Total Ventilator Days Research Articles

Impact of Humidification Modality on Incidence of Endotracheal Tube Occlusion in COVID-19 Patients.

Background: Endotracheal tube (ETT) occlusion is reported at a higher frequency among coronavirus disease-2019 (COVID-19) patients. Prior to the COVID-19 pandemic, literature examining patient and ventilator characteristics, including humidification, as etiologies of ETT occlusion yielded mixed results. Our study examines the relationship of humidification modality with ETT occlusion in COVID-19 patients undergoing invasive mechanical ventilation (IMV). Methods: We conducted a retrospective chart review of COVID-19 patients requiring IMV at a tertiary care center in New York from April 2020 to April 2021. Teleflex Neptune heated wire heated humidification (HH) and hygroscopic Intersurgical FiltaTherm and Sunmed Ballard 1500 heat and moisture exchangers (HME) were used. Episodes of ETT occlusion were recorded. Univariate and multivariable logistic regression models were used to investigate the relationship between humidification modality and the occurrence of ETT occlusion. Findings: A total of 201 eligible patients were identified. Teleflex HH was utilized in 50.2% of the population and the others Intersurgical and Sunmed HME devices. Median age was 62 years and 78.6% of patients had at least one medical comorbidity. Precisely, 24% of patients experienced an ETT occlusion after a median of 12 days. The HME group was younger (58.5 vs 64 years), predominantly male (75% vs 59.4%), and experienced more total ventilator days than the HH group (24 vs 12). Those using the studied HME devices had significantly higher odds of ETT occlusion (OR 4.4, 95% CI 1.8-10.6, P = .0011). Three patients (6.1%) experienced cardiac arrest as a consequence of their occlusion. There were no deaths directly attributed to ETT occlusion. Conclusions: The studied HME devices were significantly associated with higher odds of ETT occlusion in COVID-19 patients requiring invasive mechanical ventilation. These events are not without significant clinical consequences. Prolonged use of under-performing HME devices remains suspect in the occurrence of ETT occlusions.

Single institution review of operative management of giant omphalocele

PurposeOperative management of giant omphalocele that cannot be closed primarily varies based on several factors, and there is little data to guide choice of operative approach and how this impacts long-term outcomes. We aimed to characterize whether surgical approach – staged closure during the neonatal period, or delayed closure – affects outcomes. MethodsWe conducted a retrospective review of children treated for giant omphalocele who did not undergo primary closure at Children's Hospital Colorado from 2010–2022. We included patients with giant omphalocele who underwent treatment at the study site. Data collected included patient characteristics, clinical course, and outcomes. Comparisons were made based on type of closure, delayed versus staged. ResultsWe identified 24 patients; 6 delayed and 16 staged. 2 patients died prior to closure. Delayed and staged groups did not differ regarding demographics. Infants undergoing staged repair tended to have more total hospital and total ventilator days, and more post-closure ventral hernia requiring repair; short-term outcomes were otherwise comparable. There was no difference between groups in long-term outcomes, including neurodevelopmental milestones and mortality. ConclusionsLong term outcomes are equivalent between staged repair and delayed repair of giant omphalocele. However, staged repair may be associated with more ventilator days, total hospital days and higher risk of ventral hernia.

Is Ventilator-associated Event Algorithm Ideal for Surveillance? – Experience from a Neurosurgery Intensive Care Unit in Kerala

ABSTRACT Background: The ventilator-associated event (VAE) surveillance algorithm was brought in to replace the clinical ventilator-associated pneumonia (VAP) surveillance by NHSN in January 2013. This study intends to find the correlation of these surveillance criteria with the clinical VAP rates in a neurosurgery intensive care unit (ICU). Materials and Methods: This was a retrospective analysis of records of patients undergoing invasive mechanical ventilation in a neurosurgery ICU during a 3-month period. Results: Thirty-seven patients underwent invasive mechanical ventilation. The mean age was 56 years. Hypertension was the most common comorbidity among 22 (59.4%) patients. The neurological diagnosis was traumatic brain injury in 19 cases, nontraumatic intracranial hemorrhage in 12 cases, and ischemic stroke in 6 cases. Twenty-one patients had respiratory sample culture positivity and 14 were clinical VAP. The total ventilator days assessed were 82. The clinical VAP rate was 170.7, and the probable VAP (PVAP) rate for the same period was 12.19. Among the 14 patients who developed clinical VAP, 13 (88%) were hospital acquired and caused by multidrug-resistant pathogens. Six patients died during their ICU stay. ICU stay of more than 7 days was significantly associated with a clinical VAP. Conclusions: VAE was found to correlate poorly with a clinical diagnosis of VAP. When used as a surveillance tool in an ICU, it was found to miss important infection-related events in ventilated patients.

Use of Early Ketamine Sedation and Association With Clinical and Cost Outcomes Among Mechanically Ventilated Patients With COVID-19: A Retrospective Cohort Study.

To describe the utilization of early ketamine use among patients mechanically ventilated for COVID-19, and examine associations with in-hospital mortality and other clinical outcomes. Retrospective cohort study. Six hundred ten hospitals contributing data to the Premier Healthcare Database between April 2020 and June 2021. Adults with COVID-19 and greater than or equal to 2 consecutive days of mechanical ventilation within 5 days of hospitalization. The exposures were early ketamine use initiated within 2 days of intubation and continued for greater than 1 day. Primary was hospital mortality. Secondary outcomes included length of stay (LOS) in the hospital and ICUs, ventilator days, vasopressor days, renal replacement therapy (RRT), and total hospital cost. The propensity score matching analysis was used to adjust for confounders. Among 42,954 patients, 1,423 (3.3%) were exposed to early ketamine use. After propensity score matching including 1,390 patients in each group, recipients of ketamine infusions were associated with higher hospital mortality (52.5% vs. 45.9%, risk ratio: 1.14, [1.06-1.23]), longer median ICU stay (13 vs. 12 d, mean ratio [MR]: 1.15 [1.08-1.23]), and longer ventilator days (12 vs. 11 d, MR: 1.19 [1.12-1.27]). There were no associations for hospital LOS (17 [10-27] vs. 17 [9-28], MR: 1.05 [0.99-1.12]), vasopressor days (4 vs. 4, MR: 1.04 [0.95-1.14]), and RRT (22.9% vs. 21.7%, RR: 1.05 [0.92-1.21]). Total hospital cost was higher (median $72,481 vs. $65,584, MR: 1.11 [1.05-1.19]). In a diverse sample of U.S. hospitals, about one in 30 patients mechanically ventilated with COVID-19 received ketamine infusions. Early ketamine may have an association with higher hospital mortality, increased total cost, ICU stay, and ventilator days, but no associations for hospital LOS, vasopressor days, and RRT. However, confounding by the severity of illness might occur due to higher extracorporeal membrane oxygenation and RRT use in the ketamine group. Further randomized trials are needed to better understand the role of ketamine infusions in the management of critically ill patients.

Implementation of an Extubation Readiness Guideline for Preterm Infants.

Intubated preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 32 6 / 7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV NICU. This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt. Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 32 6 / 7 weeks or less of gestation.

929 Outcomes in Pediatric Spinal Cord Injuries Based on Time to Surgery

INTRODUCTION: Early surgery in individuals with traumatic spinal cord injury (SCI) has been associated with improved neurological recovery, lower risk of complications, and reduced resource utilization. Patient and healthcare-related factors may contribute to delay in surgery. This study aimed to determine factors contributing to longer time-to-surgery in pediatric patients with complete and incomplete SCI. METHODS: Patients with SCI were identified in the National Trauma Data Bank based on AIS codes. Patients who died in the ED or were transferred to another hospital were excluded. Procedure codes were used to identify patients who underwent spinal surgery. Patients were grouped by time to surgery less than or greater than 12 hours. RESULTS: 549 patients were identified with 235 incomplete and 314 complete SCI. 399 patients underwent surgery (177 incomplete; 222 complete). Of patients who underwent surgery, 55% of incomplete and 52% of complete SCI went to surgery after 12 hours. SCI patients with greater than 12-hour time-to-surgery had worse injury severity scores (32 vs 28, p < 0.05). Additionally, ICU LOS, total ventilation days, and total LOS were longer. Time-to-surgery greater than 12 hours was statistically associated with unplanned ICU stay (incomplete), unplanned OR (complete), ventilator associated pneumonia (complete), and delirium (incomplete). Time-to-surgery was not significantly associated with race, gender, or mechanism of injury. pneumonia (complete), and delirium (incomplete). Time-to-surgery was not significantly associated with race, gender, or mechanism of injury. CONCLUSIONS: Greater time-to-surgery is associated with higher risk of complications and longer hospital stays in patients with complete and incomplete SCI in the pediatric population. This data raises the question as to whether earlier surgery could reduce complications.

Propofol vs etomidate for induction prior to invasive mechanical ventilation in patients with acute myocardial infarction

BackgroundPatients with acute myocardial infarction (AMI) requiring invasive mechanical ventilation (IMV) have a high mortality. However, little is known regarding the impact of induction agents, used prior to IMV, on clinical outcomes in this population. We assessed for the association between induction agent and mortality in patients with AMI requiring IMV. MethodsWe compared clinical outcomes between those receiving propofol compared to etomidate for induction among adults with AMI between October 2015 and December 2019 using the Vizient® Clinical Data Base, a multicenter, US national database. We used inverse probability treatment weighting (IPTW) to assess for the association between induction agent and in-hospital mortality. ResultsWe identified 5,147 patients, 1,386 (26.9%) of received propofol and 3,761 (73.1%) received etomidate for IMV induction. The mean (SD) age was 66.1 (12.4) years, 33.0% were women, and 51.6% and 39.8% presented with STEMI and cardiogenic shock, respectively. Patients in the propofol group were more likely to require preintubation vasoactive medication and mechanical circulatory support (both, P < .05). Utilization of propofol was associated with lower mortality compared to etomidate (32.3% vs 36.1%, P = .01). After propensity weighting, propofol use remained associated with lower mortality (weighted mean difference −4.7%; 95% confidence interval: −7.6% to −1.8%, P = .002). Total cost, ventilator days, and length of stay were higher in the propofol group (all, P < .001). ConclusionsInduction with propofol, compared with etomidate, was associated with lower mortality for patients with AMI requiring IMV. Randomized trials are needed to determine the optimal induction agent for this critically ill patient population.

Effect of mechanical ventilation guided by transpulmonary pressure in acute respiratory distress syndrome patients: a systematic review and meta-analysis of randomized control trials.

This study aimed to investigate the effect of mechanical ventilation guided by transpulmonary pressure in patients diagnosed with acute respiratory distress syndrome (ARDS). Randomized control trials of ARDS patients that received mechanical ventilation guided by transpulmonary pressure vs. mechanical ventilation guided by traditional lung protective ventilation strategies in adults were retrieved by two reviewers independently from PubMed, EMBASE, The Cochrane Library, The China National Knowledge Infrastructure, and WanFang database before October 2022. The protocol has been registered on PROSPERO (CRD42022307816). The primary outcome was mortality. The secondary outcomes included mechanical ventilation days, oxygenation function and ventilation parameters, hemodynamics, and cytokines level. Thirteen articles (819 patients) were finally included through our search strategy. The total mortality (RR, 0.68; 95% CI, 0.54-0.85; p = 0.0006) and mechanical ventilation days (MD, -2.77; 95% CI, -4.60 - -0.94; p = 0.003) reduced when compared with the control group. Patients in the transpulmonary pressure group had higher oxygen index (MD, 40.74; 95% CI 9.81-71.68, p = 0.010) and lung compliance (MD, 7.98; 95% CI 4.55-11.41, p < 0.00001). Positive end-expiratory pressure (PEEP) was higher in the transpulmonary pressure group (MD, 5.47; 95% CI, 3.59 - 7.35; p < 0.00001). The Interlukin-6 (IL-6) level in the control group decreased obviously compared with that in the transpulmonary pressure group (SMD, -2.03; 95% CI, -3.50 - -0.56; p = 0.007). Mechanical ventilation guided by transpulmonary pressure tended to have a beneficial prognosis on ARDS patients. Oxygenation and lung mechanics parameters were also improved. The clinical effect of mechanical ventilation directed by transpulmonary pressure was superior to the traditional lung protective ventilation strategies in ARDS patients.

Association Between Health Insurance and Outcomes After Traumatic Brain Injury: A National ACS-TQP-PUF Database Study

IntroductionAccording to the US Census Bureau, roughly 8.6% of the population lacks health care coverage. Increasing evidence suggests that insurance status plays a role in outcomes after trauma. However, its role in the setting of traumatic brain injury (TBI) remains poorly understood. MethodsThe Trauma Quality Programs Participant Use Files were queried from 2017 to 2019. All patients with isolated TBI were identified. Isolated TBI was defined as: 1) Head Abbreviated Injury Scale (AIS) > 3 and 2) AIS <3 in all other anatomical regions. Patients dead on arrival, with Head AIS = 6, or missing key data were excluded. Demographic and clinical information was compared between those with and without insurance. Multivariate regressions were used to assess associations between insurance status and TBI outcomes (inhospital mortality, discharge to facility, total ventilator days, Intensive Care Unit length of stay (ICU LOS), and hospital LOS). ResultsIn total, 199,556 patients met inclusion criteria; 18,957 (9.5%) were uninsured. Compared to the insured, uninsured TBI patients were younger with a greater proportion of males. Uninsured patients were less severely injured and less comorbid. Uninsured patients had shorter unadjusted LOS in the ICU and hospital. Yet, uninsured patients experienced greater unadjusted inhospital mortality (12.7% versus 8.4%, P < 0.001).When controlling for covariates, lack of insurance was significantly associated with increased likelihood of mortality (OR 1.62; P < 0.001). This effect was most noticeable in patients with Head AIS = 4 (OR 1.55; P < 0.001) and Head AIS = 5 (OR 1.80; P < 0.001). Lack of insurance was also significantly associated with decreased likelihood of discharge to facility (OR 0.38), decreased ICU LOS (Coeff. −0.61), and decreased hospital LOS (Coeff. −0.82; all P < 0.001). ConclusionsThis study demonstrates that insurance status is independently associated with outcome disparities after isolated TBI. Despite the Affordable Care Act (ACA) reform, lack of insurance appears significantly associated with inhospital mortality, decreased likelihood of discharge to facility, and decreased time spent in the ICU and hospital.

High frequency jet ventilation for congenital diaphragmatic hernia

BackgroundThe optimal role of high frequency jet ventilation (HFJV) in lung protective stabilization of congenital diaphragmatic hernia (CDH) remains uncertain. We aimed to describe our center's experience with HFJV as both a rescue (following failed stabilization with CMV) and primary ventilation mode in the management of CDH. MethodsLiveborn CDH patients treated from 2013 to 2021 in a single institution were reviewed.We compared 3 groups based on their primary and last ventilation mode prior to surgery: CMV (Group 1); HFJV (Group 2); and CMV/HFJV (Group 3). Outcomes included a composite primary outcome (≥1 of mortality, need for ECMO or need for supplemental O2 at discharge), total invasive ventilation days and development of pneumothorax. A descriptive analysis including univariate group comparisons was performed. Multivariate logistic regression models investigating the relationship between mode of ventilation and the primary outcome adjusted by potentially confounding covariates were constructed. Results56 patients (32 Group 1, 18 Group 2, 6 Group 3) were analyzed. Group 2 and 3 patients had more severe disease based on liver position, SNAP-II score, pulmonary hypertension severity, need for inotropic support, CDHSG defect size and need for patch repair. There were no group differences in survival, need for ECMO, or pneumothorax occurrence, although infants receiving HFJV required longer invasive ventilation and had a greater need for O2 at discharge. Multivariate logistic regression revealed no associations between mode of ventilation and outcome. ConclusionsHFJV appears effective, both for CMV rescue and as a primary ventilation strategy in high risk CDH.Level of evidence: Level IV.

The association of intensive care capacity transfers with survival in COVID-19 patients from a Scottish district general hospital: A retrospective cohort study.

Background: During the second wave of COVID-19 cases within Scotland, local evidence suggested that a large number of interhospital transfers occurred due to both physical capacity and staff shortages. Although there are inherent risks with transferring critically ill patients between hospitals, there are signals in the literature that mortality is not affected in COVID-19 patients when transferred between intensive care units. With a lack of evidence in the Scottish population, and as the greatest source of capacity transfers in our critical care network at that time, we sought to determine whether these transfers impacted on survival to hospital discharge.Methods: We conducted a retrospective cohort study of all patients admitted to our unit between the 1st October 2020 and the 31st March 2021 with a primary diagnosis of COVID-19 pneumonia. Patients were grouped according to whether they underwent an interhospital capacity transfer or not, either for unit shortage of beds or unit shortage of staff. The primary outcome measure was survival to ultimate hospital discharge, and secondary outcomes included total ventilator days and total intensive care unit length of stay. Baseline characteristic data were also collected for all patients. Survival data were entered into a backward stepwise logistic regression analysis that included transfer status, and coefficients transformed into odds ratios and 95% confidence intervals.Results: A total of 108 patients were included. Of these, 30 were transferred to another intensive care unit due to capacity issues at the base hospital. From the baseline characteristic data, age was significantly higher in those transferred out, while other characteristics were similar. Unadjusted mortality rates were 30.8% for those not transferred, and 40% for those transferred out. However, when entered into a logistic regression analysis to attempt to control for confounders in the baseline characteristics, being transferred had an odds ratio of 1.14 (95% confidence interval 0.43–3.1) for survival to hospital discharge. Total ventilator days and total ICU length of stay were both higher in the transferred patients.Conclusion: This unique study of COVID-19 patients transferred from a Scottish district general hospital did not show an association between transfer status and survival to hospital discharge. However, the study was likely underpowered to detect small differences. As the situation continues to evolve, a prospective regional multi-centre study may help to provide more robust findings.

Effects of preexisting stroke on acute hospital outcomes for older adults admitted with neurotrauma and orthopedic injury

ABSTRACT Objective We aimed to examine acute trauma outcomes, specifically among those with neurotrauma (NT), in patients with preexisting cerebrovascular accident (CVA). Methods We identified patients treated for neurotrauma or orthopedic trauma at hospitals in Pennsylvania with and without an identified history of stroke with residual deficits, aged 50–99 across four groups of N = 11,648 each. We assessed mortality, craniotomy, and total hospital, ICU, step-down, and ventilator days, functional status at discharge (FSD), and discharge destination. Results Stroke history did not influence mortality but was predictive of patients undergoing craniotomy (OR = 1.25, p = 0.008). There was a moderate group effect on total ICU days, with the CVA+NT group in the ICU the longest (η2 = 0.10, p < 0.001). Patients with stroke history were less likely to be discharged to home (OR = 0.65, p < 0.001) and had poorer FSD scores across the various domains assessed. Conclusions Trauma patients with preexisting CVA were found to have poorer outcomes on a number of different metrics when compared to those without stroke history. While it is possible that functional differences pre-injury influenced FSD and discharge destination, given these results, clinicians should assess for possible comorbidities that may influence treatment.

Association Between Acute Kidney Injury During Invasive Mechanical Ventilation and ICU Outcomes and Respiratory System Mechanics.

OBJECTIVES:Compare ICU outcomes and respiratory system mechanics in patients with and without acute kidney injury during invasive mechanical ventilation.DESIGNS:Retrospective cohort study.SETTINGS:ICUs of the University of California, San Diego, from January 1, 2014, to November 30, 2016.PATIENTS:Five groups of patients were compared based on the need for invasive mechanical ventilation, presence or absence of acute kidney injury per the Kidney Disease: Improving Global Outcomes criteria, and the temporal relationship between the development of acute kidney injury and initiation of invasive mechanical ventilation.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:A total of 9,704 patients were included and 4,484 (46%) required invasive mechanical ventilation; 2,009 patients (45%) had acute kidney injury while being treated with invasive mechanical ventilation, and the mortality rate for these patients was 22.4% compared with 5% in those treated with invasive mechanical ventilation without acute kidney injury (p < 0.01). Adjusted hazard of mortality accounting for baseline disease severity was 1.58 (95% CI, 1.22–2.03; p < 0.001]. Patients with acute kidney injury during invasive mechanical ventilation had a significant increase in total ventilator days and length of ICU stay with the same comparison (both p < 0.01). Acute kidney injury during mechanical ventilation was also associated with significantly higher plateau pressures, lower respiratory system compliance, and higher driving pressures (all p < 0.01). These differences remained significant in patients with net negative cumulative fluid balance.CONCLUSIONS:Acute kidney injury during invasive mechanical ventilation is associated with increased ICU mortality, increased ventilator days, increased length of ICU stay, and impaired respiratory system mechanics. These results emphasize the need for investigations of ventilatory strategies in the setting of acute kidney injury, as well as mechanistic studies of crosstalk between the lung and kidney in the critically ill.

The effect of tracheostomy on extracorporeal membrane oxygenation outcomes.

The optimal timing for pursuing tracheostomy in patients with prolonged mechanical ventilation with either veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is a discussion of risk versus benefit. Depending on the etiology, cardiothoracic surgical patients carry some of the highest risk for respiratory failure postprocedure.Given that patients with end-stage cardiopulmonary status may be fraught with substantial comorbidities, it is critically important to manage the risk-benefit profile of performing a tracheostomy procedure on a patient requiring ECMO support.These cohorts have risk factors that may depend on each patient's inflammatory state, lung de-recruitment peri-procedure and postprocedure and bleeding requiring transfusions to name a few.We provide a descriptive analysis of ECMO patients on both VA and VV configurations who survived to hospital discharge receiving tracheostomy either during or after their ECMO course. A retrospective single-institutional study collected all consecutive patients age 18 and above who received any form of ECMO between 2016 and 2020. Five hundred forty-fivepatients were screened based on having received ECMO. Patients with mixed EMCO modality were excluded due to heterogeneity of disease process. A total of 521 patients received either VV or VA ECMO. A total of 54 patients received tracheostomy and had sufficiently clean data for analysis. Tracheostomy patients were compared based on survival to discharge, tracheostomy surgical complications, ECMO duration, ECMO configuration, inotrope and vasopressor use, transfusion rates, total ventilator days, total days on intravenoussedation, and history of cardiotomy or heart transplant were assessed. Baseline characteristics of race, age, gender, and body mass index (BMI) were also collected. A total of 54 patients received tracheostomy. Twenty-nineof those patients received tracheostomy during the course of their ECMO, of whom 13 were on VV ECMO, 16 on VA ECMO. Another 25 patients underwent tracheostomy after successful ECMO explant; 8 of those were VV ECMO with the remaining 17 were on VA ECMO before explantation, with mean delay to tracheostomy, 10 and 19 days after explant between both modalities, respectively. A statistically significantly greater proportion of VV ECMO patients received a tracheostomy at any point versusVA ECMO patients (25.93% vs. 8.35%, p ≤ .0001). No statistically significant difference was noted in timing of tracheostomy when stratified by EMCO modality (VA 51.51% after explant vs. VV 38.10% after explant, p = .33).There was a greater frequency of minor tracheostomy complications in patients who were on ECMO at the time of their tracheostomy (p = .014) than in those who received their tracheostomy after being explanted. However, these minor complications did not contribute to a change in survival to hospital discharge (p = .58). Similarly, the small number of major complications (n = 13) did not impair survival to hospital discharge (p = .84).Finally, mean duration of ECMO was longer in those who received tracheostomy during ECMO versus after ECMO. (488.45 vs. 259.72 h, p < .01). Tracheostomy is known to increase patient mobility, clinical participation, and overall decrease in sedation use. Pursuing tracheostomy during ECMO is feasible, does not result in major bleeding, and is associated with only minor complications that overall do not decrease survival. While there is an increased duration of ECMO support in the tracheostomy cohort, this may be due to existing patient conditions, and may not be causal. Research is needed to further determine the external patient factors and specific timing to optimize both VV and VA ECMO courses. We hope that our analysis will pave the initial pathway for an evidence-based guideline on optimal timing of tracheostomy in ECMO patients, whether initiated during or after ECMO and taking into consideration ECMO configuration, its expected duration, and patient comorbidities.

Risk Factors and Outcome of Sepsis in Traumatic Patients and Pathogen Detection Using Metagenomic Next-Generation Sequencing.

Objective Sepsis, a life-threatening clinical syndrome, is a leading cause of mortality after experiencing multiple traumas. Once diagnosed with sepsis, patients should be given an appropriate empiric antimicrobial treatment followed by the specific antibiotic therapy based on blood culture due to its rapid progression to tissue damage and organ failure. In this study, we aimed to analyze the risk factors and outcome of sepsis in traumatic patients and to investigate the performance of metagenomic next-generation sequencing (mNGS) compared with standard microbiological diagnostics in post-traumatic sepsis. Methods The study included 528 patients with multiple traumas among which there were 142 cases with post-traumatic sepsis. Patients' demographic and clinical data were recorded. The outcome measures included mortality during the emergency intensive care unit (EICU), EICU length of stay (LOS), all-cause 28-day mortality, and total ventilator days in 28 days after admission. A total of 89 blood samples from 89 septic patients underwent standard microbiological blood cultures and 89 samples of peripheral blood (n = 21), wound secretion (n = 41), bronchoalveolar lavage fluid (BALF) (19), ascites (n = 5), and sputum (n = 3) underwent mNGS. Pathogen detection was compared between standard microbiological blood cultures and mNGS. Results The sepsis group and non-sepsis group exhibited significant differences regarding shock on admission, blood transfusion, mechanical ventilation, body temperature, heart rate, WBC count, neutrophil count, hematocrit, urea nitrogen, creatinine, CRP, D-D dimer, PCT, scores of APACHE II, sequential organ failure assessment (SOFA), and Injury Severity Score (ISS) on admission to the EICU, and Multiple Organ Dysfunction Syndromes (MODS) (P < 0.05). Multivariate logistic regression analysis showed that scores of APACHE II, SOFA, and ISS on admission, and MODS were independent risk factors for the occurrence of sepsis in patients with multiple traumas. The 28-day mortality was higher in the sepsis group than in the non-sepsis group (45.07% vs. 19.17%, P < 0.001). The mortality during the EICU was higher in the sepsis group than in the non-sepsis group (P=0.002). The LOS in the EICU in the sepsis group was increased compared with the non-sepsis group (P=0.004). The total ventilator days in 28 days after admission in the sepsis group was increased compared with the non-sepsis group (P < 0.001). Multivariate logistic regression analysis showed that septic shock, APACHE II score on admission, SOFA score, and MODS were independent risk factors of death for patients with post-traumatic sepsis. The positive detection rate of mNGS was 91.01% (81/89), which was significantly higher than that of standard microbiological blood cultures (39.33% (35/89)). Standard microbiological blood cultures and mNGS methods demonstrated double positive results in 33 (37.08%) specimens and double-negative results in 8 (8.99%) specimens, while 46 (51.69%) samples and 2 (2.25%) samples had positive results only with mNGS or culture alone, respectively. Conclusion Our study identifies risk factors for the incidence and death of sepsis in traumatic patients and shows that mNGS may serve as a better diagnostic tool for the identification of pathogens in post-traumatic sepsis than standard microbiological blood cultures.

Abstract No.: ABS0639: A comparison of the total intraoperative fluid administered by goal directed fluid therapy and conventional fluid therapy in isolated traumatic brain injury patients undergoing early decompressive craniectomy- a prospective randomised controlled trial

Background & Aims:Traumatic brain injury patients are prone to osmotic and electrolyte disturbances, hence require a unique approach to fluid management. Primary aim of the study is to compare goal-directed therapy and conventional hemodynamic based therapy on total intra-operative fluid administered during decompressive craniectomyMethods:Prospective randomised controlled trial was conducted at PGIMER, accruing 64 adult patients with TBI undergoing decompressive craniectomy Goal directed fluid therapy (GDT) used Flo Trac, EV-1000 device (Edwards Lifesciences, Irvine, CA) to monitor Stroke volume variation, Cardiac index and mean arterial pressure Conventional fluid therapyutilisedcrystalloids infused at a rate of 2 ml/kg/hour with target MAP >70 mm of Hg. Quantitative variables were compared using unpaired t test if normally distributed, Mann Whitney U test was used for non-normally distributed quantitative and ordinal data. A P < 0.05 was considered statistically significant. The statistical analysis was done using IBM SPSS version 25.Results:There was a numerical difference in total fluid administered between both the groups but did not prove to be statistically significant (p=0.511). No significant difference in intraoperative blood loss (p=0.776), urine output (p=0.230), total ventilator days (p=0.30), total ICU days (p=0.34), total hospital days (p=0.57) and GCS at discharge (0.53). There was significant difference in levels of hematocrit (p=0.00) and levels of lactate (p=0.00) within both the groups and GCS pre- and post-surgery (p=0.04)Conclusion:No statistically significant difference between the total intraoperative fluid administered between both the groups was observed. Quest for methods to improve outcome in traumatic brain injury patients it still ongoing.

The Outcome of Late versus Early Ileostomy Closure at Low Body Weight (

Aim:The aim of this study is to determine the surgical outcome of ileostomy closure at low body weight (<1500 g) and to find any differences in complications and growth of infants whose ileostomy was reversed early (4–6 weeks) versus late (8–10 weeks).Methods:A prospective comparative study was conducted on patients who underwent ileostomy reversal created for necrotizing enterocolitis from January 2017 to December 2019. The patients were divided into two groups: group 1 (early ileostomy closure) between 4 and 6 weeks and Group 2 (late closure) between 8 and 10 weeks. The primary outcome was expressed as the presence of anastomotic leak, obstruction, perforation, wound infection, sepsis, and death.Results:A cohort of 31 patients with 16 patients in Group 1 and 15 in Group 2 were studied. The mean duration between ostomy creation and reversal was 5.1 ± 0.63 weeks in Group 1 and 8.9 ± 0.66 weeks in Group 2. The mean weight at reversal was 1435.5 ± 163.8 g for patients in Group 1 and 1405 ± 99.93 g for patients in Group 2. Weight gain at 90 days in Group 1 was 895 ± 85.2 g and in Group 2 was 455 ± 34.6 g, which was statistically significant (P < 0.00001). Parenteral nutrition, ability to reach full enteral nutrition, and total ventilator days, mortality rate, and complications were not statistically different between the groups. The overall survival rate was 87.27%.Conclusions:Ileostomy reversal at a lower weight and within 6 weeks was not associated with an increased risk of complications. Early stoma reversal may help in weight gain.

Echocardiography-guided hemodynamic management of severe sepsis and septic shock in adults: a randomized controlled trial

Background: Echocardiography (ECHO) is used to guide septic shock resuscitation, but without evidence for efficacy. Therefore, we compared the outcome of early goal-directed therapy (EGDT) and ECHO-guided management of hemodynamics in severe sepsis and septic shock.&#x0D; Methodology: This was a single center, randomized controlled trial conducted on 100 adult patients with severe sepsis or septic shock. Patients were assessed and treated with either EGDT protocol (Group I - EGDT group) or ECHO-guided resuscitation protocol (Group II - ECHO group). &#x0D; Results: Only 87 patients (45 in Group I and 42 in Group II) were analyzed. There was a significant increase of mean norepinephrine and dobutamine use and a significant decrease in total fluids needed in the first 24 h, time to normalization, time to weaning of vasopressors, total mechanical ventilation (MV) days, MV free days and ICU and hospital stay in ECHO group. At 30 days, the mortality rate in EGDT group was 35.6% which was significantly higher compared to 14.3% in the ECHO group. At 90 days, the overall mortality was significantly higher in EGDT group compared to ECHO group (40.0% vs 16.7% respectively). Hazardous ratio of mortality was 1.630 [95% confidence interval (CI): 1.123 - 2.366] and 1.653 (95% CI: 1.137 - 2.404) at 30 and 90 days respectively in EGDT group compared to ECHO group.&#x0D; Conclusions: In severe sepsis and septic shock, ECHO-guided management of hemodynamics resulted in a decrease in mortality, lower total fluid intake, higher vasopressor and inotrope support, earlier weaning of vasopressors; and reduced mechanical ventilation days, as well as ICU and hospital stay.&#x0D; Keywords: Echocardiography; EGDT; Severe sepsis; Septic Shock; Adults&#x0D; Citation: Alhabashy WS, Shalaby OM, Elgebaly AS, Abd El Ghafar MS. Echocardiography-guided hemodynamic management of severe sepsis and septic shock in adults: a randomized controlled trial. Anaesth. pain intensive care 2021;25(6):722–732;&#x0D; DOI: 10.35975/apic.v25i6.1694&#x0D; Received: June 20, 2021, Reviewed: August 10, 2021, Accepted: August 13, 2021

Equitable Allocation of Remdesivir for the COVID-19 Pandemic in Los Angeles County

Objective Subsequent to the Emergency Use Authorization (EUA) by the Food and Drug Administration, Gilead Sciences Inc. donated a supply of remdesivir to the United States government for immediate treatment of patients with COVID-19. The Los Angeles County Emergency Medical Services Agency (LAC-EMS) was tasked with the allocation. The objective of this study was to describe the process for allocation and the patients who were treated with the donated remdesivir in LAC. Methods LAC-EMS developed a strategic plan to distribute federal allocations of remdesivir to LAC hospitals based on the proportion of patients admitted with COVID-19 at each hospital. Criteria for treatment and its duration were based on the EUA at local hospital discretion. Data were collected on patients treated from May to December 2020. Variables included characteristics (age, sex, race/ethnicity), hospital care (level of care and respiratory support at start of treatment, ventilator support, total ventilator days), and outcomes (length of intensive care (ICU) and hospital stay, survival to discharge, disposition). We compared demographics of treated patients to the overall population of hospitalized patients in LAC. Results LAC-EMS distributed 34,250 vials of remdesivir in 7 allocations, which treated 5,376 patients. The median age was 60 (IQR 48–70); 62% were male, 59% Hispanic, 17% White, 6% Asian, 5% Black. Prior to remdesivir, 96% of patients required respiratory support including 49% supplemental oxygen, 35% high-flow nasal cannula, 3% continuous or bilevel positive airway pressure and 9% mechanical ventilation, with one quarter of patients in the ICU. Overall, 26% of patients were mechanically ventilated during the hospitalization, median 11 days (IQR 8–23), while 41% required ICU care, median 10 days (IQR 5–19). Median length of stay for all patients was 10 days (IQR 7–18) with 4,218 patients (74%) surviving to discharge and 80% of survivors discharged home. Compared with overall hospitalized patients with COVID-19, treated patients more likely to be male and middle-aged, and less likely to be Black. Conclusion LAC-EMS’s strategic plan to distribute donated remdesivir to hospitals based on the number of inpatients with COVID-19 resulted in the treatment of 5,376 patients of whom 74% survived to hospital discharge.

Non-Selective Thoracic Computed Tomography in Trauma Patients Results in Injury Severity Score Inflation.

Extensive research relying on Injury Severity Scores (ISS) reports a mortality benefit from routine non-selective thoracic CTs (an integral part of pan-computed tomography (pan-CT)s). Recent research suggests this mortality benefit may be artifact. We hypothesized that the use of pan-CTs inflates ISS categorization in patients, artificially affecting admission rates and apparent mortality benefit. Eight hundred and eleven patients were identified with an ISS >15 with significant findings in the chest area. Patient charts were reviewed and scores were adjusted to exclude only occult injuries that did not affect treatment plan. Pearson chi-square tests and multivariable logistic regression were used to compare adjusted cases vs non-adjusted cases. After adjusting for inflation, 388 (47.8%) patients remained in the same ISS category, 378 (46.6%) were reclassified into 1 lower ISS category, and 45 (5.6%) patients were reclassified into 2 lower ISS categories. Patients reclassified by 1 category had a lower rate of mortality (P < 0.001), lower median total hospital LOS (P < .001), ICU days (P < .001), and ventilator days (P = 0.008), compared to those that remained in the same ISS category. Injury Severity Score inflation artificially increases survival rate, perpetuating the increased use of pan-CTs. This artifact has been propagated by outdated mortality prediction calculation methods. Thus, prospective evaluations of algorithms for more selective CT scanning are warranted.