Ventilator-associated Complications Research Articles

COMPLICATIONS OF MECHANICAL VENTILATION IN CHILDREN UP TO 12 Y OF AGE

Objective: Mechanical ventilation has been proven to be lifesaving and has significantly reduced mortality in the pediatric population. Despite its life-saving advantages, mechanical ventilation is associated with complications. The study aimed to assess the complications of mechanical ventilation in children up to 12 y of age admitted to the intensive care unit. Methods: The present descriptive, observational, cross-sectional study was conducted on 165 children aged between 0 to 12 y, who were mechanically ventilated for>48 h. Patients were observed daily until the desired result was achieved and were checked to look for complications or negative effects of mechanical ventilation. Results: The majority of subjects belonged to<1 mo of age (77.58%) whereas the maximum number of patients were male (64.24%). In 77.58% of patients, the indication for mechanical ventilation was respiratory failure. The duration of ventilation in 62.43% of patients was>7 d. A total of n=62 (37.58%) patients had ventilator-associated complications. The most common complication was ventilator-associated pneumonia (n=30, 48.38%). The mean hospital stay was found to be 22.88±7.96 d. Whereas the mean hospital stay in patients without complications was significantly less compared to patients with complications (18.57±10.09 d vs 27.19±5.83 d, P=0.00015). The mortality rate was found to be 47.27%. Conclusion: Respiratory cause was the most common indication for mechanical ventilation. The most common complication was ventilator-associated pneumonia. The subjects with complications had prolonged hospital stays.

MORTALITY AND ASSOCIATED FACTORS AMONG INTENSIVE CARE UNIT ADMITTED ADULT PATIENTS WITH MECHANICAL VENTILATION IN ETHIOPIA: A SYSTEMATIC REVIEW AND META-ANALYSIS.

Introduction: The global demand for intensive care has risen, given its effectiveness in lowering mortality rates. Mechanical ventilation (MV) is integral to intensive care but introduces risks such as ventilator-associated complications. Ethiopia experiences a high intensive care unit (ICU) mortality rate. Objective: This systematic review and meta-analysis aim to comprehensively synthesize evidence on the mortality of adults undergoing MV in Ethiopia and identify associated factors. Methods: The study extensively searched databases and gray literature for research on MV outcomes, trends, and associated factors in adult ICUs. Adhering to the 2020 PRISMA checklist, a systematic review and meta-analysis sought to establish the mortality rate and key determinants among adult ICU patients on MV. The search incorporated keywords and MeSH terms, excluding studies with unsound methodologies or missing data. Data extraction, quality assessment, and analysis followed established protocols, including the JBI tool for methodological quality evaluation. STATA version 17.0 facilitated analysis, assessing heterogeneity, publication bias, and performing sensitivity and meta-regression analyses. Results: The pooled mortality rate among adult ICU patients undergoing MV was 48.61% (95% CI: 40.82, 56.40%). Significant mortality-contributing factors included medical diagnosis, Glasgow Coma Scale score, sepsis/septic shock, sedation use, multiple-organ dysfunction syndrome, and cardiovascular disease. Although some pooled odds ratios seemed insignificant, closer examination revealed significant associations in individual studies. Conclusion : The study underscores the urgent need for further research, improved ICU infrastructure, and healthcare personnel training in Ethiopia to enhance outcomes for mechanically ventilated patients. Identified factors offer valuable insights for targeted interventions, guiding tailored treatment strategies to reduce mortality. This study contributes to understanding mortality and associated factors in MV patients, informing initiatives to improve critical care outcomes in Ethiopia.

To NIRS or not: understanding clinical decision-making of respiratory support management related to acute respiratory failure using Critical Decision Method

Clinical decisions related to noninvasive respiratory support (NIRS) for acute respiratory failure patients are complex. NIRS strategies have favorable benefits for patients when successful but NIRS failure comes with longer ICU stays, increased mortality, and more intubation-related and mechanical ventilator-associated complications. Our goal is to understand how physicians make decisions regarding NIRS and explore the differences between emergency physicians and critical care physicians—who commonly make these decisions. We used the critical decision method to conduct ten semi-structured interviews with five emergency physicians and five critical care physicians from ten different healthcare systems across the United States. We found that physicians similarly use objective and subjective clinical cues but differentially use temporal and contextual cues in their decision-making. Several insights identified in our study can be helpful in the design and development of clinical decision support systems for respiratory support decision-making. Specifically, we recommend two customized distinct clinical decision support systems for respiratory support decision-making, one for each designated clinical setting (i.e., ED and ICU) with tailored designs that support the different decision-making processes.

A comparative analysis of mechanical power and Its components in pressure-controlled ventilation mode and AVM-2 mode

Background Mechanical ventilation is a critical therapeutic intervention in the management of patients with respiratory failure. Understanding the implications of different ventilation modes is essential in preventing ventilator-induced lung injuries (VILI). Recently, mechanical power has emerged as a critical element in the development of VILI and mortality. Previous bench work studies have suggested that new optimal (adaptive) modes, such as Adaptive Ventilation Mode 2 (AVM-2), can reduce the mechanical power in turn might reduce the rates of VILI. This study aims to compare the conventional Pressure-Controlled Ventilation (PCV) mode with an emerging design of Adaptive Ventilation Mode-2 (AVM-2), to measure the differences in mechanical power, alongside it’s components of PEEP, Tidal, Elastic, Resistive, Inspiratory, Total work, tidal volume, driving pressure and Power Compliance Index. Methods Between January 2023 and June of 2023, we conducted a prospective crossover study on twenty-two subjects admitted to our ICU within the first day after initiation of mechanical ventilation. Subjects were initially started on PCV settings chosen by the primary treatment team, then switched to AVM-2 with comparable minute ventilation. Mechanical power and its work components (tidal, resistive, PEEP, elastic, inspiratory, total), tidal volume, driving pressure, respiratory rate, and positive end-expiratory pressure, were recorded for each patient every 15 min for the duration of 2 consecutive hours on each mode. Statistical analysis, including paired t-tests were performed to assess the significance of differences between the two ventilation modes. The data is provided in means and 土 SD. Results There were significant differences between PCV and AVM-2 in mechanical power (J/min): 21.62 土 7.61 vs 14.21 土 6.41 (P < 0.001), PEEP work (J): 4.83 土 2.71 vs 4.11 土 2.51 (P < 0.001), Tidal work (J): 3.83 土 1.51 vs 2.21 土 0.89 (P < 0.001), Elastic work (J): 8.62 土 3.13 vs 6.32 土 3.21 (P < 0.001), Resistive work (J): 3.23 土 1.61 vs 1.81 土 1.31 (P 0.013), Inspiratory work (J): 6.95 土 2.58 vs 4.05 土 2.01 (P < 0.001), Total work (J): 11.81 土 3.81 vs 8.11 土 4.23 (P < 0.001). There were significant differences between PCV and AVM-2 in tidal volume (ml): 511 土 8.22 vs 413 土 10.21 (P < 0.001), tidal volume / IBW 7.38 土 1.74 vs 6.49 土 1.72 (P 0.004), driving pressure (cmH2O): 24.45 土 6.29 vs 20.11 土 6.59 (P 0.012), minute ventilation (L/min): 8.96 土 1.34 vs 7.42 土 1.41 (P < 0.001). The respiratory rate (bpm) was not significantly different between PCV and AVM-2 19.61 土 4.32 vs 18.32 土 1.43 (P 0.176). There were no significant differences between PCV and AVM-2 in static compliance (ml/cmH2O) 20.24 土 5.16 vs 22.72 土 6.79 (P 0.346), PaCO2 (mmHg) 44.94 土 9.62 vs 44.13 土 10.11 (P 0.825), and PaO2:FiO2 243.54 土 109.85 vs 274.21 土 125.13 (P 0.343), but significantly higher power compliance index in PCV vs AVM-2: 1.11 土 0.41 vs 0.71 土 0.33 (P < 0.001). Conclusion This study demonstrates that the choice of mechanical ventilation mode, whether PCV or AVM-2, significantly impacts mechanical power and its constituent variables. AVM-2 mode was associated with reduced mechanical power, and its’ components alongside the driving pressure, and tidal volumes, indicating its potential superiority in terms of lung-protective ventilation strategies. Clinicians should consider these findings when selecting the most appropriate ventilation mode to minimize the risk of ventilator-associated complications and improve patient outcomes. Further research is warranted to explore the clinical implications of these findings and to refine best practices in mechanical ventilation. Key words: Mechanical power, Work, PCV, AVM-2, VILI

Application of ventilator-associated events (VAE) in ventilator-associated pneumonia (VAP) notified in Brazil (IMPACTO MR-PAV): a protocol for a cohort study

IntroductionCertain criteria for ventilator-associated events (VAE) definition might influence the type of an event, its detection rate and consequently the resource expenditure in intensive care unit. The Impact of Infections...

Extubation in operating room versus early extubation in ICU after open-heart surgery in patients with CHDs.

The "Fast track" protocol is an early extubation strategy to reduce ventilator-associated complications and induce early recovery after open-heart surgery. This study compared clinical outcomes between operating room extubation and ICU extubation after open-heart surgery in patients with CHD. We retrospectively reviewed 215 patients who underwent open-heart surgery for CHDs under the scheduled "Fast track" protocol between September 2016 and April 2022. The clinical endpoints were post-operative complications, including bleeding, respiratory and neurological complications, and hospital/ICU stays. The patients were divided into operating room extubation (group O, n = 124) and ICU extubation (group I, n=91) groups. The most frequently performed procedures were patch closures of the atrial septal (107/215, 49.8%) and ventricular septal (89/215, 41.4%) defects. There were no significant differences in major post-operative complications or ICU and hospital stay duration between the two groups; however, patients in group I showed longer mechanical ventilatory support (0.0 min vs. 59.0 min (interquartile range: 17.0-169.0), p < 0.001). Patients in Group O showed higher initial lactate levels (3.2 ± 1.7 mg/dL versus 2.5 ± 2.0 mg/dL, p = 0.007) and more frequently used additional sedatives and opioid analgesics (33.1% versus 19.8%, p = 0.031). Extubation in the operating room was not beneficial for patients during post-operative ICU or hospital stay. Early extubation in the ICU resulted in more stable hemodynamics in the immediate post-operative period and required less use of sedatives and analgesics.

General anesthesia vs. conscious sedation and local anesthesia for endovascular treatment in patients with posterior circulation acute ischemic stroke: An updated systematic review and meta-analysis

IntroductionThe best anesthetic choice for patients with acute posterior circulation stroke during endovascular treatment (EVT) remains uncertain. MethodWe searched five databases to identify studies that met the inclusion criteria. Our primary outcome measure was functional independence (FI). Secondary outcomes were 3-month mortality, any intracranial hemorrhage (ICH), symptomatic ICH (sICH), successful reperfusion, and procedure- and ventilator-associated complications. ResultsA total of 10 studies were included in our meta-analysis. No significant differences were detected between the general anesthesia (GA) and conscious sedation and local anesthesia (CS/LA) groups in 3-month FI (nine studies; OR=0.69; 95% CI 0.45–1.06; P=0.083; I2=66%;), 3-month mortality (nine studies; OR=1.41; 95% CI 0.94–2.11; P=0.096; I2=61.2%;), any ICH (three studies; OR=0.75; 95% CI 0.44–1.25; P=0.269; I2=0%;), or sICH (six studies; OR=0.64; 95% CI 0.40–1.04; P=0.073; I2=0%;). No significant differences were observed for successful reperfusion (10 studies; OR=1.17; 95% CI 0.91–1.49; P=0.219; I2=0%;), procedure-related complications (four studies; OR=1.14; 95% CI 0.70–1.87; P=0.603; I2=7.9%;), or respiratory complications (four studies; OR=1.19; 95% CI 0.61–2.32; P=0.616; I2=64.9%;) between the two groups. ConclusionsOur study showed no differences in 3-month FI, 3-month mortality, and successful reperfusion between patients treated with GA and those treated with CS/LA. Additionally, no increased risk of hemorrhagic transformation or pulmonary infection was observed in the CS/LA group. These results indicate that CS/LA may be an EVT option for acute posterior circulation stroke patients.

Impact of multizonal decontamination of upper respiratory tract on incidence of ventilator-associated pneumonia: multicenter randomized pilot study

INTRODUCTION: Ventilator-associated pneumonia (VAP) is the one of nosocomial infections in intensive care units. VAP can result in prolonged duration of hospitalization and invasive mechanical ventilation (MV) that is associated with attributive mortality. OBJECTIVE: The aim of our pilot multicenter randomized study was to assess effect of the multizonal decontamination of upper airway including subglottic space on the VAP incidence and time of onset, as well as colonization upper airway and clinical outcomes. MATERIALS AND METHODS: Sixty patients requiring the prolonged MV were included in the prospective study. All participants were randomized into three groups: the control, the local antiseptic (LA) and the bacteriophage (BP). All patients were managed using similar VAP protective bundle. Infection-related ventilator-associated complications (IVAC) were registered based on clinical, laboratory, and instrumental examination. Diagnosis of VAP was confirmed if CPIS was ≥ 6 points. RESULTS: A total incidence of IVAC did nоt differ between groups: 15 (75 %), 14 (70 %), and 17 (85 %) cases in the control, LA, and BP groups, respectively. The VAP incidence was lower in the LA and BP groups compared with the controls: 3 (15 %) and 3 (15 %) vs 10 (50 %) cases (χ2 = 8.35; p = 0.015). The overall mortality was 30 % and did not differ between the groups. Multi-selective decontamination resulted in a trend to increased ventilator-associated tracheobronchitis incidence in the BP group and to silent colonization in both LA and BP groups (p = 0.07). No differences in the duration of MV, ICU and hospital stay were observed. CONCLUSIONS: The combined multizonal upper airway decontamination involving subglottic space is associated with a reduction of the VAP incidence but did not change the overall IVAC rate. Multizonal decontamination based on subglottic bacteriophage instillation might have a potential to influence the microbial heterogeneity of upper airways.

A proposed new method of hemostasis for erosive-hemorrhagic complications of the trachea and bronchi

Ventilator-associated complications are the most frequent ones that prevent the recovery of intensive care patients. This study aimed to evaluate the effectiveness of the endoscopic treatment of acute hemorrhagic lesions of the tracheobronchial tree in patients with ventilator-associated tracheobronchitis. A total of 5 patients (22.4±3.3 mean age, 18 to 36 years) with prolonged mechanical ventilation (&gt;48 hours) in the resuscitation and intensive care unit were monitored. The diagnosis of ventilator-associated tracheobronchitis was established on the basis of clinical signs, radiological and microbiological criteria. Fine-dispersed powder with hemostatic properties (HEMOBEN) was used as a hemostatic agent when applying the method. A morphometric study noted that ventilator-associated tracheobronchitis is accompanied by a pronounced lymphoid-neutrophilic infiltration of the tracheal and bronchial mucosa (signs of diffuse catarrhal inflammation of varying degrees and erosive deforming endobronchitis are verified), and in a complicated course with the presence of a purulent-inflammatory and erosive-hemorrhagic component with its vascularization and metaplastic changes and violations of the integrity of the epithelial lining also leads to a violation of the integrity of tissues due to destruction and necrosis. Hence, a method has been developed to stop bleeding in case of mucosal damage by local application of HEMOBEN, which allows us to quickly cover the bleeding surface with an adequate hemostatic effect.

Increasing rates of ventilator-associated events: Blame it on COVID-19?

Background: Rates of ventilator-associated events (VAEs), including infection-related ventilator-associated complications (IVACs) and probable ventilator-associated pneumonia (PVAPs) have increased nationwide since the onset of the COVID-19 pandemic. In December 2021, our health system adopted a new electronic medical record (EMR), which changed the way surveillance for VAEs is performed. We reviewed surveillance criteria, COVID-19 status, and culturing practices in attempts to understand why VAE rates continue to be elevated. Methods: We collected data on VAE type, culture data, COVID-19 status, and surveillance criteria for all patients meeting NHSN definitions for VAE from 2018 through November 2022. For all patients in 2022 (post-EMR transition), 2 physicians (A.D. and M.D.) manually reviewed documented ventilator settings from flow sheets to validate the automated EMR data, and they evaluated culture data for appropriateness. Cultures were defined as appropriate unless they were included in “pancultures” for leukocytosis without concern for pneumonia documented. Rates were compared using an interrupted time series (ITS) analysis before and after the onset of the COVID-19 pandemic and the EMR transition. Patient level data were compared across periods using the χ2 test. All analyses were performed using SAS version 9.4 software. Results: COVID-19 has been implicated in the increasing number of VAEs since the pandemic began: 6% of patients in 2020, 18% in 2021, and 23% in 2022 (P &lt; .001). The percentage of patients meeting criteria for VAE by positive end-expiratory pressure (PEEP) decreased from 2018 to 2022 (92%, 95%, 93%, 85%, 85%, respectively; P = .0004). Patients meeting criteria for VAE by fraction of inspired oxygen (FiO2) increased from 2018 to 2022 (9%, 6%, 11%, 17%, 19%, respectively; P = .0002). Manual review of 2022 data indicated opportunities for test stewardship in 8 of 65 patients with cultures (12%). ITS analysis revealed that IVAC+ rates were climbing prior to the onset of the COVID-19 pandemic (Fig. 1). We observed a marked increase in rates with the implementation of our new EMR and the changes to our surveillance process (0.32 cases per 100 ventilator days). Manual review of records from 2022 revealed 5 patients in which documentation of ventilator settings to meet VAE diagnosis could not be retrieved from flow sheets. Conclusions: COVID-19 continues to affect VAE despite vaccine availability and may partially account for elevated rates nationwide. However, changes in EMR-automated VAE surveillance may also affect rates. Our findings suggest that automated surveillance captures transient or spurious changes in ventilator machine settings that do not accurately represent clinical status. These data may contribute to spurious increases in VAE. More studies are needed to better understand the impact of both COVID-19 and automated surveillance on VAE.Disclosures: None

Assessment of changes in the national surveillance data for adult and pediatric VAE during the COVID-19 pandemic in hospitals

Background: Among US acute-care hospitals (ACHs) reporting to the NHSN, significant increases in the incidence of Ventilator-Associated Events (VAEs) were observed during the COVID-19 pandemic years in comparison with 2019. We assessed changes in the national event-level VAE data, including the incidence of specific event-types: Ventilator-Associated Condition (VAC), Infection-related Ventilator-Associated Complication (IVAC) and Possible Ventilator-Associated Pneumonia (PVAP). We also examined changes in associated pathogens, and we evaluated incidence density rates (IDRs) of pediatric VAE (PedVAE) before and during the pandemic years. Methods: We analyzed data on VAE and PedVAE reported to NHSN between 2019 through the second quarter of 2022 (2022Q2) in ACHs. Annual proportions of VAC, IVAC, or PVAP were calculated; changes versus 2019 were assessed. The 10 most common PVAP pathogens reported annually were examined, and the percentages and ranks for each were calculated. Among pediatric and neonatal locations, PedVAE IDR were calculated as the number of events per 1,000 ventilator days and were compared between the pre-pandemic and pandemic years. All comparisons were conducted using a mid-P exact test, and P&lt;0.05 was considered statistically significant. Results: Between 1,266 - 1,357 ACHs reported VAE data each year. A total of 24,836 (2019), 37,592 (2020), and 50,362 (2021) VAEs were reported. The proportion of VAC events in 2020 (64.1%) was significantly higher than in 2019 (62.9%), while the 2020 and 2021 PVAP proportions (8.7% and 9.2%, respectively) were significantly lower than in 2019 (10.0%). The majority of VAEs were reported from the same location types annually. The top 3 PVAP pathogens reported for each year remained unchanged: Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella. However, the proportion identified as Haemophilus influenzae decreased significantly each year from 2019-2021, with the rank dropping from #5 in 2019 (6.6%) to #10 in 2021 (2.3%). Between 199 – 257 ACHs conducted PedVAE surveillance. PedVAE IDR were significantly lower in 2020 (0.8), 2021 (1.1), and the first half of 2022 (0.8) when compared to 2019 (1.3). Conclusions: This study provides a national view of specific VAEs before and during the COVID-19 pandemic. Some changes in the associated pathogens, and the proportions of VAC and PVAP, were observed. This study is the first to produce national benchmarks for PedVAE IDR. Additional ACHs conducting PedVAE surveillance in NHSN would improve the representativeness of our results.Disclosures: None

Ventilator associated events:incidence, microbiological profile and outcome in the intensive care unit in a tertiary hospital of eastern Nepal

Ventilator associated events (VAE) refer to new surveillance definition developed by Centre for Disease Control and prevention (CDC)/ National Healthcare Safety Network (NHSN) is in use since the year 2013, switching the focus of surveillance from ventilator associated pneumonia (VAP) to ventilator associated events (VAE). A number of studies have been conducted in the United States and other Western countries to evaluate its practicality. However, information on VAE in Asian countries is scarce. The purpose of this preliminary study was to illuminate the incidence and microbiological profile of VAEs in tertiary hospital in Nepal, as a first step in the effort to determine its practicality.The objective of the study was to determine the incidence, etiological agent and mortality of VAE in patients on mechanical ventilation in medical Intensive care unit (ICU) of a tertiary hospital. Patients admitted in ICU on Mechanical Ventilation were evaluated daily using the VAE surveillance criteria. At least 2 days of stable or decreasing ventilator settings followed by at least 2 days of increased ventilator settings was used as definition of VAE. Three tiered approach of VAE, namely Ventilator-Associated Condition (VAC), Infection-related Ventilator-Associated Complication (IVAC) and Possible VAP (PVAP) was used for the final classification of cases. Of the 313 patients admitted to the ICU over the period of one year, 52 patients received MV for ≥2 days and met baseline criteria for VAEs Surveillance. Out of 52 patients, 14(27%) developed VAC only, 13(25%) developed IVAC only and 25(48%) patients developed PVAP. Endotracheal aspirate culture was positive in 25 patients (48%). The organisms isolated 14(53.84%), 7(26.92%), 4(15.38%), and 1(3.84%). Polymicrobial growth was observed in one Almost all the isolates 25 (96%) being multidrug resistant. Overall mortality rate in patients with VAE was 36.5% with highest mortality rate in PVAP (44%). Early onset PVAP was observed in 9 (36%) where as 16 (64%) had late‑ onset VAP.VAE mostly being health care associated event and prevalence of multidrug resistance in as observed in this study warrant clinician to practices infection control measures and rationale use of antimicrobials as effective measures for infection control.

Aerosolized Antibiotics to Manage Ventilator-Associated Infections: A Comprehensive Review.

Ventilator-associated lower respiratory tract infectious complications in critically ill patients cover a wide spectrum of one disease process (respiratory infection), initiating from tracheal tube and/or tracheobronchial colonization, to ventilator associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). VAP occurence has been associated with increased intensive care unit (ICU) morbidity (ventilator days, as well as length of ICU and hospital stay) and ICU mortality. Therefore, treatments that aim at VAP/VAT incidence reduction are a high priority. The aim of the present review is to discuss the current literature concerning two major aspects: (a) can aerosolized antibiotics (AA) administered in a pre-emptive way prevent the occurrence of ventilator-associated infections? and (b) can VAT treatment with aerosolized avert the potential evolution to VAP? There were identified eight studies that provided data on the use of aerosolized antibiotics for the prevention of VAT/VAP. Most of them report favorable data on reducing the colonisation rate and the progression to VAP/VAT. Another four studies dealt with the treatment of VAT/VAP. The results support the decrease in the incidence to VAP transition and/or the improvement in signs and symptoms of VAP. Moreover, there are concise reports on higher cure rates and microbiological eradication in patients treated with aerosolized antibiotics. Yet, differences in the delivery modality adopted and resistance emergence issues preclude the generalisability of the results. Aerosolized antibiotic therapy can be used to manage ventilator-associated infections, especially those with difficult to treat resistance. The limited clinical data raise the need for large randomized controlled trials to confirm the benefits of AA and to evaluate the impact on antibiotic selection pressure.

Predicting respiratory decompensation in mechanically ventilated adult ICU patients.

Introduction: Mechanical ventilation is a life-saving treatment in the Intensive Care Unit (ICU), but often causes patients to be at risk of further respiratory complication. We created a statistical model utilizing electronic health record and physiologic vitals data to predict the Center for Disease Control and Prevention (CDC) defined Ventilator Associated Complications (VACs). Further, we evaluated the effect of data temporal resolution and feature generation method choice on the accuracy of such a constructed model. Methods: We constructed a random forest model to predict occurrence of VACs using health records and chart events from adult patients in the Medical Information Mart for Intensive Care III (MIMIC-III) database. We trained the machine learning models on two patient populations of 1921 and 464 based on low and high frequency data availability. Model features were generated using both basic statistical summaries and tsfresh, a python library that generates a large number of derived time-series features. Classification to determine whether a patient will experience VAC one hour after 35h of ventilation was performed using a random forest classifier. Two different sample spaces conditioned on five varying feature extraction techniques were evaluated to identify the most optimal selection of features resulting in the best VAC discrimination. Each dataset was assessed using K-folds cross-validation (k = 10), giving average area under the receiver operating characteristic curves (AUROCs) and accuracies. Results: After feature selection, hyperparameter tuning, and feature extraction, the best performing model used automatically generated features on high frequency data and achieved an average AUROC of 0.83 ± 0.11 and an average accuracy of 0.69 ± 0.10. Discussion: Results show the potential viability of predicting VACs using machine learning, and indicate that higher-resolution data and the larger feature set generated by tsfresh yield better AUROCs compared to lower-resolution data and manual statistical features.

Shared Experiences

Shared Experiences

Targeted Therapy of Severe Infections Caused by Staphylococcus aureus in Critically Ill Adult Patients: A Multidisciplinary Proposal of Therapeutic Algorithms Based on Real-World Evidence

(1) Introduction: To develop evidence-based algorithms for targeted antibiotic therapy of infections caused by Staphylococcus aureus in critically ill adult patients. (2) Methods: A multidisciplinary team of four experts had several rounds of assessment for developing algorithms concerning targeted antimicrobial therapy of severe infections caused by Staphylococcus aureus in critically ill patients. The literature search was performed by a researcher on PubMed-MEDLINE (until August 2022) to provide evidence for supporting therapeutic choices. Quality and strength of evidence was established according to a hierarchical scale of the study design. Two different algorithms were created, one for methicillin-susceptible Staphylococcus aureus (MSSA) and the other for methicillin-resistant Staphylococcus aureus (MRSA). The therapeutic options were categorized for each different site of infection and were selected also on the basis of pharmacokinetic/pharmacodynamic features. (3) Results: Cefazolin or oxacillin were the agents proposed for all of the different types of severe MSSA infections. The proposed targeted therapies for severe MRSA infections were different according to the infection site: daptomycin plus fosfomycin or ceftaroline or ceftobiprole for bloodstream infections, infective endocarditis, and/or infections associated with intracardiac/intravascular devices; ceftaroline or ceftobiprole for community-acquired pneumonia; linezolid alone or plus fosfomycin for infection-related ventilator-associated complications or for central nervous system infections; daptomycin alone or plus clindamycin for necrotizing skin and soft tissue infections. (4) Conclusions: We are confident that targeted therapies based on scientific evidence and optimization of the pharmacokinetic/pharmacodynamic features of antibiotic monotherapy or combo therapy may represent valuable strategies for treating MSSA and MRSA infections.

Evaluation of a Closed Suction System With Integrated Tube-Scraping Technology.

Endotracheal tube (ETT) scraping or sweeping refers to mucus removal from an ETT that can increase airway resistance. The study objective was to evaluate the effect of ETT scraping on the duration of mechanical ventilation, time to first successful spontaneous breathing trial (SBT), duration of hospital stay, and occurrence of ventilator-associated events (VAEs). This was a single-center, randomized clinical trial of adult subjects intubated between October 2019-October 2021. Subjects were randomly assigned to either ETT suctioning via a standard in-line suction catheter (control group) or ETT suctioning and scraping via a suction catheter with balloon-sweeping technology (experimental group). Airway suctioning was performed as clinically indicated, and the ETT was scraped every time a respiratory therapist suctioned the subject. The study outcome was duration of mechanical ventilation, time to first successful SBT, hospital length of stay, and VAE rate. Intent-to-treat statistical analysis was performed. Of 272 randomized subjects, the median age was 63 (interquartile range [IQR] 52-73) y; 143 (53%) were males, and 154 (57%) had a primary diagnosis of acute respiratory failure. There were no significant differences between the groups in median duration (h) of mechanical ventilation (72 [37-187] vs 70.6 [37-148], P = .58). There was no significant difference between the study groups in median time (h) to the first successful SBT (46.7 [IQR 30-87] vs 45.7 [IQR 27-95], P = .81), length of hospital stay (P = .76), the incidences of ventilator-associated conditions (P = .13), or infection-related ventilator-associated complications (P = .47). ETT suctioning plus scraping, compared to ETT suctioning alone, did not significantly improve the duration of mechanical ventilation, time to first successful SBT, length of hospital stay, and VAEs. These study findings do not support the routine use of ETT scraping for mechanically ventilated patients.

Infection-Related Ventilator-Associated Complications in Critically Ill Patients with Trauma: A Retrospective Analysis.

Trauma is a leading cause of death and disability. Patients with trauma undergoing invasive mechanical ventilation (IMV) are at risk for ventilator-associated events (VAEs) potentially associated with a longer duration of IMV and increased stay in the intensive care unit (ICU). We conducted a retrospective cohort study aimed to evaluate the incidence of infection-related ventilator-associated complications (IVACs), possible ventilator-associated pneumonia (PVAP), and their characteristics among patients experiencing severe trauma that required ICU admission and IMV for at least four days. We also determined pathogens implicated in PVAP episodes and characterized the use of antimicrobial therapy. In total, 88 adult patients were included in the main analysis. In this study, we observed that 29.5% of patients developed a respiratory infection during ICU stay. Among them, five patients (19.2%) suffered from respiratory infections due to multi-drug resistant bacteria. Patients who developed IVAC/PVAP presented lower total GCS (median value, 7; (IQR, 9) vs. 12.5, (IQR, 8); p = 0.068) than those who did not develop IVAC/PVAP. We observed that less than one-third of trauma patients fulfilling criteria for ventilator associated events developed a respiratory infection during the ICU stay.

Infection-Related Ventilator-Associated Complication and Possible Ventilator-Associated Pneumonia among Mechanically Ventilated Patients of Adult Medical and Surgical Intensive Care Units.

Objective An observational study was conducted to evaluate (1) the incidence rates of infection-related ventilator-associated complication (IVAC) and possible ventilator-associated pneumonia (PVAP) among mechanically ventilated patients of adult medical and surgical intensive care units (ICUs) and (2) the pathogen distribution in patients with PVAP. Materials and Methods The IVAC and PVAP rates of medical and surgical ICUs, between July 1, 2017, and June 30, 2021, per 1,000 mechanical ventilator (MV) days were calculated. The significance of difference in IVAC and PVAP rates between medical and surgical ICUs was calculated. The level of significance was set at less than 0.05. Results MV utilization ratios of adult medical and surgical ICUs were 0.32 and 0.26, respectively ( p < 0.001). About 8 and 7 episodes of IVAC and 14 and 6 episodes of PVAP were reported from adult medical and surgical ICUs, accounting for IVAC rates of 3.17 and 1.8 per 1,000 MV ( p > 0.05) and PVAP rates of 2.46 and 1.59 per 1,000 MV days in medical and surgical ICUs, respectively ( p > 0.05). Acinetobacter baumannii complex either singly or in combination was isolated in 11/20 PVAP cases. Conclusion IVAC and PVAP were more in medical compared with surgical ICUs. The most common pathogen in patients with PVAP was A. baumannii complex. More studies are warranted to monitor the significance of ventilator-associated event on patient outcomes.

Ventilator-associated Events Surveillance in a Trauma Intensive Care Unit: A Prospective Study of Incidence, Predictive Values, Sensitivity, Specificity, Accuracy, and Concordance with Ventilator-associated Pneumonia.

IntroductionThe Centres for Disease Control and Prevention (CDC) introduced a new definition of ventilator-associated events (VAEs) in 2013 in place of longstanding ventilator-associated pneumonia (VAP) definition. Three entities under VAE, ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and possible ventilator-associated pneumonia (PVAP), were introduced.ObjectivesTo assess the incidence of all VAEs in a tertiary care trauma ICU and to find the predictive value of VAE and sensitivity of VAE definitions for VAP.DesignCohort prospective study at trauma intensive care unit (ICU) of PGIMER, Chandigarh, from July 2018 till June 2019.Materials and methodsPatients admitted in trauma ICU were checked for VAP and VAE criteria defined by CDC.ResultsFour hundred and sixty five patients were observed. Around 378 patients were included in the study with 4046 patient days and 3031 mechanical ventilation (MV) days. Incidence rate of PVAP, IVAC, VAC, and VAP was 2.97, 6.60, 10.23, and 9.24 per 1000 ventilator days, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of diagnosing VAP were 0.61, 0.97, 0.68, and 0.97 for VAC; 0.80, 0.97, 0.57, and 0.99 for IVAC; and 0.78, 0.94, 0.25, and 0.9 for PVAP, respectively. Kendall's W test showed that there was very poor concordance between VAP and VAE.How to cite this articleKaur K, Jain K, Biswal M, Dayal SK. Ventilator-associated Events Surveillance in a Trauma Intensive Care Unit: A Prospective Study of Incidence, Predictive Values, Sensitivity, Specificity, Accuracy, and Concordance with Ventilator-associated Pneumonia. Indian J Crit Care Med 2022;26(5):584–590.