Requirement For Mechanical Ventilation Research Articles

Clinical Profile and Predictors Affecting Outcome in Community-Acquired Acute Kidney Injury: A 3 Months Follow-Up Study

Background Community-Acquired Acute Kidney Injury (CA-AKI) is often a devastating clinical syndrome allied with high hospital mortality. Moreover, only limited prospective data exist on the outcomes of CA-AKI. Hence, this follow-up study was conducted to assess clinical profiles and the factors affecting outcomes in CA-AKI. Materials and Methods A prospective study enrolling 283 participants was conducted from the year 2021 to 2022. AKI patients defined as per Kidney Disease Improving Global Outcomes (KDIGO) criteria were included. Data were collected on demographics, clinical features, and etiological factors. Patients were followed for three months. Univariate and multinomial analyses were done to predict outcomes. The Cox regression model was fitted to identify predictors of mortality. Results The mean age of patients was 41.67±16.21 years with male predominance. Most of the patients required non-ICU (81.9%) care. Around 36% and 39.6 % of AKI patients were oliguric and required dialysis, respectively. Most patients had a single etiology, with sepsis being the most common cause. Most patients were in KDIGO stage 3, followed by stage 2. At three months of follow-up, 40.6%, 12.3%, and 4.2% had complete, partial, and non-recovery, respectively, and 30.4% died. Age, single etiology, hepatorenal syndrome, sepsis, requirement of mechanical ventilation and vasopressors, comorbidities and glomerulonephritis were significantly associated with mortality. Conclusion CA-AKI is significantly associated with higher mortality, even for those patients who require non-ICU care on presentation. This highlights the pressing need for AKI prevention, early detection, and intervention to mitigate reversible risk factors and optimize clinical outcomes.

A retrospective analysis of the clinical profile and factors associated with mortality and poor hospital outcomes in adult Guillain–Barre syndrome patients

Guillain–Barré syndrome (GBS) is an acute autoimmune polyneuropathy with substantial geographic variations in demography, antecedent events, clinical manifestations, electrophysiological sub-types, diagnostic findings, treatment modalities, and prognostic indicators. However, there is limited contemporary data on GBS patient profiles and prognostic factors from low-resource settings like Ethiopia. The objective of this study is to investigate the clinical profile, factors associated with mortality, and hospital outcomes among GBS patients admitted to Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, Ethiopia. A retrospective cross-sectional study was conducted among 60 GBS patients admitted to TASH from January 2018 to December 2022. Data on demographics, clinical features, treatments, complications, and outcomes were extracted from medical records. Bivariate and multivariate logistic regression analyses identified factors associated with mortality and poor hospital outcomes. The cohort had a mean age of 28.5 years, with 76.7% aged 14–34 years. Males comprised 61.7% of cases. Ascending paralysis (76.7%) was the predominant presentation. Absent or reduced reflexes were seen in 91.7% of patients. The most common antecedent event was gastroenteritis (26.7%), followed by upper respiratory tract infection (URTI) (15%) and vaccination (11.7%). The mean interval from symptom onset to hospital presentation was 8.77 days, and the peak symptom severity was 4.47 days. The axonal variant (75.5%) was the most common subtype, followed by the demyelinating variant (24.5%). Intravenous immunoglobulin was administered to 41.7% of patients. Respiratory failure requiring invasive mechanical ventilator (MV) support occurred in 26.7% of cases. The mortality rate was 10%, with mechanical ventilation being the only factor significantly associated with mortality (95% CI 2.067–184.858; P < 0.010). At discharge, 55% had a good outcome, and 45% had a poor outcome, according to the Hughes Functional Disability Scale (HFDS). Mechanical ventilation (AOR 0.024, 95% CI 0.001–0.607) and a GBS disability score > 3 (AOR 0.106, 95% CI 0.024–0.467) were factors significantly associated with poor hospital outcomes. GBS in this cohort primarily affected individuals of young age, commonly preceded by gastroenteritis and characterized by a high frequency of the axonal variant. Mechanical ventilation was found to be significantly linked to mortality. Alongside mechanical ventilation requirements, severe disability upon presentation emerged as a crucial determinant of poor outcomes upon discharge, underscoring the importance of early identification of high-risk patients and prompt interventions.

Safety and Efficacy of N-Acetylcysteine as an Adjuvant Therapy in Critically Ill COVID-19 Patients

Abstract Background COVID-19 may cause pneumonia, acute respiratory distress syndrome, cardiovascular alterations, and multiple organ failure, which have been ascribed to a cytokinestorm, a systemic inflammatory response, and an attack by the immune system. Moreover, an oxidative stress imbalance has been demonstrated to occur in COVID- 19 patients. N- Acetyl-L-cysteine (NAC) is a precursor of reduced glutathione (GSH). Aim of the Work we retrospectively will investigate safety and efficacy of NAC dose given in paracetamol toxicity as an adjuvant therapy in critically ill COVID-19 patients with acute respiratory distress and determine whether NAC in high doses can avoid respiratory failure in patients with COVID-19. Patients and Methods This was a retrospective observational study in which all cases were collected from ICU of Ain shams university hospitals during COVID-19 outbreak. All data were extracted from clinical records. All patients initially admitted to ICU with SPO2 less than 94 % were included between December 2020 to February 2022. Exclusion Criteria included Need for immediate mechanical ventilation on admission, known allergy or hypersensitivity to NAC, end stage renal and liver diseases, heart failure and pregnancy. All patients with severe COVID-19 (confirmed or suspected received standard care, according to the institutional protocol. Results Patients were randomized into two equal groups (number (n)=40 each) as the N1(NAC) group who was given intravenously, initially 150 mg/kg in 200 mL of 0.9% NaCL for 60 minutes (first bag), followed by 50 mg/kg in 500 mL of 0.9% NaCL for 4 hours (second bag), and then 100 mg/kg in 1000 mL of 0.9%NaCL for 16 hours (third bag) and N2(Non NAC) group who received intravenously N-acetylcysteine (NAC) 600mg /12hr and The primary endpoint was the need for mechanical ventilation. Secondary endpoints were time of mechanical ventilation, admission to the intensive care unit (ICU), time in ICU, and mortality. There were no statistically significant differences between the two groups (p &amp;gt; 0.05) The effect of NAC on mechanical ventilations, mortality, ICU stays, and hospital stays is a matter of controverse in ARDS patients. We found that intravenous high dose of NAC did not improve oxygenation, mortality rate and did not reduce the requirement for mechanical ventilation when administered for COVID 19 patients with ARDS. Also, the duration of ICU and hospital stays were relatively prolonged in the NAC-treated patients. These might be due to prolonged survival time with NAC-treated patients, but not to be detected with the small single centered trial.. Conclusion Use of high doses of NAC administration can not affect the need of mechanical ventilation, rate of mortality, the need, duration of ICU admission and hospital stays for patients with severe COVID-19.

Deep learning model utilization for mortality prediction in mechanically ventilated ICU patients

Background:The requirement for mechanical ventilation has increased in recent years. Patients in the intensive care unit (ICU) who undergo mechanical ventilation often experience serious illness, contributing to a high risk of mortality. Predicting mortality for mechanically ventilated ICU patients helps physicians implement targeted treatments to mitigate risk. Methods:We extracted medical information of patients with invasive mechanical ventilation during ICU admission from the Medical Information Mart for Intensive Care III (MIMIC-III) dataset. This information includes demographics, disease severity, diagnosis, and laboratory test results. Patients who met the inclusion criteria were randomly divided into the training set (n=11,549, 70%), the test set (n=2,475, 15%), and the validation set (n=2,475, 15%). The Synthetic Minority Over-sampling Technique (SMOTE) was utilized to resolve the imbalanced dataset. After literature research, clinical expertise and an ablation study, we selected 12 variables which is fewer than the 66 features in the best existing literature. We proposed a deep learning model to predict the ICU mortality of mechanically ventilated patients, and established 7 baseline machine learning (ML) models for comparison, including K-nearest Neighbors (KNN), Logistic Regression, Decision Tree, Random Forest, Bagging, XGBoost, and Support Vector Machine (SVM). Area under the Receiver Operating Characteristic Curve (AUROC) was used as an evaluation metric for model performance. Results:Using 16,499 mechanically ventilated patients from the MIMIC-III database, the Neural Network model outperformed existing literature by 7.06%. It achieved an AUROC score of 0.879 (95% Confidence Interval (CI) [0.861-0.896]), an accuracy of 0.859 on the test set, and was well-calibrated with a Brier score of 0.0974, significantly exceeding previous best results. Conclusions:The proposed model demonstrated an exceptional ability to predict ICU mortality among mechanically ventilated patients. The SHAP analysis showed respiratory failure is a significant indicator of mortality prediction compared to other related respiratory dysfunction diseases. We also incorporated mechanical ventilation duration variable for the first time in our prediction model. We observed that patients with higher mortality rates tended to have longer mechanical ventilation times. This highlights the model’s potential in guiding clinical decisions by indicating that longer mechanical ventilation may not necessarily enhance patient survival chances.

Association of Hyperoxia During Cardiopulmonary Bypass and Postoperative Delirium in the Pediatric Cardiac ICU.

ICU delirium commonly complicates critical illness associated with factors such as cardiopulmonary bypass (CPB) time and the requirement of mechanical ventilation (MV). Recent reports associate hyperoxia with poorer outcomes in critically ill children. This study sought to determine whether hyperoxia on CPB in pediatric patients was associated with a higher prevalence of postoperative delirium. Secondary analysis of data obtained from a prospective cohort study. Twenty-two-bed pediatric cardiac ICU in a tertiary children's hospital. All patients (18 yr old or older) admitted post-CPB, with documented delirium assessment scores using the Preschool/Pediatric Confusion Assessment Method for the ICU and who were enrolled in the Precision Medicine in Pediatric Cardiology Cohort from February 2021 to November 2021. None. Of 148 patients, who underwent cardiac surgery, 35 had delirium within the first 72 hours (24%). There was no association between hyperoxia on CPB and postoperative delirium for all definitions of hyperoxia, including hyperoxic area under the curve above 5 predetermined Pao2 levels: 150 mm Hg (odds ratio [95% CI]: 1.176 [0.605-2.286], p = 0.633); 175 mm Hg (OR 1.177 [95% CI, 0.668-2.075], p = 0.572); 200 mm Hg (OR 1.235 [95% CI, 0.752-2.026], p = 0.405); 250 mm Hg (OR 1.204 [95% CI, 0.859-1.688], p = 0.281), 300 mm Hg (OR 1.178 [95% CI, 0.918-1.511], p = 0.199). In an additional exploratory analysis, comparing patients with delirium within 72 hours versus those without, only the z score for weight differed (mean [sd]: 0.09 [1.41] vs. -0.48 [1.82], p < 0.05). When comparing patients who developed delirium at any point during their ICU stay (n = 45, 30%), MV days, severity of illness (Pediatric Index of Mortality 3 Score) score, CPB time, and z score for weight were associated with delirium (p < 0.05). Postoperative delirium (72 hr from CPB) occurred in 24% of pediatric patients. Hyperoxia, defined in multiple ways, was not associated with delirium. On exploratory analysis, nutritional status (z score for weight) may be a significant factor in delirium risk. Further delineation of risk factors for postoperative delirium versus ICU delirium warrants additional study.

L-carnitine: A novel approach in management of acute cholinesterase inhibitor insecticide poisoning.

Cholinesterase inhibitors (ChEIs) insecticide poisoning is a serious global health concern that results in hundreds of thousands of fatalities each year. Although inhibition of the cholinesterase enzyme is the main mechanism of ChEI poisoning, oxidative stress is considered the mechanism underlying the related complications. The study aimed to assess the oxidative status of the patients with ChEI insecticide poisoning and the role of L-carnitine as adjuvant therapy in their management. Human studies on the efficacy and safety of L-carnitine in treating insecticide poisoning are limited despite its growing research interest as a safe antioxidant. This prospective study was conducted on eighty patients with acute ChEIs insecticide poisoning admitted to Alexandria Poison Center, Alexandria Main University Hospital, Egypt. Patients were allocated into two equal groups randomly. The L-carnitine (LC) group received the conventional treatment (atropine & toxogonin) and LC and the standard treatment (ST) group received the standard treatment only. Outcome measures were fatality rate, the total administered dose of atropine & toxogonin, length of hospital stay, and the requirement for ICU admission or mechanical ventilation. The study results revealed that malondialdehyde (MDA) significantly decreased in the LC group. Cholinesterase enzyme levels increased significantly after treatment in the LC group than in the ST group. The LC group needed lower dosages of atropine and toxogonin than the ST group. Also, the LC group showed no need for ICU admission or mechanical ventilation. The study concluded that LC can be considered a promising adjuvant antioxidant treatment in acute ChEIs pesticide poisoning.

The synergistic effects of mechanical ventilation and intrauterine inflammation on cerebral inflammation in preterm fetal sheep.

Intrauterine inflammation and the requirement for mechanical ventilation independently increase the risk of perinatal brain injury and adverse neurodevelopmental outcomes. We aimed to investigate the effects of mechanical ventilation for 24 h, with and without prior exposure to intrauterine inflammation, on markers of brain inflammation and injury in the preterm sheep brain. Chronically instrumented fetal sheep at ~115 days of gestation were randomly allocated to receive a single intratracheal dose of 1 mg lipopolysaccharide (LPS) or isovolumetric saline, then further randomly allocated 1 h after to receive mechanical ventilation with room air or no mechanical ventilation (unventilated control + saline [UVC, n = 7]; in utero mechanical ventilation + saline [VENT, n = 8], unventilated control + intratracheal LPS [UVC + LPS, n = 7]; in utero ventilation + intratracheal LPS [VENT + LPS, n = 7]). Serial fetal blood and plasma samples were collected throughout the experimental protocol for assessment of blood biochemistry and plasma interleukin (IL)-6 levels. After 24 h of mechanical ventilation, fetal brains were collected for RT-qPCR and immunohistochemical analyses. LPS exposure increased numbers of microglia and upregulated pro-inflammatory related genes within the cortical gray matter (GM) and subcortical white matter (SCWM) (pLPS < 0.05). Mechanical ventilation alone increased astrocytic cell density in the periventricular white matter (PVWM) (pVENT = 0.03) but had no effect on pro-inflammatory gene expression. The combination of ventilation and LPS increased plasma IL-6 levels (p < 0.02 vs. UVC and VENT groups), and exacerbated expression of pro-inflammatory-related genes (IL1β, TLR4, PTGS2, CXCL10) and microglial density (p < 0.05 vs. VENT). This study demonstrates that 24 h of mechanical ventilation after exposure to intrauterine inflammation increased markers of systemic and brain inflammation and led to the upregulation of pro-inflammatory genes in the white matter. We conclude that 24 h of mechanical ventilation following intrauterine inflammation may precondition the preterm brain toward being more susceptible to inflammation-induced injury.

Outpatient insulin use in type 2 diabetes mellitus and acute respiratory distress syndrome outcomes: A retrospective cohort study.

The impact of type 2 diabetes mellitus (T2DM) on acute respiratory distress syndrome (ARDS) is debatable. T2DM was suspected to reduce the risk and complications of ARDS. However, during coronavirus disease 2019 (COVID-19), T2DM predisposed patients to ARDS, especially those who were on insulin at home. To evaluate the impact of outpatient insulin use in T2DM patients on non-COVID-19 ARDS outcomes. We conducted a retrospective cohort analysis using the Nationwide Inpatient Sample database. Adult patients diagnosed with ARDS were stratified into insulin-dependent diabetes mellitus (DM) (IDDM) and non-insulin-dependent DM (NIDDM) groups. After applying exclusion criteria and matching over 20 variables, we compared cohorts for mortality, duration of mechanical ventilation, incidence of acute kidney injury (AKI), length of stay (LOS), hospitalization costs, and other clinical outcomes. Following 1:1 propensity score matching, the analysis included 274 patients in each group. Notably, no statistically significant differences emerged between the IDDM and NIDDM groups in terms of mortality rates (32.8% vs 31.0%, P = 0.520), median hospital LOS (10 d, P = 0.537), requirement for mechanical ventilation, incidence rates of sepsis, pneumonia or AKI, median total hospitalization costs, or patient disposition upon discharge. Compared to alternative anti-diabetic medications, outpatient insulin treatment does not appear to exert an independent influence on in-hospital morbidity or mortality in diabetic patients with non-COVID-19 ARDS.

In-hospital mortality patterns and risk factors in patients with cancer with COVID-19.

e23070 Background: The current body of knowledge regarding outcomes of patients with cancer and COVID-19 is conflicting, with some studies suggesting worsened mortality in those with both diseases This study seeks to shed light on the distinctive factors influencing in-hospital mortality in these two cohorts, providing crucial insights that can guide targeted interventions and enhance healthcare strategies for individuals facing the dual burden of cancer and COVID-19. Methods: We conducted a retrospective review of all patients hospitalized with COVID-19 at our institution between January 1, 2021 and April 1, 2023. Patients were stratified into a cohort of those with cancer and coexisting COVID-19 infection and those with solely COVID-19. The cancer and COVID-19 cohort included patients over the age of 18 who had received treatment for cancer within the last 6 months. Information regarding patient demographic characteristics and comorbidities, as well as in-hospital treatment characteristics and outcomes. We performed descriptive analysis and conducted Chi-squared and t-tests to assess for differences in baseline characteristics between cohorts, then developed Cox proportional hazards models to evaluate risk factors for in-hospital mortality. Results: 456 patients with cancer and COVID-19 were compared with 12,566 patients with only COVID-19. In-hospital mortality was 8.2% in the cancer cohort compared with 9.0% in the COVID-19 only cohort. Patients in the cancer cohort were more likely to be male (55.7% vs 48.2%, p = 0.004), older (71 vs 64 years, p &lt; 0.001) with histories of heart failure (27% vs 21%, p = 0.002), chronic kidney disease (50% vs 39%, p &lt; 0.001), COPD (35% vs 24%, p &lt; 0.001), and anemia (57% vs 24%, p &lt; 0.001). The cancer cohort experienced significantly longer length of stay (9 vs 7 days, p &lt; 0.001). Requirement of mechanical ventilation and ICU stay were similar between groups. Multivariate Cox proportional hazards ratios demonstrated similar mortality between cohorts (HR = 0.863, p = 0.361), with age (HR = 1.041, p &lt; 0.001) and history of acute myocardial infarction (HR = 1.275, p = 0.01) being significant predictors of death. Conclusions: Our study demonstrates the complex relationship between cancer, COVID-19, and in-hospital mortality. Despite differences in baseline characteristics between the cohorts, our findings reveal that, after adjusting for confounding factors, there is no significant disparity in mortality rates between patients concurrently battling cancer and COVID-19 and those solely afflicted by COVID-19. The identification of age and a history of acute myocardial infarction as significant predictors of mortality underscores the need for targeted interventions and vigilant management strategies for individuals facing the dual burden of cancer and COVID-19, ensuring equitable and effective healthcare outcomes in this complicated patient population.

Unveiling the impact: Exploring thrombotic outcomes in hospitalized patients with COVID-19—Comparing those with and without a cancer diagnosis.

e23318 Background: There is a shared hypercoagulable association of COVID-19 and cancer, noting an increased risk of thromboembolic events (TEE)in both conditions. The current study focuses on patients with concurrent COVID-19 and underlying cancer and compares incidence of TEE and related outcomes in this complex intersection of acute viral infection and oncological challenges. Methods: In this retrospective cohort study, we examined data from the Charleston Area Medical Center’s (CAMC) COVID-19 Registry, involving 5,479 adult, symptomatic, PCR-positive COVID-19 hospitalized patients (3/1/2020 to 1/20/2024). Demographics, co-morbidities, lab values, treatments, and outcomes were assessed. Propensity score matching (3:1) non-cancer patients vs those with an active cancer diagnosis was undertaken using sex and age. SAS 9.4 was utilized for the analysis. The groups were compared using Chi-square/Fisher’s Exact tests for categorical variables and t-tests for continuous variables and a logistic regression modelling to determine differences in key variables, the incidence of thromboembolic events and other outcomes. Results: After propensity matching, 1,623 non-cancer and 427 active cancer patients were included. The incidence of venous thromboembolism (VTE) was higher in the active cancer group (9.42% vs 4.2%, P &lt; 0.001) with no significant differences in acute stroke. Intensive care unit (ICU) admissions, mechanical or non-invasive ventilation requirement, and mortality were not different although more patients with cancer were discharged to hospice (11.8% vs 3.3%, P &lt; 0.001). However, mean D-dimer results in both groups were &gt; 2.5 mg/L, it was not performed consistently. The active cancer group had greater frequencies of abnormal ferritin levels (59.1% vs 49.1%, P=0.01), and elevated procalcitonin levels &gt; 0.05 ng/mL (72.9% vs 60.6%, p &lt; 0.001). Among key treatments, remdesivir was used more frequently in cancer patients (41.4% vs 35.7%, P &lt; 0.01). In addition to the cancer diagnosis (OR = 1.729 95% CI [1.1-2.8] P =0.02), LOS &gt; / = 7days was also a predictor of TEE (OR= 1.825 95% CI [1.1-2.9] P &lt; 0.01). Conclusions: Symptomatic VTE rates in our COVID-19 and active cancer cohort align with published studies. Diligence in evaluation of D-dimer, early detection of TEE and adherence to published guidelines in prophylaxis and treatment is recommended.

Risk Factors for Pediatric Critical COVID-19: A Systematic Review and Meta-Analysis.

Risk stratification is a cornerstone of the Pediatric Infectious Diseases Society COVID-19 treatment guidance. This systematic review and meta-analysis aimed to define the clinical characteristics and comorbidities associated with critical COVID-19 in children and adolescents. Two independent reviewers screened the literature (Medline and EMBASE) for studies published through August 31, 2023, that reported outcome data on patients aged ≤21 years with COVID-19. Critical disease was defined as an invasive mechanical ventilation requirement, intensive care unit admission, or death. Random effects models were used to estimate pooled odds ratios (OR) with 95% confidence intervals (CI), and heterogeneity was explored through subgroup analyses. Among 10,178 articles, 136 studies met the inclusion criteria for review. Data from 70 studies, which collectively examined 172,165 children and adolescents with COVID-19, were pooled for meta-analysis. In previously healthy children, the absolute risk of critical disease from COVID-19 was 4% (95% CI, 1%-10%). Compared with no comorbidities, the pooled OR for critical disease was 3.95 (95% CI, 2.78-5.63) for the presence of one comorbidity and 9.51 (95% CI, 5.62-16.06) for ≥2 comorbidities. Key risk factors included cardiovascular and neurological disorders, chronic pulmonary conditions (excluding asthma), diabetes, obesity, and immunocompromise, all with statistically significant ORs >2.00. While the absolute risk for critical COVID-19 in children and adolescents without underlying health conditions is relatively low, the presence of one or more comorbidities was associated with markedly increased risk. These findings support the importance of risk stratification in tailoring pediatric COVID-19 management.

Malnutrition elevates delirium and ICU stay among critically ill older adult COVID-19 patients.

Malnutrition among intensive care unit (ICU) patients is associated with a higher risk of mortality and prolonged hospitalization. However, the influence of malnutrition on severe outcomes of ICU patients with coronavirus disease 2019 (COVID-19) is unclear. By evaluating the effect of malnutrition on the outcomes of COVID-19 in the ICU in older adult patients, this study will contribute to new knowledge of assessing the nutritional status and recovery of these patients. In the current single center prospective study, 310 critically ill COVID-19 patients with an age range of ≥65 years were recruited. Data on demographic characteristics, laboratory parameters, comorbidities, medications, and types of mechanical ventilation were collected in the first 24 h of ICU admission. Malnutrition was defined based on the two-step approach of the Global Leadership Initiative on Malnutrition (GLIM) scale at baseline. During the 45 days after the baseline, we collected data on delirium incidence, mortality, invasive mechanical ventilation (IMV) requirement, length of ICU and hospital admission, and re-hospitalization. In this study, the prevalence of malnutrition was 63.4% among critically ill COVID-19 patients. During the 45-day follow-up, 190 (61.3%) COVID-19 deaths were recorded among the baseline 310 patients. After controlling for potential confounders, malnutrition was associated with an increased risk of delirium so malnourished COVID-19 patients had a significantly 35% higher risk of delirium than those without malnutrition (HR: 1.35, 95% CI: 1.01-1.83). Such a significant association was not for COVID-19 mortality and IMV requirement. In addition, malnutrition was associated with a significantly 84% greater odds of prolonged ICU admission (OR: 1.84, 95% CI: 1.09-3.10). No significant association was seen between malnutrition and re-hospitalization and also prolonged hospital admission. Malnutrition was associated with an increased risk of delirium and prolonged ICU admission among critically ill older adult COVID-19 patients. Prevention, diagnosis, and treatment of malnutrition could be a key component in improving outcomes in these patients.

Tracheostomy Timing in Unselected Critically Ill Patients with Prolonged Intubation: A Prospective Cohort Study.

Background: Tracheostomy procedures are performed in the intensive care unit (ICU) for prolonged intubation, unsuccessful weaning and infection prevention through either percutaneous or surgical techniques. This study aimed to outline the impact of tracheostomy timing in the ICU on mortality, need for mechanical ventilation, and complications. Methods: Patients were included in the study on the day of tracheostomy. Demographic information, tracheostomy timing, technique, complications, sedation requirement and need for mechanical ventilation at discharge were recorded by an anesthesiologist, including the pre-tracheostomy period. Results: Tracheostomy was performed on 33 patients during the first 14 days of intubation and on 54 patients on the 15th day and beyond. There was no significant difference between the tracheostomy timing and mortality, sedation requirement, or weaning from the ventilator. We observed that patients who underwent tracheostomy with the surgical technique experienced more complications, but there was no significant difference. Tracheostomy performed after the 14th day was shown to be associated with prolonged hospital stay. Conclusions: Early tracheostomy does not have any influence on the need for mechanical ventilation, sedation and mortality. The optimal timing for tracheostomy is still controversial. We are of the opinion that randomized controlled trials involving patient groups with similar survival expectations are needed.

Emergency Department SpO2/FiO2 Ratios Correlate with Mechanical Ventilation and Intensive Care Unit Requirements in COVID-19 Patients.

Patients with coronavirus 2019 (COVID-19) are at high risk for respiratory dysfunction. The pulse oximetry/fraction of inspired oxygen (SpO2/FiO2) ratio is a non-invasive assessment of respiratory dysfunction substituted for the PaO2:FiO2 ratio in Sequential Organ Failure Assessment scoring. We hypothesized that emergency department (ED) SpO2/FiO2 ratios correlate with requirement for mechanical ventilation in COVID-19 patients. Our objective was to identify COVID-19 patients at greatest risk of requiring mechanical ventilation, using SpO2/FiO2 ratios. We performed a retrospective review of patients admitted with COVID-19 at two hospitals. Highest and lowest SpO2/FiO2 ratios (percent saturation/fraction of inspired O2) were calculated on admission. We performed chi-square, univariate, and multiple regression analysis to evaluate the relationship of admission SpO2/FiO2 ratios with requirement for mechanical ventilation and intensive care unit (ICU) care. A total of 539 patients (46% female; 84% White), with a mean age 67.6 ± 18.6years, met inclusion criteria. Patients who required mechanical ventilation during their hospital stay were statistically younger in age (P = 0.001), had a higher body mass index (P < .001), and there was a higher percentage of patients who were obese (P = 0.03) and morbidly obese (P < .001). Shortness of breath, cough, and fever were the most common presenting symptoms with a median temperature of 99°F. Average white blood count was higher in patients who required ventilation (P = <0.001). A highest obtained ED SpO2/FiO2 ratio of ≤300 was associated with a requirement for mechanical ventilation. A lowest obtained ED SpO2/FiO2 ratio of ≤300 was associated with a requirement for intensive care unit care. There was no statistically significant correlation between ED SpO2/FiO2 ratios >300 and mechanical ventilation or intensive care unit (ICU) requirement. The ED SpO2/FiO2 ratios correlated with mechanical ventilation and ICU requirements during hospitalization for COVID-19. These results support ED SpO2/FiO2 as a possible triage tool and predictor of hospital resource requirements for patients admitted with COVID-19. Further investigation is warranted.

Pediatric Shock: The Magnitude, Its Determinants and Short-Term Outcome on Patients. A Cross-Sectional Hospital-Based Study.

Pediatric shock is a potentially fatal illness which develops after a systemic circulatory system failure in children. It appears to be a common emergency in children and produces substantial morbidity and mortality particularly if there is no early identification and therapy. The extent and causes of shock-induced death among children in Ethiopia have not been sufficiently studied. This study was conducted to evaluate the magnitude, determinants and short-term outcome of shock in pediatric patients who visited Ayder Comprehensive Specialized Hospital in Tigray, Northern Ethiopia. From October 1, 2020, to July 30, 2022, an observational cross-sectional study was carried out at Ayder Comprehensive Specialized Hospital. The study included 132 children from the age of 1 month to 18 years. According to pediatric advanced life support guidelines, shock was diagnosed among patients. To gather information, a pretested questionnaire was employed. To examine the relationship between the independent variables and shock outcome, bivariate logistic regression was performed, and statistical significance was defined as a P-value of 0.05 or lower. The prevalence of shock was 2.2%. This study revealed 70.5% decompensated stage of shock. Mortality rate of shock was 45.5% (95% CI: 37.1-53.8). A delayed presentation by more than one week with an adjusted odd ratio (AOR) of 16.9 (95% CI: 2.3-123), type of shock other than hypovolemic shock with AOR of 8.3 (95% CI: 1.4-48), stage of shock with AOR of 27.8 (95% CI: 2.8-157), requirement of mechanical ventilation with AOR of 11 (95% CI: 2.6-53) and length of hospital stay less than three days with AOR of 9 (95% CI: 1.7-48) were identified as a predictor of mortality by shock in children. According to this study, shock causes a high rate of child mortality. Independent predictors of mortality included delayed presentation, shock type, stage of shock, the need for mechanical ventilation, and brief hospital stay (less than three days).

Outcomes of transcatheter aortic valve replacement in patients with history of chest wall irradiation: Propensity matched analysis of five years data from national inpatient sample (2016–2020)

IntroductionChest radiotherapy has been utilized to treat intra-thoracic and mediastinal tumors. Chest wall irradiation (C-XRT) survivors frequently develop valvular disease, including aortic stenosis, which eventually requires valve replacement. Previous trials have shown worse outcomes with surgical aortic valve replacement. However, transcatheter aortic valve replacement (TAVR) outcomes-related data in patients with C-XRT is limited. MethodsThe national inpatient sample (NIS) database was queried from 2016 to 2020 to identify adult hospitalizations with TAVR, which were dichotomized based on a history of C-XRT using ICD-10-CM codes. Propensity score matching was performed to derive age, sex, hospital characteristics, and co-morbidities matched controls without a history of C-XRT. The outcomes studied were inpatient mortality and complications, mean length of stay (LOS), and total hospital charge (THC). Multivariate logistic and linear regression were used to analyze the outcomes. ResultsOf 296,670 patients who underwent TAVR between 2016 and 2020, 515 had a history of C-XRT. Upon propensity score matching in patients undergoing TAVR, Patients with a history of C-XRT showed significantly lower adjusted odds of in-hospital mortality (adjusted odd ratio [aOR] 0.04, 95 % CI [0.003–0.57], p = 0.017), lower mean LOS by 1.6 days (−1.88 to −1.26 days, p < 0.001) and reduced mean THC (−$74,720, [−$88,784 to -$60,655], p < 0.001). Additionally, patients with C-XRT had significantly lower adjusted odds of inpatient complications, mainly acute myocardial infarction, cerebrovascular events, acute respiratory failure, acute kidney injury, need for vasopressors and cardiopulmonary resuscitation, whereas similar odds of complications, including a requirement of intubation, mechanical ventilation, hemodialysis, and cardiogenic shock. ConclusionOur analysis showed reduced adjusted odds of in-hospital mortality, length of stay, total hospital charges, and inpatient complications in patients undergoing TAVR with a history of C-XRT. TAVR appears to be a safe and viable alternative in this population subgroup.

Prognostic Accuracy of Screening Tools for Clinical Deterioration in Adults With Suspected Sepsis in Northeastern Thailand: A Cohort Validation Study.

We sought to assess the performance of commonly used clinical scoring systems to predict imminent clinical deterioration in patients hospitalized with suspected infection in rural Thailand. Patients with suspected infection were prospectively enrolled within 24 hours of admission to a referral hospital in northeastern Thailand between 2013 and 2017. In patients not requiring intensive medical interventions, multiple enrollment scores were calculated including the National Early Warning Score (NEWS), the Modified Early Warning Score, Between the Flags, and the quick Sequential Organ Failure Assessment score. Scores were tested for predictive accuracy of clinical deterioration, defined as a new requirement of mechanical ventilation, vasoactive medications, intensive care unit admission, and/or death approximately 1 day after enrollment. The association of each score with clinical deterioration was evaluated by means of logistic regression, and discrimination was assessed by generating area under the receiver operating characteristic curve. Of 4989 enrolled patients, 2680 met criteria for secondary analysis, and 100 of 2680 (4%) experienced clinical deterioration within 1 day after enrollment. NEWS had the highest discrimination for predicting clinical deterioration (area under the receiver operating characteristic curve, 0.78 [95% confidence interval, .74-.83]) compared with the Modified Early Warning Score (0.67 [.63-.73]; P < .001), quick Sequential Organ Failure Assessment (0.65 [.60-.70]; P < .001), and Between the Flags (0.69 [.64-.75]; P < .001). NEWS ≥5 yielded optimal sensitivity and specificity for clinical deterioration prediction. In patients hospitalized with suspected infection in a resource-limited setting in Southeast Asia, NEWS can identify patients at risk of imminent clinical deterioration with greater accuracy than other clinical scoring systems.

Lactate level is an independent predictor of mortality in patients with hematologic malignancy receiving urgent chemotherapy in intensive care unit

BackgroundIntensive care unit (ICU) survival of cancer patients has improved. Urgent chemotherapy has become feasible in critically ill patients with specific organ dysfunction due to hematological malignancies. ObjectiveThe aim of the study was to assess ICU mortality rates and the factors associated with mortality in patients with hematologic malignancies receiving urgent chemotherapy in the ICU. MethodsWe retrospectively included all patients admitted to the ICU who received chemotherapy due to hematologic malignancy in 2012–2022. ResultsOf the 129 patients undergoing chemotherapy in the ICU, 50 (38.7 %) died during the ICU follow-up. The following conditions were significantly more common among nonsurvivors: presence of infection at the time of ICU admission (p < 0.001), the requirement for mechanical ventilation during ICU stay (p < 0.001), the need for noninvasive mechanical ventilation during ICU stay (p = 0.014), vasopressor support (p < 0.001), and sepsis (p < 0.001). Logistic regression analysis revealed that among laboratory parameters on ICU admission, lactate (p = 0.008), albumin (p = 0.022), C-reactive protein (p = 0.046), baseline sequential organ failure assessment (SOFA) score (p < 0.001), newly developed heart failure (p = 0.006), and the requirement for vasopressor agents during ICU stay (p < 0.001) significantly influenced the risk of mortality in the univariate analysis. The multivariate analysis revealed lactate levels (p = 0.047) on ICU admission as an independent predictor of mortality. ConclusionThe development of heart failure and lactate levels on admission were the main predictors of mortality. Additionally, higher SOFA scores revealed that illness severity was closely associated with mortality. Future studies should focus on strategies to further reduce these risks and achieve the best outcomes for these patients.

A randomised clinical trial of awake prone positioning in COVID-19 suspects with acute hypoxemic respiratory failure

BackgroundAwake prone position (APP) has been reported to improve oxygenation in patients with COVID-19 disease and to reduce the requirement for invasive mechanical ventilation for patients requiring support with high flow nasal cannula. There is conflicting data for patients requiring lower-level oxygen support. Research questionDoes APP reduce escalation of oxygen support in COVID-19 patients requiring supplementary oxygen?The primary outcome was defined as an escalation of oxygen support from simple supplementary oxygen (NP, HM, NRB) to NIV (CPAP or BiPAP), HFNC or IMV; OR from NIV (CPAP or BiPAP) or HFNC to IMV by day30. Study designTwo center, prospective, non-blind, randomised controlled trial. Patients with confirmed or suspected COVID-19 pneumonia requiring ≥ 5 liters/min oxygen to maintain saturations ≥ 94 % were randomised to either APP or control group. The APP group received a 3-h APP session three times per day for three days. ResultsBetween 9 May and July 13, 2021, 89 adults were screened and 61 enrolled, 31 to awake prone position and 30 controls. There was no difference in the primary outcome, 7 (22.6 %) patients randomised to APP and 9 (30.0 %) controls required escalation of oxygen support (OR 0.68 (0.22–2.14), P = 0.51). There were no differences in any secondary outcomes, in APP did not improve oxygenation. InterpretationIn COVID-19 patients, the use of APP did not prevent escalation of oxygen support from supplementary to invasive or non-invasive ventilation or improve patient respiratory physiology. Trial registrationNCT04853979 (clinicaltrials.gov).

Improving Outcome in Severe Myasthenia Gravis and Guillain-Barré Syndrome.

When progressive and severe, myasthenia gravis and Guillain-Barré syndrome may have the potential for fatal and unfavorable clinical outcomes. Regardless of important differences in their clinical course, the development of weakness of oropharyngeal muscles and respiratory failure with requirement of mechanical ventilation is the main driver of poor prognosis in both conditions. The need for prolonged mechanical ventilation is particularly relevant because it immobilizes the patient and care becomes extraordinarily complex due to daily risks of systemic complications. Additionally, patients with myasthenia gravis often require long-term immunosuppressive treatments with associated toxicity and infectious risks. Unlike myasthenia gravis, the recovery period is prolonged in Guillain-Barré syndrome, but often favorable, even in the more severely affected patients. Outcome, for a large part, is determined by expert neurocritical care.