121 (81.76%) male compared with 27(18.24%) female patients were enrolled with insignificant p-value of 0.730. In this study prolonged ventilation was found in 5(6.76%) obese and 8(10.81%) non-obese patients with insignificant p-value of 0.070. Renal Failure was found in 2 (2.70%) obese and 8 (10.81%) non-obese patients with significant p-value of 0.02 and mortality in 4(5.41%) obese and 2 (2.70%) non-obese patients with significant p-value of 0.0482. Conclusion: The results of the current investigation demonstrated that an obese BMI was a reliable indicator of morbidity or mortality following CABG.

Association of Conventional Ultrafiltration on Postoperative Pulmonary Complications

BackgroundPostoperative pulmonary complications increase mortality after cardiac surgery. Conventional ultrafiltration may reduce pulmonary complications by removing mediators of bypass-induced inflammation and countering hemodilution. We tested the primary hypothesis that conventional ultrafiltration reduces postoperative pulmonary complications, and secondarily, improves early pulmonary function assessed by the ratio of PaO2 to fractional inspired oxygen concentration. MethodsThis retrospective analysis compared the incidence of postoperative pulmonary complications in adult patients who underwent cardiac surgery, with and without the use of conventional ultrafiltration, by using logistic regression with adjustment for confounding variables. The primary outcome was a composite of reintubation, prolonged ventilation, pneumonia, or pleural effusion. Secondarily, we examined early postoperative lung function using a quantile regression model. We also explored whether red blood cell transfusion differed between groups. ResultsOf 8026 patients, 1043 (13%) received conventional ultrafiltration. After adjustment for confounding variables, the incidence of the composite primary outcome was higher in the conventional ultrafiltration group (12.1% vs 9.9%; P = .03), with an estimated odds ratio of 1.25 (95% CI, 1.02-1.53; P = .03). The median (quantiles) PaO2–to–fractional inspired oxygen concentration ratio was 373 (303-433) vs 368 (303-428), with the estimated adjusted difference in medians of 5 (95% CI, −5.9 to 16; P = .37). The estimated odds ratio of intraoperative transfusion was 1.38 (95% CI, 1.19-1.60; P < .0001) and for postoperative transfusion was 1.30 (95% CI, 1.14-1.49; P = .0001). ConclusionsUse of conventional ultrafiltration was not associated with a reduction in the composite of postoperative pulmonary complications or improved early pulmonary function. We found no evidence of benefit from use of conventional ultrafiltration during cardiac surgery.

Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation—Evolving Concepts

Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient's respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.

Progression of distal aorta after endovascular fenestration/stenting in acute type A aortic dissection with malperfusion syndrome

ObjectiveThe study objective was to evaluate the progression of dissected distal aorta in patients with acute type A aortic dissection with malperfusion syndrome treated with endovascular fenestration/stenting and delayed open aortic repair. MethodsFrom 1996 to 2021, 927 patients presented with acute type A aortic dissection. Of these, 534 had DeBakey I dissection with no malperfusion syndrome and underwent emergency open aortic repair (no malperfusion syndrome group), whereas 97 patients with malperfusion syndrome underwent fenestration/stenting and delayed open aortic repair (malperfusion syndrome group). Sixty-three patients with malperfusion syndrome treated with fenestration/stenting were excluded due to no open aortic repair, including death from organ failure (n = 31), death from aortic rupture (n = 16), and discharged alive (n = 16). ResultsCompared with the no malperfusion syndrome group, the malperfusion syndrome group had more patients with acute renal failure (60% vs 4.3%, P < .001). Both groups had similar aortic root and arch procedures. Postoperatively, the malperfusion syndrome group had similar operative mortality (5.2% vs 7.9%, P = .35) and permanent dialysis (4.7% vs 2.9%, P = .50), but more new-onset dialysis (22% vs 7.7%, P < .001) and prolonged ventilation (72% vs 49%, P < .001). The growth rate of the aortic arch (0.38 vs 0.35 mm/year, P = .81) was similar between the malperfusion syndrome and no malperfusion syndrome groups. The descending thoracic aorta growth rate (1.03 vs 0.68 mm/year, P = .001) and abdominal aorta growth rate (0.76 vs 0.59 mm/year, P = .02) were significantly higher in the malperfusion syndrome group. The cumulative incidence of reoperation over 10 years (18% vs 18%, P = .81) and 15-year survival outcome (50% vs 48%, P = .43) were similar between the malperfusion syndrome and no malperfusion syndrome groups. ConclusionsEndovascular fenestration/stenting followed by delayed open aortic repair was a valid approach for patients with malperfusion syndrome.

Investigation of the relationship between prolonged ventilation and the Glasgow Prognostic Score after elective isolated coronary bypass surgeries in advanced-age patients

Objectives: Coronary artery bypass graft (CABG) surgeries are the most beneficial treatment method for atherosclerotic heart disease. Prolonged ventilation is a significant condition that poses risks such as infection, renal failure, prolongs hospital stays, and increases treatment costs. In this current study, we aimed to reveal the relationship between prolonged mechanical ventilation and Glasgow Prognostic Score (GPS), in patients aged 65 years and older who underwent isolated CABG. Methods: Patients aged 65 years and over who underwent elective isolated coronary bypass surgery with cardiopulmonary bypass in our clinic, between June 2017 and June 2022, were included in the study retrospectively. The patients who were extubated within eight hours of the surgeries were determined as Group 1, whereas those who were extubated after 8 hours were determined as Group 2. Results: Prolonged ventilation occurred in 101 (20.7%) patients (Group 2). The median age of the 385 patients included in Group 1 and 101 patients in Group 2 was 68 (66 to 91) and 71 (66 to 88) years, respectively (p = 0.216). The two groups were similar in regards to gender, hypertension, smoking, diabetes mellitus, body mass index, history of cerebrovascular accident and left ventricular ejection fraction rates. In the multivariate analysis, left ventricular ejection fraction &amp;lt;35% (OR: 1.136, 95% CI: 1.065-1.652, p = 0.029), total perfusion time (OR: 1.190, 95% CI: 1.040-1.659, p = 0.012), and GPS = 2 (OR: 1.479, 95% CI: 1.130-2.169, p = 0.004) were determined as independent predictors for prolonged ventilation. Conclusions: GPS value calculated preoperatively in elderly patients is a parameter that indicates the increased ventilation need. With the GPS score evaluation, patient groups at risk for prolonged ventilation can be identified and necessary precautions can be undertaken.

Central aortic versus axillary artery cannulation for aortic arch surgery

ObjectiveCentral aortic cannulation for aortic arch surgery has become more popular over the last decade; however, evidence comparing it with axillary artery cannulation remains equivocal. This study compares outcomes of patients who underwent axillary artery and central aortic cannulation for cardiopulmonary bypass during arch surgery. MethodsA retrospective review of 764 patients who underwent aortic arch surgery at our institution between 2005 and 2020 was performed. The primary outcome was failure to achieve uneventful recovery, defined as having experienced at least 1 of the following: in-hospital mortality, stroke, transient ischemic attack, bleeding requiring reoperation, prolonged ventilation, renal failure, mediastinitis, surgical site infection, and pacemaker or implantable cardiac defibrillator implantation. Propensity score matching was used to account for baseline differences across groups. A subgroup analysis of patients undergoing surgery for aneurysmal disease was performed. ResultsBefore matching, the aorta group had more urgent or emergency operations (P = .039), fewer root replacements (P < .001), and more aortic valve replacements (P < .001). After successful matching, there was no difference between the axillary and aorta groups in failure to achieve uneventful recovery, 33% versus 35% (P = .766), in-hospital mortality, 5.3% versus 5.3% (P = 1), or stroke, 8.3% versus 5.3% (P = .264). There were more surgical site infections in the axillary group, 4.8% versus 0.4% (P = .008). Similar results were seen in the aneurysm cohort with no differences in postoperative outcomes between groups. ConclusionsAortic cannulation has a safety profile similar to that of axillary arterial cannulation in aortic arch surgery.

Abstract Number ‐ 113: A Lateral Medullary Infarct Complicated by Central Hypoventilation Syndrome

Introduction A 43‐year‐old male with no known past medical history presented to a primary stroke center for sudden onset headache, nausea, vomiting, and dizziness while driving. A computed tomography angiogram of the head and neck revealed a left vertebral artery occlusion, and the patient was transferred to our comprehensive stroke center for further evaluation and treatment. Upon arrival at our facility, the patient was noted to have a national institute of health stroke scale score of 7 with left facial droop, dysarthria, and right upper extremity dysmetria. A cerebral angiogram revealed a tortuous left vertebral artery with dissection in the V4 segment. Subsequent brain diffusion weighted imaging revealed an acute infarct in the right lateral medulla measuring 1.4cm and several acute cerebellar infarcts. (fig. 1) In the postangiography period, the patient had dysphagia, sialorrhea, multiple aspiration episodes, and oral secretions requiring early tracheostomy and percutaneous endoscopic gastrostomy on hospital day (HD) #6. The subsequent hospital course was complicated by prolonged singultus lasting until HD #23 and repetitive vomiting requiring a transition from a gastric to a gastro‐jejunal feeding tube. Methods A central hypoventilation syndrome (CHS) prolonged ventilator weaning. Despite preserved ability to take large‐volume voluntary breaths, the patient experienced multiple episodes of sleep‐associated apnea and rapid shallow breathing pattern during daily spontaneous breathing trials (SBT). The apnea episodes were registered with ventilator apnea alarms set at 20 seconds. This pattern continued when attempting an SBT utilizing a T‐piece adaptor. The ability to maintain adequate minute ventilation in an asleep state subsequently improved, and the patient was able to tolerate 48 hours of spontaneous breathing with no apnea on HD #35. Results Few cases of CHS secondary to lateral medullary infarction (LMI) have been documented in the literature.(1‐3) As the respiratory drive originates from neurons in the latero‐rostro‐ventral medulla, infarcts in this brainstem region may lead to respiratory failure. More specifically to our patient, ataxic breathing may result from lesions in the rostro‐ventral medulla with yawning and hiccups being seen in lesions to the posterolateral medulla.(4) As our patient presented with a sizable 1.4cm lesion, likely impairing these brainstem centers, it is expected that his symptoms would account for multiple respiratory symptoms. The unique feature of the acquired CHS in the setting of LMI is its unilateral location implying lateralization of the respiratory control. In addition to the aforementioned symptoms, his lesion likely led to prolonged weaning from the ventilator as has been described previously.(5) Conclusions This case raises awareness regarding potentially disastrous complications of the lateral medullary syndrome like central hypoventilation syndrome. We urge caution and careful evaluation of patients with lateral medullary infarctions for disorders of the respiratory control system.

Acquired Tracheomalacia Requiring Urgent Tracheostomy Exchange in Patients With COVID-19.

Tracheostomy for prolonged ventilation of patients with COVID-19 was often delayed due to high viral loads and persistent high ventilatory requirements. With prolonged intubation and significant dose corticosteroid use, patients with COVID-19 are at risk for tracheomalacia, and urgent tube exchange may be required to address persistent cuff leak and to maintain adequate mechanical ventilation. We sought to describe our single center experience with COVID-19 patients requiring tracheostomy and the tracheal complications that followed. We performed a review of patients with COVID-19 who underwent tracheostomy from June 2020 to October 2021. 45 patients were identified; 82.2% survived their index hospitalization. Tracheostomy was performed after 16.4days of mechanical ventilation. 22.2% required urgent exchange to an extended length tracheostomy tube after 7.2days from initial tracheostomy. Placement of an extended length tracheostomy tube can reduce cuff leak in ventilated COVID-19 patients and may be considered during initial tracheostomy placement.

Balloon pulmonary angioplasty followed by pulmonary endarterectomy: Combination treatment for high-surgical-risk patients with chronic thromboembolic pulmonary hypertension.

Our goal was to evaluate the combined effects of balloon pulmonary angioplasty (BPA) followed by pulmonary endarterectomy (PEA) to treat high-surgical-risk patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study included 58 patients with CTEPH who had pulmonary vascular resistance of ≥1000 dyn·s/cm5, mean pulmonary arterial pressure (mPAP) of ≥45 mmHg or mPAP of 38-44 mmHg with comorbidities. Of these, 21 patients underwent the combined therapy of BPA followed by PEA (BPA group) and 37 underwent direct PEA (non-BPA group). Preoperative and postoperative results were compared between the 2 groups. An early postoperative composite event comprised the postoperative use of extracorporeal membrane oxygenation or intra-aortic balloon pump, in-hospital death, rescue BPA, prolonged ventilation, tracheostomy, prolonged stay in the intensive care unit, deep sternal wound infection and cerebral infarction. Before the first intervention (before BPA or direct PEA), patients in the BPA group had a higher mPAP than those in the non-BPA group. After undergoing BPA before PEA, the BPA group demonstrated significantly decreased mPAP and pulmonary vascular resistance (43 vs 52 mmHg, P < 0.001; 636 vs 965 dyn·s/cm5, P = 0.003, respectively) and significantly increased cardiac output (4.1 vs 3.5 l/min, P = 0.041). Notably, the number of patients with the early postoperative composite event was significantly lower in the BPA group than in the non-BPA group (4.8% vs 35.1%, P = 0.011). Compared with direct PEA, the combination therapy of BPA followed by PEA can be a feasible and effective risk-reduction strategy for high-surgical-risk patients with CTEPH.

National trends and clinical outcomes of interventional approaches following admission for infected necrotizing pancreatitis in the United States.

With recent studies demonstrating the efficacy of minimally invasive approaches following infected necrotizing pancreatitis, latest guideline recommendations support their use. However, large-scale studies are lacking, and the national landscape following these guidelines remains poorly characterized. The present study examined trends in intervention strategies and the association of approach on clinical outcomes and resource use in a nationally representative cohort. The 2016-2019 National Inpatient Sample was queried for adult hospitalizations for pancreatitis with infected necrosis. Patients were classified as drain only (DO) if they received only percutaneous or endoscopic drainage, minimally invasive (MIS) if they underwent endoscopic or laparoscopic debridement, and Open if they underwent open debridement. The primary outcome was in-hospital mortality, while secondary outcomes included perioperative complications, home discharge, and resource use. Multivariable regression models were developed to evaluate the association of intervention with clinical and financial endpoints. Of 4,605 patients who received interventions, 1,735 (37.6%) were DO, 1,490 (32.4%) were MIS, and 1,380 (30.0%) were considered Open. The proportion of DO and MIS increased, while Open declined (2016, 47.0%; 2019, 24.6%; p < 0.001). Compared with Open, MIS had lower rates of abdominal compartment syndrome while having greater rates of preoperative closed drainage (31.9% vs. 13.8%, p < 0.001). After adjustment, odds of in-hospital mortality, respiratory failure, prolonged ventilation, and acute kidney injury were significantly higher in the Open cohort compared with MIS. Hospitalization duration was longer ( β , +12.1 days; 95% confidence interval, 6.8-17.5), and costs were higher ( β , +$58.7K; 95% confidence interval, 33.5-83.9) in Open compared with MIS. Minimally invasive approaches for infected pancreatic necrosis have increased over time, while open necrosectomy has declined. Open approaches compared with drainage only or minimally invasive debridement were associated with greater odds of numerous in-hospital complications and resource burden. Prognostic and Epidemiological; Level IV.

Vasoactive-ventilation-renal score and outcomes in infants and children after cardiac surgery.

There is a need to index important clinical characteristics in pediatric cardiac surgery that can be obtained early in the postoperative period and accurately predict postoperative outcomes. A prospective cohort study was conducted in the pediatric cardiac ICU and ward on all children aged <18 years undergoing cardiac surgery for congenital heart disease from September 2018 to October 2020. The vasoactive-ventilation-renal (VVR) score was analyzed to predict outcomes of cardiac surgeries with a comparison of postoperative variables. A total of 199 children underwent cardiac surgery during the study period. The median (interquartile range) age was 2 (0.8-5) years, and the median weight was 9.3 (6-16) kg. The most common diagnoses were ventricular septal defect (46.2%) and tetralogy of Fallot (37.2%). At the 48th h, area under the curve (AUC) (95% CI) values were higher for the VVR score than those for other clinical scores measured. Similarly, at the 48th h, AUC (95% CI) values were higher for the VVR score than those for the other clinical scores measured for the length of stay and mechanical ventilation. The VVR score at 48 h postoperation was found to best correlate with prolonged pediatric intensive care unit (PICU) stay, length of hospitalization, and ventilation duration, with the greatest AUC-receiver operating characteristic (0.715, 0.723, and 0.843, respectively). The 48-h VVR score correlates well with prolonged ICU, hospital stay, and ventilation.

A STUDY ON THE PREDICTORS OF MORBIDITY AND MORTALITY IN ORGANOPHOSPHORUS POISONING

Background: Poisoning from organophosphorus (OP) pesticides can occur as a result of occupational, accidental, or purposive exposure.Cholinergic syndromes,central nervous system (CNS) disorders,and cardiovascular disorders are some of the clinical manifestations.The most common causes of death are cardiovascular and respiratory failure.Aim:To assess various parameters that can predict the outcome of patients suffering from OP poisoning. Materials and Methods: A prospective study was conducted at Government general hospital vijayawada Over a one-year period of time.The clinical history of OP compound exposure and low blood levels of pseudo cholinesterase were used to make the diagnosis of OP poisoning.Results:The current study enrolled 133 patients, 98.5% of whom were suicidal and only 1.5% were exposed accidentally.The majority of cases involved young males,with an F/M ratio of 1:3.2.Younger people and patients who required prolonged ventilator support had a higher mortality rate.The death rate was proportional to the amount of poison consumed. Lag time,organ failure (Acute Renal Failure),and plasma pseudocholinesterase levels are all factors to consider. Acute complications were frequently observed and treated. There was no clear link found between liver dysfunction, electrolyte imbalance, and clinical outcome. Conclusion: According to this case study, mortality is directly proportional to the lag time, amount of OP substances consumed, and clinical severity.Acute renal failure, severity, pseudocholinesterase levels, and duration of ventilatory support are all factors to consider.This study emphasises the importance of prompt diagnosis and the initiation of early and effective treatment, which may result in fewer complications and lower mortality rates

Effects of aggressive and conservative strategies for mechanical ventilation liberation

BackgroundThe optimal approach for transitioning from strict lung protective ventilation to support modes of ventilation when patients determine their own respiratory rate and tidal volume remains unclear. While aggressive liberation from lung protective settings could expedite extubation and prevent harm from prolonged ventilation and sedation, conservative liberation could prevent lung injury from spontaneous breathing. Research questionShould physicians take a more aggressive or conservative approach to liberation? MethodsRetrospective cohort study of mechanically ventilated patients from the Medical Information Mart for Intensive Care IV database (MIMIC-IV version 1.0) estimating effects of incremental interventions modifying the propensity for liberation to be more aggressive or conservative relative to usual care, with adjustment for confounding via inverse probability weighting. Outcomes included in-hospital mortality, ventilator free days, and ICU free days. Analysis was performed on the entire cohort as well as subgroups differentiated by PaO2/FiO2 ratio, and SOFA. Results7433 patients were included. Strategies multiplying the odds of a first liberation relative to usual care at each hour had a large impact on time to first liberation attempt (43 h under usual care, 24 h (0.95 CI = [23,25]) with an aggressive strategy doubling liberation odds, and 74 h (0.95 CI = [69,78]) under a conservative strategy halving liberation odds). In the full cohort, we estimated aggressive liberation increased ICU-free days by 0.9 days (0.95 CI = [0.8,1.0]) and ventilator free days by 0.82 days (0.95 CI = [0.67,0.97]), but had minimal effect on mortality (only a 0.3% (0.95 CI = [−0.2%,0.8%]) difference between minimum and maximum rates). With baseline SOFA≥ 12 (n = 1355), aggressive liberation moderately increased mortality (58.5% [0.95 CI = (55.7%,61.2%)]) compared with conservative liberation (55.1% [0.95 CI = (51.6%,58.6%)]). InterpretationAggressive liberation may improve ventilator free and ICU free days with little impact on mortality in patients with SOFA score < 12. Trials are needed.

Identification of genetic susceptibility in preterm newborns with bronchopulmonary dysplasia by whole-exome sequencing: BIVM gene may play a role

Bronchopulmonary dysplasia (BPD) is a common chronic respiratory diseasein preterm infants caused by multifactorial etiology. Genetic factors areinvolved in the occurrence of BPD, but studies have found that candidate geneshave poor reproducibility and are influenced by ethnic heterogeneity;therefore, more exploration is still needed. We performed whole-exon sequencingin 34 preterm infants with BPD and 32 non-BPD control neonates. The data wereanalyzed and interpreted by Fisher difference comparison, PLINK and eQTLassociation analysis, KEGG and GO enrichment analysis, STRING tool, Cytoscapesoftware, ProtParam tool, HOPE online software, and GEOR2 analysis on NCBI GEOdataset. BPD has a highly heterogeneity in different populations, and we found35 genes overlapped with previous whole-exon sequencing studies, such as APOBgene. Arterial and epithelial cell development and energy metabolism pathwaysaffect BPD. In this study, 24 key genes were identified, and BIVM rs3825519mutation leads to prolonged assisted ventilation in patients with BPD. A novelDDAH1 mutation site (NM_012137: exon1: c.89 T > G: p.L30R) was found in 9 BPD patients.Conclusion: BIVM gene rs3825519 mutation may play a role in the pathogenesis of BPD by affecting cilia movement, and the DDAH1 and APOB genes mutations may have a pathogenic role in BPD.What is Known:• Genetic factors are involved in the occurrence of bronchopulmonary dysplasia.• The candidate genes have poor reproducibility and are influenced by ethnic heterogeneity, therefore, more exploration is still needed.What is New:• We identified the role of susceptible SNPs in BPD in Shenzhen, China, and identified 24 key genes that influence the pathogenesis of BPD, and also found 35 genes overlapped with previous whole exon sequencing studies, such as APOB gene.• We found that BIVM and DDAH1 genes may play a pathogenic role in the pathogenesis of BPD.

The end-tidal alveolar dead space fraction for risk stratification during the first week of invasive mechanical ventilation: an observational cohort study

BackgroundThe end-tidal alveolar dead space fraction (AVDSf = [PaCO2−PETCO2]/PaCO2) is a metric used to estimate alveolar dead space. Higher AVDSf on the first day of mechanical ventilation is associated with mortality and fewer ventilator-free days. It is not clear if AVDSf is associated with length of ventilation in survivors, how AVDSf performs for risk stratification beyond the first day of ventilation, or whether AVDSf adds predictive value to oxygenation (oxygenation index [OI]) or severity of illness (Pediatric Risk of Mortality [PRISM III]) markers.MethodsRetrospective single-center observational cohort study of children and young adults receiving invasive mechanical ventilation. In those with arterial or capillary blood gases, AVDSf was calculated at the time of every blood gas for the first week of mechanical ventilation.ResultsThere were 2335 children and young adults (median age 5.8 years [IQR 1.2, 13.2]) enrolled with 8004 analyzed AVDSf values. Higher AVDSf was associated with mortality and longer length of ventilation in survivors throughout the first week of ventilation after controlling for OI and PRISM III. Higher OI was not associated with increased mortality until ≥ 48 h of ventilation after controlling for AVDSf and PRISM III. When using standardized variables, AVDSf effect estimates were generally higher than OI for mortality, whereas OI effect estimates were generally higher than AVDSf for the length of ventilation in survivors. An AVDSf > 0.3 was associated with a higher mortality than an AVDSf < 0.2 within each pediatric acute respiratory distress syndrome severity category.The maximum AVDSf within 12 h of intensive care unit admission demonstrated good risk stratification for mortality (AUC 0.768 [95% CI 0.732, 0.803]). AVDSf did not improve mortality risk stratification when added to PRISM III but did improve mortality risk stratification when added to the gas exchange components of PRISM III (minimum 12-h PaO2 and maximum 12-h PCO2) (p < 0.00001).ConclusionsAVDSf is associated with mortality and length of ventilation in survivors throughout the first week of invasive mechanical ventilation. Some analyses suggest AVDSf may better stratify mortality risk than OI, whereas OI may better stratify risk for prolonged ventilation in survivors than AVDSf.

Preterm prelabor rupture of membranes in singletons: maternal and neonatal outcomes.

To determine the effect of gestational age at delivery on maternal and neonatal outcomes in preterm prelabor rupture of membranes (PPROM) and assess various predictors of neonatal and infant mortality in these pregnancies. United States birth data from CDC-National Center for Health Statistics natality database for years 2004-2008 was used to identify singleton pregnancies with PPROM and delivery from 32 0/7 to 36 6/7weeks. Controls were singletons at 37-40weeks, without PPROM. Maternal and neonatal complications reported by all states were analyzed along with neonatal outcomes such as chorioamnionitis and hyaline membrane disease, reported by a subgroup of states. OR (95% CI) were calculated after adjusting for preeclampsia, diabetes, chronic hypertension, maternal race, and infant sex. There were 134,502 PPROM cases and similar number of controls. There was a significant decrease in need for prolonged ventilation, hyaline membrane disease, 5min Apgar score <7, and NICU admission with advancing gestational age. Placental abruption decreased and chorioamnionitis and cord prolapse were not different between 34 and 37weeks. We found reductions in early death, neonatal death, and infant mortality with advancing gestational age (p<0.001 for each). Gestational age at delivery was the strongest predictor for early death,neonatal death, and infant mortality in PPROM. These differences persisted after adjusting for antenatal steroid use. We provide population-based evidence showing a decrease in neonatal complications and death with advancing gestational age in PPROM. Gestational age at delivery in pregnancies with PPROM is the strongest predictor of mortality risk.

Predictive factors for postoperative myasthenic crisis in patients with myasthenia gravis.

Thymectomy plays an important role in the comprehensive treatment of myasthenia gravis (MG). The present study aimed to investigate the risk factors for postoperative myasthenic crisis (POMC) in these patients and then establish a predicting model based on preoperatively available indicators. The clinical records of 177 consecutive patients with MG who received extended thymectomy between January 2018 and September 2022 in our department were retrospectively reviewed. Patients were divided into two groups according to whether they developed POMC and needed ventilation support for more than 24 hours. Univariate and multivariate regression analyses were conducted to identify the independent risk factors of POMC. Then a nomogram was constructed to intuitively show the results. Finally, the calibration curve and bootstrap resampling were used to evaluate its performance. POMC occurred in 42 (23.7%) patients. By multivariate analysis, body mass index (BMI) (p = 0.029), Osserman classification (p = 0.015), percentage of predicted forced vital capacity (FVC, pred%) (p = 0.044), percentage of predicted forced expiratory volume in the first second (FEV1, pred%) (p = 0.043) and albumin to globulin ratio (AGR) (p = 0.009) were identified as independent risk factors and entered into the nomogram. The calibration curve showed good concordance between the predicted and actual probability of prolonged ventilation. Our model is a valuable tool for predicting POMC in MG patients. For those high-risk patients, appropriate preoperative treatment is necessary to improve the symptoms and greater attention to postoperative complications is needed.