Sedation Vacations in Neurocritical Care: Friend or Foe?

PURPOSE OF REVIEW: To evaluate the role of sedation vacations in optimizing patient outcomes and enhancing the quality of care in neurological intensive care units (ICUs). We discuss the importance of sedation management in neurocritical care, considering recent research findings and clinical guidelines. RECENT FINDINGS: Recent studies have highlighted the significance of sedation interruption protocols in improving patient outcomes in the ICU setting. Evidence suggests that daily sedation interruptions can reduce the duration of mechanical ventilation, ICU length of stay, and mortality rates. However, the implementation of these protocols requires careful consideration of patient-specific factors and a multidisciplinary approach. Sedation vacations play a critical role in neurocritical care by reducing mechanical ventilation duration, ICU stay length, and mortality rates. Despite the benefits, the presence of complications must be addressed to avoid adverse outcomes. Continued research is necessary to refine these strategies and improve guideline quality, ensuring safe and effective sedation management in critically ill neurological patients.

The relationship between positive end-expiratory pressure (PEEP) and intra-abdominal pressure (IAP) in mechanically ventilated patients: A prospective observational study.

BACKGROUND: Positive end-expiratory pressure is a crucial mechanical breathing parameter. Intra-abdominal hypertension is well defined as a sustained increase in the intra-abdominal pressure ≥12 mmHg. There are still controversies about mechanical ventilation's effect and use of positive end-expiratory pressure on intra-abdominal pressure. AIMS: We aimed to delineate the relationship between positive end-expiratory pressure and intra-abdominal pressure in mechanically ventilated patients admitted to the intensive care units of a large tertiary hospital in Upper Egypt. STUDY DESIGN: This study was a prospective observational study. The study was conducted at a university hospital from October 2023 to February 2024. The enrolled adult patients were allocated into two groups based on their positive end-expiratory pressure: group I, low pressure (<8 cm H2O) and group II, high pressure (8-10 cm H2O). RESULTS: A total of 120 patients were enrolled, 60 patients in each group. The most commonly encountered diagnoses were pneumonia (32/120, 26.7%) and acute respiratory distress syndrome (ARDS) (31/120, 25.8%), respectively. There was a significant difference between the intra-abdominal pressure mean values of the two patient groups, 18.9 ± 3.3 versus 24.4 ± 5.9 mmHg in the group of low versus high pressure (correlation value of .454, p < .001), respectively. There were highly significant correlations between intra-abdominal pressure categories and the patient groups (correlation value of .495, p < .001). There were 24 (40%) versus 0 (0%) patients of high pressure versus low pressure within the category IV group of intra-abdominal hypertension (>25 mmHg). CONCLUSIONS: We observed a significant relationship between positive end-expiratory pressure and intra-abdominal pressure in mechanically ventilated patients. The patient group with high pressure had higher mean values compared with the group with low pressure. The study highlights the importance of closely monitoring intra-abdominal pressure in mechanically ventilated patients who receive positive end-expiratory pressure. Further studies are warranted. RELEVANCE TO CLINICAL PRACTICE: The relationship between positive end-expiratory pressure and intra-abdominal pressure is an essential issue in daily critical care nursing clinical practice. Considering the occurrence of multiple organ dysfunction as a result of a non-detected increase in intra-abdominal pressure, critical care nurses should pay attention to measuring this pressure to maintain intra-abdominal pressures that are safe for mechanically ventilated and critically ill intensive care unit patients, thereby preventing these undue effects.

Independent Risk Factors and Economic Burden Associated With Delayed Extubation Following Pediatric Liver Transplantation.

BACKGROUND: Successful early extubation (EE) after liver transplant (LT) has been shown to reduce intensive care unit (ICU) and hospital length of stay and infectious, vascular, and sedation-related complications in adults. EE may not always be feasible in children, and many may require prolonged mechanical ventilation. Limited data exists regarding the candidacy of EE, risk factors, consequences, and hospital costs of delayed extubation (DE) in pediatric LT. METHODS: We conducted a retrospective review to investigate predictive factors and associated costs of EE and DE in infants and children after orthotopic LT at our institution between 2011 and 2021. RESULTS: Of 338 LT (median age 39 months, 54% females), 246 (73%) had EE (within 24 h of LT), while 27% had DE. Age < 1 year (p = 0.0019), diagnosis of biliary atresia (0.02), abnormal pre-LT echocardiogram (0.02), and patients with ongoing hospital admission before LT (0.0001) were independently associated with DE. Hospital costs were significantly (∼3-fold) higher (p < 0.0001) in the DE group. In addition, factors associated with increased total hospital costs were age < 1 year and hospitalization before LT. CONCLUSION: EE post-LT is feasible and merits a trial. The prevalence of DE though modest is associated with increased resource utilization and hospital costs. Children who can be extubated early and those at risk for DE can be identified pre-operatively for optimal planning and allocation of resources.

Towards an improved wind effect assessment for asbestos abatement: A methodology for reduced-scale experiments.

During building renovation or demolition, asbestos fibers can be released which can contaminate the environment, leading to potential occupational health and public health concerns. Strict asbestos abatement procedures and regulations are in place to mitigate this risk, which involve sealing the worksite and depressurizing it relative to the outdoor environment (i.e., indoor pressure lower than the outdoor pressure) using mechanical ventilation. However, the depressurization of the containment can be breached by the effects of the wind. Hence, it is essential to identify which wind conditions are problematic and how to prevent their effects. To conduct corresponding laboratory measurements, it is first required to scale down the building and its containment zone including a working mechanical ventilation system. This paper presents an innovative methodology for conducting reduced-scale experiments on buildings equipped with mechanical ventilation systems for contaminant containment. The methodology, here explained in the context of asbestos abatement, could also be applied to any other type of particulate pollutant. The methodology of this research study includes the design of a mechanical ventilation system for depressurization; a method to scale down the building and the ventilation system for testing in a wind tunnel; and 3D steady Reynolds averaged Navier-Stokes (RANS) simulations for optimizing the positioning of the ventilation components. The methodology is applied for a single-zone building including its ventilation system, which is found to achieve the targeted indoor depressurization of -40 Pa, making it ready for wind tunnel tests.

Evaluation of lung homogeneity in neonates and small infants during general anaesthesia using electrical impedance tomography: a prospective observational study.

Background: Prolonged mechanical ventilation can create heterogeneous ventilation patterns, which increase the risk of lung injury in infants. However, little is understood about the risk of brief exposure to mechanical ventilation during anaesthesia. The aim of this prospective observational study was to describe the regional pattern of lung ventilation during general anaesthesia in healthy neonates and infants, using electrical impedance tomography. Methods: Twenty infants (age 3 days to 12 months), without known lung disease and receiving general anaesthesia with endotracheal intubation for supine positioned surgery, were included in the study. Anaesthesia and ventilation management was at the discretion of the treating clinician. Standardised lung imaging using electrical impedance tomography was made at six time points during anaesthesia from induction to post-extubation. At each time point, the gravity-dependent and right-left lung centre of ventilation was calculated. Results: Tidal ventilation favoured the dorsal lung regions at induction, with a median (inter-quartile range) centre of ventilation (CoV) of 58.2 (53.9-59.3)%. After intubation, there was a redistribution of ventilation to the ventral lung, with the greatest change occurring early in surgery: CoV of 53.8 (52.3-55.2)%. After extubation, CoV returned to pre-intubation values: 56.5 (54.7-58)%. Across all time points, the pattern of ventilation favoured the right lung. Conclusions: General anaesthesia creates heterogenous patterns of ventilation similar to those reported during prolonged mechanical ventilation. This potentially poses a risk for lung injury that may not be recognised clinically. These results suggest the need to better understand the impact of general anaesthesia on the developing lung. Clinical trial registration: Australian New Zealand Clinical Trials Registry (ACTRN 12616000818437, 22 June 2016).

Early deep-to-light sedation versus continuous light sedation for ICU patients with mechanical ventilation: a cohort study.

BACKGROUND: Sedation strategies have not been well established for patients being treated with invasive mechanical ventilation (MV). This study aimed to compare the potential effects of alternative sedation strategies - including early deep-to-light sedation (DTLS), continuous deep sedation (CDS) and continuous light sedation (CLS, the currently recommended strategy) - on ventilator, intensive care unit (ICU) or hospital mortality. METHODS: A cohort study was conducted using two large validated ICU databases, including the Registry of Healthcare-associated Infections in ICUs in China (ICU-HAI) and the Medical Information Mart for Intensive Care (MIMIC). Patients who received MV for more than 3 days with one of three sedation strategies were included. Multivariable survival analyses with inverse probability-weighted competing risk models were conducted separately for ICU-HAI and MIMIC cohorts. Adjusted estimates were pooled using fixed-effects models. RESULTS: In total, 6700 patients (2627 ICU-HAI, 4073 MIMIC) were included in the cohort study, of whom 2689 received CLS, 2079 CDS and 1932 DTLS. Compared to CLS, DTLS was associated with lower ICU mortality (9.3% vs. 11.0%; pooled adjusted HR 0.78, 95% CI 0.66-0.94) and hospital mortality (16.0% vs. 14.1%; 0.86, CI 0.74-1.00); and CDS was associated with higher ventilator mortality (32.8% vs. 7.0%; 4.65, 3.91-5.53), ICU mortality (40.6% vs. 11.0%; 3.39, 2.95-3.90) and hospital mortality (46.8% vs. 14.1%; 3.27, 2.89-3.71) than CLS. All HRs were qualitatively consistent in both cohorts. CONCLUSIONS: Compared to the continuous light sedation, early deep-to-light sedation strategy was associated with improved patient outcomes, and continuous deep sedation was confirmed with poorer patient outcomes.

Long-term lung function recovery after ECMO versus non-ECMO management in acute respiratory failure: a systematic review and meta-analysis.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is increasingly employed to support lung function in patients with acute respiratory failure (ARF). However, the long-term outcomes of the approach have not been encouraging when compared to those of conventional mechanical ventilation. Further, the long-term effects of ECMO on lung function and recovery are unclear. For this review, we examined the long-term lung function outcomes of patients with ARF treated with and without ECMO. METHODS: We searched the Embase, CENTRAL, Web of Science, and PubMed sites for studies comparing long-term (≥ 6 months) pulmonary function test results in patients with ARF treated with and without ECMO published until January 2024. We conducted a meta-analysis for percentage predicted values. RESULTS: We included five studies. Our meta-analysis showed similar values of forced vital capacity (FVC%) (MD, 0.47; 95% CI, -3.56-4.50) and forced expiratory flow in the first second % (MD, 1.79; 95% CI, -2.17-5.75) in patients with ARF treated with or without ECMO. The FEV1/FVC % values were slightly higher in patients treated with ECMO than in those without ECMO (MD, 2.03; 95% CI, 0.01-4.04; p-value = 0.05). According to the meta-analysis, the values for total lung capacity % (MD, -3.20; 95% CI, -8.83-2.44) and carbon monoxide diffusion capacity % (MD, -0.72; 95% CI, -3.83-2.39) were also similar between patients undergoing ECMO and those without it. CONCLUSION: The meta-analysis of a small number of studies with significant selection bias indicates that patients with ARF treated with ECMO may have comparable long-term pulmonary function recovery to those treated with conventional strategies. Further investigations including a larger number of patients and focusing on the long-term impact of ECMO are needed to supplement the current evidence.

Comparison of Web-Based and On-Site Lung Simulators for Education in Mechanical Ventilation.

BACKGROUND: Training in mechanical ventilation is a key goal in critical care fellowship education. Web-based simulators offer a cost-effective and readily available alternative to traditional on-site simulators. However, it is unclear how effective they are as teaching tools. In this study, we evaluated the test scores of fellows who underwent mechanical ventilation training by using a web-based simulator compared with fellows who used an on-site simulator during a mechanical ventilation course. METHODS: This was a nonrandomized controlled trial conducted as part of a mechanical ventilation course that involved 70 first-year critical care fellows. The course was identical except for the simulation technology used. One group of instructors used a traditional on-site simulator, the ASL 5000 Lung Solution (n = 39). The second group was instructed in using a web-based simulator, VentSim (n = 31). Each fellow completed a pre-course test and a post-course test by using a validated, case-based ventilator waveform examination that consisted of 5 questions with a total possible score of 100. The primary outcome was a comparison of the mean scores on the posttest between the 2 groups. The study was designed as a non-inferiority trial with a predetermined margin of 10 points. RESULTS: There was no significant difference in the mean ± SD pretest scores between the web-based and the on-site groups (21.1 ± 12.6 and 26.9 ± 13.6 respectively; P = .11). The mean ± SD posttest scores were 45.6 ± 25.0 for the web-based simulator and 43.4 ± 16.5 for on-site simulator (mean difference 2.2; one-sided 95% CI -7.0 to ∞; P non-inferiority = .02 [non-inferiority confirmed]). Changes in mean ± SD scores (posttest - pretest) were 25.9 ± 20.9 for the web-based simulator and 16.5 ± 15.9 for the on-site simulator (mean difference 9.4, one-sided 95% CI 0.9 to ∞; P non-inferiority < .001 [non-inferiority confirmed]). CONCLUSIONS: In the education of first-year critical care fellows on mechanical ventilation waveform analysis, a web-based mechanical ventilation simulator was non-inferior to a traditional on-site mechanical ventilation simulator.

Family-Led Coaching of Patients During Weaning From Sedation and Mechanical Ventilation in the ICU.

BACKGROUND: ICU patients are weaned from sedation and mechanical ventilation through spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs). Weaning can be distressing for patients and their families. Family-led coaching could reassure patients and reduce stress for families by engaging them in patient care. This study developed and piloted a family-led coaching tool to support patients undergoing SATs/SBTs. METHODS: Patient and family member dyads were recruited from 2 medical-surgical ICUs in Calgary, Canada (February 3-August 1, 2023). Surveys were administered to collect family (1) demographics, (2) anxiety and satisfaction with ICU care, (3) feedback on the tool, and (4) attitudes about family presence during SATs/SBTs (also collected from clinicians). Tool feasibility was determined by calculating the proportions of (1) eligible patients who were recommended for participation in the study by clinicians and (2) families approached who consented to participate in the study. RESULTS: One thousand one hundred fifty patients were admitted to the study ICUs during the study period of which 819 received mechanical ventilation, and 42 were recommended by bedside clinicians for participation in the study. Twenty-five dyads were approached, 21 dyads consented to participate, and one withdrew consent before data collection. Of the enrolled families, 12 (60%) reported the coaching tool to be useful, and 5 (25%) recommended minor suggestions such as "shortening" the tool. Fourteen (70%) families reported positive experiences (through open-ended feedback) with being present for the SAT/SBT. State-Trait Anxiety Inventory (Y1) scores (scale range 20-80 points) significantly decreased in families from the first (pre coaching) to the second (post coaching) measures (mean decrease 8.2 points, SD 10.3, P = .001). All clinicians indicated they were comfortable with family presence and/or coaching during SATs/SBTs. CONCLUSION: Family-led coaching of patients during SATs/SBTs appears to be feasible, favorably perceived by families and clinicians, and potentially associated with lower family anxiety.

Evaluation of Dexmedetomidine Withdrawal and Management After Prolonged Infusion.

PURPOSE: Dexmedetomidine is often used for longer than its labeled indication of 24 hours, raising concerns for potential withdrawal. Data are limited regarding this syndrome in adult patients. This study aimed to further characterize dexmedetomidine withdrawal in critically ill adult patients after prolonged use. METHODS: This was an institutional review board-approved, single-center, retrospective chart review conducted at a tertiary academic medical center. Adult intensive care unit (ICU) patients on dexmedetomidine for ≥72 hours in 2019 were screened for inclusion. Exclusion criteria were interruption of dexmedetomidine for >6 hours, indications for dexmedetomidine other than sedation, or patients with neurological or burn injury. The major end point was the incidence of dexmedetomidine withdrawal, defined as meeting ≥2 of the following criteria within 24 hours of discontinuation: newly positive Confusion Assessment Method for ICU, Richmond Agitation Sedation Scale score of ≥+2, hypertension, and tachycardia. Minor end points were incidence of individual withdrawal signs as previously described, additional sedatives or antipsychotics required, dose and duration of dexmedetomidine infusion, length of ventilation, ICU and hospital length of stay, and new onset of the following: fever, vomiting, loose stools/diarrhea, diaphoresis, or seizure. FINDINGS: Of the 152 patients included, dexmedetomidine withdrawal occurred in 54 patients (35.5%). Rebound hypertension was the most common withdrawal sign (47 patients [87.0%]). In the withdrawal group, significantly more patients required additional ß-blockers (29 [53.7%] vs 10 [10.2%]; P < 0.01), were reinitiated on dexmedetomidine (16 [29.6%] vs 10 [10.2%]; P < 0.01), and required a start or increased dose of clonidine (6 [11.1%] vs 3 [3.1%]; P = 0.04). There was no significant difference in the cumulative dose or duration of dexmedetomidine between the groups. Length of ventilation was longer in the withdrawal group (171 hours [83.7-280.8 hours] vs 159 hours [149.0-335.7 hours]; P < 0.01), but there was no difference in ICU or hospital length of stay. IMPLICATIONS: Prolonged use of dexmedetomidine was associated with withdrawal syndrome in 35.5% of patients in our study. Larger trials are needed to confirm the risk factors for dexmedetomidine withdrawal and identify measures to prevent withdrawal.

Prone position applied to COVID-19 patients: Systematic review-meta-analysis.

BACKGROUND: Position change and interventions to increase lung capacity should be considered in mechanically ventilated patients. The most effective of these is the prone position. AIM: This systematic review and meta-analysis aimed to determine the effects of the prone position on respiratory parameters and outcomes and to guide nurses working in the intensive care unit. STUDY DESIGN AND METHODS: This systematic review-meta-analysis was conducted in accordance with the Preferred Reporting in Systematic Reviews and Meta-Analyses guideline. ScienceDirect, CINAHL, Academic Search Complete (EBSCOhost), MEDLINE, EMBASE, Web of Science, Cochrane and PubMed databases were searched between January 2022 and January 2023 to access studies related to prone position in COVID-19 patients. RESULTS: Twenty-three studies were included. This meta-analysis shows that a prone position is feasible and can achieve improvements in gas exchange. Prone position increases PaO2/FiO2 in the majority of patients followed with a diagnosis of COVID-19 and severe hypoxemic. CONCLUSIONS: The study has shown that the prone position is effective in improving patients' respiratory function and oxygenation. RELEVANCE TO CLINICAL PRACTICE: The results presented in this article support the notion that the prone position can be an effective strategy in the clinical management of COVID-19 patients.

Serum glucose/potassium ratio as an indicator of early and delayed outcomes of acute carbon monoxide poisoning.

BACKGROUND: Carbon monoxide (CO) poisoning is a major health problem associated with a high rate of severe morbidity and mortality. AIMS: This study aimed to evaluate the validity of the serum glucose/potassium (Glu/K) ratio as a quick predictor of both early and delayed unfavorable outcomes following acute CO poisoning. PATIENTS AND METHODS: This prospective cohort study included 136 patients with acute CO poisoning admitted at Tanta Poison Control Center, Egypt, between January 2023 and June 2024. The serum Glu/K ratio was calculated for all patients. The primary outcome was a prediction of mortality. Secondary outcomes were the prediction of delayed neurological sequelae (DNS) within six months after CO exposure, the need for mechanical ventilation, and the need for hyperbaric oxygen. A receiver operating curve analysis was applied to test the performance of the Glu/K ratio in predicting acute CO poisoning outcomes. RESULTS: The mortality rate was 12.5% of patients with acute CO poisoning. Meanwhile, 14.7% of patients developed DNS. Furthermore, mechanical ventilation was required in 16.9% of patients. An elevated Glu/K ratio was significantly associated with the severity of acute CO poisoning. At a cut-off value of >31.62, the Glu/K ratio demonstrated an AUC of 0.649 for predicting mortality. The Glu/K ratio was employed to predict DNS at a cut-off value of 33.10, with a sensitivity of 60.0%, a specificity of 82.76%, and an AUC of 0.692. CONCLUSIONS: Early Glu/K ratio may be an effective, reliable, and convenient laboratory predictor of mortality, DNS, and the need for mechanical ventilation in patients with acute CO poisoning.

Development and validation of a novel nomogram for predicting mechanical ventilation after cervical spinal cord injury.

OBJECTIVE: This study aimed to investigate the risk factors relating to the need for mechanical ventilation (MV)in isolated cervical spinal cord injury (cSCI) patients and to construct a nomogram prediction model. DESIGN: Retrospective analysis study. PARTICIPANTS: A total of 5784 patients (N=5784) who had a cSCI were admitted to the National Spinal Cord Injury Model System database (NSCID) between 2006 and 2021. SETTING: NSCID observation data was initially collected during rehabilitation hospitalization. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): A univariate and multivariate logistic regression analysis was used to identify the independent factors affecting the use of MV in cSCI patients, these independent influencing factors were used to develop a nomogram prediction model. The area under the receivers operating characteristic curve (AUROC), calibration curve and decision curve analysis (DCA) were employed to evaluate the efficiency and the clinical application value of the model respectively. RESULTS: In a series of 5784 included patients, 926 cases (16.0%) were admitted to spinal cord model system inpatient rehabilitation with the need of MV. Logistic regression analysis demonstrated that associated injury, American Spinal Cord Injury Association (ASIA) impairment scale (AIS), the sum of unilateral optimal motor scores for each muscle segment of upper extremities (sUEM) and neurological level of injury (NLI) were independent predictors of the use of MV (p<0.05). The prediction nomogram of MV usage in cSCI patients was established based on the above independent predictors. The AUROC of the training set, internal verification set and external verification set were 0.871 (0.857-0.886), 0.867 (0.843-0.891) and 0.850 (0.824-0.875) respectively. The calibration curve and DCA results showed that the model had a good calibration and clinical practicability. CONCLUSION: The nomograph prediction model based on sUEM, NLI, associated injury and AIS can accurately and effectively predict the risk of MV in cSCI patients, to help clinicians screen high-risk patients and formulate targeted intervention measures.

Differences between women and men in prolonged weaning.

BACKGROUND: In recent years, the importance of sex as a factor influencing medical care has received increasing attention in the field of intensive care medicine. The objective of this study was to examine the influence of sex in prolonged weaning. METHODS: A retrospective analysis of patients undergoing prolonged weaning at Thoraxklinik, University Hospital Heidelberg between 12/08 and 12/23 was conducted. Patients with neuromuscular diseases were excluded from the analyses. The risk factors for weaning failure in men and women were identified through stepwise cox-regression analyses. RESULTS: A total of 785 patients were included, of whom 313 (39.9%) were women. 77.9% of the women and 75.4% of the men were successfully weaned from invasive ventilation. In group comparisons and multivariable analyses, sex was not found to be a risk factor for weaning failure. Cox regression analyses were performed separately for both sexes on the outcome of weaning failure, adjusting for relevant covariates. The results indicated that age ≥ 65 years (HR 2.38, p < 0.001) and the duration of IMV before transfer to the weaning centre (HR 1.01/day, p < 0.001) were independent risk factors in men. In women, however, the duration of IMV before transfer (HR 1.01, p < 0.001), previous non-invasive ventilation (HR 2.9, p 0.005), the presence of critical illness polyneuropathy (HR 1.82; p = 0.040) and delirium (HR 2.50, p = 0.017) were identified as relevant risk factors. In contrast delirium was associated with a favourable weaning outcome in men (HR 0.38, p = 0.020) and nosocomial pneumonia as a reason for prolonged weaning in women (HR 0.43; p = 0.032). CONCLUSION: The analyses indicate that there are sex-based differences in the risk factors associated with weaning failure. Further studies, ideally prospective, should confirm these findings to assess whether sex is a factor that should be taken into account to improve weaning outcomes.

Impact of mechanical power on ICU mortality in ventilated critically ill patients: a retrospective study with continuous real-life data.

BACKGROUND: Over the past decade, numerous studies on potential factors contributing to ventilation-induced lung injury have been carried out. Mechanical power has been pointed out as the parameter that encloses all ventilation-induced lung injury-contributing factors. However, studies conducted to date provide data regarding mechanical power during the early hours of mechanical ventilation that may not accurately reflect the impact of power throughout the period of mechanical ventilatory support on intensive care unit mortality. METHODS: Retrospective observational study conducted at a single center in Spain. Patients admitted to the intensive care unit, > o = 18 years of age, and ventilated for over 24 h were included. We extracted the mechanical power values throughout the entire mechanical ventilation in controlled modes period from the clinical information system every 2 min. First, we calculate the cutoff-point for mechanical power beyond which there was a greater change in the probability of death. After, the sum of time values above the safe cut-off point was calculated to obtain the value in hours. We analyzed if the number of hours the patient was under ventilation with a mechanical power above the safe threshold was associated with intensive care unit mortality, invasive mechanical ventilation days, and intensive care unit length of stay. We repeated the analysis in different subgroups based on the degree of hypoxemia and in patients with SARS CoV-2 pneumonia. RESULTS: The cut-off point of mechanical power at with there is a higher increase in intensive care unit mortality was 18 J/min. The greater the number of hours patients were under mechanical power > 18 J/min the higher the intensive care unit mortality in all the study population, in patients with SARS CoV-2 pneumonia and in mild to moderate hypoxemic respiratory failure. The risk of death in the intensive care unit increases 0.1% for each hour with mechanical power exceeding 18 J/min. The number of hours with mechanical power > 18 J/min also affected the days of invasive mechanical ventilation and intensive care unit length of stay. CONCLUSIONS: The number of hours with mechanical power > 18 J/min is associated with mortality in the intensive care unit in critically ill patients. Continuous monitoring of mechanical power in controlled modes using an automated clinical information system could alert the clinician to this risk.

Phenotypes based on respiratory drive and effort to identify the risk factors when P0.1 fails to estimate ∆PES in ventilated children.

BACKGROUND: Monitoring respiratory effort and drive during mechanical ventilation is needed to deliver lung and diaphragm protection. Esophageal pressure (∆PES) is the gold standard measure of respiratory effort but is not routinely available. Airway occlusion pressure in the first 100 ms of the breath (P0.1) is a readily available surrogate for both respiratory effort and drive but is only modestly correlated with ∆PES in children. We sought to identify risk factors for P0.1 over or underestimating ∆PES in ventilated children. METHODS: Secondary analysis of physiological data from children and young adults enrolled in a randomized controlled trial testing lung and diaphragm protective ventilation in pediatric acute respiratory distress syndrome (PARDS) (NCT03266016). ∆PES (∆PES-REAL), P0.1 and predicted ∆PES (∆PES-PRED = 5.91*P0.1) were measured daily to identify phenotypes based upon the level of respiratory effort and drive: one passive (no spontaneous breathing), three where ∆PES-REAL and ∆PES-PRED were aligned (low, normal, and high effort and drive), two where ∆PES-REAL and ∆PES-PRED were mismatched (high underestimated effort, and overestimated effort). Logistic regression models were used to identify factors associated with each mismatch phenotype (High underestimated effort, or overestimated effort) as compared to all other spontaneous breathing phenotypes. RESULTS: We analyzed 953 patient days (222 patients). ∆PES-REAL and ∆PES-PRED were aligned in 536 (77%) of the active patient days. High underestimated effort (n = 119 (12%)) was associated with higher airway resistance (adjusted OR 5.62 (95%CI 2.58, 12.26) per log unit increase, p < 0.001), higher tidal volume (adjusted OR 1.53 (95%CI 1.04, 2.24) per cubic unit increase, p = 0.03), higher opioid use (adjusted OR 2.4 (95%CI 1.12, 5.13, p = 0.024), and lower set ventilator rate (adjusted OR 0.96 (95%CI 0.93, 0.99), p = 0.005). Overestimated effort was rare (n = 37 (4%)) and associated with higher alveolar dead space (adjusted OR 1.05 (95%CI 1.01, 1.09), p = 0.007) and lower respiratory resistance (adjusted OR 0.32 (95%CI 0.13, 0.81), p = 0.017). CONCLUSIONS: In patients with PARDS, P0.1 commonly underestimated high respiratory effort particularly with high airway resistance, high tidal volume, and high doses of opioids. Future studies are needed to investigate the impact of measures of respiratory effort, drive, and the presence of a mismatch phenotype on clinical outcome. TRIAL REGISTRATION: NCT03266016; August 23, 2017.

Management of analgosedation during noninvasive respiratory support: an expert Delphi consensus document developed by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI).

BACKGROUND: Discomfort can be the cause of noninvasive respiratory support (NRS) failure in up to 50% of treated patients. Several studies have shown how analgosedation during NRS can reduce the rate of delirium, endotracheal intubation, and hospital length of stay in patients with acute respiratory failure. The purpose of this project was to explore consensus on which medications are currently available as analgosedatives during NRS, which types of patients may benefit from analgosedation while on NRS, and which clinical settings might be appropriate for the implementation of analgosedation during NRS. METHODS: The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects of the use of analgesics and sedatives during NRS treatment. The methodology applied is in line with the principles of the modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales which were then subjected to blind votes for consensus. RESULTS: The use of an analgosedation strategy in adult patients with acute respiratory failure of different origins may be useful where there is a need to manage discomfort. This strategy should be considered after careful assessment of other potential factors associated with respiratory failure or inappropriate noninvasive respiratory support settings, which may, in turn, be responsible for NRS failure. Several drugs can be used, each of them specifically targeted to the main component of discomfort to treat. In addition, analgosedation during NRS treatment should always be combined with close cardiorespiratory monitoring in an appropriate clinical setting. CONCLUSIONS: The use of analgosedation during NRS has been studied in several clinical trials. However, its successful application relies on a thorough understanding of the pharmacological aspects of the sedative drugs used, the clinical conditions for which NRS is applied, and a careful selection of the appropriate clinical setting.

Risk factors for postoperative delirium in adult patients undergoing cardiopulmonary bypass in cardiac surgery.

OBJECTIVE: To identify risk factors for postoperative delirium in adult patients undergoing cardiopulmonary bypass. METHODS: The medical records of 214 patients who underwent cardiopulmonary bypass at the First Affiliated Hospital of Hunan Normal University from January 2022 to January 2024 were retrospectively analyzed. Based on the occurrence of postoperative delirium, patients were divided into a delirium group (49 cases) and a non-delirium group (165 cases). Outcome measures, including clinical baseline data, preoperative left ventricular ejection fraction (LVEF), preoperative Acute Physiology and Chronic Health Evaluation II (APACHE II) score, anesthesia duration, surgery duration, aortic cross-clamp duration, intraoperative mean arterial pressure (MAP), intraoperative blood loss, length of intensive care unit (ICU) stay, postoperative mechanical ventilation duration, as well as postoperative MAP, were compared between the two groups. Logistic regression analysis was performed to identify the potential factors associated with post-operative delirium in patients. RESULTS: Of the included 214 patients, 49 patients experienced delirium, resulting in an incidence of 22.90%. The delirium group had significantly lower LVEF and significantly higher APACHE II scores compared to the non-delirium group (all P<0.001). No significant difference was observed between the two groups in terms of anesthesia duration, surgery duration, aortic cross-clamp duration, intraoperative MAP, and intraoperative blood loss (all P>0.05). The delirium group experienced significantly longer length of ICU stay and postoperative mechanical ventilation duration as compared to the non-delirium group (all P<0.001), but no significant difference was observed in terms of postoperative MAP between the two groups (P>0.05). Logistic regression analysis identified preoperative New York Heart Association classification (NYHA) (OR: 6.755, 95% CI: 2.529-18.039, P<0.001), preoperative LVEF (OR: 6.886, 95% CI: 2.383-19.899, P<0.001), preoperative APACHE II score (OR: 7.788, 95% CI: 2.740-22.135, P<0.001), length of ICU stay (OR: 9.463, 95% CI: 3.563-25.135, P<0.001), and postoperative mechanical ventilation duration (OR: 9.744, 95% CI: 3.419-27.768, P<0.001) as independent factors influencing the occurrence of delirium in adult patients undergoing cardiopulmonary bypass. CONCLUSION: Postoperative delirium is a prevalent complication among patients undergoing cardiac surgery. Independent risk factors for postoperative delirium in adult patients undergoing cardiopulmonary bypass during cardiac surgery include preoperative NYHA class III or IV, lower LVEF, higher APACHE II score, an extended length of stay in the ICU, and prolonged postoperative mechanical ventilation duration.

Comparison of Dynamic and Static Compliance in Two Ventilation Methods with Tidal Volume of 6 and 10 ml/kg: Randomized Clinical Trial.

Background: Pulmonary compliance is an important lung factor and is affected by tidal volume. In this study, static and dynamic compliance with tidal volumes of 6 and 10 ml/kg have been evaluated in patients undergoing abdominal cancer surgery. Methods: This randomized clinical trial was conducted on 50 patients who were candidate for abdominal cancer surgery. This study was done in patients aged 20-65 years without chronic diseases. After induction of anesthesia, the first group was ventilated with a tidal volume of 10 ml/kg and 8 breaths/minute, and also the second group was ventilated with a tidal volume of 6 mL/kg and 14 breaths/minute. From the beginning and every 15 minutes, expiratory tidal volume, peak and plateau airway pressure, heart rate and blood pressure were measured for two hours. The data was analyzed with SPSS v.20 and P < 0.05 was meaningful. Results: There was no significant difference between the two groups for demographic characteristics. There was no significant difference between the two groups in the dynamic and static compliance of the patients during the study. However, the static compliance decreased in the 6 ml/kg group and increased in the 10 ml/kg group, but the difference was not statistically significant (P = 0.32). The peak, plateau pressure and hemodynamic parameters were the same in the two groups. Conclusion: In general, the static and dynamic compliance was not significantly different in the two groups despite a slight decrease in the 6 ml/kg group and a slight increase in the 10 ml/kg group.