Support In ICU Research Articles

Incidence, Risk Factors and Microbiological Profile of Ventilator Associated Pneumonia Patients in ICU in Tertiary Care Hospital

Background: VAP, or ventilator-associated pneumonia, is one of the most common ICU-acquired diseases and a significant cause of mortality among Intensive Care Unit patients. Infectious illnesses are currently underestimated in the South Asian Region, which has limited health resources.
 Objective: To examine the incidence of VAP, risk factors associated and the microbiological profile in ICU patients in tertiary care hospitals.
 Methods: A total of 114 patients under mechanical who satisfied all inclusion criteria were selected. Detailed history, investigations were undertaken. The diagnosis of VAP was made according to clinical and laboratory findings (as per CDC criteria) and incidence was derived from the number of patients developing VAP out of the total number of patients on ventilatory support in ICU.
 Results: We included 114 patients in our study. Out of 114 patients, the majority were above 70 years age group Mean age of study population was 61.29±13.42 years. Out of 114, 80 patients i.e. 70.2% were males and 34(29.8%) were females. Male: female ratio was 2.3:1. Klebsiella Pneumonia was a commonly observed organism in cultures i.e. 30.7%, followed by Pseudomonas Aeruginosa in 27.2% and Acinetobacter Baumani in 19.3%. Antibiotic sensitivity pattern of Klebsiella Pneumonia showed resistance to Carbapenemase in 20(57.1%) cases and to ESBL in 15(42.9%) cases. Death rate in our study was 17.5%
 Conclusion: The outcome of VAP depends on rapid identification of the causative microorganism. Empirical therapy based on knowledge of the most prevalent microorganisms and their resistance pattern has an impact on lowering morbidity and mortality, shortening the length of hospital stay, lowering of treatment expenses, and prevents the development of MDR bacteria in patients with VAP.

Dexmedetomidine Versus Midazolam: Does Choice of Sedatives Effect the Duration of Mechanical Ventilation

Objective: To evaluate Dexmedetomidine and Midazolam in mechanical ventilation regarding the extubation time.
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Department of Anaesthesia, Combined Military Hospital, Kharian, from May to Dec 2019.
 Methodology: A total of 88 patients on mechanical ventilator support in ICU were included. In Group-D (Dexmedetomidine), a loading dose of 1 μg/kg Dexmedetomidine over ten minutes was given, and sedation was maintained by continuous infusion at the rate of 0.2–0.6 μg/kg/hr. In Group-M (Midazolam), an intravenous 0.5–1 mg bolus of Midazolam was given over two minutes and maintained by continuous infusion at 10-50 μg /kg/hr; doses were increased incrementally 1–2 mg/hour until desired sedation level was achieved. The Richmond Agitation and Sedation Score assessed the sedation level. The total duration of mechanical ventilation and time from weaning off trial to extubation was recorded.
 Results: In this study, the mean duration of mechanical ventilation was 63.07±32.07 hours in Group-D versus 86.14±38.96 hours in Group-M (p-value=0.003). The mean extubation time was 25.09±7.33 hours in Group-D versus 30.31±8.37 hours in Group-M (p-value =0.002).
 Conclusion: This study concluded that Dexmedetomidine is superior Midazolam in providing sedation to mechanically ventilated patients. It reduces the duration of mechanical ventilation and time of extubation.Keywords: Dexmedetomidine, Extubation, Mechanical ventilation, Midazolam, Sedation.

Clinical characteristics and outcomes of extracorporeal membrane oxygenation used in a non-cardiac surgical intensive care unit: Siriraj experiences and literature review

Background: Extracorporeal membrane oxygenation (ECMO) has substantially increased in frequency of use over the past decades. Occasionally, patients who require ECMO support are admitted to an ICU rather than medical or cardiac ICU, where physicians may be not familiar with the process of how to care for ECMO patients. The aims of this case series were to explore the utilization of ECMO support in a non-cardiac general surgical ICU (SICU) in terms of indications, ECMO-related complications and clinical outcomes. Methods: Adult patients admitted to the SICU from January 2014 to June 2021 who received ECMO support were included. Demographic data, data regarding ECMO utilization and clinical outcomes were described. Current evidence and updated literature were also researched and reviewed. Results: A total of 18 patients were admitted to the SICU and received ECMO support, but four died within four hours of SICU admission. The most common reason for ECMO support was extracorporeal cardiopulmonary resuscitation (ECPR) (9 cases, 50.0%), followed by cardiac and/or respiratory support. The majority of patients received venoarterial ECMO support (15 cases, 83.3%). Unfractionated heparin was used in 10 cases (71.4%) and the anticoagulant effect was monitored with aPTT, which was maintained at a lower range (30–50 seconds). There was no thromboembolic event, and four patients (28.6%) developed major bleeding. The overall hospital mortality was as high as 77.8%. Conclusion: There was a small volume of cases receiving ECMO support in the SICU. ECPR was the most common reason for ECMO support in these patients. Overall, the hospital mortality was 77.8%. To improve outcomes in these patients, appropriate patient selection, well-organized protocols, and a multidisciplinary approach are mandatory.

Nutritional support in ICU: What is new?

Nutritional support (NS) is an integral component of the management of critically ill patients. Delivery of nutrients and energy to critically ill patients largely depends on the stage of the disease. The emphasis is on the gradual achievement of the target values of protein and energy, the predominant use of the enteral method of delivery of food components, the continuity of nutritional support between departments. When performing NS in patients in the acute stage of CC, it is important to take into account the ratio of protein and energy in the mixtures administered to prevent excess energy delivery and reduce mortality. Equally important is the composition, quality of the protein of the tube feeding and its tolerance. The positive clinical effects of the use of metabolically oriented tube feeding with a high content of arginine, vitamins A, E, C, the trace element Zn and Se allow us to consider nutritional support as one of the components of the prevention and treatment of pressure ulcers in hemodynamically stable patients in the ICU.

Clinical Characteristics and Early Outcomes of Children with COVID-19 Infection admitted to Children Hospital in Dhaka City

Background: The burden of COVID-19 infection in children is lesser than adult; however, there are only a few data describing COVID-19 in pediatrics. Objective: The purpose of the present study was to determine the clinical characteristics and early outcomes of children with COVID-19 infection admitted to children Hospital in Dhaka city. Methodology: This is a prospective observational study included children of RT-PCR positive COVID-19 cases admitted to Dr. MR Khan Shishu Hospital & ICH between June2020 to November 2020. A total 95 children were enrolled. Patients were categorized clinically and visited every day during their hospital stay. This study included mode of presentation, the pattern of comorbidities, presence of co-infection, clinical trajectory & early outcomes. Clinical outcomes included survival, duration of oxygenation, lengths of hospital stay. Data were analyzed after collection of demographic and clinical data of 95 enrolled children. Results: Among 95 children with COVID-19 admitted to Dr. M R Khan Shishu Hospital & ICH, 56 (58.95%) were male and 39(41.05%) were female. Maximum 35 (36.84%) of the patients were between 1-5 years age group. 65 (68.42%) presented with respiratory symptoms and 19 (20%) presented with gastrointestinal symptoms. Twenty-five patients (26.32%) had significant preexisting comorbidities. Most common symptoms were fever 73(76.84%), cough 65(68.42%), sore throat 24(25.26%), diarrhea 21(22.11%). Oxygenation was required for 5 patients (5.26%). 1 patient (0.95%) had died and 1required ventilatory support in ICU. The median (range) hospital lengths of stay was 7(3-14) days. Conclusion: Most of the children with COVID-19 presented with mild to moderate symptoms & gastrointestinal symptoms were not uncommon. Most of the patients had good prognosis and only few patients required respiratory support. Bangladesh Journal of Infectious Diseases, April 2022;9(Suppl_1): S9-S13

The Efficacy and Safety of Automatic Modes During Respiratory Support After Cardiac Surgery

Aims. To compare the efficacy and safety of semiautonomous Adaptive Support Ventilation (ASV) and fully automated (closed-loop, Intellivent-ASV) mechanical ventilation and oxygenation versus conventional mechanical ventilation mode during respiratory support in cardiac surgery patients.Material and methods. In this study, 40 adult patients were ventilated by conventional mechanical ventilation managed by 8 physicians (control group), whereas other two groups patients were ventilated by Intellivent-ASV (n=40) or in a semiautomatic ASV mode (n=40). The groups received standard care, except for the modes of ventilation.Results. In the Intellivent-ASV group, the number of manual changes in ventilator settings was significantly lower: 0 (0–0) versus 2 (2–3) (ASV) and 4 (3–5) in the control group (P<0.0001). There were significant differences in the duration of respiratory support in ICU which was 226±31 min (Intellivent group) vs 259±66 (ASV) and 271±78 min (control) (P=0.0042; P1–2=0.0167; P1–3=0.009). The Intellivent-ASV group patients received more protective ventilation than patients in the semiautomated and physician-controlled groups (lower values of driving pressure (6 (6–7) cm H2O vs. 6 (6–7) and 7 (7–9) cm H2O (P<0.0001)), tidal volume (6 (6–7) vs. 7 (7–7.7) and 7 (7–8) ml/kg/PBW (P<0.0001)), FiO2 (26 (24–30)% vs. 34 (30–35)% and 34 (30–38)%) with no differences between the groups in paO2/FiO2. There were no significant differences between the groups in frequency of undesirable events and duration of ICU stay.Conclusion. The use of intelligent technologies makes it possible to interactively individualize respiratory support, significantly reducing clinician's involvement in this process without compromising patient safety and the quality of ventilation.

Clinical decision support in the neonatal ICU

Clinical Decision Support (CDS) tools help the healthcare team diagnose, monitor, and treat patients more efficiently and consistently by executing clinical practice guidelines and recommendations. As a result, CDS has a direct impact on the delivery and healthcare outcomes. This review covers the fundamental concepts, as well as the infrastructure needed to create a CDS tool and examples of its use in the neonatal setting. This article also serves as a primer on what to think about when proposing the development of a new CDS tool, or when upgrading an existing one. We also highlight important elements that influence CDS development, such as informatics methodologies, data and device interoperability, and regulation.

Implementation and evaluation of sepsis surveillance and decision support in medical ICU and emergency department.

To improve the timely diagnosis and treatment of sepsis many institutions implemented automated sepsis alerts. Poor specificity, time delays, and a lack of actionable information lead to limited adoption by bedside clinicians and no change in practice or clinical outcomes. We aimed to compare sepsis care compliance before and after a multi-year implementation of a sepsis surveillance coupled with decision support in a tertiary care center. Single center before and after study. Large academic Medical Intensive Care Unit (MICU) and Emergency Department (ED). Patients 18years of age or older admitted to *** Hospital MICU and ED from 09/4/2011 to 05/01/2018 with severe sepsis or septic shock. Electronic medical record-based sepsis surveillance system augmented by clinical decision support and completion feedback. There were 1950 patients admitted to the MICU with the diagnosis of severe sepsis or septic shock during the study period. The baseline characteristics were similar before (N=854) and after (N=1096) implementation of sepsis surveillance. The performance of the alert was modest with a sensitivity of 79.9%, specificity of 76.9%, positive predictive value (PPV) 27.9%, and negative predictive value (NPV) 97.2%. There were 3424 unique alerts and 1131 confirmed sepsis patients after the sniffer implementation. During the study period average care bundle compliance was higher; however after taking into account improvements in compliance leading up to the intervention, there was no association between intervention and improved care bundle compliance (Odds ratio: 1.16; 95% CI: 0.71 to 1.89; p-value 0.554). Similarly, the intervention was not associated with improvement in hospital mortality (Odds ratio: 1.55; 95% CI: 0.95 to 2.52; p-value: 0.078). A sepsis surveillance system incorporating decision support or completion feedback was not associated with improved sepsis care and patient outcomes.

Characteristics and Outcomes of Pediatric Rapid Response With a Respiratory Trigger.

Authors of adult rapid response (RRT) studies have established that RRT triggers play an important role in outcomes, but this association is not studied in pediatrics. In this study, we explore the characteristics and outcomes of pediatric rapid response with a respiratory trigger (Resp-RRT). We hypothesize that outcomes differ on the basis of patients' primary diagnoses at the time of Resp-RRT. We conducted a 2-year retrospective observational study at an academic tertiary care pediatric hospital. Among the 1287 Resp-RRTs in 1060 patients, those with a respiratory diagnosis (N = 686) were younger, less likely to have complex chronic conditions, and less likely to have concurrent triggers (P < .01) than those with a nonrespiratory diagnosis (N = 601). Patients with a respiratory diagnosis were more likely to receive noninvasive ventilation, less likely to receive vasoactive support, and had lower 30-day mortality (P < .01). Among those with a respiratory diagnosis, the 541 patients with acute illness were younger, less likely to have complex chronic conditions, and less likely to receive vasoactive support than those with acute on chronic illness (N = 100) (P < .01). Among pediatric respiratory-triggered RRT events, patients with a respiratory diagnosis were more likely to receive acute respiratory support in ICU but have better long-term outcomes. Presence of complex chronic conditions increases risk of acute respiratory support and mortality. The interplay of primary diagnosis with RRT trigger can potentially inform resource needs and outcomes for pediatric Resp-RRTs.

Comparing the Intellivent-ASV® Mode with Conventional Ventilation Modes during Weaning after Uncomplicated Cardiac Surgery

The objective: to compare efficacy and safety of Intellivent-ASV® with conventional ventilation modes during weaning in the patients after cardiac surgery.Subjects and methods. In this randomized controlled trial, 40 adult patients were ventilated with conventional ventilation modes and 40 with Intellivent-ASV after uncomplicated cardiac surgery. Eight physicians were involved in the study.Care of both groups was standardized, except for the modes of postoperative ventilation.We compared:- The physician’s workload, through accounting number of manual ventilator settings and time they spent near the ventilator in every group,- Duration of tracheal intubation in ICU,- Evaluation of ventilation safety by considering driving pressure, mechanical power, positive end expiratory pressure, and tidal volume level,- The frequency of adverse events, postoperative complications, and lethality.Results. There were significant differences in the duration of respiratory support in ICU: 226 ± 31 min (Intellivent Group) vs 271 ± 78 min (Control Group) (p = 0.0013).In Intellivent Group, the number of manual ventilator settings and time spent by physicians near the ventilator before tracheal extubation were significantly lower: 0 vs 4 (2–6), and 35 (25–53) sec vs 164 ± 69 sec respectively (p &lt; 0.001 in both cases).Intellivent-ASV provided significantly more protective ventilation through reduction in the driving pressure, tidal volume, FiO2 and PEEP levels but no difference was noted between paO2/FiO2 ratio. ∆P and Vt were significantly lower in Intellivent Group – ∆P on mechanical ventilation was 6 (5–7) cm H2O vs 7.25 (6.5–9.5) cm H2O (p &lt; 0.001); Vt on mechanical ventilation was 6 (5.2–7) vs 7 (6–9.5) ml/kg/PBW (p = 0.000003). PEEP and FiO2 levels were also significantly lower in Intellivent Group, PEEP on mechanical ventilation was 5 (5–7.5) cm H2O vs 7 (5–11.5) cm H2O and FiO2 level was 26 (22–30) % vs 34 (30–40) %.There were no significant differences between the groups in frequency of adverse events and duration of ICU and hospital stay.Conclusion. Application of Intellivent-ASV mode after uncomplicated cardiac surgery provides more protective mechanical ventilation and reduces the physician’s workload without compromising the quality of respiratory support and safety of patients.

MO365URINARY BIOMARKERS AND POOR OUTCOMES IN PATIENTS WITH COVID-19 ADMITTED TO A REFERENCE HOSPITAL IN NORTHEAST BRAZIL

Background and AimsKidney biomarkers improve early and specific AKI detection and also poor outcomes in different clinical contexts. Kidney disease is an important risk factor for poor outcomes in COVID-19. The aim of this study was to evaluate association of early levels of kidney biomarkers with poor outcomes in hospitalized patients with COVID-19.MethodThis is a prospective study conducted at the Instituto Dr. Jose Frota Hospital, an important public reference hospital for COVID-19 in northeast Brazil. Medical records with clinical, epidemiologic, laboratory and outcomes were collected. The urinary NGAL, KIM-1, MCP-1 and nephrin were the kidney biomarkers quantified at hospital admission. ELISA assays were used for analysis and biomarkers urinary concentrations were adjusted for urinary creatinine. Data were expressed as mean± standard deviation or median.ResultsA total of 69 patients collected urine and were included in this study. Male gender was predominant (65%) and mean age was 56±19 years. Regarding outcomes, the group had 62% of death, 92% of ICU admission and 65% of invasive respiratory support in ICU. Urinary NGAL and MCP-1 were significantly elevated in patients that needed invasive respiratory support in comparison with non-invasive support: uNGAL (median=104 [IQR=74-153] vs 71 [31-79] ng/mg-Cr, p=0.013), and uMCP-1 (3055 [1127-5008] vs 1315 [574-2127] pg/mg-Cr, p=0.027). Urinary nephrin and KIM-1 was also elevated, however with no statistical significance. Moreover, all urinary biomarkers were higher in ICU admission group and death group, but with p>0.05. In ROC curve analysis for prediction of invasive respiratory support, uNGAL had AUC=0.696 (0.565-0.827),p=0.012 and cut-off=78 ng/mg-Cr; uMCP-1 had AUC=0.676 (0.539-0.813), p=0.023 and cut-off=1354 pg/mg-Cr. In survival analysis, patients with uNGAL >78 ng/mg-Cr had worse prognosis and died more quickly (19 vs 48 days, log-rank test; p=0.01). In patients with uMCP-1 >1354 pg/mg-Cr, they also died more quickly, but with no significance (25 vs 48 days, log-rank test; p=0.08).ConclusionUrinary biomarkers NGAL and MCP-1 quantified at hospital admission were associated with poor outcomes, mostly with needed of invasive respiratory support in ICU. Prediction cut-off values for invasive respiratory support was useful to determine the survival prognosis.

English

BACKGROUND Due to the impaired ocular defence mechanisms, patients in the intensive care unit are more prone for ocular surface disorders. This creates the need for identifying the causal factors and educating the health care staff working in (intensive care unit) ICU, regarding ocular surface disorders. The prevalence of ocular surface disorders in ICU patients is about 60 %.1 We wanted to study the proportion and causative factors of ocular surface disorders in intensive care unit patients. METHODS A cross sectional study was conducted among 100 patients admitted in intensive care unit of S.V.R.R.G.G. Hospital, Tirupathi, for a duration of one year. A detailed history, clinical examination, fluorescein staining, Schirmer’s test and conjunctival cultures was done. RESULTS Out of 100 patients, 50 patients were on ventilator support and 50 patients were without ventilator support in ICU. Overall prevalence of superficial punctate keratitis was 78 %, lagophthalmos 20 %, dry eyes 88 %, microbial keratitis 17 % in patients. The prevalence of ocular surface disorders was more in ventilator supported patients. CONCLUSIONS Ocular examination should be a part of routine examination in an intensive care unit setting, because the risk of microbial keratitis can be reduced by preventing exposure keratopathy with the help of meticulous eye care. KEYWORDS Ocular Surface Disorders, Intensive Care Unit, Ventilator Support, Microbial Keratitis, Eye Care

COVID-19 cohort on children with cancer: delay in treatment and increased frequency of deaths

Abstract Objectives: to describe epidemiological characteristics and deaths in children with cancer and COVID-19 at a reference hospital in Recife, Brazil. Methods: cohort involving children under the age of 19 underwent cancer treatment during April to July 2020. During the pandemic, real-time reverse transcriptase polymerase chain reaction assay (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS -CoV-2) in nasal / oropharyngeal swab were collected in symptomatic patients or before hospitalization. Those with detectable results were included in this cohort study. The outcomes were delayed on cancer treatment and death. Descriptive analysis was performed and presented in preliminary results. Results: 48 children participated in the cohort, mostly with hematological neoplasms (66.6%.),69% were male, median age was 5.5 years. The most frequent symptoms were fever (58.3%) and coughing (27.7%);72.9% required hospitalization, 20% had support in ICU and 10.5% on invasive ventilatory assistance.66.6% of the patients had their oncological treatment postponed, 16.6% died within 60 days after confirmation of SARS-CoV-2 infection. Conclusions: COVID-19 led a delay in the oncological treatment for children with cancer and a higher mortality frequency when compared to the historical series of the service. It would be important to analyze the risk factors to determine the survival impact.

Venous Thrombo-Embolism in Hospitalized SARS-CoV-2 Patients Treated with Three Different Anticoagulation Protocols: Prospective Observational Study.

Simple SummaryThe aims of this study are: (1) to analyze the risk of vein thrombosis and pulmonary embolism in patients affected by pneumonia due to Covid-19; (2) to evaluate conditions that could increase this risk; (3) to verify the efficacy of different doses of antithrombotic drugs to prevent these life-threatening complications. Seventy-four patients were enrolled (44 men and 30 women, average age 68.6). All of them were screened with lower limb ultrasound. Laboratory analyses including D-dimers were tested the same day. In case of clinical suspicion of pulmonary embolism, they performed a CT pulmonary angiography. A total of 28.4% (21 patients) were diagnosed with deep vein thrombosis or pulmonary embolism. This finding confirms that these patients were at increased risk of venous thromboembolism, as already reported from other studies. Mechanical ventilation, higher d-dimer levels, longer length of hospitalization and admission to intensive care unit showed to be statistically associated with thromboembolic events. In addition, the study showed that an intermediate or high dose of anticoagulation did not decrease the risk of thromboembolic events compared to lower doses. On the other hand, six patients reported severe bleeding that could be caused by higher doses of anticoagulant drugs.The purpose of this study is to assess thrombotic risk in CoViD-19/pneumonia patients with acute respiratory failure and to compare populations treated with three different antithrombotic prophylaxis protocols. The primary outcome is to analyze the prevalence of thrombotic events in hospitalized patients, while the secondary outcome is to analyze the correlation between different anticoagulation targets with thrombotic events. All patients referred to our hospital for acute respiratory failure due to COVID-19 pneumonia between 18 and 31 May 2020 were included. Seventy-four patients were enrolled (44 men and 30 women, average age 68.6). Diagnosis of venous thromboembolism was made in 21 cases (28.4%) and thrombotic events were associated with positive pressure ventilation support (p = 0.024) and hospitalization in ICU (p < 0.0001). These patients presented higher levels of D-dimer (p < 0.0001) and their hospital length of stay was >16 days longer. Forty-seven out of 74 patients (63.5%) received intermediate or therapeutic dose of anticoagulation, while twenty-seven patients (34.5%) received standard antithrombotic prophylaxis. The analysis showed that an intermediate or therapeutic dose of anticoagulation did not decrease the prevalence of thrombotic events. On the other hand, six patients reported severe hemorrhagic complications. Despite intermediate or therapeutic-dose of anticoagulation, a high number of patients with acute respiratory failure secondary to COVID-19 developed thrombotic complications.

Advanced Respiratory Support in the Contemporary Cardiac ICU.

Prospective cohort study. The Critical Care Cardiology Trials Network is a research collaborative of cardiac ICUs across the United States and Canada. We included all medical cardiac ICU admissions at 25 cardiac ICUs during two consecutive months annually at each center from 2017 to 2019. We evaluated the use of advanced respiratory therapies including invasive mechanical ventilation, noninvasive ventilation, and high-flow nasal cannula versus no advanced respiratory support across admission diagnoses and the association with in-hospital mortality. Of 8,240 cardiac ICU admissions, 1,935 (23.5%) were treated with invasive mechanical ventilation, 573 (7.0%) with noninvasive ventilation, and 281 (3.4%) with high-flow nasal cannula. Admitting diagnoses among those with advanced respiratory support were diverse including general medical problems in patients with heart disease as well as primary cardiac problems. In-hospital mortality was higher in patients who received invasive mechanical ventilation (38.1%; adjusted odds ratio, 2.53; 2.02-3.16) and noninvasive ventilation or high-flow nasal cannula (8.8%; adjusted odds ratio, 2.25; 1.73-2.93) compared with patients without advanced respiratory support (4.6%). Reintubation rate was 7.6%. The most common variables associated with respiratory insufficiency included heart failure, infection, chronic obstructive pulmonary disease, and pulmonary vascular disease. One-third of cardiac ICU admissions receive respiratory support with associated increased mortality. These data provide benchmarks for quality improvement ventures in the cardiac ICU, inform cardiac critical care training and staffing patterns, and serve as foundation for future studies aimed at improving outcomes.

Smart Mode of Mechanical Lung Ventilation During Early Activation of Cardiosurgical Patients

Purpose of the study: a comparative assessment of safety and quality of respiratory support carried out using the ASV mode vs. conventional protocol, in which ventilation parameters are set by an ICU physician during early postoperative period in cardiosurgical patients.Materials and methods. The modes of a respiratory support included automated ASV ventilation (40 patients) versus conventional ventilation (38 patients) managed by 8 ICU physicians were compared in a cohort of cardiosurgical patients in a randomized controlled study.The comparison included ventilation parameters, all efforts of physicians to adjust ventilator settings and time it took, duration of respiratory support in ICU, incidence of adverse events in the course of weaning, total time in ICU and hospital, postoperative complications and mortality.Results. There was no reliable difference in the duration of postoperative trachea intubation, which was equal to 267±76 minutes (the ASV group) and 271±80 minutes (the control group).The number of manual adjustments, which was 2 vs. 4 (P&lt;0.00001), and the time spent by a clinical physician near a ventilator, which was 99±35 seconds vs. 166±70 seconds, were reliably lower in the ASV group (P=0.00001).The time between restoration of patient’s own respiratory activity and transfer to the assisted breathing mode was longer in the control group and amounted to 30 (0–90) min. while in the smart mode, the transfer took place immediately after restoration (P=0.004969).When ASV was used, the driving pressure was reliably lower during all phases of respiratory support: ΔP 7.2±1.6 vs. 9.3±2.1 cm H2O, (P=0.000001); there was no reliable difference in the tidal volume: 7.0 (6–8.5) (ASV) vs. 7 (6–10) ml/kg/ideal body mass (the control group).Conclusion. ASV represents a lung-protective ventilation that reduces physician’s time cost and medical staff efforts in ALV management without compromising patient’s safety and respiratory support quality.

SUN-LB066 Assessing the Need for Individualized Sick Day Protocol in a Patient with Secondary Adrenal Insufficiency and Pneumonia

Introduction: Secondary Adrenal Insufficiency (SAI) has a prevalence of 280 per million [1]. Most patients with chronic SAI are on daily glucocorticoid replacement therapy. However, due to underlying inability to mount cortisol response to illness, it is critical to implement a Sick Day Protocol (SDP). We present the case of septic shock due to pneumonia, in a patient with secondary hypocortisolism following meningeal tumor resection. Case Presentation: A 60 year old Caucasian female presented to ED with fever and progressively worsening cough with purulent sputum for four days. She had hypertension, hypothyroidism, Type 2 diabetes, and secondary hypocortisolism following resection of meningotheliomatous meningioma. At presentation she was febrile and in septic shock with elevated WBC with left shift [14 (4.5 -11 K/microL)], lactic acid [7.2 (0.7-2.0 mmol/L)] and procalcitonin [41 (<0.5 ng/ml)]. Despite bolus IV fluids, stress dose steroids and broad-spectrum antibiotics, patient continued to be encephalopathic and hypotensive (MAP <65 mm Hg). She thus required pressor support (Norepinephrine) in ICU. Chest X-ray and CT confirmed pneumonia in left lower lobe and lingula. Home regimen of hydrocortisone comprised 17.5 mg at 0900 and 7.5 mg at 1700. Within 12 hours of stress dose hydrocortisone (250 mg) she was successfully weaned off norepinephrine with resolution of encephalopathy, and WBC normalized. She was given stress dose hydrocortisone (200 mg/day) for four days. She was then discharged home with instruction to finish oral course of antibiotics, continue home dosing of hydrocortisone and to further discuss SDP with primary healthcare provider. Discussion: In times of severe physiological stress, cortisol levels can raise up to tenfold normal levels. Cortisol plays key role in maintaining vascular integrity, potentiating vasoconstrictor effects of catecholamines and mediating anti-inflammatory effects on immune system [2]. Patients with chronic adrenal insufficiency require hydrocortisone dosing of 10-12 mg/m2 body surface area (15-25mg/day) in two doses with two-thirds of the dose optimally administered in AM to mimic physiological cycling [1]. This patient had symptoms of pneumonia for four days and had only been taking her regular hydrocortisone doses. This case emphasizes the need for individualized counselling for early SDP in patients with SAI.

Application of albumen powder during the early standardized nutritional support in ICU

Objective To explore the value of the application of albumen powder during the early standardized nutritional support in ICU. Methods Totally 80 patients treated in ICU were enrolled. Randomized digital tables were used to divide patients into experimental and control groups. Nutritive medium was used for enteral nutrition in the control group, and intermixture of nutritive medium and albumen powder was used in experimental group. Results After the intervention, the value of index was significantly better than the control group. The sebum thickness, muscle thickness and plasma total protein and serum album in experimental group before intervention were (0.99±0.72) cm, (2.19±1.14) cm, (62.14±6.87) g/L,(35.32±2.98) g/L, and were (1.01±0.72) cm, (2.18±1.13) cm, (64.31±6.97) g/L, (36.13±3.02)g/L in control group, the difference between the two groups was not statistically significant. After intervention, the value were (1.06±0.53)cm, (2.25±0.69) cm, (69.87±7.16)g/L,(40.32±3.17) g/L in control group, (1.39±0.63)cm, (2.62±0.81)cm, (44.21±3.22)g/L,(75.24±7.32)g/L in experimental group, there were significant difference between two groups (t=2.182-5.445, P<0.01 or 0.05). The incidence of gastrointestinal reaction in experimental group was 20% (8/40) which was lower than 35% (14/40) of control group significantly(χ2=19.57,P=0.000). Conclusion Application of albumen powder could improve the index including sebum thickness, muscle thickness, plasma total protein and serum album and reduce the incidence of gastrointestinal reaction of patients in ICU. Key words: Intensive care units; Albumen powder; Enteral nutrition

Inhalative sedation with small tidal volumes under venovenous ECMO.

Inhalative sedation is an emerging method for long-term sedation in intensive care therapy. There is evidence that it is easy to control and may be beneficial compared to intravenous sedation. Yet little is known about the use in patients with compromised lung function. In this retrospective analysis, we searched files of patients receiving inhalative sedation under venovenous extracorporeal membrane oxygenator (vv-ECMO) support due to lung failure. After ethical approval, we performed a retrospective analysis of patients receiving vv-ECMO support and inhalative sedation in the surgical ICU in 2015. Isoflurane was administered via the AnaConDa®-system. Sedation was tested using Richmond Agitation and Sedation scale (RASS). 7 patients were identified. Median age was 50years (26/70years). All were male. Median ECMO runtime was 129h (37/1008h) and the survival rate was 57.9%. Dose of isoflurane was 1.7ml/h (0.8 / 4.0ml/h) resulting in expiratory concentrations of 0.8 Vol% (0.3/1.8 Vol%), inspiratory of 0.6 Vol% (0.1/1.4 Vol%). Higher concentrations of isoflurane were associated with increased depth of sedation (expiratory p = 0.016; inspiratory p = 0.027; averaged p = 0.015). With tidal volume below 350ml, association was still present for expiratory and averaged concentrations of isoflurane (expiratory p = 0.031; inspiratory p = 0.082; average p = 0.039). This is the first study that shows that inhalative concentrations of isoflurane are associated with depth of sedation in patients with lung failure. We were able to show that even with major impacts in lung mechanics and function targeted sedation with volatile anaesthetics is feasible and dose-response relationship appears to exist.

Health related quality of life in survivors of acute respiratory illness who required invasive respiratory support in a tertiary Pediatric ICU - A Prospective observational study

Objectives: To assess long term health related quality of life in all PICU survivors with acute respiratory illness requiring invasive respiratory support, three to eight years after discharge Materials and Methods: All premorbidly well children between 1month to 15years of age who were ventilated for more than 48 hours for acute respiratory illness between March 2008- February 2014 and who were survived and discharged were included in our study. Neonates, children with acute neurological dysfunction, premorbidly unwell children, readmission to PICU were excluded.Data was collected from medical records. Those who were non contactable were written a postal letter. Quality of life assessment was done with the help of the Health Utility Index 2 which has 6 domains; sensation, mobility, emotion, cognition, self care and pain. Functioning within each attribute is represented by four or five levels. The assessment was done either by telephone questionnaire or by objective assessment in PICU office/Out patient department(OPD) by using HUI2 index. By using this,the outcome is classified as NORMAL(Score>0.99),FAIR(0.89-0.99) and POOR(Score<0.89). Results: In our study we had total 259 children who were admitted with acute respiratory illness requiring invasive ventilation in PICU for more than 48 hours during our study period. Out of these, 67 children (26%) died during PICU stay due to various complications and 46 (18%) were discharged against medical advice. Among 146 children, we were able to contact 66 children and the remaining 74 children could not be contacted through telephone or postal service. In the study group, six children died after discharge due to various causes . HUI2 questionnaire details were obtained either through personal interview (n=24) or by telephonic interview (n=42). HUI2 assesment was done for 66 children (Mean age 7.8± 2.6 years). Mean HUI2 score was 0.94±0.062. Majority of children are having good quality of life (84%) and 16% having poor quality of life who were affected in more than one domain. Of these 66 children, only one child was having learning disability and was affected badly in 4 domains(Score of 0.69) of quality of life. He needs spectacles to see and can walk with some limitation and often anxious and studies less compared to peer groups. Most common affected domain in our study group is ‘Cognition’. 23(35%) children are able to learn and remember school work less than their peer groups at school otherwise there were normal in all other domains. This is based on their parents perspective. Second most common affected domain is ‘Emotion’. 12(19%) children in our study group (66) are occasionally irritable, angry, depressed, anxious due to various reasons. Third most common affected domain is ‘Sensation’. Eleven(17%) children among our study group required either spectacles or hearing aid. In the ‘Pain’ domain, only 7 children (11%) out of 66 has occasional pain and discomfort. In the ‘selfcare’ domain, only 5 children (8%) out of 66 children are affected. These children have some difficulty to handle their day to day activities. Least commonly affected domain is ‘Mobility’(1.5%) where only one child was affected who needs some assistance while walking. In our study, duration of PICU stay, complications of ventilation (VAP, Pneumothorax, Pneumo-mediastinum) and multiorgan dysfunction (ARF,ALF,DIC-9) had influence on the long term outcome but it is not statistically significant (P value 0.128, 0.206 and 0.638 respectively). This may be due to the decrease in effect of acute illness in long term quality of life. In our study there was no correlation noted between maternal and paternal education and quality of life. Majority of PICU survivors(84%) have a good long term Quality of life (HUI mean score 0.94+/0.06). Even though, factors (Duration of PICU stay, complications of ventilation and multiorgan dysfunction) influencing long term quality of life were present more in the Poor outcome group, they are not statistically significant. This may be due to the decrease in effect of acute illness in long term quality of life.