Ventilatory Support Research Articles

Prenatally Diagnosed Congenital High Airway Obstruction Syndrome: Perinatal Management and Outcome—A Single Tertiary Care Center Experience

AbstractTo report our experience with the management of prenatally diagnosed cases of congenital high airway obstruction syndrome (CHAOS) and the postnatal outcome of those who underwent an ex utero intrapartum treatment (EXIT) procedure. This is a single center, retrospective observational study of prenatally diagnosed CHAOS cases using two-dimensional ultrasound from December 2017 to December 2022 in a tertiary care facility. Of the total nine fetuses prenatally diagnosed with CHAOS, three (33.3%) were associated with multiple congenital anomalies, seven out of nine (77.8%) developed ascites, and one had fetal hydrops. Five (55.6%) underwent medical termination of pregnancy and two were lost to follow-up (22.2%). The remaining two continued pregnancy and required EXIT tracheostomy at the time of delivery (22.2%). Microarray was performed in both which was normal. Postnatally, both infants are tracheostomy dependent with one requiring frequent ventilator support. CHAOS even when isolated generally has poor prognosis without intervention. Performing an EXIT procedure at birth can significantly improve postnatal survival by minimizing hypoxic damage. However, the long-term medical and surgical challenges for survivors remain numerous especially speech disorders, even after lifesaving fetal intervention and surgical correction. Therefore, an accurate prenatal diagnosis is necessary to give the couple an option of continuing pregnancy after realistic counseling regarding the prognosis and postnatal outcome.

Long-Term Pulmonary and Neurodevelopmental Outcomes of Meconium Aspiration Syndrome Affected Infants: A Retrospective National Population-Based Study in Taiwan

Introduction: Meconium aspiration syndrome (MAS) may cause severe pulmonary and neurologic injuries in affected infants after birth, leading to long-term adverse pulmonary or neurodevelopmental outcomes. Methods: This retrospective population-based cohort study enrolled 1,554,069 mother-child pairs between 2004 and 2014. A total of 8,049 infants were in the MAS-affected group, whereas 1,546,020 were in the healthy control group. Children were followed up for at least 3 years. According to respiratory support, MAS was classified as mild, moderate, and severe. With the healthy control group as the reference, the associations between MAS severity and adverse pulmonary outcomes (hospital admission, intensive care unit (ICU) admission, length of hospital stay, or invasive ventilator support during admission related to pulmonary problem) or adverse neurodevelopmental outcomes (cerebral palsy, needs for rehabilitation, visual impairment, or hearing impairment) were accessed. Results: MAS-affected infants had a higher risk of hospital and ICU admission and longer length of hospital stay, regardless of severity. Infants with severe MAS had a higher risk of invasive ventilator support during re-admission (odds ratio: 17.50, 95% confidence interval [CI]: 7.70–39.75, p < 0.001). Moderate (hazard ratio [HR]: 1.66, 95% CI: 1.30–2.13, p < 0.001) and severe (HR: 4.94, 95% CI: 4.94–7.11, p < 0.001) MAS groups had a higher risk of adverse neurodevelopmental outcome, and the statistical significance remained remarkable in severe MAS group after adjusting for covariates (adjusted HR: 2.28, 95% CI: 1.54–3.38, p < 0.001) Conclusions: Adverse pulmonary or neurodevelopmental outcomes could occur in MAS-affected infants at birth. Close monitoring and follow-up of MAS-affected infants are warranted.

#862 Prevalence and surrogate predictors of acute kidney injury in tropical infections in eastern India

Abstract Background and Aims Acute kidney injury (AKI) in tropical countries is strikingly different from the other countries with a temperate climate. The epidemiology of AKI is largely influenced by environmental factors and climatic conditions and differ significantly its outcome and the surrogate predictors are not much studied. 1. To observe the spectrum and estimate the prevalence of AKI in tropical infections. 2. To evaluate the outcome and surrogate predictor of tropical AKI. Method This was a tertiary level single centre prospective observational study. All patients admitted with tropical infections associated AKI (KDIGO) were enrolled in two years and underwent complete history taking, clinical examinations and necessary laboratory investigations according to situations.. All patients were followed up more than 6 month. All data recorded were analysed in suitable statistical tool. Univariate analysis is followed by multivariate analysis was done for predictors followed by hazards ratio and Neglekers test. Results Out of 132 patients with Tropical AKI M:F was 1.5:1. Mean age was 42.3 ± 14.4 year, About 35.6% had Malaria,31.1% Dengue, 17% Scrub typhus, 10.4% Leptospira, and 5.9% patients had Typhoid fever. Malaria was the most common causative factor followed by Dengue. study reflecting the high dengue incidence occurring in the months of August, September, October &amp; November. Among Malaria AKI (MAKI) 43.75% (21) had Falciparum malaria, 50% (24) had Vivax malaria and 6.25% (3) had dual infection. Out of 132 patients with Tropical AKI about 60% totally recovered at the time of discharge. 40% patients had Shock. Among them 60% Dengue AKI, 33.3% Malarial AKI 5 (21.7%) Scrub typhus, 4 (28.6%) Leptospira AKI &amp; 3 (37%) Typhoid AKI patients had Shock. About 23% patients required RRT. Among them 8 (25%) patients died, 5 (15.6%) patients had CKD progression compared to non-RRT group where only 3 (2.9%) patients died, and 2 (1.94%) patients had progression to CKD. Total 11 (8.1%) patients died during hospital stay and only 7 (6.2%) patients had progressed to CKD. The mean Hospital stay was 5.51 ± 3.8 days. S hock at presentation, requirement of ICU support ( in form of ionotropic and ventilatory support), Need of RRT, prolong hospital stay, late referral was the bad prognostic predictor in terms of death. Though not statistically significant, presence of anaemia, hyponatraemia, deranged liver function &amp; hypoalbuminemia were more in patients who died compared to survival group. Limitations: Small enrolments. non inclusion of all cause including snake bite, less biopsy in this study. Conclusion There are wide spectrum of tropical AKI with high mortality and morbidity. A greater awareness and early intervention is necessary for prompt diagnosis, treatment and favourable outcome.

#2719 Hypoalbuminemia as a mortality risk factor in acute kidney injury

Abstract Background and Aims Preexisting hypoalbuminemia in many studies was an independent factor of mortality in patients with acute kidney injury (AKI). Albumin replacement in patients with AKI did not affect their survival. Each 1.0 g/l decrease in serum albumin was associated with an increased probability of developing AKI (OR 1.685). Also, it was shown that serum albumin level below 32 g/l is a significant risk factor for the occurrence of AKI. The mortality of patients with AKI is extremely high, approximately 50%, in patients with AKI who require dialysis treatment it is 50-70%, while in patients on supportive ventilation or with multisystem organ failure it is even 80-90%. Method The retrospective study included 280 patients diagnosed with AKI in the period from 2014 to 2018. Demographic, laboratory parameters and therapeutic procedures were analyzed in order to determine their influence on the treatment outcome. Binary logistic regression was used to test statistical significance to identify potential mortality factors. Results The incidence of AKI was 6.5%. The mean age was 67.8±13.8 years (19, 91) without statistically significant difference by gender (50.4% men) (p = 0.22). The most prevalent is prerenal AKI 57.1%, followed by renal 24.3% and postrenal 18.6%. Renal replacement therapy is required in 15.7% of patients. Intermittent HD was applied statistically significantly more often, 90.9%, and continuous renal replacement therapy (CRRT) procedures were applied in 9.1% of patients (p &amp;lt; 0.001). Mortality was 18.6%. With each increase in the patient's age by one year, the probability of a fatal outcome increases by 1.045 times (p = 0.000; OR: 1.045). Hypoproteinemia and hypoalbuminemia increase the probability of death. For each unit decrease in albumin by 1 g/l, the risk of death increases by 13% (p = 0.000; OR: 0.872), and each decrease in protein by 1 g/l increases the risk of death by 7% (p = 0.000 ; OR: 0.939). Among other factors that showed statistical significance are hyperphosphatemia (p = 0.001; OR: 1.990), acidosis (p = 0.007; OR: 0.002), inflammation (p = 0.029; OR: 1.003). Conclusion Acute kidney injury is accompanied by a high mortality rate. Low serum albumin levels at the time of diagnosis are a significant independent factor of acute kidney function impairment and death. Other risk factors that contribute to a poor outcome in patients with AOB are age, hyperphosphatemia, acidosis, and inflammation.

Determinants of antibiotic prescription in children with adenovirus respiratory tract infections

We performed this study to evaluate factors associated with antibiotic prescriptions in children with adenovirus infection, since no studies have attempted to address this aspect in the pediatric population. Retrospective study of children younger than 18 years of age tested positive for adenovirus on a syndromic nasopharyngeal test from 2018 to 2023. We compared the need of pediatric intensive care unit (PICU), invasive ventilation, and other respiratory support, viral etiologies, clinical presentations, imaging, and laboratory results in the precovid (2018–2019) and covid (2020–2022) period. The use of antibiotics was studied with multivariable logistic regression including demographic as well as clinical data as covariates. Two hundred fifty-eight patients were enrolled. One hundred fifty-eight patients received an antibiotic (mean duration 6.2 (±2.7) days (median 4; IQR: 4–7)). Presence of seizures and C-reactive protein values as predictors for antibiotic prescription (OR for seizures: 12.17; 95% CI: 1.42–103.91; p = 0.022; OR for CrP: 1.03; 95% CI: 1.01–1.04; p = 0.001). Seventy-four patients received intravenous antibiotics (74/156, 47.4%). Risk factors for intravenous antibiotic were the presence of decay (OR: 3.74; 95% CI: 1.25–11.71; p = 0.018), CrP values (OR: 1.02; 95% CI: 1.00–1.03; p = 0.001), and presence of seizures (OR: 16.34; 95% CI: 2.65–100.83; p = 0.003). Duration of intravenous antibiotics correlated with the presence of seizures (Coeff: 1.6; 95% CI: 0.41–2.89; p = 0.009) even when adjusted for CrP values. Conclusion: The clinical presentation of adenovirus infection in children is non-specific, leading to frequent antibiotic prescription despite bacterial co-infections was rare. Higher CrP values and presenting with seizures are significantly associated with a higher risk of receiving antibiotics. Rapid microbiological tests and newer biomarkers can help clinicians to improve antibiotic prescription in this cohort of children.What is Known:•Adenovirus infection is a common cause of fever and respiratory tract infections in children.•Children with adenovirus infections frequently receive antibiotics, but determinants of this practice are poorly established.What is New:• Higher C-reactive protein values and presenting with seizures are significantly associated with antibiotic prescription. • Since the beginning of COVID-19 and implementation of rapid diagnostics, less children with adenovirus infection received antibiotics.

COVID-19 Impact on Female Patients at Tertiary Care Hospital – A Retrospective Study

Objectives: Corona virus disease-19 (COVID-19) has impacted worldwide leading to a high mortality rate. It has been observed that male mortality rate is higher than females due to which it is crucial to systematically study gender differences in disease manifestations. Our study evaluated the association between mortality in COVID-19-positive cases and gender. Materials and Methods: This retrospective study was conducted in the cardiology department at a tertiary care hospital which included 699 patients with a confirmed positive diagnosis of COVID-19 by reverse transcription polymerase chain reaction and &gt;18 years of age. Data from the medical records of the department were collected during an 8-month period (July 2020–February 2021). Results: Of the 699 patients enrolled in the study within 8 months, 232 (33.1%) were female and 467 (66.7%) were male. Female mortality accounted for 18.99% and male mortality 14.56%. Comparing the severity of the disease, 36% of females showed more severe disease presentation. In the course of the disease with treatment, 51.29% of females required oxygen support. Conclusion: This study showed differences in the mortality rate, ventilation support requirement, and severity of disease in COVID-19 affected males and females.

Optimizing Resuscitation of the Donation after Circulatory Death Heart by Mitochondrial Protection in a Female Porcine Model.

Due to the shortage of donor organs, an increasing number of transplant organs are harvested after circulatory arrest (donation after circulatory death [DCD]). Using a translational porcine model of DCD, this study developed and evaluated a protocol based on cardioprotection by multidrug postconditioning to optimize resuscitation of DCD hearts during ex situ heart perfusion (ESHP). Hearts of female pigs (45.0 ± 4.5 kg) were procured following a clinically identical DCD protocol, consisting of the termination of ventilator support and confirmation of circulatory arrest, followed by a 15-min standoff period. DCD hearts were randomly allocated to ESHP (38.4°C) in the absence (untreated, N = 5) or presence (treated, N = 5) of a postconditioning treatment added to the perfusate, consisting of Intralipid (1%), sevoflurane (2% v/v), and remifentanil (3 nM). All hearts were perfused with blood and Krebs-Henseleit solution (1:1) for 60 min in Langendorff mode and for an additional 300 min in working mode for a total perfusion time of 6 h. Oxidative capacity and detailed left ventricular mechanical function under an increasing workload (left atrial pressure, 6 to 12 mmHg) were assessed hourly. Left ventricular tissue was snap-frozen at the end of ESHP and used for molecular analyses. Left ventricular inotropy (LVdP/dtmax) did not decline over time in treated DCD hearts and was significantly higher at the end of the protocol as compared with untreated DCD hearts (ΔLVdP/dtmax = 440 mmHg/s; P = 0.009). Treated DCD hearts exhibited persistently higher left ventricular stroke work index during the 6-h period of ESHP, whereas untreated DCD hearts displayed a significant decline (change in left ventricular stroke work index = -3.10 ml · mmHg/g; P(time within untreated group) < 0.001). Treated DCD hearts displayed higher metabolic activity as measured by oxygen consumption (ΔO2 = 3.11 ml O2 · min-1 · 100 g-1; P = 0.004) and released lower amounts of cell-free mitochondrial DNA into the perfusate, a marker of potential graft dysfunction. Treated hearts also used fatty acids from Intralipid as an energy source, whereas untreated DCD hearts showed glyceroneogenesis with triglyceride accumulation and depletion of tricarboxylic acid cycle intermediates; reduced mitochondrial complex I, II, and III activities with accumulation of mitochondrial NADH, and signs of ultrastructural damage. A translationally relevant protective ESHP protocol consisting of treatment with Intralipid, sevoflurane, and remifentanil markedly accelerated functional recovery and improved viability of DCD hearts.

Evaluation of the Efficacy and Safety of Intravenous Immunoglobulin (IVIG) in Moderate-to-Severe Hospitalized COVID-19 Patients: A Randomized, Open-Label Parallel-Group Study.

Since February 2020, the world has been overwhelmed by the SARS-CoV-2 outbreak, and several patients suffered interstitial pneumonia and respiratory failure requiring mechanical ventilation, threatening the capability of healthcare systems to handle this amount of critical cases. Intravenous immunoglobulins (IVIG) possess potential immunomodulatory properties beneficial for COVID-19 patients, yet evidence supporting IVIG as adjunctive therapy remains sparse. This study evaluated the outcomes of adjunctive IVIG with the standard of care (SoC) in moderate-to-severe COVID-19 patients. This randomized study included 59 moderate-to-severe COVID-19 patients with known comorbidities. One arm (n = 33) received high-dose IVIG (400 mg/kg/day) within 48 hours for five days alongside SoC, while the other arm (n = 26) received SoC, comprising steroids, enoxaparin, and remdesivir. The primary endpoint was clinical improvement, as measured by the National Early Warning Score 2 (NEWS2) and discharged/death proportions. Secondary outcomes included IVIG safety, hospitalization duration, changes in oxygen saturation, inflammatory markers, IgG titer, CTSS (CT severity score), and radiological findings. There was an improvement in the NEWS2 at the end of treatment in the IVIG arm (5.67 vs. 5.96). A significant absolute effect improvement (Day 1 vs. Day 9) was seen in serum LDH, D-dimer, hs-CRP, IL-6, CTSS, procalcitonin, respiratory rate, and chest radiographic findings. SARS-CoV-2 IgG titer increased significantly in the IVIG arm. There was a statistically significant reduction in mortality in the IVIG group (5 vs. 10). IVIG was a safe and effective adjunctive therapy to SoC treatment in moderate-to-severe COVID-19 patients needing ventilatory support. Furthermore, studies are required to validate our findings. This trial is registered with CTRI/2021/05/033622.

Comparison of clinical features of cystic fibrosis patients eligible but not on CFTR modulators to ineligible for CFTR modulators.

Cystic fibrosis transmembrane conductance regulator (CFTR) modulator drugs target the underlying defect and improve CFTR function. They are a part of standard care in many countries, but not all patients are eligible for these drugs due to age and genotype. Here, we aimed to determine the characteristics of non-eligible patients for CFTR modulators in the CF registry of Turkey (CFRT) to highlight their clinical needs. This retrospective cohort study included CF patient data from the CFRT in 2021. The decision of eligibility for the CFTR modulator was determined according to the 'Vertex treatment-Finder' on the Vertex® website. Demographic and clinical characteristics of patients were compared between eligible (group 1) and ineligible (group 2) groups for CFTR modulators. Among the study population (N = 1527), 873 (57.2%) were in group 1 and 654 (42.8%) were in group 2. There was no statistical difference between groups regarding sex, meconium ileus history, diagnoses via newborn screening, FEV1 z-score, CF-associated complications, organ transplant history, and death. Patients in group 2 had a higher incidence of pancreatic insufficiency (87.7% vs. 83.2%, p = .010), lower median height z-scores (-0.87 vs. -0.55, p < .001), lower median body mass index z-scores (-0.65 vs. -0.50, p < .001), longer days receiving antibiotics due to pulmonary exacerbation (0 [interquartile range, IQR: 0-2] vs. 0 [IQR: 0-7], p = 0.001), and more non-invasive ventilation support (2.6% vs. 0.9%, p = 0.008) than patients in group 1. The ineligible group had worse clinical outcomes than the eligible group. This highlights their need for life-changing drugs to improve clinical outcomes.

Expiratory braking defines the breathing patterns of asphyxiated neonates during therapeutic hypothermia.

Although neonatal breathing patterns vary after perinatal asphyxia, whether they change during therapeutic hypothermia (TH) remains unclear. We characterized breathing patterns in infants during TH for hypoxic-ischemic encephalopathy (HIE) and normothermia after rewarming. In seventeen spontaneously breathing infants receiving TH for HIE and in three who did not receive TH, we analyzed respiratory flow and esophageal pressure tracings for respiratory timing variables, pulmonary mechanics and respiratory effort. Breaths were classified as braked (inspiratory:expiratory ratio ≥1.5) and unbraked (<1.5). According to the expiratory flow shape braked breaths were chategorized into early peak expiratory flow, late peak expiratory flow, slow flow, and post-inspiratory hold flow (PiHF). The most braked breaths had lower rates, larger tidal volume but lower minute ventilation, inspiratory airway resistance and respiratory effort, except for the PiHF, which had higher resistance and respiratory effort. The braked pattern predominated during TH, but not during normothermia or in the uncooled infants. We speculate that during TH for HIE low respiratory rates favor neonatal braked breathing to preserve lung volume. Given the generally low respiratory effort, it seems reasonable to leave spontaneous breathing unassisted. However, if the PiHF pattern predominates, ventilatory support may be required.

A Phase I trial of Non-invasiveVentilationand seizure prophylaxis with levetiracetam InChildren withCerebral Malaria Trial (NOVICE-M Trial).

African children with cerebral malaria and seizures caused Plasmodium falciparum are at greater risk of poor outcomes including death and neurological sequelae. The agonal events are severe hypoventilation and respiratory arrest often triggered by seizures. We hypothesised that prophylactic anti-seizure medication (ASM) could avert 'spikes' of intracranial pressure during or following seizures and that adequate ventilation could be supported by biphasic Cuirass Ventilation (BCV) which requires no intubation. A Phase I trial conducted in Kilifi, Kenya designed to provide data on safety, feasibility and preliminary data on seizure control using prophylactic ASM (levetiracetam) and BCV as non-invasive ventilatory support in children with cerebral malaria. Children aged 3 months to 12-years hospitalised with P falciparum malaria (positive rapid diagnostic test or a malaria slide), a Blantyre Coma Score ≤2 and a history of acute seizures in this illness are eligible for the trial. In a phased evaluation we will study i) BCV alone for respiratory support (n=10); ii) prophylactic LVT: 40mg/kg loading dose then 30mg/kg every 12 hours given via nasogastric tube for 72 hours (or until fully conscious) plus BCV support (n=10) and; iii) prophylactic LVT: 60mg/kg loading dose then 45mg/kg every 12 hours given via nasogastric tube for 72 hours (or until fully conscious) plus BCV support (n=10). Primary outcome measure: cumulative time with a clinically detected seizures or number of observed seizures over 36 hours. Secondary outcomes will be assessed by feasibility or ability to implement BCV, and recovery from coma within 36 hours. Safety endpoints include: aspiration during admission; death at 28 days and 180 days; and de-novo neurological impairments at 180 days. This is a Phase I trial largely designed to test the feasibility, tolerability and safety of using non-invasive ventilatory support and LVT prophylaxis in cerebral malaria. ISRCTN76942974 (5.02.2019); PACTR202112749708968 (20.12.2021).

Hypophosphatemia in Chronic Obstructive Pulmonary Disease Patients Requiring Mechanical Ventilation and Its Impact on Weaning in an Intensive Care Unit of a Tertiary Care Hospital in Eastern India.

Background Hypophosphatemia, defined as a serum phosphate level less than 2.5 mg/dL, is a frequent finding in patients with chronic obstructive pulmonary disease (COPD) and has been speculated to negatively affect weaning outcomes. This study aimed to determine the incidence of hypophosphatemia in COPD patients requiring mechanical ventilation and evaluate the predictive role of hypophosphatemia as an indicator of successful weaning from mechanical ventilation in such patients admitted to the intensive care unit (ICU) in a tertiary care hospital in eastern India. Methodology This prospective observational study included 60 adult patients aged 18 to 75 years with acute exacerbations of COPD on mechanical ventilation in the ICU who were planned to undergo a weaning trial. Serum phosphate levels were assessed at the time of admission and before each weaning attempt. Weaning outcomes at each attempt, length of ventilator and ICU stay, and mortality were recorded. Data collection was initiated after approval of the Institutional Ethics Committee. Receiver operating curve (ROC) analysis was done to identify the cut-off value of serum phosphate which predicted successful weaning. Results Of 60 participants, hypophosphatemia on admission was present in 15 (25%) patients. Despite the correction, 13 (21.7%) patients had hypophosphatemia before the first weaning attempt. Only 22 patients out of 60 were successfully weaned off from mechanical ventilation in the first trial, accounting for a success rate of 36.7%, of whom 20 were normophosphatemic (90.9%). In the second and third weaning trials, hypophosphatemia was significantly associated with weaning failure. Overall differences in mean serum phosphate levels among those who failed to wean in each weaning trial and the successful attempt were statistically significant (p < 0.001). On ROC analysis of serum phosphate level before the first weaning trial, a cut-off value of ≥3.0 mg/dL was identified to have 86.4% sensitivity, 55.3% specificity, 52.8% positive predictive value, 87.5% negative predictive value, and 66.7% diagnostic accuracy in predicting weaning success. Five patients died, accounting for a mortality rate of 8.3%. Lower mean serum phosphate levels before the first weaning trial, higher mean age, and longer ventilator and ICU days were significantly associated with mortality among our study participants (p < 0.05). Conclusions Our findings suggest that maintaining normal serum phosphate levels is critical to successfully weaning off patients with COPD from ventilator support.

Critical care therapies pre- and post-heart transplant and their impact: Analysis from the Pediatric Cardiac Critical Care Consortium

BackgroundFew studies highlighting the critical care management of patients after heart HTx (HTx) have been published to date. This analysis provides a contemporary representation of critical care burden pre- and post-HTx, describes care differences based on pre-transplant diagnosis and outlines the impact of intensive care unit (ICU) therapies on outcomes. MethodsData from PC4 Collaborative Registry was analyzed for pediatric patients undergoing HTx between 08/2014-04/2022. Results1877 HTx in 1857 patients were reported from 42 centers; 56.5% had congenital heart disease (CHD). Patients with CHD were younger, smaller, more likely male, White race, and publicly insured. Their pre-HTx ICU course was characterized by a higher need for catheterization, increased likelihood of inotropic support and mechanical ventilation with lower VAD rates. Their operative courses were significant for longer bypass and cross-clamp times. Postoperatively, CHD patients required more CPR and utilized more ICU therapies such as inotropes, ECMO and renal replacement. Those with CHD had a longer duration of ventilatory support (68.6 vs. 27.3 hours), total hospital stays (37.1 vs. 22.9 days) and higher hospital mortality (7.8% vs. 1.8%); all p<0.0001. Longer cardiopulmonary bypass and longer deep hypothermic circulatory arrest times and delayed sternal closure were independent risk factors for hospital mortality. Lastly, there was no association between total surgical volume for a center and outcomes but there was a significant relationship between center transplant volume and outcomes with higher volume centers demonstrating significantly lower mortality. ConclusionA diagnosis of CHD prior to HTx is associated with a greater use of ICU specific therapies compared non-CHD cohort. Operative factors, particularly in CHD patients, are independently associated with higher hospital mortality as was low transplant volume at the center. The study provides basis for further investigating ICU and operative factors that can be modified to improve transplant outcomes.

Colchicine and/or Naltrexone for Hospitalized COVID-19 Patients Not Requiring High Levels of Ventilatory Support (COLTREXONE): A Prospective, Randomized, Open-Label Trial.

We assessed the efficacy and safety of colchicine and low-dose naltrexone (LDN), alone and in combination, in preventing progression to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this prospective, randomized, open-label trial, colchicine and LDN were compared to standard of care (SOC) in patients hospitalized with SARS-CoV-2 not requiring high levels of ventilatory support. Patients were randomly assigned to colchicine alone, LDN alone, colchicine/LDN in combination, or SOC. The primary outcome was time to disease recovery. Secondary outcomes included total time hospitalized,study enrollment, level of care, oxygen support, and adverse events. One-hundred and thirty-seven patients were randomized (Nc = 34, Nc+ldn = 33, Nldn = 35, Nsoc = 35). Eighty-four patients (61%) achieved disease recovery by day 5. There was no significant difference in the proportion of patients who experienced the primary efficacy outcome among those who received colchicine, LDN, or between the four study arms.Patients receiving colchicine had a shorter length of enrollment but not a significant reduction in the length of stay. Diarrhea was the most common adverse reaction. In adults hospitalized with SARS-CoV-2 not requiring high-level ventilatory support, colchicine and LDN, alone and in combination, were not associated with significant reductions in progression to severe disease.

Clinical characteristics and outcomes of respiratory syncytial virus-associated ARF in immunocompetent patients: A seven-year experience at a tertiary hospital in France

Respiratory syncytial virus (RSV) is widely recognized as a cause of acute respiratory failure in infants and immunocompromised patients. However, RSV can also contribute to acute respiratory failure in adults, particularly among the elderly population. The objective of this study was to analyze the clinical characteristics and outcomes of immunocompetent adults hospitalized for RSV infection. This retrospective study included all immunocompetent adult patients consecutively admitted to a tertiary care hospital with RSV-related acute respiratory failure over a seven-year period (2016-2023). Diagnosis of RSV infection was made through nasal swabs or pulmonary samples, with multiplex reverse transcription polymerase chain reaction (RT-PCR). Patients were eligible for inclusion if they required supplemental oxygen therapy for at least 48h. One hundred and four patients met the inclusion criteria. Median age [IQR] was 77 years [67-85]. Ninety-seven patients had at least one comorbidity (97/104, 93%). At the time of RSV diagnosis, 67 patients (67/104, 64%) experienced acute decompensation of a pre-existing chronic comorbidity. Antibiotics were started in 80% (77/104) of patients; however, only 16 patients had a confirmed diagnosis of bacterial superinfection. Twenty-six patients needed ventilatory support (26/104, 25%) and 21 were admitted to the intensive care unit (21/104, 20%). The median duration of oxygen therapy [IQR] was 6 days [3-9], while the median hospital length of stay [IQR] was 11 days [6-15]. The overall mortality rate within 1 month of hospital admission was 13% (14/104). The sole variables associated with one-month mortality were age and maximum oxygen flow during hospitalization. RSV-associated acute respiratory failure affected elderly individuals with multiple comorbidities and was associated with prolonged hospitalization and a high mortality rate.

Extreme Delta Brush Electroencephalography Pattern in Anti-yo Encephalitis: A Case Report

Autoimmune encephalitis is complex and gradually being recognized. Anti-N-methyl-D-aspartate Receptor (Anti-NMDAR) encephalitis was the most well-known and its unique electroencephalography (EEG) pattern is extreme delta brush (EDB). Anti-Yo encephalitits is far less than common anti-NMDAR encephalitis (anti-NMDARE). A 78-year-old male presented with progressive apathy, hypotension, unsteady gait, and depressed consciousness. EEG revealed an EDB pattern while the serum test was positive for anti-Yo antibodies. The patient then received 10 rounds of plasma exchange, and his blood pressure stability improved. Consequently, urine cytology and abdominal computed tomography revealed atypical cells and linear enhancement in the bladder dome, respectively. However, instead of further pathological confirmation and treatment, the patient’s family requested hospice care. As a result, the patient died of desaturation 7 days later after the withdrawal of ventilatory support. First recognized in 2012, EDB is believed to be specific to NMDARE. However, to date, EDB has not been well described, and no description is available regarding its reactivity. To our knowledge, this is the first case of EDB with anti-Yo encephalitis. Similar to the cases of EDB with anti-NMDARE, our patient did not have satisfied prognosis despite no further investigation and treatment of the possible underlying malignancy. As the prevalence and underlying mechanism of this EEG pattern are unclear, further studies are warranted to identify the potentially similar mechanisms and correlation between anti-NMDAR and anti-Yo encephalitis.

Optimizing ventilatory support in ARDS: A comprehensive guide for ICU nurses on patient care

The emergence of COVID-19 as a global pandemic has placed an unprecedented strain on healthcare systems worldwide, highlighting a critical shortage of trained healthcare professionals equipped to manage such a crisis. This deficit poses a significant challenge to the delivery of healthcare services, particularly in the context of intensive care units (ICUs) where the use of advanced medical technologies, such as ventilators, is paramount. For nurses with limited experience in ICU settings, navigating the complexities of invasive positive pressure ventilation (IPPV), a principal method of mechanical ventilation for critically ill patients can be daunting. This article aims to serve as a comprehensive guide for nurses less familiar with the intricacies of managing patients on IPPV, offering insights and strategies to enhance their competence and confidence in this critical aspect of patient care.

Lived experiences of caregivers with infants treated at home with continuous invasive or noninvasive ventilation.

Caring for children dependent upon continuous invasive ventilation in the home setting requires extensive expertise, coordination, and can result in impaired caregiver quality of life. Less is known regarding the experiences of caregivers with children requiring continuous noninvasive ventilation. To evaluate caregiver experiences with invasive and noninvasive home mechanical ventilation, and to compare parental quality of life based on the child's mode of ventilation. Caregivers of infants who were discharged home with continuous ventilatory support were recruited to complete semi-structured qualitative interviews. Interviews explored their decision-making process, the transition to home, and health related quality of life. Caregivers of 16 children were interviewed, of whom eight were treated with continuous invasive ventilation, and eight with continuous noninvasive ventilation. The decision to pursue home ventilation in both groups was greatly influenced by the desire to be discharged and reunite the family at home. Following the transition to home, caregivers from both groups described high rates of insomnia, emotional distress, work disruption and familial hardship. Despite this, parents were overwhelmingly pleased with the decision to proceed with home ventilation and perceived their children to be living enriched lives outside of the hospital. Factors associated with easing the transition to home were in-hospital training and the presence of a robust support system. Lives of families with children dependent on continuous mechanical ventilation are characterized by isolation, lifestyle disruption, adverse mental and physical health consequences, and impaired interpersonal relationships, irrespective of the mode of ventilation.

Beta 2-microglobulin is an independent risk marker of acute kidney injury in adult patients with hemophagocytic lymphohistiocytosis

Background and AimsThe role of beta2-microglobulin (β2-MG) in predicting acute kidney injury (AKI) in hemophagocytic lymphohistiocytosis patients has been poorly studied. This study aimed to analyze the clinical characteristics of hemophagocytic lymphohistiocytosis patients and identify risk factors that predict AKI development.MethodsThis retrospective observational cohort study conducted at a single-center involved 938 patients diagnosed with hemophagocytic lymphohistiocytosis, who were divided into AKI group and non-AKI group. Patient data were collected and analyzed using univariate and multivariate binary logistic regression to identify potiential risk factors associated with AKI occurrence. ResultsAmong the enrolled patients, 486 were male (51.9%), the median age was 37 years (interquartile range, 28.0, 52.0), 58.4% experienced AKI. Mechanical ventilation (8.0% vs. 0.8%) and vasopressor support (21.7% vs. 4.1%) occurred at significantly higher rates in the AKI group compared to the non-AKI group, with significantly higher in-hospital mortality (5.5% vs. 1.3%) and 28-day mortality (12.8% vs. 5.4%). When β2-MG was used as a continuous variable, multifactorial analysis showed that β2-MG, transplantation, and vasopressor support were independently associated with risk for the development of AKI.ConclusionsThe incidence of morbidity and mortality in patients with hemophagocytic lymphohistiocytosis complicated by AKI remains high. Monitoring levels of β2-MG may provide clinicians with timely indicators of changes in renal function, facilitating adjustments to treatment strategies.Graphical abstract

Optimizing Triage: Assessing Shock Index, Pediatric Age-Adjusted as an Adjunct to Improve Emergency Severity Index Mistriage.

We investigated the diagnostic value of shock index, pediatric age-adjusted (SIPA) in predicting Emergency Severity Index level 3 patients' outcomes. Secondary objectives included exploring the impact of fever and participant variables on SIPA's predictive ability. A retrospective chart review identified children aged 1 to 15 years triaged as a level 3 in the emergency department between January 2018 and December 2021. Shock index, pediatric age-adjusted thresholds based on age, 1 to 6 years (>1.2), 7 to 12 years (>1.0), and 13 to 17 years (>0.9), were used. We assessed elevated SIPA and SIPA corrected for fever to evaluate associations with outcomes and interventions. Our findings, involving 192 patients, revealed that elevated SIPA demonstrated enhanced discrimination relative to nonelevated SIPA. Patients with elevated SIPA had more average interventions: 1.14 versus 0.74, P < 0.016; average interventions using SIPA corrected for fever: 1.14 versus 0.77, P < 0.006; average interventions controlling for race and sex: 1.15 versus 0.71, P < 0.001; hospital admission: 64.4% versus 42.9%, P = 0.004; hospital length of stay (LOS): 3.06 days (SE, 0.42) versus 1.46 days (SE, 0.23); hospital LOS using SIPA corrected for fever: 2.75 days (SE, 0.44) versus 1.72 days (SE, 0.24); ventilatory support: 16.44% versus 3.36%, P < 0.002; fluid bolus: 28.77% versus 14.29%, P < 0.015; intravenous medications (antibiotics, antiepileptics, immune globulin, albumin): 45.21% versus 30.25%, P < 0.036. There was no difference between other interventions, pediatric intensive care admission, and LOS between the 2 groups. Importantly, SIPA was unaffected by fever, race, or sex. Shock index, pediatric age-adjusted identifies level 3 Emergency Severity Index pediatric patients more likely to require hospital admission, longer LOS, and a lifesaving intervention especially ventilatory support, intravenous fluids, or specific intravenous medications. Shock index, pediatric age-adjusted's predictive ability remained unaffected by fever, race, or sex, making it a valuable tool in preventing mistriage and justifying inclusion in the Emergency Severity Index danger zone vitals criteria for up-triage.