scholarly journals COVID-19 Associated Pulmonary Aspergillosis in Mechanically Ventilated Patients

2021 ◽  
Author(s):  
Nitipong Permpalung ◽  
Teresa Po-Yu Chiang ◽  
Allan B Massie ◽  
Sean X Zhang ◽  
Robin K Avery ◽  
...  
Keyword(s):  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Pulmonary Vascular Disease ◽  
Pulmonary Aspergillosis ◽  
Mechanically Ventilated ◽  
Clinical Criteria ◽  
Preventative Measures ◽  
Severity Scores ◽  
Poor Outcomes ◽  
Disease Severity Scores

Abstract Background COVID-19 associated pulmonary aspergillosis (CAPA) occurs in critically ill COVID-19 patients. Risks and outcomes remain poorly understood. Methods A retrospective cohort study of adult mechanically ventilated COVID-19 patients admitted to five Johns Hopkins hospitals was conducted between March and August 2020. CAPA was defined using composite clinical criteria. Fine and Gray competing risks regression was used to analyze clinical outcomes and multilevel mixed-effects ordinal logistic regression was used to compare longitudinal disease severity scores. Results Amongst the cohort of 396 people, 39 met criteria for CAPA. Compared to those without, patients with CAPA were more likely to have underlying pulmonary vascular disease (41% vs 21.6%, p=0.01), liver disease (35.9% vs 18.2%, p=0.02), coagulopathy (51.3% vs 33.1%, p=0.03), solid tumors (25.6% vs 10.9%, p=0.017), multiple myeloma (5.1% vs 0.3%, p=0.027), corticosteroid exposure during index admission (66.7% vs 42.6%, p=0.005), and had a lower BMI (median 26.6 vs 29.9, p=0.04). People with CAPA had worse outcomes as measured by ordinal severity of disease scores, requiring longer time to improvement (adjusted odds ratio 1.081.091.1, p<0.001), and advancing in severity almost twice as fast (subhazard ratio, sHR 1.31.82.5, p<0.001). People with CAPA were intubated twice as long as those without (sHR) 0.40.50.6, p<0.001) and had a longer hospital length of stay [median (IQR) 41.1 (20.5, 72.4) vs 18.5 (10.7, 31.8), p<0.001]. Conclusion CAPA is associated with poor outcomes. Attention towards preventative measures (screening and/or prophylaxis) is warranted in people with high risk of developing CAPA.

Daily Interruption of Sedation with Physical and Occupational Therapy in Mechanically Ventilated Patients

2018 ◽  
pp. 309-316
Author(s):  
Michael Wolfe ◽  
Daniel Saddawi-Konefka
Keyword(s):  
Occupational Therapy ◽  
Functional Status ◽  
Intervention Group ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Control Group ◽  
Icu Patients ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Ventilated Patients

Schweickert et al. studied effects of early physical and occupational therapy in mechanically ventilated patients. 109 mechanically ventilated medical ICU patients (with independent functional status prior to hospitalization) were randomized to receive physical and occupational therapy initiated at time of enrollment (intervention group) vs. physical and occupational therapy ordered at the discretion of the primary team (control group), with both groups receiving daily interruptions of sedation. The primary outcome, independent functional status at time of discharge, was met in 59% of the intervention group vs. 35% of the control group (p = 0.02). Lower rates of ICU and hospital delirium were observed in the intervention group. Hospital length of stay and mortality were unaffected. This study demonstrated that physical and occupational therapy can be safely accomplished in critically ill, mechanically ventilated medical ICU patients, and that early implementation of therapy may improve return to independent functional status at hospital discharge.

Should Benzodiazepine Sedation be Delivered by Infusion or Bolus?

2013 ◽  
Vol 14 (1) ◽  
pp. 24-27
Author(s):  
James Hutchinson ◽  
Georgina Harlow ◽  
David Sinton ◽  
Tony Whitehouse
Keyword(s):  
Mechanical Ventilation ◽  
Mode Of Delivery ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Limited Data ◽  
Mechanically Ventilated ◽  
Ventilation Duration ◽  
Mechanical Ventilation Duration ◽  
Observational Cohort ◽  
Randomised Controlled

Benzodiazepine sedation for mechanically ventilated patients in intensive care (ICU) is common practice worldwide. We performed a literature review to investigate whether benzodiazepine sedation is best delivered by continuous infusion or intermittent bolus. PubMed, Ovid and Cochrane databases were searched. Only four studies, involving 481 patients, were found. Three were randomised controlled trials and one was an observational cohort study; all used different benzodiazepines, sometimes in conjunction with opiates. The studies measured different outcomes including mechanical ventilation duration, length of ICU and hospital stay, quality and complications of sedation and mortality. Use of intermittent sedation or opiate boluses alone reduced mechanical ventilation duration, ICU and hospital length of stay. However such limited data means that the optimal mode of delivery for benzodiazepine sedation remains unresolved.

scholarly journals “Difficult to Sedate”: Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children

Children ◽  
2021 ◽  
Vol 8 (5) ◽  
pp. 348
Author(s):  
Nataly Shildt ◽  
Chani Traube ◽  
Mary Dealmeida ◽  
Ishaan Dave ◽  
Scott Gillespie ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Pediatric Intensive Care ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Opiate Withdrawal ◽  
Successful Implementation ◽  
Chromosomal Disorders ◽  
Mechanically Ventilated ◽  
Single Center Study

We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08–0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.

The Importance of Duration of Acute Kidney Injury after Severe Trauma:  A Cohort Study

2020 ◽  
Author(s):  
Gabrielle Elise Hatton ◽  
John A Harvin ◽  
Charles E Wade ◽  
Lillian S Kao
Keyword(s):  
Acute Kidney Injury ◽  
Cohort Study ◽  
Kidney Injury ◽  
Severe Trauma ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Discharge Disposition ◽  
Prolonged Hospitalization ◽  
Post Traumatic ◽  
Poor Outcomes

Abstract Introduction: Acute kidney injury (AKI) is common after severe trauma. AKI incidence and AKI stage have previously been shown to be associated with poor outcomes after trauma. However, AKI duration may also be important for outcomes after trauma, given that it has been shown to be associated with long-term morbidity and mortality in general intensive care unit (ICU) and hospitalized patients. We hypothesized that duration of AKI is independently associated with poor outcomes after trauma. Methods: A cohort study was conducted at a single, level 1 trauma center. Patients admitted to the ICU between 2009 and 2018 were included. Data were extracted from the trauma registry and electronic medical records. AKI within 7 days from presentation was defined according to the Kidney Disease Improving Global Outcomes guidelines. Multivariable analyses were performed to assess the association between AKI incidence, AKI stage, and AKI duration with outcomes including prolonged ICU and hospital length-of-stay, discharge to home, and mortality. Collinearity was assessed using the variance inflation factor. Results: Of 7049 patients included, 72% were male, the median age was 41 years (IQR 27-58), and 10% expired. The AKI incidence was 45%, with 69% of these patients presenting with AKI on arrival. The majority (73%) of patients who suffered AKI recovered within 2 days. After adjustment in separate models, AKI incidence, AKI stage and AKI duration were each associated with prolonged hospitalization, an unfavorable discharge disposition, and mortality. AKI stage and duration were collinear and therefore not used in the same model. Conclusions: Post-traumatic AKI was common on arrival and frequently short-lasting. Duration was correlated with highest AKI stage, and both were separately associated with prolonged hospitalization, discharge destination other than home, and mortality on adjusted analyses. Given the high incidence of AKI on arrival, stage or duration may be better targets for future interventions and quality improvement initiatives to improve outcomes after post-traumatic AKI.

scholarly journals Location of Intracerebral Hemorrhage Affects Outcome After Minimally Invasive Endoscopic Hematoma Evacuation

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Rui Song ◽  
Dominic A Nistal ◽  
Jacopo Scaggiante ◽  
Alexander G Chartrain ◽  
Natalia Romano Spica ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Intracerebral Hemorrhage ◽  
Univariate Analysis ◽  
Functional Independence ◽  
Primary Outcome Measure ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Clinical Criteria ◽  
Hematoma Evacuation ◽  
Lobar Hemorrhage

Abstract INTRODUCTION Treatment for intracerebral hemorrhage (ICH) has been largely medical after negative findings from trials evaluating open craniotomy for hematoma evacuation. Location of hemorrhage has always been a determinant of outcome in ICH. This has ramifications for outcomes after minimally invasive (MIS) evacuation. We present analysis of ICH outcome after endoscopic evacuation stratified by hemorrhage location. METHODS Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit previously published clinical criteria including age = 18, National Institutes of Health Stroke Scale (NIHSS) = 6, hematoma volume = 15, and baseline modified Rankin Score (mRS) = 3 with a computed tomography angiography (CTA) negative for vascular malformation. Retrospective review was performed on patients who were treated in a single health system from December 2015 to August 2018. Hematoma location was stratified as deep or lobar. Univariate analysis and multivariate logistic regression were performed on demographic, radiographic, and clinical outcomes including the location variable with 6 mo mRS as the primary outcome measure. RESULTS Univariate analysis revealed patients with lobar hemorrhage had significantly better initial admission Glasgow Coma Scale (GCS) (11.7 vs 8.9, P < .0001) and NIHSS score (13.7 vs 19.6, P < .0001) but significantly higher preoperative volume (64.1 vs 41.4, P = .001). Those with lobar hemorrhage also had significantly lower neurosurgical and hospital length of stay (8.1 vs 12.9, P = .003 and 16.9 vs 29.0, P = .02, respectively) and higher rate of 6 mo functional independence as defined by mRS 0 to 3 (68.6% vs 31.2%, P = .001). Multivariate analysis showed lobar location was a significant predictor of functional independence at 6 mo (OR 12.8, P = .003). CONCLUSION In our experience, lobar hemorrhage is a predictor of good outcome after endoscopic ICH evacuation. Current and future trials may benefit from stricter patient selection and further studies are needed to confirm the effect of hemorrhage location on outcome.

scholarly journals Marijuana: Proposed Treatment in Trauma Patients

2017 ◽  
Vol 2 (1) ◽  
Keyword(s):  
Injury Severity ◽  
Hospital Costs ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Publication Date ◽  
Trauma Patients ◽  
Severity Scores ◽  
Standardized Treatment ◽  
Cannabinoid Hyperemesis Syndrome ◽  
Key Phrases

Background: A standardized treatment approach for trauma patients who test positive for marijuana/THC does not currently exist in the literature. Several medications are recommended to treat withdrawal and the cannabinoid hyperemesis syndrome. Methods: A literature search was conducted through Medline and PUBMED following PRISMA guidelines. Key phrases searched for included “marijuana treatment, trauma marijuana patients, and THC interactions with other medications”. Article selection was based on relevance, with focus on diagnosis and management of marijuana positive patients. All studies, regardless of publication date, were considered due to the paucity of published literature. Results: Of the 1853 studies identified, 24 were selected to have material relevant and useful to this review. Both retrospective and prospective reports were identified in order toclosely examine the relationship between marijuana use and Injury Severity Scores, hospital length of stay, and related hospital costs. Limitations: Limitations of this article are similar to all PRISMA-guided review articles: the dependence on previously published research and availability of references as outlined in our methodology. Conclusion: Patients experiencing marijuana withdrawal should be evaluated for divalproex to reduce marijuana cravings; nefazodone to decrease anxiety and muscle pain; and lofexidine to improve sleep as well as help address withdrawal related stress. Administration of benzodiazepines can be considered to limit aggression. Lorazepam and haloperidol have been shown to be effective for cannabinoid hyper emesis syndrome. All trauma patients should receive tobacco, alcohol, and drug screening, followed by reflex confirmatory blood testing to increase accuracy. Patients testing positive for marijuana should be individually addressed, since cannabis and cannabinoids have been found to alter anesthetic potency. In addition, all marijuana/THC patients should undergo counseling in an effort to reduce use and prevent further morbidity and use related complications.

scholarly journals Tracheostomy Practice in Mechanically Ventilated Patients With SARS-CoV-2 Induced Acute Respiratory Distress Syndrome: a Single-center Retrospective Study With Focus on Tracheomalacia

2021 ◽  
Author(s):  
Marcello Guarnieri ◽  
Patrizia Andreoni ◽  
Hedwige Gay ◽  
Riccardo Giudici ◽  
Maurizio Bottiroli ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Invasive Mechanical Ventilation ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Single Center ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Factors Associated ◽  
Ventilated Patients

Abstract Background: The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare, but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. Aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence.Methods. Retrospective, single-center study performed in an Italian teaching hospital. All adult patients admitted to the Intensive Care Unit (ICU) between February 24 and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, while information regarding airway management was collected daily.Results. A total of 151 patients were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 39.7%. A tracheostomy was performed in 73 (48.3%) patients: open surgical technique in 54 patients (74%) and percutaneous Ciaglia technique in 19 patients (26%). Patients in whom a tracheostomy was performed had, compared to the other patients, a longer duration of mechanical ventilation and longer ICU and hospital length of stay. Tracheomalacia was diagnosed in 8 (5%) patients. The factors associated with tracheomalacia were female sex, obesity, and tracheostomy.Conclusions. In our population, approximately 50% of patients with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized patients had a longer ICU and hospital length of stay. Five percent of our population was diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature and the underlying mechanisms are not fully understood.

Abstract 9: Predictors of Poor Outcome in Patients Not Thrombolysed Due to Mild or Resolving Symptoms ("Too Good To Treat")

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Syed F Ali ◽  
Urooba Faheem ◽  
Aneesh B Singhal ◽  
Anand Viswanathan ◽  
Scott B Silverman ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Time Frame ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Factors Associated ◽  
Poor Outcome ◽  
Poor Outcomes ◽  
Iv Tpa

Introduction: A common reason for exclusion of patients with acute ischemic stroke presenting within the time frame for IV tPA is that they are “too good to treat” due to rapidly improving or mild symptoms. Several studies have reported poor outcomes in this group which motivated us to evaluate patient factors associated with poor outcomes. Methods: Using our institutional GWTG database, we analyzed 2,745 consecutive stroke admissions (01/2009 - 07/2013). Univariate and multivariable analysis were carried out to determine factors associated with poor outcome, defined as not being discharged home. Results: Of the total 2,745 patients, 306 (11.1%) presented within the window for IV tPA but did not receive the treatment due to symptoms too mild or rapidly improving as judged by the treating team. Of these 306, 64.1% were discharged home, 26.5% to IRF, 7.2% to SNF and 2.9% expired/hospice. Patients with poor outcome were older, more frequently Hispanic and presented with more vascular risk factors such as hypertension, diabetes, CAD, PAD and atrial fibrillation than good outcome patients. They also had higher median initial NIHSS. Patients in both groups had similar adherence to early antithrombotics, dysphagia screening and DVT prophylaxis. Poor outcome patients had higher rates of in-hospital complications and a longer hospital length of stay (Table 1). On univariate analysis, factors associated with poor outcome included age [OR 1.50 (1.30 - 1.70), p<0.0001], ethnicity [4.15 (1.25 - 13.81), p=0.020], diabetes mellitus [1.91 (1.11 - 3.29), p=0.019], atrial fibrillation [1.82 (1.02 - 3.25), p=0.042], PAD [9.02 (1.04 - 78.20), p=0.046], NIHSS [1.16 per point (1.06 - 1.27), p=0.001], in-hospital pneumonia (all cases had poor outcome) or UTI [7.04 (1.92 - 25.81), p=0.003]. In multivariable analysis, only age [1.50 (1.30 - 1.70), p<0.0001], ethnicity [6.61 (1.83 - 23.85), p=0.004], NIHSS [1.14 per point (1.04 - 1.26), p=0.007] and UTI [7.30 (1.72 - 31.00), p=0.007] remained significant. Conclusion: A substantial percentage of patients deemed “too good” for IV tPA were unable to be discharged home. Factors such as advanced age and higher NIHSS should be considered in tPA decision-making to optimize outcomes. Large, multi-center prospective studies are underway to study the predictors of poor outcomes in this group.

scholarly journals Surgical Treatment of Costal Cartilage Fractures With Titanium Plate Internal Fixation

2021 ◽  
Author(s):  
Yang Li ◽  
Yonghong Zhao ◽  
Yi Yang ◽  
Weiming Wu ◽  
Xiang Guo ◽  
...  
Keyword(s):  
Internal Fixation ◽  
Costal Cartilage ◽  
Good Prognosis ◽  
Hospital Length ◽  
Pain Severity ◽  
Hospital Length Of Stay ◽  
Titanium Plate ◽  
Severity Scores ◽  
Significant Difference

Abstract Background: This study aim to evaluate surgical procedures for titanium plate internal fixation of costal cartilage fractures with displacement or nonunion. Methods: From January 2019 to October 2020, 13 patients with costal cartilage fractures were treated with titanium plate internal fixation in the thoracic surgery department of the Shanghai Sixth People’s Hospital. Pain severity scale scores and respiratory function were evaluated preoperatively and postoperatively. All the patients had a 6-month follow-up for treatment evaluation. Results: The mean hospital length of stay was 10.7 days. A statistically significant difference (P < 0.05) was found between preoperative and postoperative pain severity scores( 7.69 vs. 5.00). VC (24.6% vs. 44.5%) and FEV1 (25.3% vs. 44.0%) were also significantly different before operation and after operation (P<0.05). At follow-up, healing of the nonunion or fracture was confirmed in all the cases. Conclusion: The rigid titanium plate application ensured a safe and easy management of costal cartilage fractures and nonunion with a good prognosis as compared with other methods.

scholarly journals Clinical Characteristics and Outcomes of Critically Ill Mechanically Ventilated Patients Receiving Adjunctive Ketamine for Sedation: an Investigator-Driven, Open-Label, Randomized, Controlled Trial

2021 ◽  
Author(s):  
Marwa Amer ◽  
Mohammed Bawazeer ◽  
Khalid Maghrabi ◽  
Kamel Alshaikh ◽  
Mohammad Shaban ◽  
...  
Keyword(s):  
Clinical Characteristics ◽  
Primary Outcome ◽  
Controlled Trial ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Adherence Rate ◽  
Consent Rate ◽  
Open Label ◽  
Icu Patients ◽  
Mechanically Ventilated

AbstractBackgroundKetamine has been shown to decrease sedative requirements in intensive care unit (ICU). Randomized trials are lacking on patient-centered outcomes. We aimed to compare the clinical characteristics and outcomes of mechanically ventilated adult ICU patients receiving ketamine as an adjunct analgosedative with those receiving standard of care (SOC) alone. We also described the feasibility during COVID-19 pandemic.MethodsIn this randomized, open-label trial either ketamine or SOC, in a 1:1 ratio, was administered to patients who were intubated within 24 hours (medical, surgical, or transplant/oncology ICUs), expected to require mechanical ventilation (MV) for the next calendar day, and had the institutional pain and sedation protocol initiated. Ketamine infusion was 2 μg/kg/min on day 1 and 1 μg/kg/min on day 2. The primary outcome was the 28-day MV duration and ventilator-free days as co-primary outcome. Cox-proportional regression analysis was used to assess factors associated with probability for weaning off MV.ResultsA total of 83 patients (43 in SOC and 40 in ketamine) were included. Demographics were balanced between the groups. The median duration of MV was not significantly different between the groups [median (interquartile range): 7 (3-9.25) for ketamine and 5 (2-8) for SOC, p= 0.15]. The median ventilation-free days was 19 days (IQR 0-24.75) in the ketamine and 19 days (IQR 0-24) in the SOC (p=0.70). Surgical and transplant/oncology ICU patients had a higher probability of weaning off MV than those in medical ICU [hazard ratio (95% confidence interval): 2.09 (1.06–4.14) for surgical ICU, 2.11 (1.02–4.35) for transplant/oncology ICU]. More patient was at goal RASS in ketamine compared to SOC. The sedatives and vasopressors cumulative doses were similar between the two arms at 48 hours. We found no difference in 28-day mortality rate, ICU and hospital length of stay, and hemodynamic changes. The consent rate was adequate and the protocol adherence rate was 97.5%.ConclusionsKetamine as an adjunct agent for sedation did not decrease the duration of MV and appeared to be safe, feasible, and effective in subgroups of ICU patients. No effect was noted in sedative and pressors requirements, or on hemodynamics.Trial registrationClinicalTrials.gov: NCT04075006 and current-controlled trials: ISRCTN14730035

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