Ventilated Intensive Care Unit Patients Research Articles

The Effect of Mentha spicata Essential Oil (Supermint Oral Drops) on Gastric Residual Volume in Mechanically Ventilated Intensive Care Unit Patients: A Parallel-Group, Triple-Blinded, Randomised, Placebo-Controlled Trial

IntroductionDelayed gastric emptying is a prevalent problem in intensive care unit (ICU) patients on mechanical ventilation receiving enteral nutrition. This study aimed to assess the effect of Mentha spicata essential oil (Supermint oral drops) on gastric residual volume (GRV) in this patient population. MethodsIn this clinical trial study, from 01 May 2020 to 30 January 2021, 60 mechanically ventilated ICU patients were randomly assigned to intervention and control groups. From the first day of their feeding, patients in the intervention and control groups respectively received 20 drops of the Supermint and placebo dissolved in 40 ml of water, three times daily for four days. The GRV was measured at the baseline and during four days of intervention. Data were analyzed using a generalized estimation equation (GEE) regression model. ResultsOf the patients, 58.1 % were female. The mean age of patients was 71.5 (SD=14.2), and 65.5% were hospitalized for Coronavirus disease 2019 (COVID-19). The results of the GEE regression model indicated no significant difference between the two groups in terms of the baseline GRV (p=0.181). There was a significant interaction between time and the treatment group (p < 0.001), which suggested that GRV changes over time was different between the two groups. In the control group, the average GRV increased by 0.07 for each unit increase in time, while in the Supermint group, it decreased significantly by 1.09. ConclusionsThe current study's finding suggested that Mentha spicata essential oil may have the potential to reduce GRV in ICU patients undergoing mechanical ventilation. Further studies are needed to confirm this finding. IRCT code NOIRCT20191223045868N1. Date: 03/28/2020)Available at: https://irct.ir/trial/46580

Respiratory rate monitoring in ICU patients and healthy volunteers using electrical impedance tomography: a validation study.

The respiratory rate (RR) is considered one of the most informative vital signals. A well-validated standard for RR measurement in mechanically ventilated patient is capnography; a noninvasive technique for expiratory CO2 measurements. Reliable RR measurements in spontaneously breathing patients remains a challenge as continuous mainstream capnography measurements are not available. This study aimed to assess the accuracy of RR measurement using electrical impedance tomography (EIT) in healthy volunteers and intensive care unit (ICU) patients on mechanical ventilation and spontaneously breathing post-extubation. Comparator methods included RR derived from both capnography and bioimpedance electrocardiogram (ECG) measurements. &#xD;Approach: Twenty healthy volunteers wore an EIT belt and ECG electrodes while breathing through a capnometer within a 10 - 40 breaths per minute (BPM) range. Nineteen ICU patients underwent similar measurements during pressure support ventilation and spontaneously breathing after extubation from mechanical ventilation. Stable periods with regular breathing and no artefacts were selected, and agreement between measurement methods was assessed using Bland-Altman analysis for repeated measurements. &#xD;Main Result: Bland-Altman analysis revealed a bias less than 0.2 BPM, with tight limits of agreement (LOA) 1.5 BPM in healthy volunteers and ventilated ICU patients when comparing EIT to capnography. Spontaneously breathing ICU patients had wider LOA (2.5 BPM) when comparing EIT to ECG bioimpedance, but gold standard comparison was unavailable. RR measurements were stable for 91% of the time for capnography, 68% for EIT, and 64% of the ECG bioimpedance signals. After extubation, the percentage of stable periods decreased to 48% for EIT signals and to 55% for ECG bioimpedance. &#xD;Significance: In periods of stable breathing, EIT demonstrated excellent RR measurement accuracy in healthy volunteers and ICU patients. However, stability of both EIT and ECG bioimpedance RR measurements declined in spontaneously breathing patients to approximately 50% of the time. &#xD.

Neuropsychological follow-up of isoflurane sedated intensive care patients: a substudy of a randomized trial.

Inhaled sedation of intensive care unit (ICU) patients ventilated >24 hours may have long term effects. We hypothesized that isoflurane has a better neuropsychological outcome in a One-year follow-up compared to propofol sedation. All 66 patients included by the coordinating center of the ISOCONDA study (EudraCT#: 2016-004551-67) took part in this substudy (DRKS00020240). A delirium test (CAM-ICU) was performed 24 hours after end of sedation. Sedation-, ventilator-, ICU- and delirium-free days within 30 days were calculated. Patients were sent five questionnaires one, three and twelve months after ICU discharge: ICU-Memory-tool (ICU-MT), Short-Form-36-Health-survey (SF-36), Posttraumatic-Stress-Scale-14 (PTSS-14), WHO-Five-Well-Being-Index (WHO-5) and Hospital-Anxiety-Depression-Scale (HADS). CAM-ICU was positive in 17% of patients, however 68% showed signs of delirium during the ICU stay (no group differences). Mortality was lower after isoflurane (30-days: 1/33 versus 7/33, P=0.024; One-year: 9/33 versus 14/33, P=0.156). Isoflurane led to significantly more sedation- (median [IQR]: 28[25-29] versus 24[21-29], P=0.016), ventilator- (28[24-29] versus 22[4-28], P=0.011), ICU- (23[13-26] versus 11[0-25], P=0.044) and delirium-free days (25[21-29] versus 20[12-28], P=0.031). Return rate of questionnaires was high (87/128). In the ICU-MT, isoflurane patients recalled significantly more factual memories after one year. Generally, the psychological tests suggested a poor quality of life (SF-36), high rates of post-traumatic-stress-disorder (PTSS-14: 38%) and depression (WHO-5: 54%, HADS: 43%), without significant group differences. Isoflurane sedation leads to more delirium free days during the ICU treatment and more factual memories of the ICU stay one year after the ICU stay. However long-term outcome of ventilated ICU patients is poor, and there were no differences between isoflurane and propofol sedation.

Factors Associated with the Nutritional Status of Mechanically Ventilated Patients in Intensive Care Unit: A Cross Sectional Study

Background: Nutritional status significantly impacts the outcomes of critically ill patients in intensive care units (ICU), with malnutrition being a common complication that can exacerbate morbidity and mortality rates. The Nutrition Risk in the Critically ill (NUTRIC) score is a valuable tool for identifying patients at risk of malnutrition and guiding nutritional interventions. Objective: This study aimed to evaluate the factors influencing the nutritional status, as assessed by the NUTRIC score, of mechanically ventilated patients in ICUs across tertiary care hospitals, and to explore the association between nutritional risk and patient outcomes. Methods: A cross-sectional descriptive study was conducted in five tertiary care hospitals in Khyber Pakhtunkhwa, Pakistan, from August to December 2023. The study included patients aged 18 and above, who were mechanically ventilated for more than 48 hours. The NUTRIC score was calculated based on data collected on demographics, clinical characteristics, and laboratory investigations. Multiple linear regression analysis was performed to identify factors affecting the NUTRIC score using SPSS version 25. Results: Out of 335 patients, 75.2% were male, and 51.3% were aged between 50-75 years. A high NUTRIC score (indicating higher risk of malnutrition) was found in 25% of patients, while 74.9% had a low NUTRIC score. Factors significantly affecting the NUTRIC score included ventilation status (invasive/non-invasive), number of comorbidities, age, status of life (alive/deceased), and length of stay in ICU. The mortality rate was 3.9%, with a higher prevalence in older age groups. Conclusion: The study highlights the prevalence of nutritional risk among mechanically ventilated ICU patients and underscores the importance of early nutritional assessment and intervention. Targeted nutritional support, especially for patients with higher risk profiles, is crucial for improving outcomes and reducing mortality rates in this vulnerable population.

Clinical effect of pulmonary rehabilitation in patients with mechanical ventilation: A meta-analysis.

To systematically evaluate the clinical efficacy of pulmonary rehabilitation in patients with mechanical ventilation in an intensive care unit (ICU). Relevant studies were identified in the PubMed, Web of Science, National Library of Medicine, China National Knowledge Infrastructure and Wanfang databases. A meta-analysis was performed after screening based on the inclusion and exclusion criteria, data extraction and literature quality evaluation. In total, 19 studies involving 2181 participants were included. The results of the meta-analysis revealed that compared with patients with conventional rehabilitation measures, patients with pulmonary rehabilitation measures had a higher offline success rate (relative risk (RR) = 1.16; 95% confidence interval (CI): 1.09, 1.24; p < 0.00001) and higher arterial oxygen partial pressure levels (mean difference (MD) = 8.96; 95%CI: 5.98, 11.94; p < 0.0001) and these measures significantly shortened the duration of mechanical ventilation (standardised MD (SMD) = -1.08; 95%CI: -1.58, -0.59; p < 0.0001) and ICU stay (SMD = -1.41; 95%CI: -1.94, -0.88; p < 0.0001). Aspiration significantly reduced the incidence of ventilator-associated pneumonia (RR = 0.35; 95%CI: 0.24, 0.51; p < 0.00001) and deep vein thrombosis (RR = 0.32; 95%CI: 0.13, 0.76; p = 0.01) in ICU patients with mechanical ventilation. Pulmonary rehabilitation measures can improve the success rate of weaning from mechanical ventilation in ICU patients, shorten the time of mechanical ventilation and ICU hospitalisation and reduce the incidence of related adverse reactions, but the impact on mortality requires further study.

Association between selective digestive decontamination and decreased rate of acquired candidemia in mechanically ventilated ICU patients: a multicenter nationwide study

BackgroundCandidemia is a high-risk complication among intensive care unit (ICU) patients. While selective digestive decontamination (SDD) has been shown to be effective in preventing ICU-acquired bacterial secondary infection, its effects on ICU-acquired candidemia (ICAC) remain poorly explored. Therefore, we sought to assess the effects of SDD on ICAC.MethodUsing the REA-REZO network, we included adult patients receiving mechanical ventilation for at least 48 h from January 2017 to January 2023. Non-parsimonious propensity score matching with a 1:1 ratio was performed to investigate the association between SDD and the rate of ICAC.ResultsA total of 94 437 patients receiving at least 48 h of mechanical ventilation were included throughout the study period. Of those, 3 001 were treated with SDD and 651 patients developed ICAC. The propensity score matching included 2 931 patients in the SDD group and in the standard care group. In the matched cohort analysis as well as in the overall population, the rate of ICAC was lower in patients receiving SDD (0.8% versus 0.3%; p = 0.012 and 0.7% versus 0.3%; p = 0.006, respectively). Patients with ICAC had higher mortality rate (48.4% versus 29.8%; p < 0.001). Finally, mortality rates as well as ICU length of stay in the matched populations did not differ according to SDD (31.0% versus 31.1%; p = 0.910 and 9 days [5–18] versus 9 days [5–17]; p = 0.513, respectively).ConclusionIn this study with a low prevalence of ICAC, SDD was associated with a lower rate of ICAC that did not translate to higher survival.

Assessing an Exposure Keratopathy Prevention Strategy in Mechanically Ventilated Patients: A Retrospective Study.

Patients who are intubated and sedated are at risk for developing exposure keratopathy, which can lead to permanent vision loss. This retrospective study assesses the incidence of exposure keratopathy (EK) in intensive care unit (ICU) patients before and after implementation of an EK Prevention Order Set. At one tertiary care hospital (Bronx, NY), an "Exposure Keratopathy Prevention Order Set" was implemented to ameliorate this risk which included the application of white petrolatum-mineral oil lubricating ointment every 6 hours in both eyes. This retrospective chart review study analyzed the incidence of EK diagnosis before and after implementation of this EK Prevention Order Set. Patients who were on mechanical ventilation at the time of ophthalmology consult request between January 1, 2021, and December 31, 2021, were included. Ophthalmology consult notes of patients with EK diagnosis were reviewed for details regarding the consult request, examination findings, diagnosis, and treatment plan. There were 247 and 361 ventilated ICU patients before and after the order set, respectively. The number of ophthalmology consults decreased slightly after the order set from 15 of 247 to 20 of 361 ventilated patients. In addition, the rate of EK among ventilated patients decreased from 4.5% (11 of 247 patients over 151 days) to 2.2% (8 of 361 patients over 212 days; P =0.154) with a risk ratio of 0.50 (95% CI 0.20-1.22). The number of patients diagnosed with EK trended down after implementation of the EK Prevention Order Set.

Enteral citrulline supplementation versus placebo on SOFA score on day 7 in mechanically ventilated critically ill patients: the IMMUNOCITRE randomized clinical trial

BackgroundRestoring plasma arginine levels through enteral administration of L-citrulline in critically ill patients may improve outcomes. We aimed to evaluate whether enteral L-citrulline administration reduced organ dysfunction based on the Sequential Organ Failure Assessment (SOFA) score and affected selected immune parameters in mechanically ventilated medical intensive care unit (ICU) patients.MethodsA randomized, double-blind, multicenter clinical trial of enteral administration of L-citrulline versus placebo for critically ill adult patients under invasive mechanical ventilation without sepsis or septic shock was conducted in four ICUs in France between September 2016 and February 2019. Patients were randomly assigned to receive enteral L-citrulline (5 g) every 12 h for 5 days or isonitrogenous, isocaloric placebo. The primary outcome was the SOFA score on day 7. Secondary outcomes included SOFA score improvement (defined as a decrease in total SOFA score by 2 points or more between day 1 and day 7), secondary infection acquisition, ICU length of stay, plasma amino acid levels, and immune biomarkers on day 3 and day 7 (HLA-DR expression on monocytes and interleukin-6).ResultsOf 120 randomized patients (mean age, 60 ± 17 years; 44 [36.7%] women; ICU stay 10 days [IQR, 7–16]; incidence of secondary infections 25 patients (20.8%)), 60 were allocated to L-citrulline and 60 were allocated to placebo. Overall, there was no significant difference in organ dysfunction as assessed by the SOFA score on day 7 after enrollment (4 [IQR, 2–6] in the L-citrulline group vs. 4 [IQR, 2–7] in the placebo group; Mann‒Whitney U test, p = 0.9). Plasma arginine was significantly increased on day 3 in the treatment group, while immune parameters remained unaffected.ConclusionAmong mechanically ventilated ICU patients without sepsis or septic shock, enteral L-citrulline administration did not result in a significant difference in SOFA score on day 7 compared to placebo.Trial registration: ClinicalTrials.gov Identifier NCT02864017 (date of registration: 11 August 2016).

Efficacy and safety of ciprofol for long-term sedation in patients receiving mechanical ventilation in ICUs: a prospective, single-center, double-blind, randomized controlled protocol.

Introduction: Critically ill patients who receive mechanical ventilation after endotracheal intubation commonly experience discomfort and pressure. The major sedative drugs that are currently used in clinical practice present with many complications, such as hypotension, bradycardia, and respiratory depression. Ciprofol (HSK3486), which is a newly developed structural analog of propofol, is a short-acting gamma-aminobutyric acid (GABA) receptor agonist, and its mechanism of action is sedation or anesthesia by enhancing GABA-mediated chloride influx. The high efficacy of ciprofol for short-term sedation is comparable to that of propofol, and it has a relatively low incidence of adverse effects and high level of safety, which has been confirmed by multiple clinical studies. However, few studies have examined its safety and efficacy for long-term sedation. The purpose of the study is to evaluate the efficacy and safety of ciprofol for long-term sedation in mechanically ventilated patients. Methods: A prospective, single-center, double-blind, randomized, propofol-controlled, non-inferiority trial is proposed. The study will enroll 112 mechanically ventilated patients hospitalized in the intensive care unit (ICU) of the Shanghai Fourth People's Hospital affiliated with Tongji University based on the inclusion and exclusion criteria of the study, and randomly assign them to a group sedated with either ciprofol or propofol. The primary outcome is the percentage of time spent under target sedation, and secondary outcomes include drug dose, number of cases requiring additional dextrometropine, incidence of systolic blood pressure <80 or >180mmHg, incidence of diastolic blood pressure <50 or >100mmHg, incidence of heart rate <50 beats per minute (bpm) or >120bpm, inflammatory indicators, blood lipid levels, liver and kidney functions, nutritional indicators, ventilator-free days within the 7-day period after enrollment, 28-day mortality, ICU stay duration, and hospitalization costs. Discussion: We hypothesize that the efficacy and safety of ciprofol for long-term sedation in mechanically ventilated ICU patients will not be inferior to that of propofol. Trial registration: Chinese Clinical Trials Registry identifier ChiCTR2200066951.

A single-centre observational study of delayed defaecation in brain-injured patients in an adult intensive care unit

BackgroundThe incidence of delayed defaecation is high in enterally fed ventilated patients in intensive care units (ICUs). Those with brain injury may be harmed by increased intracranial pressure if delayed defaecation leads to abdominal distension. There are no studies evaluating a bowel guideline in the treatment of delayed defaecation in ventilated brain-injured ICU patients. ObjectiveThe objective of this study was to assess the incidence and clinical associations of delayed defaecation and level of compliance to an ICU bowel guideline. MethodsData were collected on ventilated adult patients with brain injury admitted for more than 3 days to one New Zealand ICU over a 2-year period. ResultsData were analysed for 117 patients; 56 (48%) who defaecated within 3 days of ICU admission (Group one) and 61 (52%) with delayed defaecation after 3 days (Group two). Compliance with the bowel guideline was low. Only 1 of 61 patients who should have had a rectal examination did so, and only 7 of 61 patients who should have had an aperient on day 3 did so. All seven received Movicol®, which was not part of the guideline. Use of aperients and enemas was found to be associated with stool passage (odds ratio: 93; 95% confidence interval: 5.2–1668; p = 0.002). Patients with delayed defaecation had longer ICU stays (mean 7.1 ± 4 SD vs 5.9 ± 3 days, p = 0.07) and more often had high gastric residual volumes after day 4 (27/61 vs 14/56; p = 0.003). No differences were seen between the groups in the incidence of ventilator-associated pneumonia, bacterial infections, diarrhoea, vomiting, duration of mechanical ventilation, or mortality. ConclusionDelayed defaecation was common, and compliance with the guideline was low. Movicol® and phosphate enemas were effective in stool production.

Impact of Dexmedetomidine Infusion on Opioid and Benzodiazepine Doses in Ventilated Pediatric Patients in the Cardiac Intensive Care Unit.

Dexmedetomidine (DEX) is frequently used as an adjunct agent for prolonged sedation in the intensive care unit (ICU), though its effect on concomitant opioids or benzodiazepines infusions is unclear. We explored the impact of DEX on concomitant analgosedation in a cohort of ventilated pediatric patients in a cardiac ICU, with stratification of patients according to duration of ventilation (< 5 versus ≥ 5 days) following DEX initiation. We conducted a retrospective analysis on ventilated patients receiving a DEX infusion ≥ 24 h and at least one other sedative/analgesic infusion (January 2011-June 2021). We evaluated trends of daily doses of opioids and benzodiazepines from 24 h before to 72 h following DEX initiation, stratifying patients based on ventilation duration after DEX initiation (< 5 versus ≥ 5 days). After excluding 1146 patients receiving DEX only, 1073 patients were included [median age 234 days (interquartile range 90, 879)]. DEX was associated with an opioid infusion in 99% of patients and a benzodiazepine infusion in 62%. Among patients ventilated for < 5 days (N = 761), opioids increased in the first 24 h following DEX initiation [+ 1.12 mg/kg/day (95% CI 0.96, 1.23), P < 0.001], then decreased [- 0.90 mg/kg/day (95% CI - 0.89, - 0.71), P < 0.001]; benzodiazepines slowly decreased [- 0.20 mg/kg/day (95% CI - 0.21, - 0.19), P < 0.001]. Among patients ventilated for ≥ 5 days (N = 312), opioid administration doubled [+ 2.09 mg/kg/day (95% CI 1.82, 2.36), P < 0.001] in the first 24 h, then diminished minimally [- 0.18 mg/kg/day (95% CI - 0.32, - 0.04), P = 0.015] without returning to baseline; benzodiazepine administration decreased minimally [- 0.03 mg/kg/day (95% CI - 0.05, - 0.01), P = 0.010]. Similar trends were confirmed when adjusting for age, gender, surgical complexity, recent major invasive procedures, duration of mechanical ventilation before DEX initiation, extubation within 72 h following DEX initiation, mean hourly DEX dose, and use of neuromuscular blocking infusion. While in patients ventilated < 5 days opioids initially increased and then quickly decreased in the 72 h following DEX initiation, among patients ventilated ≥ 5 days opioids doubled, then decreased only minimally; benzodiazepines decreased minimally in both groups, although more slowly in the long-ventilation cohort. These findings may inform decision-making on timing of DEX initiation in ventilated patients already being treated with opioid or benzodiazepine infusions.

Characterization of upper airway microbiome across severity of COVID-19 during hospitalization and treatment.

Longitudinal studies on upper respiratory tract microbiome in coronavirus disease 2019 (COVID-19) without potential confounders such as antimicrobial therapy are limited. The objective of this study is to assess for longitudinal changes in the upper respiratory microbiome, its association with disease severity, and potential confounders in adult hospitalized patients with COVID-19. Serial nasopharyngeal and throat swabs (NPSTSs) were taken for 16S rRNA gene amplicon sequencing from adults hospitalized for COVID-19. Alpha and beta diversity was assessed between different groups. Principal coordinate analysis was used to assess beta diversity between groups. Linear discriminant analysis was used to identify discriminative bacterial taxa in NPSTS taken early during hospitalization on need for intensive care unit (ICU) admission. A total of 314 NPSTS samples from 197 subjects (asymptomatic = 14, mild/moderate = 106, and severe/critical = 51 patients with COVID-19; non-COVID-19 mechanically ventilated ICU patients = 11; and healthy volunteers = 15) were sequenced. Among all covariates, antibiotic treatment had the largest effect on upper airway microbiota. When samples taken after antibiotics were excluded, alpha diversity (Shannon, Simpson, richness, and evenness) was similar across severity of COVID-19, whereas beta diversity (weighted GUniFrac and Bray-Curtis distance) remained different. Thirteen bacterial genera from NPSTS taken within the first week of hospitalization were associated with a need for ICU admission (area under the receiver operating characteristic curve, 0.96; 95% CI, 0.91-0.99). Longitudinal analysis showed that the upper respiratory microbiota alpha and beta diversity was unchanged during hospitalization in the absence of antimicrobial therapy.

The impact of the COVID-19 pandemic on ICU clinical trials: a description of one research team’s experience

BackgroundDisruptions to clinical trials conducted in the intensive care unit (ICU) due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2; coronavirus disease 2019 [COVID-19]) pandemic included fewer new trials activated and more trials stopped. While a number of ongoing, non-COVID-19 clinical trials remained open to enrollment, the direct impact of the pandemic on ICUs instilled chaos in this already challenging environment. The numerous challenges need to be reported so investigators can proactively plan and manage these myriad challenges. Thus, the purpose of this study was to describe the impact of the COVID-19 pandemic on screening and accrual for a non-COVID-19 parent clinical trial enrolling critically ill ICU patients receiving mechanical ventilatory support.MethodsA descriptive, retrospective design using quantitative data from detailed screening logs and qualitative observations with field notes from a parent clinical trial were used to address the objectives. The primary aims of the two-site parent clinical trial (n = 190) are to test the efficacy of self-administration of sedative therapy by mechanically ventilated ICU patients on anxiety and delirium occurrence. ICUs from two academic medical centers [names removed for blinding] plus a community hospital in Minnesota were screened daily for alert patients (Richmond Agitation Sedation Scale [RASS] − 2 to + 1), following commands, hemodynamically stable with sufficient hand grip strength to depress a push-button device. Screening data were summarized based on the primary reason patients were not enrolled (screen failures, declinations of consent). Descriptive statistics (frequencies, percentages), chi-square, and Fisher’s Exact test were used to describe the data and to determine any differences among distributions of screening failures and recruitment declinations during the defined pre-pandemic (August 27, 2018–March 15, 2020, 2976 screened patients) and pandemic timeframes (March 16, 2020–February 28, 2022, 3912 screened patients). Qualitative data from varied sources such as screening logs, institutional email communications, staff field notes, and research team meeting minutes were summarized into themes.ResultsDespite significantly fewer screen failures due to hypotension, cognitive impairment/dementia, coma, or chemical paralysis with 938 additional patients on the screening log, more were accrued pre-pandemic (n = 55) than during the pandemic period (n = 45); declination reasons were non-significant. Pandemic burdens experienced by study personnel, ICU care providers, and patients/families were revealed that attributed to decreased accrual.ConclusionsWhile the parent clinical trial remained opened, cumulative factors adversely impacted the trial during the pandemic period with fewer patients accrued. The human toll of the pandemic on research staff, clinicians, and patients/family members demands that investigators be proactive in managing these challenges to conduct ICU clinical trials successfully, including careful oversight of human and financial resources.Trial registrationClinicalTrials.gov NCT#02,819,141 Registered 29 June 2016.

Continuation of enteral nutrition until extubation in critically ill patients.

There is substantial variation in enteral nutrition practices for airway procedures in critically ill patients across individual specialists and intensive care units (ICUs). Fasting times can vary between 0 h and longer than 24 h before planned extubations. 1 Varghese JA Tatucu-Babet OA Miller E et al. Fasting practices of enteral nutrition delivery for airway procedures in critically ill adult patients: a scoping review. J Crit Care. 2022; 72154144 Crossref PubMed Scopus (0) Google Scholar Patients receiving mechanical ventilation are often underfed, and interruptions are one of the main causes that energy prescriptions are not met. 2 Torrini F Gendreau S Morel J et al. Prediction of extubation outcome in critically ill patients: a systematic review and meta-analysis. Crit Care. 2021; 25: 391 Crossref PubMed Scopus (11) Google Scholar Airway procedures, such as extubation or tracheotomy, lead to the longest fasting periods in the ICU, but the implementation of unit-wide guidelines can reduce fasting time and maximise caloric intake. 3 Segaran E Barker I Hartle A Optimising enteral nutrition in critically ill patients by reducing fasting times. J Intensive Care Soc. 2016; 17: 38-43 Crossref PubMed Scopus (26) Google Scholar , 4 Hoffmann M Schwarz CM Fürst S et al. Risks in management of enteral nutrition in intensive care units: a literature review and narrative synthesis. Nutrients. 2020; 13: 82 Crossref PubMed Scopus (4) Google Scholar However, most of this common practice comes from the theatre, and mainly preoperative fasting practice guidelines are being used with the hope of minimising the risk of aspiration in airway procedures. 5 Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2017; 126: 376-393 Crossref PubMed Scopus (450) Google Scholar Patients are at increased risk of aspiration due to oropharyngeal dysfunction for several hours following extubation 6 Schefold JC Berger D Zürcher P et al. Dysphagia in mechanically ventilated ICU patients (DYnAMICS): a prospective observational trial. Crit Care Med. 2017; 45: 2061-2069 Crossref PubMed Scopus (95) Google Scholar and up to 20% of patients have to be reintubated within 7 days. 2 Torrini F Gendreau S Morel J et al. Prediction of extubation outcome in critically ill patients: a systematic review and meta-analysis. Crit Care. 2021; 25: 391 Crossref PubMed Scopus (11) Google Scholar A question that remained unanswered was whether it is really safe to continue enteral nutrition until attempting to extubate. Continued enteral nutrition until extubation compared with fasting before extubation in patients in the intensive care unit: an open-label, cluster-randomised, parallel-group, non-inferiority trialContinued enteral nutrition until extubation in critically ill patients in the intensive care unit was non-inferior to a 6-h fasting maximum gastric vacuity strategy comprising continuous gastric tube suctioning, in terms of extubation failure within 7 days (a patient-centred outcome), and thus represents a potential alternative in this population. Full-Text PDF

Effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients (CONFIDENCE): protocol for a multicentre randomised controlled trial

BackgroundFluid therapy is a common intervention in critically ill patients. It is increasingly recognised that deresuscitation is an essential part of fluid therapy and delayed deresuscitation is associated with longer invasive ventilation and length of intensive care unit (ICU) stay. However, optimal timing and rate of deresuscitation remain unclear. Lung ultrasound (LUS) may be used to identify fluid overload. We hypothesise that daily LUS-guided deresuscitation is superior to deresuscitation without LUS in critically ill patients expected to undergo invasive ventilation for more than 24 h in terms of ventilator free-days and being alive at day 28.MethodsThe “effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients” (CONFIDENCE) is a national, multicentre, open-label, randomised controlled trial (RCT) in adult critically ill patients that are expected to be invasively ventilated for at least 24 h. Patients with conditions that preclude a negative fluid balance or LUS examination are excluded. CONFIDENCE will operate in 10 ICUs in the Netherlands and enrol 1000 patients. After hemodynamic stabilisation, patients assigned to the intervention will receive daily LUS with fluid balance recommendations. Subjects in the control arm are deresuscitated at the physician’s discretion without the use of LUS. The primary endpoint is the number of ventilator-free days and being alive at day 28. Secondary endpoints include the duration of invasive ventilation; 28-day mortality; 90-day mortality; ICU, in hospital and total length of stay; cumulative fluid balance on days 1–7 after randomisation and on days 1–7 after start of LUS examination; mean serum lactate on days 1–7; the incidence of reintubations, chest drain placement, atrial fibrillation, kidney injury (KDIGO stadium ≥ 2) and hypernatremia; the use of invasive hemodynamic monitoring, and chest-X-ray; and quality of life at day 28.DiscussionThe CONFIDENCE trial is the first RCT comparing the effect of LUS-guided deresuscitation to routine care in invasively ventilated ICU patients. If proven effective, LUS-guided deresuscitation could improve outcomes in some of the most vulnerable and resource-intensive patients in a manner that is non-invasive, easy to perform, and well-implementable.Trial registrationClinicalTrials.gov NCT05188092. Registered since January 12, 2022

Changing Trend in the Antibiotic Resistance Pattern of Klebsiella Pneumonia Isolated From Endotracheal Aspirate Samples of ICU Patients of a Tertiary Care Hospital in North India.

Introduction Klebsiella pneumonia is one of the most prevalent bacteria that cause nosocomial infections, particularly in critically ill patients in the intensive care unit (ICU). Multi-drug-resistant Klebsiella pneumoniae (MDRKP) has become an urgent risk to public health as its prevalence has sharply surged around the globe in recent decades. Therefore, this research was conducted to evaluate shifts over a four-year period in drug susceptibility patterns among Klebsiella pneumoniae isolates from mechanically ventilated intensive care unit patients. Materials and methods This is a retrospective observational study conducted in a tertiary care multi-specialty hospital and teaching institute in North India and was approved by the institutional ethics committee. The research comprised Klebsiella pneumoniae isolates from endotracheal aspirates (ETA) of patients on mechanical ventilation admitted to the general intensive care unit (ICU) of our tertiary care facility. The data from January to June 2018 and January to June 2022 were collected. According to the antimicrobial resistance profile of the strains, they were categorized as susceptible, resistant to one or two antimicrobial categories, multidrug-resistant (MDR), extensively drug-resistant (XDR), or pan-drug-resistant (PDR). The criteria for MDR, XDR, and PDR were proposed by the European Centre for Disease Prevention and Control (ECDC). IBM Statistical Package for the Social Sciences (SPSS) for Windows, Version 24.0, Armonk, NY, IBM Corp., was used for data input and analysis. Results A total of 82 cases of Klebsiella pneumonia were included in the study. Of these 82 isolates, 40 were isolated over a period of six months from January to June 2018, and the remaining 42 were isolated from January to June 2022. Among the 2018 group, five strains (12.5%) were classified as susceptible, three (7.5%) as resistant, seven (17.5%) as MDR, and 25 (62.5%) as XDR. The highest percentages of antimicrobial resistance in the 2018 group were observed with amoxicillin/clavulanic acid (90%), ciprofloxacin (100%), piperacillin/tazobactam (92.5%), and cefoperazone/sulbactam (95%). In comparison, the 2022 group showed no strain as susceptible; nine strains (21.4%) were classified as resistant; three strains (7%) as MDR; and 30 strains (93%) were classified as XDR. There was a significant increase in resistance to amoxicillin, from 10% in 2018 to nil in 2022. Overall, the rate of resistant Klebsiella pneumonia (K. pneumonia) increased from 7.5% (3/40) in 2018 to 21.4% (9/42) in 2022, while XDR Klebsiella pneumonia among the mechanically ventilated ICU patients significantly increased from 62.5% (25/40) in 2018 to 71% (30/42) in 2022. Conclusion K. pneumoniae antibiotic resistance is a real threat in Asia and requires close monitoring to be controlled. More careful attempts should be made to create a new generation of antimicrobials since the prevalence of resistance to existingmedications is rising. Antibiotic resistance should be monitored and reported by healthcare institutions regularly.

Association between the early mobilization of mechanically ventilated patients and independence in activities of daily living at hospital discharge

Physical dysfunction after discharge from the intensive care unit (ICU) is recognized as a common complication among ICU patients. Early mobilization (EM), defined as the ability to sit on the edge of the bed within 5 days, may help improve physical dysfunction. However, the barriers to, and achievement of, EM and their impact on physical dysfunction have not been fully investigated. This study aimed to investigate the achievement of EM and barriers to it and their impact on patient outcomes in mechanically ventilated ICU patients. We conducted this multicenter retrospective cohort study by collecting data from six ICUs in Japan. Consecutive patients who were admitted to the ICU between April 2019 and March 2020, were aged ≥ 18 years, and received mechanical ventilation for > 48 h were eligible. The primary outcome was the rate of independent activities of daily living (ADL), defined as a score ≥ 70 on the Barthel index at hospital discharge. Daily changes in barriers of mobilization, including consciousness, respiratory, circulatory, medical staff factors, and device factors (catheter, drain, and dialysis), along with the clinical outcomes were investigated. The association among barriers, mobilization, and Barthel index ≥ 70 was analyzed using multivariable logistic regression analysis. During the study period, 206 patients were enrolled. EM was achieved in 116 patients (68%) on the fifth ICU day. The primary outcome revealed that achieving EM was associated with a Barthel index ≥ 70 at hospital discharge [adjusted odds ratio (AOR), 3.44; 95% confidence interval (CI), 1.70–6.96]. Device factors (AOR, 0.31; 95% CI, 0.13–0.75, respectively) were significantly associated with EM achievement. EM was associated with independent ADL at hospital discharge. Time to first mobilization and barriers to achieving mobilization can be important parameters for achieving ADL independence at discharge. Further research is required to determine the most common barriers so that they can be identified and removed.

Prognostic Value of the Radiographic Assessment of Lung Edema Score in Mechanically Ventilated ICU Patients

The Radiographic Assessment of Lung Edema (RALE) score provides a semi-quantitative measure of pulmonary edema. In patients with acute respiratory distress syndrome (ARDS), the RALE score is associated with mortality. In mechanically ventilated patients in the intensive care unit (ICU) with respiratory failure not due to ARDS, a variable degree of lung edema is observed as well. We aimed to evaluate the prognostic value of RALE in mechanically ventilated ICU patients. Secondary analysis of patients enrolled in the 'Diagnosis of Acute Respiratory Distress Syndrome' (DARTS) project with an available chest X-ray (CXR) at baseline. Where present, additional CXRs at day 1 were analysed. The primary endpoint was 30-day mortality. Outcomes were also stratified for ARDS subgroups (no ARDS, non-COVID-ARDS and COVID-ARDS). 422 patients were included, of which 84 had an additional CXR the following day. Baseline RALE scores were not associated with 30-day mortality in the entire cohort (OR: 1.01, 95% CI: 0.98-1.03, p = 0.66), nor in subgroups of ARDS patients. Early changes in RALE score (baseline to day 1) were only associated with mortality in a subgroup of ARDS patients (OR: 1.21, 95% CI: 1.02-1.51, p = 0.04), after correcting for other known prognostic factors. The prognostic value of the RALE score cannot be extended to mechanically ventilated ICU patients in general. Only in ARDS patients, early changes in RALE score were associated with mortality.

940: COMPARISON OF SAT AND SBT CONDUCT DURING THE ABC TRIAL AND PILOT TRIAL

Introduction: The “B” element in the ABCDEF bundle stands for “both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)”. Implementation of this key component has been shown to decrease time on the ventilator, in the intensive care unit (ICU) and hospital, and one-year mortality. We aimed to compare sedation use and SAT and SBT conduct between two randomized controlled trials. Methods: The 2008 Awakening and Breathing Controlled (ABC) Trial found that daily paired SATs and SBTs improved one-year survival. In 2021, the Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial enrolled ventilated ICU patients in similar clinical settings as the ABC trial patients. We compared sedation use and SAT and SBT conduct in the ABC Trial’s interventional group (SAT+SBT; n=167, 1140 patient instances) with that in the PILOT study (n=2083, 8355 patient instances). We also examined reasons for failure of SAT and SBT safety screens and trials. Results: ABC’s interventional group of paired SAT and SBT safety screens had 1140/1140 (100%) patient-instances on sedatives and/or analgesic boluses or infusions while only 4228/8355 (51%) were in the PILOT trial. SAT safety screens were done in all ABC patient-instances on sedation and in 3889/4228 (92%) in PILOT. SAT safety screens were passed in 939/1140 (82%) instances in ABC and in 1897/3889 (49%) in PILOT. SAT was done in 895/939 (95%) in ABC and 1867/1897 (98%) in PILOT and passed in 837/895 (94%) in ABC and 1145/1867 (61%) in PILOT. Anxiety, agitation and pain were more common reasons for SAT failure in PILOT. SBT safety screens were done in 983/983 (100%) in ABC and 2083/2541 (82%) in PILOT and passed in 647/983 (66%) in ABC and 4475/8031 (56%) in PILOT. SBTs trials were done in all ABC’s instances and 8031/8370 (96%) in PILOT and passed in 319/603 (53%) in ABC and 3337/4454 (75%) in PILOT. Conclusions: Over the past 13 years, there has been a dramatic decrease in amount of continuous sedation and/or analgesia given to ICU patients. Performance of SAT/SBT safety screens, SATs, and SBTs remain high many years after the ABC study. Continued optimization of anxiety, agitation, and analgesia needs to occur to improve passing SATs. However, despite this, passing SBTs was higher in the PILOT trial.

Quantitative EEG signatures of delirium and coma in mechanically ventilated ICU patients

ObjectiveTo identify quantitative electroencephalography (EEG)-based indicators of delirium or coma in mechanically ventilated patients. MethodsWe prospectively enrolled 28 mechanically ventilated intensive care unit (ICU) patients to undergo 24-hour continuous EEG, 25 of whom completed the study. We assessed patients twice daily using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the ICU (CAM-ICU). We evaluated the spectral profile, regional connectivity and complexity of 5-minute EEG segments after each assessment. We used penalized regression to select EEG metrics associated with delirium or coma, and compared mixed-effects models predicting delirium with and without the selected EEG metrics. ResultsDelta variability, high-beta variability, relative theta power, and relative alpha power contributed independently to EEG-based identification of delirium or coma. A model with these metrics achieved better prediction of delirium or coma than a model with clinical variables alone (Akaike Information Criterion: 36 vs 43, p = 0.006 by likelihood ratio test). The area under the receiver operating characteristic curve for an ad hoc hypothetical delirium score using these metrics was 0.94 (95%CI 0.83–0.99). ConclusionsWe identified four EEG metrics that, in combination, provided excellent discrimination between delirious/comatose and non-delirious mechanically ventilated ICU patients. SignificanceOur findings give insight to neurophysiologic changes underlying delirium and provide a basis for pragmatic, EEG-based delirium monitoring technology.