Ventilator Usage Research Articles

Assessing follow-up care compliance in children hospitalized for traumatic brain injuries

Background and Hypothesis: There is limited information regarding healthcare utilization and outcomes in children hospitalized for traumatic brain injury (TBI). Nearly 50% of adults hospitalized for trauma do not attend follow-up appointments, although completion of post-discharge care is associated with improved outcomes and decreased likelihood of subsequent emergency department (ED) visits. The Regestrief Institute Indiana Network for Patient Care (INPC) is a regional health information exchange (HIE) with health record data. This includes inpatient, outpatient, and ED visits, as well as imaging and lab data. The objective of this study is to use HIE data to assess long-term healthcare utilization, complications, and sequelae of pediatric patients hospitalized for TBI to see if follow-up compliance can identify patients at risk for post-TBI complications, including unplanned care, as well as long-term secondary health conditions. 
 
 Methods: 387 patients treated at a pediatric level 1 trauma center in Indiana admitted for TBI were identified using trauma registry data. EHR data in the INPC on patients for two years post-discharged were analyzed. Associations between compliance with follow-up care instructions given at discharge/subsequent medical visits and longitudinal utilization/outcomes were examined using Fisher’s exact test. 
 
 Results: After reviewing patient records, we found that 60.7% of patients received all follow-up care and 8.5% of patients received partial follow-up care, leaving 25.1% of patients receiving no follow up care and 5.7% of patients lost to follow-up after discharge. 12% of patients went to the ER for an injury-related issue and 6.2% of patients were readmitted. 19.4% of individuals experienced complications from injury while 12.4% of individuals had suspected sequela. Factors influencing recovery included race, age, insurance, injury severity, ICU admission, and ventilator usage. 
 
 Implications and Importance: Using HIE data can identify factors of hospitalized children vulnerable to not achieving optimal recovery and determine what care is critical to improving long-term health and quality of life outcomes.

Gram-negative bacilli bacteremia: a 7 year retrospective study in a referral Brazilian tertiary-care teaching hospital.

Introduction. Bloodstream infection is one of the most frequent and challenging hospital-acquired infections and it is associated with high morbidity, mortality and additional use of healthcare resources.Hypothesis/Gap Statement: Bloodstream infections have consequences for the patient, such as the evolution to mortality and inappropriate empirical antibiotic prescription, especially when caused by multidrug-resistant Gram-negative bacilli.Objective. To assess the impact of bloodstream infection and the status of multidrug resistance (MDR) in the evolution of patients who received inappropriate initial antibiotic therapy.Methods. A retrospective surveillance was conducted on nosocomial bloodstream infections caused by Gram-negative bacilli (GNB) from January 2012 to December 2018 in an adult intensive care unit of a Brazilian tertiary teaching hospital.Results. We identified 270 patients with GNB nosocomial bacteremia. Non-survivors were older (with an average age of 58.8 years vs 46.9 years, P=<0.0001), presented more severe illnesses, were immunosuppressed (73.7 vs 37.6%, P=<0.0001), were more likely to have septic shock (55.8 vs 22.4%, P=<0.0001) and had an increased usage of mechanical ventilators (98.6 vs 89.6%, P=0.0013) than survivors. In a logistic regression model, inappropriate empirical antibiotic therapy was not an independent predictor of mortality, different from mechanical ventilator (P=<0.0001; OR=28.0; 95% CI=6.3-123.6), septic shock (P=0.0051; OR=2.5; 95% CI=1.3-4.9) and immunosuppression (P=0.0066; OR=2.6; 95% CI=1.3-5.2). In contrast, in a separate model, MDR was strongly associated with the prescription of inappropriate initial antibiotic therapy (P=0.0030; OR=5.3; 95% CI=1.7-16.1). The main isolated pathogens were Acinetobacter baumannii (23.6 %) and Klebsiella pneumoniae (18.7 %). The frequency of MDR organisms was high (63.7 %), especially among non-fermenting bacilli (60.9 %), highlighting A. baumannii (81.6 %) and Pseudomonas aeruginosa (41.8 %).Conclusion. Illness severity (septic shock and immunosuppression) and mechanical ventilation were identified as predictors of mortality. Additionally, MDR was a major determinant of inappropriate antibiotic empirical therapy, but not associated with mortality, and both characteristics were not statistically associated with death.

Clinical outcomes of patients hospitalized for COVID-19 versus SARS: a meta-analysis.

Estimating the case-fatality rate and clinical outcomes for patients with coronavirus disease 2019 (COVID-19) is crucial because health care systems must adequately prepare for outbreaks and design appropriate policies. A systematic search of PubMed, Embase, and Medline+Journal (via OVID) were conducted for relevant journal publications from database inception to May 4, 2020. Articles that reported the fatality rates and clinical outcomes of patients hospitalized for COVID-19 or severe acute respiratory syndrome (SARS) infection were included. Nine clinical reports (four SARS reports and five COVID-19 reports) with a total of 851 patients (367 and 484 patients with SARS and COVID-19, respectively) were analyzed. A greater proportion of hospitalized patients with COVID-19 had bilateral pneumonia (90.0% [76.3%–96.2%] vs. 35.9% [21.4%–53.6%], p < 0.001) and required ventilators (23.8% [18.8%–29.6%] vs. 15.3% [11.9%–19.4%], p = 0.010) compared with hospitalized patients with SARS. The case-fatality rate was 9.5% (6.5%–13.7%) and 6.1% (3.5%–10.3%) among patients with COVID-19 and SARS, respectively (p = 0.186). The case-fatality rate among hospitalized patients with COVID-19 was comparable to that during the 2003 SARS outbreak. A higher incidence of bilateral pneumonia and increased ventilator usage were noted among patients with COVID-19 compared with patients with SARS.

Intensive Care Unit Capacity and Its Associated Risk Factors During the COVID-19 Surge in the Republic of Korea: Analysis Using Nationwide Health Claims Data.

ObjectiveTo identify risk factors for intensive care unit (ICU) admission and mechanical ventilator usage among confirmed coronavirus disease (COVID-19) patients and estimate the effects of mitigation efforts on ICU capacity in Korea.Patients and MethodsData on profiles and medical history of all confirmed COVID-19 patients in the past 1 year were extracted from the Korean National Health Insurance System’s claims database to assess risk factors for ICU admission and ventilator use. We used a time-series epidemic model to estimate the ICU census in Daegu from the reported hospital data.FindingsMultivariate regression analysis revealed male sex, old age, and residing in Daegu city as significant risk factors for ICU admission. The number of patients requiring ICU admission exceeded the bed capacity across all Daegu hospitals before March 9, 2020, and therefore, critically ill patients were transferred to nearby hospitals outside Daegu. This finding was consistent with our prediction that the ICU census in Daegu would peak on March 16, 2020, at 160 through mitigation efforts, without which it would have reached 300 by late March 2020.ConclusionOlder age and male sex were risk factors for ICU admission. In addition, the geographic location of the hospital seems to contribute to the severity of the COVID-19 patients admitted to the ICU and to the ICU capacity.

Does Cardiac Remodeling in Pediatric Myocarditis Associated with Initial Cardiac Function?

Background: In pediatric myocarditis, the relationship between cardiac remodeling with initial cardiac function remains uncertain. The authors hypothesized that cardiac remodeling in viral myocarditis is not associated with initial cardiac function. Objective: The primary objective is to determine an association between cardiac remodeling with initial cardiac function, and the secondary aim is to study the factors that influence cardiac remodeling. Materials and Methods: A retrospective cohort study of children under 15 years old, clinically diagnosed as presumed acute viral myocarditis and treated at Ramathibodi Hospital between January 2002 and June 2017. Results: Twenty-three patients were enrolled. Patients had a median age of two years (25 days-14.5 years), and 15 (65%) patients were female. The most common presenting symptoms were respiratory, cardiac, and gastrointestinal symptoms, respectively. The various supportive treatments included Dobutamine (80%), intravenous immunoglobulin (86%), and mechanical ventilator usage (80%). Fifteen patients (65%) survived at discharge, six (25%) expired, and two (9%) were referred to another institution for cardiac transplantation. Nineteen patients (83%) had an initial left ventricular ejection fraction (LVEF) of less than 55%. In this group, eight (40%) patients had completed cardiac remodeling during the follow-up period. The authors found that those with initial mild-to-moderate systolic dysfunction had a better chance for complete remodeling as compared with those who had an initial severe systolic dysfunction. Factor associated with incomplete cardiac remodeling was dopamine usage (OR 0.06, 95% CI 0.0049 to 0.7345, p=0.028). Conclusion: Initial cardiac function is important and associated with complete cardiac remodeling. Those with initial mild-to-moderate systolic dysfunction have better remodeling and recovery than the one with initial severe systolic dysfunction. Keywords: Myocarditis, Pediatric, Cardiac function, Cardiac remodeling

Physiological and socioeconomic characteristics predict COVID-19 mortality and resource utilization in Brazil.

Given the severity and scope of the current COVID-19 pandemic, it is critical to determine predictive features of COVID-19 mortality and medical resource usage to effectively inform health, risk-based physical distancing, and work accommodation policies. Non-clinical sociodemographic features are important explanatory variables of COVID-19 outcomes, revealing existing disparities in large health care systems. We use nation-wide multicenter data of COVID-19 patients in Brazil to predict mortality and ventilator usage. The dataset contains hospitalized patients who tested positive for COVID-19 and had either recovered or were deceased between March 1 and June 30, 2020. A total of 113,214 patients with 50,387 deceased, were included. Both interpretable (sparse versions of Logistic Regression and Support Vector Machines) and state-of-the-art non-interpretable (Gradient Boosted Decision Trees and Random Forest) classification methods are employed. Death from COVID-19 was strongly associated with demographics, socioeconomic factors, and comorbidities. Variables highly predictive of mortality included geographic location of the hospital (OR = 2.2 for Northeast region, OR = 2.1 for North region); renal (OR = 2.0) and liver (OR = 1.7) chronic disease; immunosuppression (OR = 1.7); obesity (OR = 1.7); neurological (OR = 1.6), cardiovascular (OR = 1.5), and hematologic (OR = 1.2) disease; diabetes (OR = 1.4); chronic pneumopathy (OR = 1.4); immunosuppression (OR = 1.3); respiratory symptoms, ranging from respiratory discomfort (OR = 1.4) and dyspnea (OR = 1.3) to oxygen saturation less than 95% (OR = 1.7); hospitalization in a public hospital (OR = 1.2); and self-reported patient illiteracy (OR = 1.1). Validation accuracies (AUC) for predicting mortality and ventilation need reach 79% and 70%, respectively, when using only pre-admission variables. Models that use post-admission disease progression information reach accuracies (AUC) of 86% and 87% for predicting mortality and ventilation use, respectively. The results highlight the predictive power of socioeconomic information in assessing COVID-19 mortality and medical resource allocation, and shed light on existing disparities in the Brazilian health care system during the COVID-19 pandemic.

Evaluation of Nosocomial Infections in Reanimation Intensive Care Unit: Analysis of Six Years Surveillance

Objective: Nosocomial infections (NI) raise costs due to the increased in mortality and long-term hospitalization. There are more NIs in intensive care units (ICU) probably due to invasive procedures. In order to reduce NIs, the most important step in terms of prevention is the identification of the common pathogens with their infection rates among these units. For this purpose, the centers should conduct surveillance studies and often evaluate their data.&#x0D; Methods: We evaluated the infection rates and ratios, between January 1st, 2014 and August 31st, 2019 in Reanimation Intensive Care Unit (ICU) in our hospital. Method of the surveillance was, prospective, active, laboratory and patient based.&#x0D; Results: In our reanimation ICU, 1591 patients were followed up during the study period. 192 NIs were observed in 179 patients on 21,840 intensive care days. NI rate was found to be 11.25 and Infection density rate was found to be 8.20 and their change over the years was examined. Analysis regarding the source of infections revealed that ventilator-related pneumonia (27.08%) and central venous catheter-related blood-stream infection (25.52%) was most commonly observed during the study period. The ventilator usage rate was 0.54 (11.859 ventilator days) and the central venous catheter usage rate was 0.94 (20.566 catheter days) in the study period. Acinetobacter baumannii (n = 96, 50%), Pseudomonas aeruginosa (n = 24, 12.5%) and Klebsiella pneumonia (n = 18, 9.38%) were most commonly isolated.

Crisis Standards of Care Implementation at the State Level in the United States.

In 2009, the Institute of Medicine published guidelines for implementation of Crisis Standards of Care (CSC) at the state level in the United States (US). Based in part on the then concern for H1N1 pandemic, there was a recognized need for additional planning at the state level to maintain health system preparedness and conventional care standards when available resources become scarce. Despite the availability of this framework, in the years since and despite repeated large-scale domestic events, implementation remains mixed. Coronavirus disease 2019 (COVID-19) rejuvenates concern for how health systems can maintain quality care when faced with unrelenting burden. This study seeks to outline which states in the US have developed CSC and which areas of care have thus far been addressed. An online search was conducted for all 50 states in 2015 and again in 2020. For states without CSC plans online, state officials were contacted by email and phone. Public protocols were reviewed to assess for operational implementation capabilities, specifically highlighting guidance on ventilator use, burn management, sequential organ failure assessment (SOFA) score, pediatric standards, and reliance on influenza planning. Thirty-six states in the US were actively developing (17) or had already developed (19) official CSC guidance. Fourteen states had no publicly acknowledged effort. Eleven of the 17 public plans had updated within five years, with a majority addressing ventilator usage (16/17), influenza planning (14/17), and pediatric care (15/17), but substantially fewer addressing care for burn patients (9/17). Many states lacked publicly available guidance on maintaining standards of care during disasters, and many states with specific care guidelines had not sufficiently addressed the full spectrum of hazard to which their health care systems remain vulnerable.

Re-Examining the Race to Send Ventilators to Low-Resource Settings.

COVID-19 is devastating health systems globally and causing severe ventilator shortages. Since the beginning of the outbreak, the provision and use of ventilators has been a key focus of public discourse. Scientists and engineers from leading universities and companies have rushed to develop low-cost ventilators in hopes of supporting critically ill patients in developing countries. Philanthropists have invested millions in shipping ventilators to low-resource settings, and agencies such as the World Health Organization and the World Bank are prioritizing the purchase of ventilators. While we recognize the humanitarian nature of these efforts, merely shipping ventilators to low-resource environments may not improve outcomes of patients and could potentially cause harm. An ecosystem of considerable technological and human resources is required to support the usage of ventilators within intensive care settings. Medical-grade oxygen supplies, reliable electricity, bioengineering support, and consumables are all needed for ventilators to save lives. However, most ICUs in resource-poor settings do not have access to these resources. Patients on ventilators require continuous monitoring from physicians, nurses, and respiratory therapists skilled in critical care. Health care workers in many low-resource settings are already exceedingly overburdened, and pulling these essential human resources away from other critical patient needs could reduce the overall quality of patient care. When deploying medical devices, it is vital to align the technological intervention with the clinical reality. Low-income settings often will not benefit from resource-intensive equipment, but rather from contextually appropriate devices that meet the unique needs of their health systems.

Prediction of Acquired Morbidity Using Illness Severity Indices in Pediatric Intensive Care Patients.

To assess the ability of two illness severity scores, Pediatric Logistic Organ Dysfunction Score 2 and Pediatric Index of Mortality 3, in predicting PICU-acquired morbidity. Retrospective chart review conducted from April 2015 to March 2016. Single-center study in a multidisciplinary PICU in a tertiary pediatric hospital in Singapore. The study included all index admissions of patients 0-18 years old to the PICU during the study period. None. Three outcomes were assessed at hospital discharge: mortality, survival with new morbidity defined as an increase in the Functional Status Scale score of greater than or equal to 3 points from baseline, and survival without morbidity. Of 577 consecutive admissions, 95 were excluded: 82 readmissions, 10 patients greater than or equal to 18 years old, two patients with missing baseline data, and one transferred to another PICU. Of 482 patients, there were 37 hospital deaths (7.7%) and 39 (8.1%) with acquired new morbidity. Median admission Pediatric Logistic Organ Dysfunction Score 2 and Pediatric Index of Mortality 3 scores differed among the three outcome groups. In addition, differences were found in emergency admission and neurologic diagnosis rates, PICU mechanical ventilation usage rates, and PICU length of stay. The highest proportion of neurologic diagnoses was observed in the new morbidity group. The final model simultaneously predicted risks of mortality, survival with new morbidity and survival without morbidity using admission Pediatric Logistic Organ Dysfunction Score 2 score, admission type, neurologic diagnosis, and preexisting chronic disease. Pediatric Logistic Organ Dysfunction Score 2 was superior to Pediatric Index of Mortality 3 in predicting risks of mortality and new morbidity, as indicated by volume under surface values of 0.483 and 0.362, respectively. Risk of mortality, survival with new morbidity, and survival without morbidity can be predicted simultaneously using admission Pediatric Logistic Organ Dysfunction Score 2, admission type, admission diagnosis, and preexisting chronic disease. Future independent studies will be required to validate the proposed model before clinical implementation.

Proposal for Coronavirus Disease 2019 Management.

Setting:The coronavirus disease 2019 pandemic has raised fear throughout the nation. Current news and social media predictions of ventilator, medication, and personnel shortages are rampant.Patients:Patients with coronavirus disease 2019 are presenting with early respiratory distress and hypoxemia, but not hypercapnia.Interventions:Patients who maintain adequate alveolar ventilation, normocapnia, and adequate oxygenation may avoid the need for tracheal intubation. Facemask continuous positive airway pressure has been used to treat patients with respiratory distress for decades, including those with severe acute respiratory syndrome. Of importance, protocols were successful in protecting caregivers from contracting the virus, obviating the need for tracheal intubation just to limit the spread of potentially infectious particles.Conclusions:During a pandemic, with limited resources, we should provide the safest and most effective care, while protecting caregivers. Continuous positive airway pressure titrated to an effective level and applied early with a facemask may spare ventilator usage. Allowing spontaneous ventilation will decrease the need for sedative and paralytic drugs and may decrease the need for highly skilled nurses and respiratory therapists. These goals can be accomplished with devices that are readily available and easier to obtain than mechanical ventilators, which then can be reserved for the sickest patients.

Clinical effect of nebulized acetylcysteine inhalation combined with bronchoscopy in the treatment of elderly patients with severe ventilator-associated pneumonia

Objective: To explore the clinical effect of nebulized acetylcysteine inhalation combined with bronchoscopy in treating elderly patients with severe ventilator-associated pneumonia (VAP). Methods: From January 2016 to December 2017, 80 elderly patients with severe VAP who were hospitalized in Zhejiang Hospital were divided into acetylcysteine+ bronchoscopy group [24 males and 16 females, aged (78±7) years] and bronchoscopy group [26 males and 14 females, aged (80±7) years]using random number table for a prospective cohort study. Patients in bronchoscopy group were treated with bronchoscopy in addition to conventional supportive care of symptoms. Patients in acetylcysteine+ bronchoscopy group received nebulized acetylcysteine inhalation therapy on the basis of the treatment given to patients in bronchoscopy group. Patients in both groups received treatment continuously for 7 days. The simplified clinical pulmonary infection score (CPIS) in both groups was assessed before and after treatment. Venous blood of 10 mL was collected before and after treatment to detect leukocyte count, serum C-reactive protein, and procalcitonin. Arterial blood of 1 mL was collected before and after treatment to detect partial arterial oxygen pressure (PaO(2)), partial arterial carbon dioxide pressure (PaCO(2)), oxygenation index. The inhalation platform pressure (Pplat), dynamic lung compliance (Cdyn), airway resistance, work of breathing, time of antibiotic use, and time of mechanical ventilation of patients in two groups were recorded before and after treatment. Data were statistically analyzed with chi-square test and t test. Results: (1) The simplified CPIS, leukocyte count, serum C-reactive protein, and procalcitonin of patients in acetylcysteine+ bronchoscopy group were significantly lower than those in bronchoscopy group after treatment (t=2.32, 2.15, 6.08, 7.12, P<0.05 or P<0.01). The simplified CPIS, leukocyte count, serum C-reactive protein, and procalcitonin of patients in acetylcysteine+ bronchoscopy group and bronchoscopy group after treatment were significantly lower than those before treatment (t=13.76, 13.60, 12.70, 8.32, 11.44, 14.28, 9.48, 9.50, P<0.01). (2) Compared with bronchoscopy group, patients in acetylcysteine+ bronchoscopy group had significantly higher PaO(2) and oxygenation index (t=4.14, 2.55, P<0.05 or P<0.01) but significantly lower PaCO(2) (t=4.36, P<0.01) after treatment. The PaO(2) and oxygenation index of patients in acetylcysteine+ bronchoscopy group after treatment were significantly higher than those before treatment (t=10.90, 43.72, P<0.01). The PaO(2) and oxygenation index of patients in bronchoscopy group after treatment were also significantly higher than those before treatment (t=6.55, 43.03, P<0.01). The PaCO(2) of patients in both groups after treatment were significantly lower than those before treatment (t=21.54, 21.92, P<0.01). (3) The Cdyn of patients in acetylcysteine+ bronchoscopy group after treatment was significantly higher than that in bronchoscopy group (t=5.41, P<0.01), and Pplat, airway resistance, and work of breathing were significantly lower than those in bronchoscopy group (t=2.18, 5.46, 2.49, P<0.05 or P<0.01). The Cdyn of patients in both groups after treatment were significantly higher than those before treatment (t=16.10, 10.90, P<0.01), and Pplat, airway resistance, and work of breathing were significantly lower than those before treatment (t=21.18, 11.13, 9.32, 15.50, 5.17, 5.97, P<0.01). (4)The time of mechanical ventilation and antibiotic usage of patients in acetylcysteine+ bronchoscopy group were (6.9±1.9)and (8.7±2.8) d, respectively, which were significantly shorter than (10.1±2.2) and (11.6±3.5) d in bronchoscopy group (t=6.85, 4.09, P<0.01). Conclusions: Nebulized acetylcysteine inhalation combined with bronchoscopy can significantly control the degree of lung infection in elderly patients with severe VAP, improve patients' respiratory mechanics parameter and blood gas analysis indicator, and shorten the time for mechanical ventilation and antibiotic usage.

Noninvasive ventilation usage time and survival rate in patients with acute respiratory failure: some key insights.

The possibility of avoiding adverse events by recommending early determination of mask-on proportions in the first 24 h of admission and, consequently, NIV failure in ARF patients https://bit.ly/2T0QYVN

Noninvasive ventilation usage time and survival rate in patients with acute respiratory failure: some key insights.

Dose–response characteristics of noinvasive ventilation differ between hypoxaemic and hypercapnic respiratory failure https://bit.ly/2SYitiC

Surgical fixation of rib fractures decreases intensive care length of stay in flail chest patients.

BackgroundNonoperative treatment is currently the standard therapy for rib fractures. However, there is a trend towards surgical fixation from conservative management over the last decade. While surgical fixation of rib fractures has shown promising results, its impact on the clinical results remains unclear based on the current literature. As such, the present study aims to compare the short-term outcomes of multiple rib fracture patients treated by surgical fixation with traditional conservative management.MethodsData for patients with multiple (three or more) rib fractures admitted to our department between January 2012 and January 2019 were retrospectively collected and analyzed. Propensity score matched patients were compared between those treated with surgical rib fixation and those of nonoperatively treated. Primary outcomes were hospital length of stay for multiple rib fracture patients, and intensive care unit (ICU) length of stay for flail chest patients. Secondary outcomes included in hospital mortality, ICU usage rate, duration of ventilator support, ventilator usage rate, and pneumonia.ResultsThe study included 1,201 patients with mean age of 50.1±12.7 years, of whom 954 (79.4%) were male. The average number of rib fractures was 6.3±2.4, with a mean injury severity score of 20.5±7.3. Among them, 563 (46.9%) patients had surgical rib fixation and 638 (53.1%) patients received nonoperative treatment. There were 191 patients with a flail chest, 133 (69.6%) had operative rib fixation and 58 (30.4%) were nonoperatively treated. After propensity score match, the hospital length of stay was not significantly differed between surgery and conservative management in multiple rib fracture patients (10.7±3.4 vs. 10.2±3.8 days, P=0.067), nor were the secondary outcomes, in terms of in hospital mortality (0.9% vs. 1.1%, P=0.704), ICU usage rate (12.3% vs. 12.9%, P=0.820), duration of ventilator support (100.1±13.9 vs. 99.8±20.7 hours, P=0.822), ventilator usage rate (12.0% vs. 12.9%, P=0.732), and pneumonia (24.3% vs. 24.9%, P=0.861). For patients with a flail chest, shorter ICU length of stay was found to be associated with surgical rib fixation comparing with nonoperative treatment (5.5±1.9 vs. 6.7±2.1 days, P=0.011). No secondary outcomes such as in hospital mortality (4.4% vs. 4.4%, P=1.000), ICU usage rate (20.0% vs. 22.2%, P=0.796), duration of ventilator support (113.1±20.4 vs. 131.2±19.5 hours, P=0.535), ventilator usage rate (20.0% vs. 20.0%, P=1.000), pneumonia (28.9% vs. 31.1%, P=0.818) were significant different between the operative and nonoperative groups.ConclusionsSurgical rib fixation results in a shorter ICU length of stay in patients with a flail chest, and a comparable outcome for patients with multiple rib fractures when compared with nonoperative treatment.

Regional difference and related cooling electricity savings of air pollutant affected natural ventilation in commercial buildings across the US

Maintaining indoor air pollutants under acceptable levels is significant to protect occupants from exposure to excessive air pollutants in natural ventilation. In this paper, using the representative air pollutant concentration data, we present the natural ventilation usability with associated cooling energy saving potentials in different location settings (urban and city center, suburban and rural) of the US under the influence of local weather conditions and major outdoor air pollutants, i.e. PM2.5, PM10 and ozone. It is found that the impacts of air pollutants on natural ventilation are usually higher in urban/suburban areas than rural areas (up to 25% difference) with the PM2.5 being the most significant outdoor air pollutant affecting natural ventilation usage. Ozone could become increasingly influential on natural ventilation as moving from urban to suburban/rural areas. As to the cooling energy saving considering the impacts of outdoor air pollutants, natural ventilation is estimated to save approximately 10%–40% cooling energy (800–2600 kWh per small commercial building) annually in different location settings of investigated areas across the US. The following economic analysis demonstrates that these electricity savings lead to approximately 80–540 dollars annual savings of building operation cost per building. If the time of use rate is adopted, these cost savings could further increase by approximately 20% (Los Angeles) to more than 50% (Albuquerque) depending on different rate structures, which further demonstrates the potential of adopting natural ventilation as a sustainability measurement with benefits for building owners without compromising occupants health.

Correlation of red cell distribution width value with the duration of mechanical ventilator usage in patients treated in pediatric intensive care unit

Background: Red cell distribution width (RDW) is the coefficient of erythrocyte volume variation. High RDW may indicate heterogeneous erythrocyte size in terms of size and volume (anisocytosis). RDW is affected by the degree of hypoxic tissue; the higher the hypoxia, the higher the RDW. The goal of the study was to see the correlation between RDW and the duration of ventilator usage on patients treated in the intensive care unit. Patients and Methods: This study employed a cross-sectional design. The participants of this research are children treated with mechanical ventilator in the pediatric intensive care unit (PICU) in Sanglah General Hospital from January to December 2018. The duration of mechanical ventilator usage and RDW value data was generated from the medical records. Results: There were sixty patients treated in the PICU during the study period, including 24 females (40%) and 36 males (60%). The average of oxygen index (OI) was 6.9 (0.9–20.57) and ventilator usage duration was 7.43 (1–32). Analysis of correlation between RDW and hemoglobin (Hb), FiO2, positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), mean airway pressure, OI, and days of ventilator usage revealed that RDW has a strong positive correlation with Hb (r = 0.43), FiO2(r = 0.82), PEEP (r = 0.17), PIP (r = 0.41), OI (r = 0.76), and days of ventilator usage (r = 0.87). The result of a subgroup analysis of days of ventilator usage had a strong positive correlation with RDW. In mild-degree pediatric acute respiratory distress syndrome, the correlation score was r = 0.89, moderate degree was r = 0.766, and severe degree was r = 0.71. Conclusion: There is a strong positive correlation between RDW and the duration of mechanical ventilator usage.

Clinical and MRI predictors of coma duration, intensive care and outcome of traumatic brain injury

This research is aimed to study the clinical and MRI predictors of coma duration, the intensity of critical care, and outcome of traumatic brain injury (TBI). The data from 309 patients with TBI of varying severity were included in the analysis, of whom 257 (86.7%) were treated in the intensive care unit (ICU), including 196 (63.4%) patients admitted in a comatose state lasting longer than 1 day. All patients underwent brain MRI within 21 days after the injury. MRI findings were classified according to MRI grading scale of brain damage level and localization proposed previously. The proposed MRI grading significantly correlated with the Glasgow coma (GCS, r=-0.67; p<0.0001) and Glasgow outcome (0.69; p<0.001) scores in the entire group. In a subgroup of comatose patients (GCS<9) it correlated with coma duration (r=0.52; p<0.0001). Spearman correlation analysis showed a significant relationship between the MRI classification and a number of parameters: ICU length of stay (r=0.62; p<0.0001), the duration of artificial ventilation (r=0.47; p<0.0001), the rate of artificial ventilation, sedatives, analgesics, mannitol, hypertonic saline and vasopressors usage (p<0.01). These data confirm the relationship between higher grades of MRI classification (deep brain damage) and the need for the escalation of intensive care main components. Our results support the hypothesis that the levels and localization of brain damage, estimated by the proposed MRI grading scale, might be predictors of coma duration, intensity and duration of intensive care, and TBI outcomes. A prognosis based on clinical and neuroimaging data comparison can be valuable for planning and efficient use of the hospital beds and ICU resources, for optimizing the patient flow and timing of patient transfer to neurorehabilitation facilities.

Ventilator Pricing Decision at ICS Hospital

In this short and hypothetical case study, a decision game has been constructed using predictive modelling. Set in the backdrop of COVID-19, the protagonist is the director of a multi-speciality hospital that has been turned into covid treatment facility. The director is trying to make a pricing decision by discussing the same with his fellow consultant of the hospital. The options are whether the patient will be charged a flat package rate for covid treatment or should it be proportionate to the ventilator usage based on patient’s body weight. The users of this game will be encouraged to apply linear regression in order to take management decisions. They would also engage in checking the existence of heteroscedasticity and its effects on the gaming decisions.

Modified McKeown procedure with uniportal thoracoscope for upper or middle esophageal cancer: initial experience and preliminary results.

Uniportal video-assisted thoracic surgery (VATS) resections are of increasing interest in many thoracic surgery departments. With each experience in VATS lobectomy, we have incrementally improved the less invasive techniques in esophagectomy. Here, we report the preliminary results and feasibility of a modified McKeown procedure with uniportal thoracoscopy for upper or middle esophageal cancer in our institution. Between March 2015 and May 2016, modified uniportal McKeown procedure with uniportal thoracoscopy for upper or middle esophageal cancer was attempted in 44 patients in our institution. Of the patients treated with uniportal thoracoscopy and laparoscopy, no patients were converted to open procedures, and all had a complete resection. The mean operative time was 408±34 min (range, 394-495 min). The mean thoracic operation was 163±16 min (range, 135-199 min). The mean blood loss was 245±102 mL (range, 100-450 mL). The mean number of lymph nodes resected was 24 (range, 14-36). The mean ventilator usage of the patients after surgery was 0.3±0.6 days, and the mean intensive care stay was 1.6 days (range, 1 to 7 days). The mean hospital stay was 11.8 days (range, 7 to 22 days). Major complications developed in 2 patients, both of whom had to undergo tracheotomy due to respiratory failure. No patients died of complications postoperatively, and none had clinically significant anastomotic leaks. Modified McKeown minimally invasive esophagectomy (MIE) with uniportal thoracoscopy seems to be a feasible option for patients with upper or middle esophageal cancer. Larger studies with longer follow-up are needed to further investigate this approach.