Ventilated Intensive Care Patients Research Articles

Weaning-associated interventions for ventilated intensive care patients: A scoping review.

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing. To provide an overview of interventions associated with ventilator weaning. We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered. Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies). Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion). This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

ATME—Needs, requirements and cross-sectoral patient journeys of patients with out-of-hospital mechanical ventilation and intensive care in outpatient settings: study protocol for an observational study

IntroductionAn increasing number of tracheotomised and/or ventilated patients with high-cost out-of-hospital intensive care needs and, at the same time, a decreasing number of healthcare professionals inevitably lead to challenges in...

The accurate identification of the percutaneous tracheostomy insertion site using digital palpation in children.

Percutaneous tracheostomy (PT) may be required frequently in long-term ventilated intensive care patients. Although the overall risks are low, serious complications may occur, especially in children. Hence, this study aimed to assess physician accuracy in identifying PT insertion sites by digital palpation in children aged between 5 and 13 years. Participants were asked to identify the needle entry point (interspace between 2nd and 3rd or 3rd and 4th tracheal rings) for PT using digital palpation. Then, a single operator scanned the neck of each child with a linear high-frequency transducer. An accurate estimation was defined as a mark made between the upper and lower borders of the tracheal rings within the midline. In the study including 104 patients, the PT insertion site was accurately identified with digital palpation in a total of 50.9% of patients, compared with sonographic findings. The time required to determine the PT entry point by USG was longer than the palpation technique (114.7 vs. 43.8 s, P<0.001). The mean distance between the entry points of both methods was 4.53±2.03 mm. The majority of inaccurate assessments (45%) was above the 2nd tracheal ring. The lower the skin-to-air-mucosal interface distance, the higher the success of the PT entry point detection with the digital palpation method. A one-unit increase in body mass index was related to increasing the risk of failure by 1.1 times (P=0.030). Significant physician inaccuracy exists in PT insertion sites in children aged between 5 and 13 years, especially as BMI increases. Pre-procedural USG may help identify the landmarks for PT.

Safety during interhospital helicopter transfer of ventilated COVID-19 patients. No clinical relevant changes in vital signs including non-invasive cardiac output

BackgroundDuring the COVID-19 pandemic in The Netherlands, critically ill ventilated COVID-19 patients were transferred not only between hospitals by ambulance but also by the Helicopter Emergency Medical Service (HEMS). To date, little is known about the physiological impact of helicopter transport on critically ill patients and COVID-19 patients in particular. This study was conducted to explore the impact of inter-hospital helicopter transfer on vital signs of mechanically ventilated patients with severe COVID-19, with special focus on take-off, midflight, and landing.MethodsAll ventilated critically ill COVID-19 patients who were transported between April 2020 and June 2021 by the Dutch ‘Lifeliner 5’ HEMS team and who were fully monitored, including noninvasive cardiac output, were included in this study. Three 10-min timeframes (take-off, midflight and landing) were defined for analysis. Continuous data on the vital parameters heart rate, peripheral oxygen saturation, arterial blood pressure, end-tidal CO2 and noninvasive cardiac output using electrical cardiometry were collected and stored at 1-min intervals. Data were analyzed for differences over time within the timeframes using one-way analysis of variance. Significant differences were checked for clinical relevance.ResultsNinety-eight patients were included in the analysis. During take-off, an increase was noticed in cardiac output (from 6.7 to 8.2 L min−1; P < 0.0001), which was determined by a decrease in systemic vascular resistance (from 1071 to 739 dyne·s·cm−5, P < 0.0001) accompanied by an increase in stroke volume (from 88.8 to 113.7 mL, P < 0.0001). Other parameters were unchanged during take-off and mid-flight. During landing, cardiac output and stroke volume slightly decreased (from 8.0 to 6.8 L min−1, P < 0.0001 and from 110.1 to 84.4 mL, P < 0.0001, respectively), and total systemic vascular resistance increased (P < 0.0001). Though statistically significant, the found changes were small and not clinically relevant to the medical status of the patients as judged by the attending physicians.ConclusionsInterhospital helicopter transfer of ventilated intensive care patients with COVID-19 can be performed safely and does not result in clinically relevant changes in vital signs.

Isoflurane promotes early spontaneous breathing in ventilated intensive care patients: A post hoc subgroup analysis of a randomized trial.

Spontaneous breathing is desirable in most ventilated patients. We therefore studied the influence of isoflurane versus propofol sedation on early spontaneous breathing in ventilated surgical intensive care patients and evaluated potential mediation by opioids and arterial carbon dioxide during the first 20h of study sedation. We included a single-center subgroup of 66 patients, who participated in a large multi-center trial assessing efficacy and safety of isoflurane sedation, with 33 patients each randomized to isoflurane or propofol sedation. Both sedatives were titrated to a sedation depth of -4 to -1 on the Richmond Agitation Sedation Scale. The primary outcome was the fraction of time during which patients breathed spontaneously. Baseline characteristics of isoflurane and propofol-sedated patients were well balanced. There were no substantive differences in management or treatment aside from sedation, and isoflurane and propofol provided nearly identical sedation depths. The mean fraction of time spent spontaneously breathing was 82% [95% CI: 69, 90] in patients sedated with isoflurane compared to 35% [95% CI: 22, 51] in those assigned to propofol: median difference: 61% [95% CI: 14, 89], p<.001. After adjustments for sufentanil dose and arterial carbon dioxide partial pressure, patients sedated with isoflurane were twice as likely to breathe spontaneously than those sedated with propofol: adjusted risk ratio: 2.2 [95%CI: 1.4, 3.3], p<.001. Isoflurane compared to propofol sedation promotes early spontaneous breathing in deeply sedated ventilated intensive care patients. The benefit appears to be a direct effect isoflurane rather than being mediated by opioids or arterial carbon dioxide.

Pressure support ventilation in intensive care patients receiving prolonged invasive ventilation

Background: To our knowledge, the use and management of pressure support ventilation (PSV) in patients receiving prolonged (≥ 7 days) invasive mechanical ventilation has not previously been described. Objective: To collect and analyse data on the use and management of PSV in critically ill patients receiving prolonged ventilation. Design, setting and participants: We performed a multicentre retrospective observational study in Australia, with a focus on PSV in patients ventilated for ≥ 7 days. Main outcome measures: We obtained detailed data on ventilator management twice daily (8am and 8pm moments) for the first 7 days of ventilation. Results: Among 143 consecutive patients, 90/142 (63.4%) had received PSV by Day 7, and PSV accounted for 40.5% (784/1935) of ventilation moments. The most common pressure support level was 10 cmH2O (352/780) observations [45.1%]) with little variation over time, and 37 of 114 patients (32.4%) had no change in pressure support. Mean tidal volume during PSV was 8.3 (7.0-9.5) mL/kg predicted bodyweight (PBW) compared with 7.5 (7.0-8.3) mL/kg PBW during mandatory ventilation (P < 0.001). For 74.6% (247/331) of moments, despite a tidal volume of more than 8 mL/kg PBW, the pressure support level was not changed. Among 122 patients exposed to PSV, 97 (79.5%) received likely over-assistance according to rapid shallow breathing index criteria. Of 784 PSV moments, 411 (52.4%) were also likely over-assisted according to rapid shallow breathing index criteria, and 269/346 (77.7%) having no subsequent adjustment of pressure support. Conclusions: In patients receiving prolonged ventilation, almost two-thirds received PSV, which accounted for 40.5% of mechanical ventilation time. Half of the PSV-treated patients were exposed to high tidal volume and two-thirds to likely over-assistance. These observations provide evidence that can be used to inform interventional studies of PSV management.

Paediatric acute respiratory distress syndrome (PARDS)

<h2>Abstract</h2> Acute respiratory distress syndrome (ARDS) is a syndrome with acute, diffuse, inflammatory lung injury associated with non-haemodynamic lung oedema. It is responsible for almost a quarter of the ventilated patients in intensive care. The causes of ARDS are variable. They include primary pulmonary diseases such as pneumonia, drowning and aspiration and extra-pulmonary conditions including sepsis, trauma or burns. Although ARDS is well recognized in children, it is, in our experience, underdiagnosed in the paediatric intensive care units. This short article describes the diagnostic criteria, the causes and the management of ARDS in children.

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia.

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia.

Wound care in the era of COVID-19.

Journal of Wound CareVol. 29, No. 8 ViewpointWound care in the era of COVID-19Harold D Waller, Maureen W McCarthy, Jeremy Goverman, Haytham Kaafarani, Anahita DuaHarold D Waller1 Department of Surgery, Massachusetts General Hospital, Boston, MA, USSearch for more papers by this author, Maureen W McCarthy1 Department of Surgery, Massachusetts General Hospital, Boston, MA, USSearch for more papers by this author, Jeremy Goverman1 Department of Surgery, Massachusetts General Hospital, Boston, MA, USSearch for more papers by this author, Haytham Kaafarani1 Department of Surgery, Massachusetts General Hospital, Boston, MA, USSearch for more papers by this author, Anahita Dua2 Division of Vascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School. Boston MA, USSearch for more papers by this authorHarold D Waller; Maureen W McCarthy; Jeremy Goverman; Haytham Kaafarani; Anahita DuaPublished Online:17 Aug 2020https://doi.org/10.12968/jowc.2020.29.8.432AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References 1 Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck–the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc 2020. https://doi.org/10.7547/20-051 Crossref, Medline, Google Scholar2 Steinman MA, Perry L, Perissinotto CM. Meeting the care needs of older adults isolated at home during the COVID-19 pandemic. JAMA Intern Med 2020. https://doi.org/10.1001/jamainternmed.2020.1661 [Epub ahead of print] Crossref, Google Scholar3 Girard R, Baboi L, Ayzac L et al.. The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning. Intensive Care Med 2014; 40(3):397–403. https://doi.org/10.1007/s00134-013-3188-1 Crossref, Medline, Google Scholar4 Centers for Disease Control and Prevention. Prepare your practice for COVID-19. https://tinyurl.com/ychxxmqj (accessed 19 June 2020) Google Scholar5 Allman RM, Goode PS, Burst N et al.. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Adv Wound Care 1999; 12(1):22–30 Medline, Google Scholar6 Manzano F, Navarro MJ, Roldan D et al..; Granada UPP Group. Pressure ulcer incidence and risk factors in ventilated intensive care patients. J Crit Care 2010; 25(3):469–476. https://doi.org/10.1016/j.jcrc.2009.09.002 Crossref, Medline, Google Scholar7 Cox J. Predictors of pressure ulcers in adult critical care patients. Am J Crit Care 2011; 20(5):364–375. https://doi.org/10.4037/ajcc2011934 Crossref, Medline, Google Scholar8 Kaitani T, Tokunaga K, Matsui N, Sanada H. Risk factors related to the development of pressure ulcers in the critical care setting. J Clin Nurs 2010; 19(3–4):414–421. https://doi.org/10.1111/j.1365-2702.2009.03047.x Crossref, Medline, Google Scholar9 Cox J. Pressure ulcer development and vasopressor agents in adult critical care patients: a literature review. Ostomy Wound Manage 2013; 59(4):50–54,56–60 Google Scholar10 Sayar S, Turgut S, Dogan H et al.. Incidence of pressure ulcers in intensive care unit patients at risk according to the Waterlow scale and factors influencing the development of pressure ulcers. J Clin Nurs 2009; 18(5):765–774. https://doi.org/10.1111/j.1365-2702.2008.02598.x Medline, Google Scholar11 Ghelichkhani P, Esmaeili M. Prone position in management of COVID-19 patients; a commentary. Arch Acad Emerg Med 2020; 8(1):e48 Medline, Google Scholar12 Kim RS, Mullins K. Preventing facial pressure ulcers in acute respiratory distress syndrome (ARDS). J Wound Ostomy Continence Nurs 2016; 43(4):427–429. https://doi.org/10.1097/WON.0000000000000247 Crossref, Medline, Google Scholar13 Zingarelli EM, Ghiglione M, Pesce M et al.. Facial pressure ulcers in a COVID-19 50-year-old female intubated patient. Indian J Plast Surg 2020; 53(1):144–146. https://doi.org/10.1055/s-0040-1710403 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetailsCited byWhat is the impact of COVID-19 on tissue viability services and pressure ulceration?Kathryn Vowden, Lisa Hill14 July 2021 | Journal of Wound Care, Vol. 30, No. 7 2 August 2020Volume 29Issue 8ISSN (print): 0969-0700ISSN (online): 2052-2916 Metrics History Published online 17 August 2020 Published in print 2 August 2020 Information© MA Healthcare LimitedPDF download

Pre-admission air pollution exposure prolongs the duration of ventilation in intensive care patients.

PurposeAir pollutant exposure constitutes a serious risk factor for the emergence or aggravation of (existing) pulmonary disease. The impact of pre-intensive care ambient air pollutant exposure on the duration of artificial ventilation was, however, not yet established.MethodsThe medical records of 2003 patients, admitted to the intensive care unit (ICU) of the Antwerp University Hospital (Flanders, Belgium), who were artificially ventilated on ICU admission or within 48 h after admission, for the duration of at least 48 h, were analyzed. For each patient’s home address, daily air pollutant exposure [particulate matter with an aerodynamic diameter ≤ 2.5 µm (PM2.5) and ≤ 10 µm (PM10), nitrogen dioxide (NO2) and black carbon (BC)] up to 10 days prior to hospital admission was modeled using a high-resolution spatial–temporal model. The association between duration of artificial ventilation and air pollution exposure during the last 10 days before ICU admission was assessed using distributed lag models with a negative binomial regression fit.ResultsControlling for pre-specified confounders, an IQR increment in BC (1.2 µg/m3) up to 10 days before admission was associated with an estimated cumulative increase of 12.4% in ventilation duration (95% CI 4.7–20.7). Significant associations were also observed for PM2.5, PM10 and NO2, with cumulative estimates ranging from 7.8 to 8.0%.ConclusionShort-term ambient air pollution exposure prior to ICU admission represents an unrecognized environmental risk factor for the duration of artificial ventilation in the ICU.Electronic supplementary materialThe online version of this article (10.1007/s00134-020-05999-3) contains supplementary material, which is available to authorized users.

End-Expiratory Occlusion Test to Predict Fluid Responsiveness Is Not Suitable for Laparotomic Surgery.

The end-expiratory occlusion test predicts fluid responsiveness in ventilated intensive care patients; however, its utility in the operating room is questioned. We assessed end-expiratory occlusion test in laparotomic surgery for predicting volume expansion. Forty-six patients were included in this study: stage 1 (n = 26) with an end-expiratory occlusion test of 15 seconds, followed by volume expansion, which consisted of 250 mL of colloid over 5 minutes and stage 2 (n = 20) with an end-expiratory occlusion test of 25 seconds followed by volume expansion. The last 10 patients had transdiaphragmatic pressures probed. Patients with an increase in cardiac index >15% after volume expansion were responders. Pulse pressure variation, stroke volume (SV) index, and cardiac index were analyzed. Receiver operating characteristic curves were established for changes in SV and pulse pressure induced by end-expiratory occlusion test and pulse pressure variation using the responders status for volume expansion as outcome. A total of 44 (38%) volume expansions were deemed responders. After end-expiratory occlusion test of 15 seconds, no hemodynamic variables were significantly increased. After end-expiratory occlusion test of 25 seconds, SV index increased in responders (37.1 ± 8.8 mL/m after end-expiratory occlusion test of 25 seconds versus 35.7 ± 8.6 before; P < .0001). End-expiratory occlusion test could not discriminate responders from nonresponders. Only pulse pressure variation had significantly different area under the curve from that expected by chance (0.7 [0.57-0.81]; P = .002 for end-expiratory occlusion test of 15 seconds; and 0.78 [0.64-0.89]; P = .0001 for end-expiratory occlusion test of 25 seconds). After laparotomy, gastric pressure decreased significantly (4 [2.75-5] vs 2 [2-4] cm H2O; P = .0417); no difference was noticed in the transdiaphragmatic gradient. End-expiratory occlusion test was not reliable to discriminate responders from nonresponders after volume expansion during laparotomic surgery.

Characteristic pattern of pleural effusion in electrical impedance tomography images of critically ill patients

BackgroundElectrical impedance tomography (EIT) is increasingly used for continuous monitoring of ventilation in intensive care patients. Clinical observations in patients with pleural effusion show an increase in out-of-phase impedance changes. We hypothesised that out-of-phase impedance changes are a typical EIT finding in patients with pleural effusion and could be useful in its detection. MethodsWe conducted a prospective observational study in intensive care unit patients with and without pleural effusion. In patients with pleural effusion, EIT data were recorded before, during, and after unilateral drainage of pleural effusion. In patients with no pleural effusion, EIT data were recorded without any intervention. EIT images were separated into four quadrants of equal size. We analysed the sum of out-of-phase impedance changes in the affected quadrant in patients with pleural effusion before, during, and after drainage and compared it with the sum of out-of-phase impedance changes in the dorsal quadrants of patients without pleural effusion. ResultsWe included 20 patients with pleural effusion and 10 patients without pleural effusion. The median sum of out-of-phase impedance changes was 70 (interquartile range 49–119) arbitrary units (a.u.) in patients with pleural effusion before drainage, 25 (12–46) a.u. after drainage (P<0.0001) and 11 (6–17) a.u. in patients without pleural effusion (P<0.0001 vs pleural effusion before drainage). The area under the receiver operating characteristics curve was 0.96 (95% limits of agreement 0.91–1.01) between patients with pleural effusion before drainage and those without pleural effusion. ConclusionsIn patients monitored with EIT, the presence of out-of-phase impedance changes is highly suspicious of pleural effusion and should trigger further examination.

Immediate extubation or terminal weaning in ventilated intensive care patients after therapeutic goal change

Immediate extubation or terminal weaning in ventilated intensive care patients after therapeutic goal change

Protocol-Directed Sedation Versus Non-Protocol-Directed Sedation to Reduce the Duration of Mechanical Ventilation in Intensive Care Patients.

Protocol-Directed Sedation Versus Non-Protocol-Directed Sedation to Reduce the Duration of Mechanical Ventilation in Intensive Care Patients.

Tracheotomy-Related Deaths.

Tracheotomies are frequently performed on ventilated patients in intensive care and sometimes lead to fatal complications. In this article, we discuss the causes and frequency of death associated with open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) on the basis of a review of the pertinent literature. We systematically searched the PubMed, EMBASE, and Cochrane Library databases and the Karlsruhe Virtual Catalog for publications (1990-2015) on tracheotomy-related deaths in adults, using the search terms "tracheotomy" and "tracheostomy." 39 relevant dissertations were included in the analysis as well. 109 publications were included. Of the 25 056 tracheotomies described, there were 16 827 PDTs and 7934 OSTs; for 295 tracheotomies, the technique used was not stated. 352 deaths were reported, including 113 in patients treated with PDT, 49 in those treated with OST, and 190 deaths related to a tracheotomy without specification of the method used. The frequency of death among patients with OST and those treated with PDT was similar: 0.62% for OST (95% confidence interval [0.47; 0.82]) and 0.67% for PDT ([0.56; 0.81]). The most common causes of death and their frequencies, as a percentage of all tracheotomies, were hemorrhage (OST: 0.26% [0.17; 0.40], PDT: 0.26% [0.19; 0.35]), loss of airway (OST: 0.21% [0.13; 0.34], PDT: 0.20% [0.14; 0.28]), and false passage (OST: 0.11% [0.06; 0.22], PDT: 0.20% [KI 0.15; 0.29]). Bias in the data cannot be excluded, as these were not epidemiologic data and the documentation was found to be incomplete. The likelihood of a fatal complication seems to be the same with both tracheotomy techniques as far as can be determined from the available evidence. Tracheotomy-related deaths can be avoided in several ways: by thorough training under the leadership of experienced physicians, by the use of the World Health Organization's Surgical Safety Checklist regardless of where the tracheotomy is performed, and by the continuous vigilance of nursing staff.

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia.

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia.

Evaluation of a non-invasive multisensor accelerometer for calculating energy expenditure in ventilated intensive care patients compared to indirect calorimetry and predictive equations.

Continuous measurement of resting energy expenditure (REE) in critically ill patients remains challenging but is required to prevent malnutrition. SenseWear Pro 3 Armband (SWA) is a research grade accelerometer for assessment of REE with the advantage of easy handling. In a prospective study we compared SWA with indirect calorimetry (IC) and predictive equations in critically ill, ventilated patients. REE was measured by SWA, IC and calculated by predictive formulas. Potential confounding factors that influence REE were also recorded. Results of SenseWear Armband and indirect calorimetry were compared using the Bland-Altman method. 34 ICU patients were investigated. SWA underestimated resting energy expenditure compared to IC with a mean bias of ΔREE=-253.6±333.2kcal, equivalent to -11.7% (p=0.025). This underestimation was seen in both, medical (-14.9%) and surgical (-12.9%) patients and the bias was greater in patients with fever (-19.0%), tachycardia (-18.7%) or tachypnea (-26.2%). Differences were also noted when SWA was compared to predictive formulas. At present, SWA cannot be regarded as an alternative to indirect calorimetry. Individual measurements are often inaccurate and should be used with caution until improved algorithms, based on the results of this study, have been implemented.

Ultrasonographic Evaluation of Diaphragm Thickness During Mechanical Ventilation in Intensive Care Patients.

Mechanical ventilation is associated with atrophy and weakness of the diaphragm. Ultrasound is an easy noninvasive way to track changes in thickness of the diaphragm. To validate ultrasound as a means of tracking thickness of the diaphragm in patients undergoing mechanical ventilation by evaluating interobserver and interoperator reliability and to collect initial data on the relationship of mode of ventilation to changes in the diaphragm. Daily ultrasound images of the quadriceps and the right side of the diaphragm were acquired in 8 critically ill patients receiving various modes of mechanical ventilation. Thickness of the diaphragm and the quadriceps was measured, and changes with time were noted. Interoperator and interobserver reliability were measured. Intraclass correlation coefficients between operators and between observers for thickness of the diaphragm and quadriceps were greater than 0.95, indicating excellent interoperator and interobserver reliability. Patients receiving assist-control ventilation (n = 4) showed a mean decline in diaphragm thickness of 4.7% per day. Patients receiving pressure support ventilation (n = 8) showed a mean increase in diaphragm thickness of 1.5% per day. Quadriceps thickness declined in all participants (n = 8) at a mean rate of 2.0% per day. Use of ultrasound to measure thickness of the diaphragm in 8 intensive care patients undergoing various modes of mechanical ventilation was feasible and yielded reproducible results. Ultrasound tracking of changes in thickness of the diaphragm in this small sample indicated that the thickness decreased during assist-control mode and increased during pressure support mode.

Infraclavicular axillary vein cannulation using ultrasound in a mechanically ventilated general intensive care population.

Central venous catheter (CVC) insertion is commonly undertaken in the ICU. The use of ultrasound (US) to facilitate CVC insertion is standard and is supported by guidelines. Because the subclavian vein cannot be insonated where it underlies the clavicle, its use as a CVC site is now less common. The axillary vein, however, can be seen on US just distal to the subclavian vein and placement of a CVC at this site gives a result which is functionally indistinguishable from a subclavian CVC. We evaluated placement of US-guided axillary CVCs in mechanically ventilated intensive care patients. Data were collected for 125 consecutive US-guided axillary CVC procedures in ventilated patients in an adult intensive care setting. All lines were inserted using real-time US guidance with an out-of-plane technique. One hundred and twenty-five procedures occurred in 119 patients. Successful line placement was achieved in 117 out of 125 (94%) procedures. Complications included four procedures that required repeating due to catheter malposition and one arterial puncture. The median number of attempts per procedure was one (IQR 1 to 2). Thirty-nine (31%) patients had a body mass index of 30 or above, 43 (34%) patients had a coagulopathy and 70 (56%) patients had significant ventilator dependence (FiO2 of 0.5 or above, or positive end expiratory pressure 10 cmH20 or above). The technique of US-guided axillary CVC access can be undertaken successfully in ventilated intensive care patients, even in challenging circumstances. Taken together with existing work on the utility and safety of this technique, we suggest that it be adopted more widely in the intensive care population.

Traditional landmark versus ultrasound guided tracheal puncture during percutaneous dilatational tracheostomy in adult intensive care patients: a randomised controlled trial.

IntroductionLong-term ventilated intensive care patients frequently require tracheostomy. Although overall risks are low, serious immediate and late complications still arise. Real-time ultrasound guidance has been proposed to decrease complications and improve the accuracy of the tracheal puncture. We aimed to compare the procedural safety and efficacy of real-time ultrasound guidance with the traditional landmark approach during percutaneous dilatational tracheostomy (PDT).MethodsA total of 50 patients undergoing PDT for clinical indications were randomly assigned, after obtaining informed consent, to have the tracheal puncture procedure carried out using either traditional anatomical landmarks or real-time ultrasound guidance. Puncture position was recorded via bronchoscopy. Blinded assessors determined in a standardised fashion the deviation of the puncture off midline and whether appropriate longitudinal position between the first and fourth tracheal rings was achieved. Procedural safety and efficacy data, including complications and number of puncture attempts required, were collected.ResultsIn total, 47 data sets were evaluable. Real-time ultrasound guidance resulted in significantly more accurate tracheal puncture. Mean deviation from midline was 15 ± 3° versus 35 ± 5° (P = 0.001). The proportion of appropriate punctures, defined a priori as 0 ± 30° from midline, was significantly higher: 20 (87%) of 23 versus 12 (50%) of 24 (RR = 1.74; 95% CI = 1.13 to 2.67; P = 0.006). First-pass success rate was 20 (87%) of 23 in the ultrasound group and 14 (58%) of 24 in the landmark group (RR = 1.49; 95% CI = 1.03 to 2.17; P = 0.028). The observed decrease in procedural complications was not statistically significant: 5 (22%) of 23 in the ultrasound group versus 9 (37%) of 24 in the landmark group (RR = 0.58; 95% CI = 0.23 to 1.47; P = 0.24).ConclusionsUltrasound guidance significantly improved the rate of first-pass puncture and puncture accuracy. Fewer procedural complications were observed; however, this did not reach statistical significance. These results support wider general use of real-time ultrasound guidance as an additional tool to improve PDT.Trial registrationAustralian New Zealand Clinical Trials Registry ID: ACTRN12611000237987 (registered 4 March 2011)Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0514-0) contains supplementary material, which is available to authorized users.