Tracheostomy Ventilation Research Articles

Body Weight Gain Is Associated with the Disease Stage in Advanced Amyotrophic Lateral Sclerosis with Invasive Ventilation.

We investigated the incidence of weight gain and its related factors in patients with amyotrophic lateral sclerosis (ALS) who underwent tracheostomy and invasive ventilation (TIV). Seventy-eight patients with ALS and TIV were enrolled and followed up prospectively. We clarified the clinical profiles of patients with increased weight following TIV and examined chronological variations in their body mass index (BMI), energy intake, and serum albumin levels. Post follow-up, we determined their disease stage according to their communication impairment (stage I to V) and investigated factors associated with BMI increase following TIV. Patients with a post-TIV BMI increase ≥1.86 kg/m2 demonstrated a higher incidence of ophthalmoplegia (76.2%), total quadriplegia (61.9%), severe communication impairment (stage V; 33.3%), and hypoalbuminemia than those with a BMI increase <1.86 kg/m2. Patients with stage V communication impairment exhibited a larger and faster BMI decrease before TIV (mean −4.2 kg/m2 and −2.5 kg/m2/year, respectively); a larger BMI increase (mean +4.6 kg/m2) following TIV, despite lower energy intake; and lower albumin levels post follow-up than those with lower-stage communication impairment. Multilevel linear regression analysis demonstrated an independent association between communication impairment stages (stage V) and a post-TIV BMI increase (p = 0.030). Weight gain and hypoalbuminemia during TIV in patients with ALS were associated with the disease stage and may be attributable to the neurodegenerative processes that are peculiar to ALS.

Abstract WP119: Admission Glycemic Gap In The Assessment Of Patients With Ischemic Stroke

Background: Admission glycemic gap (AGG) is derived by using HbA1c levels to establish a baseline which is compared to admission glucose (AG) levels. High AGG has been correlated with increased post-stroke cognitive impairment and a worse modified Rankin scale. Our aim is to evaluate the association of AGG with poor outcomes. Methods: Stroke patients admitted to tertiary academic hospital between 2016-2020 were tested for AGG using the formula AG - (28.7xHb1Ac-46.7). AGG was dichotomized as high (&gt;80) AGG (H-AGG) and low (=/&lt;80) AGG (L-AGG). Poor outcomes were defined as in-hospital mortality or poor discharge destination (in hospital mortality, discharge to long term care, skilled nursing home, and hospice). We also looked at the necessity for tracheostomy, PEG, and mechanical ventilation. The Pearson chi-square test was used to test for significance. A binary logistic regression was used to verify the association. The statistical analysis was performed using SPSS. Results: Of 594 patients (mean age 67, 44% female), 30 had an elevated AGG (5.1%). 33 (5.6%) had tracheostomy. 7 had (1.2%) PEG. 32 (5.4%) required mechanical ventilation. 242 patients (40.1%) had a bad outcome of which 74 (12.5% of the total) died. The age of the H-AGG and L-AGG groups was comparable, as verified by an independent sample test. The H-AGG group was associated with hospital mortality (p &lt; .001) and poor discharge destination (p &lt; .001) The association between AGG and both mortality and poor outcome was lost when adjusted for age. The elevated AGG was not associated with PEG(p=.69), tracheostomy(p=.5), and mechanical ventilation(p=.49). Discussion: An elevated AGG was found to be associated with hospital mortality and poor discharge destination on univariate analysis, while there was no association with a tracheostomy, PEG and need for mechanical ventilation. The association was lost when adjusted for the patient's age

Strategy of changing from tracheostomy and non-invasive mechanical ventilation to diaphragm pacing in children with congenital central hypoventilation syndrome.

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Incidence, causes, and predictors of unsuccessful decannulation following prolonged weaning.

Background:Liberation from prolonged tracheostomy ventilation involves ventilator weaning and removal of the tracheal cannula (referred to as decannulation). This study evaluated the incidence, causes, and predictors of unsuccessful decannulation following prolonged weaning.Methods:Observational retrospective cohort study of 532 prolonged mechanically ventilated, tracheotomized patients treated at a specialized weaning center between June 2013 and January 2021. We summarized the causes for unsuccessful decannulations and used a binary logistic regression analysis to derive and validate associated predictors.Results:Failure to decannulate occurred in 216 patients (41%). The main causes were severe intensive care unit (ICU)-acquired dysphagia (64%), long-term ventilator dependence following weaning failure (41%), excessive respiratory secretions (12%), unconsciousness (4%), and airway obstruction (3%). Predictors of unsuccessful decannulation from any cause were age [odds ratio (OR) = 1.04 year−1; 95% confidence interval (CI), 1.02–1.06; p < 0.01], body mass index [0.96 kg/m2 (0.93–1.00); p = 0.027], Acute Physiology and Chronic Health Evaluation II (APACHE-II) score [1.05 (1.00–1.10); p = 0.036], pre-existing non-invasive home ventilation [3.57 (1.51–8.45); p < 0.01], percutaneous tracheostomies [0.49 (0.30–0.80); p < 0.01], neuromuscular diseases [4.28 (1.21–15.1); p = 0.024], and total mechanical ventilation duration [1.02 day−1 (1.01–1.02); p < 0.01]. Regression models examined in subsets of patients with severe dysphagia and long-term ventilator dependence as the main reason for failure revealed little overlapping among predictors, which even showed opposite effects on the outcome. The application of non-invasive ventilation as a weaning technique contributed to successful decannulation in 96 of 221 (43%) long-term ventilator-dependent patients following weaning failure.Conclusion:Failure to decannulate after prolonged weaning occurred in 41%, mainly resulting from persistent ICU-acquired dysphagia and long-term ventilator dependence following weaning failure, each associated with its own set of predictors.

Abstract 14046: Psychosocial Impact of Risk Mitigation Strategies and Shielding From COVID-19 in Adults and Children With Early-Onset Neuromuscular Disease and Their Families

Introduction: Patients with early-onset neuromuscular diseases (NMDs) were considered clinically vulnerable to COVID-19 due to assumptions that treatments e.g. corticosteroids, or complications e.g. pre-existing respiratory failure or cardiac disease would increase risk. In the UK, most were advised to ‘shield’ and strictly limit social contact, however it is poorly understood how patients and families approached and responded to this. Methods: In-depth questionnaires specifically designed to meet research aims were completed by telephone between September 17 th and December 31 st 2020 by NMD patients or their parent. Open and closed questions enabled a) quantitative analysis and b) thematic analysis to evaluate reasoning and psychosocial impact. Results: 40 questionnaires were completed: patients were 70% male, aged 2 to 48 years with NMDs e.g. muscular dystrophies, spinal muscular atrophy. 80% (n=32) had long-term non-invasive or tracheostomy ventilation; 20% (n=8) had cardiac involvement. Strict adherence to shielding was initially reported: this included temporary cessation or reduction in external care support in 68% (n=27), leading to increased parental care. Shielding measures were often relaxed due to 1) official guidance, 2) evidence of less severe outcomes in children and NMDs, and 3) unsustainability of limited social contact. Anxiety, fear and worry were the most frequently reported emotions, but level and pervasiveness fluctuated. 75% (n=30) remained “extremely” or “very” worried about risk of COVID-19 to the patient’s health. Concern about hospital attendance during the pandemic and anxiety regarding perceived lack of capacity or access to Intensive care were common. Virtual healthcare access, experienced by 97.5% (n=39), was seen as positive, largely as an interim measure, but was less useful where examination or tests were required. Conclusions: Measures to reduce transmission of COVID-19 have disproportionately affected NMD patients and their families. For most, negative psychosocial impacts have and will continue to improve, particularly due to the success of the vaccination programme. Patients and carers require access to support and up-to-date information to minimise risk of infection and psychological burden.

Morbidity of late-season influenza during pregnancy

In the Northern Hemisphere, influenza season typically starts in December and lasts through March. Pregnant people are at increased risk for influenza-related morbidity and mortality. Potentially, new viral strains or reduced provider suspicion leading to delayed diagnosis of late-season influenza could result in an increased risk of severe infection. This study aimed to assess the incidence and morbidity associated with late-season influenza in pregnancy, compared with influenza in other seasons. This was a retrospective cohort study using the 2007-2018 National Inpatient Sample. Pregnant patients with discharge diagnosis codes consistent with influenza infection were compared on the basis of hospital admission quarter (quarter 1: October to December; quarter 2: January to March; quarter 3: April to June; quarter 4: July to September), with quarter 3 defined as "late-season." The primary outcome was the severe maternal morbidity composite defined by the Centers for Disease Control and Prevention. The secondary outcomes included sepsis, shock, acute renal failure, acute heart failure, temporary tracheostomy, and invasive mechanical ventilation. Associations between outcomes and quarter of infection were adjusted for age, hospitalization type (antepartum, delivery, or postpartum), and comorbid conditions using relative risk regression, weighted to reflect the National Inpatient Sample design. Of 7355 hospitalizations, corresponding to a weighted national estimate of 36,042, 2266 (30.8%) occurred in quarter 1, 4051 (55.0%) in quarter 2, 633 (8.6%) in quarter 3, and 405 (5.5%) in quarter 4. A nonsignificant trend toward higher rates of severe maternal morbidity was seen in the "late-season" compared with other quarters (13.9% [quarter 3] vs 10.5% [quarter 1] vs 12.1% [quarter 2] vs 13.6% [quarter 4]; P=.07). Moreover, sepsis was more common in patients with late-season influenza (8.0% [quarter 3] vs 4.8% [quarter 1] vs 5.8% [quarter 2] vs 5.9% [quarter 4]; P=.03). In the adjusted analyses, patients with late-season influenza had a 1.34 (95% confidence interval, 1.01-1.78) higher risk of severe maternal morbidity and 1.57 (95% confidence interval, 1.06-2.32) higher risk of sepsis than patients with influenza in quarter 1. Influenza infection between April and June, that is, late-season influenza, is associated with a higher risk of severe maternal morbidity and sepsis in pregnant patients. Obstetrical providers must continue to have awareness and suspicion for influenza infection during these months.

Qualitative indications for tracheostomy and chronic mechanical ventilation in patients with severe bronchopulmonary dysplasia.

BackgroundThe decision to pursue chronic mechanical ventilation involves a complex mix of clinical and social considerations. Understanding the medical indications to pursue tracheostomy would reduce the ambiguity for both providers and families and facilitate focus on appropriate clinical goals.ObjectiveTo describe potential indications to pursue tracheostomy and chronic mechanical ventilation in infants with severe BPD (sBPD).Study designWe surveyed centers participating in the Children’s Hospitals Neonatal Consortium to describe their approach to proceed with tracheostomy in infants with sBPD. We requested a single representative response per institution. Question types were fixed form and free text responses.ResultsThe response rate was high (31/34, 91%). Tracheostomy was strongly considered when: airway malacia was present, PCO2 ≥ 76–85 mmHg, FiO2 ≥ 0.60, PEEP ≥ 9–11 cm H2O, respiratory rate ≥ 61–70 breaths/min, PMA ≥ 44 weeks, and weight <10th %ile at 44 weeks PMA.ConclusionsUnderstanding the range of indications utilized by high level NICUs around the country to pursue a tracheostomy in an infant with sBPD is one step toward standardizing consensus indications for tracheostomy in the future.

Cross-sectional survey on home mechanical ventilator use: major deficiencies in a home care system in South Korea.

BackgroundDespite the increased use of home mechanical ventilation (HMV), data on home care services for HMV users in Asian countries are scarce. This study investigated the current status of HMV use in the Seoul metropolitan area.MethodsThis cross-sectional study involved three university-affiliated hospitals. Subjects who were receiving HMV at home for >3 months were included, and door-to-door visits were done to collect data (e.g., on devices, caregivers, and healthcare service use) from the subjects or their families.ResultsAmong the 140 individuals who were initially screened, 38 adults and 26 children were finally enrolled; the duration of HMV use was 14.5 (8.8–37.5) months and 20.5 (7.0–28.0) months, respectively. Tracheostomy ventilation was performed in 36.8% of the adults and 61.5% of the children, and life-support ventilator in 55.3% and 96.2%, respectively. Regarding ancillary devices, 42.1% of the adults and 80.8% of the children had an oxygen monitoring device, while only one member of each group had a cough assist device. Among those with a tracheostomy, 64.3% of adults and 81.3% of children had an AMBU-bag. Reliance on a family member for care was determined in 65.8% of adults and 88.5% of children, but a home visit by a hospital nurse during the previous year occurred in only 26.3% of the adults and 3.8% of the children. Emergency incidents at home occurred in 39.5% of the adults and 50.0% of the children, with dyspnea being the most common cause. Out-of-pocket expenses tended to be higher in the tracheostomy (vs. non-tracheostomy) group and in children (vs. adults).ConclusionsOur study highlights the challenges faced by adults and children dependent on HMV, and their families. There is an urgent need for nationwide standardization of care for patients receiving HMV at home.

Narrative Review of Tracheostomy Procedure during COVID-19 Pandemic

The COVID-19 pandemic has led to an unprecedented increase in the number of critically ill patients requiring mechanical ventilation. Tracheostomy played an important role to wean off the patients from ventilator support and maximize the resources. Tracheostomy is an aerosol generating procedure (AGP) which raised some controversial issues as it carries a risk of infection to healthcare workers. This study aims to review the issues related to tracheostomy procedure in COVID-19 patients, including the appropriate time to perform tracheostomy, criteria for patient selection, safer approach and risk of infection among healthcare workers. Related information retrieved via online search of original articles, paper reviews, recommendations and guidelines from PubMed, Medline and Google Scholar using keywords tracheostomy, COVID-19, intensive care and mechanical ventilation are summarized in this article. The suggested time frame to perform tracheostomy ranged from 7 to 21 days. Early tracheostomy performed between day 10 to 14 had beneficial outcome for the patients and helped to reduce ICU occupancy. Decision for appropriate timing was made after considering the viral load and the course of the disease. Criteria for patient selection based on suggestions from studies and guidelines were lower oxygen requirement (FiO2&lt;0.4, PEEP&lt; 10), low Sepsis Related Organ Failure (SOFA) scores, ventilation for at least 10 days and signs of improvement. Patient factors, availability of facilities and expertise were important criteria for decision to undertake tracheostomy. The patient outcomes from tracheostomy varied between centers. Most of the studies reported that none of the healthcare workers had been infected by utilizing appropriate PPE and by taking important precautions during the procedure. In conclusion, guidelines were established for tracheostomy procedure during COVID-19 but the decision to undertake the procedure still depend on a case by case basis.

Contradictory Responses to the COVID-19 Pandemic in Amyotrophic Lateral Sclerosis Patients and Their Families and Caregivers in Japan.

Objective The coronavirus disease 2019 (COVID-19) pandemic has resulted in a shortage of medical resources, including ventilators, personal protective equipment, medical staff, and hospital beds. We investigated the impact of COVID-19 in amyotrophic lateral sclerosis (ALS) patients, their families, caregivers, and medical experts. Methods We conducted a nationwide ALS webinar about COVID-19 in May 2020 and sent a questionnaire to those enrolled. Results A total of 135 participants (31 ALS patients; 23 families and caregivers of ALS patients; 81 medical experts) responded to this cross-sectional self-report questionnaire. The results showed that tracheostomy and invasive ventilation (TIV) was used in 22.6% of ALS patients, whereas 77.4% of ALS patients were not under TIV. Among non-TIV patients (n=24), 79.2% did not want TIV in the future. However, 47.4% of non-TIV patients not wanting a tracheostomy in advanced stages replied that they would want an emergency tracheostomy if they developed COVID-19-related pneumonia. These results suggest that ALS patients may be receptive to emergency treatments for reasons other than ALS. In addition, approximately half of the ALS patients agreed with the policy of not ventilating the elderly or ALS patients in case of a ventilator shortage. Furthermore, compared with medical experts, few ALS patients reported that the chance for ALS patients to obtain work was higher due to the increasing availability of remote work. Conclusions This survey indicates that the COVID-19 pandemic might be associated with increased distress about access to care and work, inducing contradictory responses and potential hopelessness among ALS patients.

Tracheostomy ventilation in motor neurone disease: a snapshot of UK practice

Introduction: Motor neurone disease (MND) is characterized by rapidly progressive motor neurone degeneration which leads to muscle wasting. Mortality and morbidity are due to respiratory muscle failure which may be offset by ventilation. The aim of this observational study was to quantify the number and characteristics of patients living with MND choosing tracheostomy ventilation (TV) in the UK. Methods: Long-term ventilation services in the UK were invited to undertake a retrospective 5-year audit of MND patients under their care between April 2013 and March 2018 who had TV. Patient characteristics, the time spent on ventilation, hospital length of stay, discharge destination, and survival data were collected. Results: Sixty-eight MND patients were initiated on TV over the 5-year period. Eighty-one percent of patients received TV in an emergency setting with more than a third of these undiagnosed at presentation. Patients choosing elective TV were more likely to be male (85%) have a bulbar presentation (54%) and an increased survival of 10 months over the observation period. The mean length of hospital stay post TV was 136 days. Two-thirds of patients were discharged to their own home. Conclusion: Very few patients living with MND in the UK are currently receiving TV. In those who choose TV, there may be a survival advantage to planning an elective procedure. Despite the long inpatient stay and high care costs involved a majority of patients survived and were discharged to their own home.

Severe adverse events in children with tracheostomy and home mechanical ventilation - Comparison of pediatric home care and a specialized pediatric nursing care facility

BackgroundAdvances in medical care and ventilator technologies increase the number of children with tracheostomy and home mechanical ventilation (HMV). Data on severe adverse events in home care and in specialized nursing care facilities are limited. Patients and methodsRetrospective analysis of incidence and type of severe adverse events in children with tracheostomy and HMV in home care compared to a specialized nursing care facility over a 7-year period. Results163.9 patient-years in 70 children (home care: 110.7 patient-years, 24 patients; nursing care facility: 53.2 patient-years, 46 patients) were analyzed. In 34 (48.6%) patients tracheostomy was initiated at the age of <1 year. 35 severe adverse events were identified, incidence of severe adverse events per patient-year was 0.21 (median 0.0 (0.0–3.0)). We observed no difference in the rate of severe adverse events between home care and specialized nursing care facility (0.21 [y-1]; median 0.0 (0.0–3.0) versus 0.23 [y-1]; median 0.0 (0.0–1.6); p = 0.690), however, significantly more tracheostomy related incidents and infections occurred in the home care setting. Young age (<1 year) (Odds ratio 3.27; p = 0.045) and feeding difficulties (nasogastric tubes and percutaneous endoscopic gastrostomy) (Odds ratio 9.08; p = 0.016) significantly increased the risk of severe adverse events. Furthermore, the rate of severe adverse events was significantly higher in patients with a higher nursing score. ConclusionPediatric home mechanical ventilation via tracheostomy is rarely associated with emergencies or adverse events in home care as well as in a specialized nursing care facility setting.

How the Management of Children With Congenital Central Hypoventilation Syndrome Has Changed Over Time: Two Decades of Experience From an Italian Center.

Background: Congenital central hypoventilation syndrome (CCHS) is a rare disorder whose clinical phenotype is closely related to genotype.Methods: A retrospective analysis has been conducted on 22 patients with CCHS, who were referred to the Pediatric Pulmonology and Respiratory Intermediate Care Unit of Bambino Gesù Children's Hospital (Italy) for a multidisciplinary follow-up program between 2000 and 2020.Results: Apnea and cyanosis were the most frequent symptoms at onset (91%). Overall, 59% of patients required tracheostomy and invasive mechanical ventilation (IMV) in the first months of life. Thirty-two percent of patients had Hirschsprung disease (HSCR) that was associated with longer polyalanine repetitions or non-polyalanine repeat expansion mutations (NPARMs). Polyalanine repeat expansion mutations (PARMs) were more frequent and two novel NPARMs (c.780dupT and C.225–256delCT) were described in 14% of patients. Focal epilepsy was first described in 14% of patients and neurocognitive and neuromotor impairment involved 27% and 23% of children, respectively. Symptoms due to autonomic nervous system dysfunction/dysregulation (ANSD)—including strabismus (27%), dysphagia (27%), abnormal heart rhythm (10%), breath-holding spells (9%), and recurrent seizures due to hypoglycemia (9%)—were associated with an increased number of polyalanine repetitions of exon 3 or NPARMs of PHOX2B gene. Overall, the number of patients with moderate to severe phenotype initially treated with non-invasive ventilation (NIV) increased over time, and the decannulation program was concluded with 3 patients who started with IMV.Conclusions: Our study confirms that more severe phenotypes of CCHS are related to the number of polyalanine repetitions or to NPARMs. Although invasive ventilation is often required by patients with severe genotype/phenotype, gradual acquisition of specific skills in the management of patients with CCHS and technological improvements in mechanical ventilation allowed us to improve our therapeutic approach in this population.

Tracheal compression by the stomach following gastric transposition in a toddler

Gastric transposition is widely employed for esophageal replacement. However, postoperative respiratory failure is one of the most fatal complications of this procedure, and its exact cause remains unclear. A 1-year-old boy with VATER association underwent retrosternal gastric transposition for a long-gap esophageal atresia. The patient experienced respiratory failure immediately after surgery. Bronchoscopy and computed tomography revealed tracheomalacia due to tracheal compression from the gastric pull-up. Extubation became difficult, and tracheostomy was performed. Intermittent decompression using a nasogastric tube, tracheostomy, and high positive end-expiratory pressure ventilation were continued until the tracheal lumen was no longer collapsed. The frequency of dyspnea gradually decreased, and the patient's transition to home medical care was possible at the age of two years. This case highlights the need to consider the effects of tracheomalacia after gastric transposition. Reconstruction through a retrosternal route may make subsequent vascular and tracheal procedures for the correction of tracheomalacia more challenging. If a posterior sternal route must be chosen because of the extensive mediastinal adhesions, it may be necessary to use a relatively small-capacity esophageal reconstruction organ, such as the large intestine, or to perform volume reduction surgery of a lifted stomach.

Presentation of SARS-CoV-2 in a Pediatric Heart Transplant Recipient with Multiple Underlying Comorbidities

A six-year-old heart transplant recipient with additional significant co-morbidities, including severe hypoxic-ischemic injury, gastrostomy, tracheostomy, and mechanical ventilation dependency, encountered SARS-CoV-2 infection. The patient received tacrolimus and mycophenolate to prevent graft rejection, presented initially with SARS-CoV-2 positive and presumed pseudomonas aeruginosa pneumonia. Twenty-three days later, the patient presented with fever recurrence with evidence for systemic inflammation, which resolved rapidly with high-dose methylprednisolone. Interestingly, while IgM to SARS-CoV-2 was present, IgG was not detected even three months after his first positive test for SARS-CoV-2. The author discusses potential immune mechanisms that might have affected the course of multi-system inflammatory syndrome children (MIS-C) in this patient.

“New Trach Mom Here…”: A qualitative study of internet‐based resources by caregivers of children with tracheostomy

Decision-making around tracheostomy placement and chronic respiratory support in children is complicated. Families often seek support and advice from outside the medical care team, including from social media. We undertook this study to characterize the content and nature of online resources created and managed primarily by caregivers of children living with tracheostomy and chronic mechanical ventilation. We used a "grey literature" search methodology to identify internet resources created by caregivers of children with tracheostomy. We included only publicly available, nonindustry associated, English language, North American websites updated at least once in 2019. We then applied inductive content analysis to establish central themes, patterns and associations. We identified six blogs/forums that met our search criteria. We identified four main themes: (1) Uncertainty, (2) Lived experience-wants, needs, and emotions, (3) Seeking context and meaning, and (4) Advice/information sharing/support. Two patterns of coping were identified on the basis of the relationships between codes. The "Acceptance pathway" is associated with a sense of self-actualization, mastery, satisfaction, return to normalcy, and ultimately acceptance. The "Resignation pathway" is associated with a sense of lack of control, frustration, burnout and stress, persistent lack of normalcy, and resignation to the tracheostomy as a negative but necessary outcome. Caregivers often come to see themselves as experts in the care of children with tracheostomy, though many still express ambivalence about their knowledge and skills. Those early in the experience express a desire for community and can potentially benefit from online resources.

Risk factors for wound infection caused by Methicillin Resistant Staphylococcus aureus among hospitalized patients: a case control study from a tertiary care hospital in India.

Methicillin Resistant Staphylococcus aureus (MRSA) causes infection in hospitals and communities. The prevalence and risk factors of MRSA infection is not homogenous across the globe. To find the risk factors of MRSA infection among hospitalized patients. Cross-sectional case control study was conducted at a tertiary care hospital in India. The risk factors were collected using checklist from 130 MRSA and 130 Methicillin sensitive staphylococcus aureus (MSSA) infected patients. The pathogens were isolated from the wound swabs according to Clinical and Laboratory Standards Institute guidelines. Both the groups were comparable in terms of age, gender, diabetic status, undergoing invasive procedures, urinary catheterization and smoking (p>0.05). Multivariate logistic regression revealed surgical treatment (OR 4.355; CI 1.03, 18.328; p=0.045), prolonged hospitalization (OR 0.307; CI 0.11, 0.832; p=0.020), tracheostomy (OR 5.298, CI 1.16, 24.298; p=0.032), pressure/venous ulcer (OR 7.205; CI 1.75, 29.606; p=0.006) and previous hospitalization (OR 2.883; CI 1.25, 6.631; p=0.013) as significant risk factors for MRSA infection. Surgical treatment, prolonged and history of hospitalization, having tracheostomy for ventilation and pressure/venous ulcer were the key risk factors. Therefore, special attention has to be given to the preventable risk factors while caring for hospitalized patients to prevent MRSA infection.

Limits and Ethics of Mechanical Ventilation and Intensive Care Medicine in Old Age

Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.In intensive care the likelihood of a successful outcome and the patient's wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes "success"; for example a patient may consider intensive care "worth it" if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.

Investigation of the Factors Associated with Mortality in Catheter-Related Bloodstream Infections: Five-Year Observation

Aim: Intravenous catheter use can cause various infections ranging from infection at the site of catheter entry to bacteremia and colonization. The purpose of this study was to identify the causative micro-organisms, and effects on morbidity-mortality of catheter-related bloodstream infections developing over the last five years.&#x0D; Material and Methods: Data for 194 patients who underwent central intravenous catheter insertion in our hospital’s intensive care unit and other departments between November 2014 and August 2019 were analyzed retrospectively. Blood samples taken from the catheter or the catheter tip, and blood samples collected simultaneously from the peripheral vein were included in the study, and culture results were recorded. Patients’ demographic data and the effects of the factors identified on morbidity and mortality were subjected to statistical analysis.&#x0D; Results: Ninety-two (47.4%) of the 194 patients included in the study were female and 102 (52.6%) were male, and mortality rate was 62.4% (n=121). The frequency of underlying medical conditions such as asthma, congestive heart failure, and cerebrovascular event, and receiving treatments such as immunosuppression, transfusion, tracheostomy, nasogastric tube, and mechanical ventilation were higher in mortal cases than non-mortal cases. A total of two hundred and forty microorganisms were detected in 194 patients, 121 (50.4%) of which were Gram negative bacteria, while 68 (28.3%) were Gram positive bacteria, and 51 (21.3%) were Candida species.&#x0D; Conclusion: As a result, it was observed that the advanced age, underlying diseases and presence of resistant microorganisms were higher in mortal cases.

Far posterior rib plating: Preliminary results of a retrospective case series.

Far posterior, or paraspinal rib fractures, defined as fractures that are medial to the medial border of the scapula (and may involve the costovertebral articulation), are often treated nonoperatively. However, in certain cases, including severe displacement, persistent pain, nonunion, or persistent respiratory distress, stabilization with open reduction and internal fixation (ORIF) may be warranted. There is a paucity of literature regarding the surgical approach and clinical outcomes following ORIF for far posterior rib fractures and fracture-dislocations. The purpose of this paper is to describe the surgical approach and to report the first collection of clinical outcomes for patients undergoing paraspinal rib ORIF. A retrospective case series was performed at a single urban level 1 trauma center. Patients 18 years of age or older who underwent ORIF of far posterior rib fractures were included in this study. Far posterior rib fractures were defined as fractures that occurred medial to the medial border of the scapula underneath the paraspinal musculature. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed. Twenty-six patients, with a mean age of 50.7 years, who underwent paraspinal rib ORIF were included in this study. The mean follow-up was 12.1 months. 80.8% of patients had a flail chest injury. On average, 3.4 ribs were instrumented posteriorly with 22.8% of patients requiring fixation spanning the costotransverse articulation. No intraoperative complications occurred. Only one patient required a repeat procedure. Total hospital length of stay averaged 17.3 days with an intensive care unit stay averaging 6.2 days. Total ventilator time averaged 4 days. 7 patients were diagnosed with postoperative pneumonia and 6 patients required tracheostomy. Open reduction and internal fixation for far posterior, or paraspinal rib fractures and fracture-dislocations is a safe procedure with low complications rates and favorable postoperative outcomes including hospital length of stay, ICU length of stay, need for tracheostomy, postoperative pneumonia, and mechanical ventilation time.