Frequency and Analysis of Unplanned Extubation in Coronavirus Disease 2019 Patients.

OBJECTIVES: To determine if patients with coronavirus disease 2019 had a greater number of unplanned extubations resulting in reintubations than in patients without coronavirus disease 2019. DESIGN: Retrospective cohort study comparing the frequency of unplanned extubations resulting in reintubations in a group of coronavirus disease 2019 patients to a historical (noncoronavirus disease 2019) control group. SETTING: This study was conducted at Henry Ford Hospital, an academic medical center in Detroit, MI. The historical noncoronavirus disease 2019 patients were treated in the 68 bed medical ICU. The coronavirus disease 2019 patients were treated in the coronavirus disease ICU, which included the 68 medical ICU beds, 18 neuro-ICU beds, 32 surgical ICU beds, and 40 cardiovascular ICU beds, as the medical ICU was expanded to these units at the peak of the pandemic in Detroit, MI. PATIENTS: The coronavirus disease 2019 cohort included patients diagnosed with coronavirus disease 2019 who were intubated for respiratory failure from March 12, 2020, to April 13, 2020. The historic control (noncoronavirus disease 2019) group consisted of patients who were admitted to the medical ICU in the year spanning from November 1, 2018 to October 31, 2019, with a need for mechanical ventilation that was not related to surgery or a neurologic reason. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: To identify how many patients in each cohort had unplanned extubations, an electronic medical records query for patients with two intubations within 30 days was performed, in addition to a review of our institutional quality and safety database of reported self-extubations. Medical charts were manually reviewed by board-certified anesthesiologists to confirm each event was an unplanned extubation followed by a reintubation within 24 hours. There was a significantly greater incidence of unplanned extubations resulting in reintubation events in the coronavirus disease 2019 cohort than in the noncoronavirus disease 2019 cohort (coronavirus disease 2019 cohort: 167 total admissions with 22 events-13.2%; noncoronavirus disease 2019 cohort: 326 total admissions with 14 events-4.3%; p < 0.001). When the rate of unplanned extubations was expressed per 100 intubated days, there was not a significant difference between the groups (0.88 and 0.57, respectively; p = 0.269). CONCLUSIONS: Coronavirus disease 2019 patients have a higher incidence of unplanned extubation that requires reintubation than noncoronavirus disease 2019 patients. Further study is necessary to evaluate the variables that contribute to this higher incidence and clinical strategies that can reduce it.

Novel combination of impella and extra corporeal membrane oxygenation as a bridge to full recovery in fulminant myocarditis.

A 31-year-old male was transferred to our hospital with severe heart failure due to viral myocarditis. He progressed to multiorgan failure requiring intubation and maximal doses of multiple vasopressors. Circulatory support was provided with an Impella device as a bridge to an extracorporeal membrane oxygenation (ECMO) system. On full mechanical cardiovascular support, the patient's hemodynamic status improved and ECMO and Impella were explanted after 48 hours. Three days later, he was extubated and continued on to a full recovery. There are no specific therapies for fulminant myocarditis but first-line treatment is supportive care. ECMO is commonly used in patients with severe heart failure. In severe systolic dysfunction, left ventricular decompression is required to reduce myocardial wall stress, decrease myocardial oxygen requirements, and enhance the chances of recovery. The Impella, an active support system, is less invasive than classical decompressive techniques and is associated with lower requirements for blood products with fewer thromboembolic complications. This is the only case reported of the contemporary use of Impella and ECMO as a bridge to full recovery in an adult with myocarditis. It also presents a novel use of the Impella device in decompressing the left ventricle of an adult patient on ECMO.

Sleep in the intensive care unit.

Adequate sleep, in terms of both quantity and quality, is an essential component of any overall health program. Sleep deprivation has serious deleterious effects on any subject, regardless of species. The most obvious and well-documented adverse effects of sleep deprivation are focused on cognitive function, cardiopulmonary function, and the immune system. Despite these deleterious effects of sleep deprivation, even on healthy subjects, intensive care patients are rarely permitted sufficient natural sleep. The causes of sleep disturbance in the intensive care unit involve factors related to the underlying clinical condition, those due to the various drugs required to provide treatment and comfort, and those related to the environment and processes of care in the intensive care unit. Only through a comprehensive approach to intensive care can an environment that promotes sleep and revitalization be constructed and maintained.

Assessment and management of patients with pulmonary disease.

OBJECTIVE: Often, the critically ill are not optimized in terms of their chronic diseases and are with little physiologic reserves. DATA SOURCES: This article contains a review of the pathophysiology of the major preexisting and chronic pulmonary disease encountered in the critically ill, such as asthma, emphysematous disease, and chronic bronchitis. It also includes a summary of other significant disease processes such as acute respiratory disease syndrome, cigarette smoking, and pulmonary alveolar proteinosis and the implications of obesity and obstructive sleep apnea. When confronted with critical illness, the morbidity is magnified. Close observation of patients for evidence that the underlying disease may complicate their pulmonary status, and vice versa, creates an environment where the whole patient can heal and recover from illness. CONCLUSION: The aim of the intensive care unit team should be recognition of the patient at risk, use of necessary therapies (i.e., bronchodilators) as early as feasible, and treatment titrated to realistic endpoints as the acute illness progresses and subsequently resolves.

Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies--American College of Critical Care Medicine Task Force 2001-2002.

OBJECTIVE: To develop clinical practice guidelines for the use of restraining therapies to maintain physical and psychological safety of adult and pediatric patients in the intensive care unit. PARTICIPANTS: A multidisciplinary, multispecialty task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM), the Society of Critical Care Medicine (SCCM), and the American Association of Critical Care Nurses (AACN). EVIDENCE: The task force members reviewed the published literature (MEDLINE articles, textbooks, etc.) and provided expert opinion from which consensus was derived. Relevant published articles were reviewed individually for validity using the Cochrane methodology (http://hiru.mcmaster.ca/cochrane/ or www.cochrane.org). CONSENSUS PROCESS: The task force met as a group and by teleconference to identify the pertinent literature and derive consensus recommendations. Consideration was given to both the weight of scientific information within the literature and expert opinion. Draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft then was reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. CONCLUSIONS: The task force developed nine recommendations with regard to the use of physical restraints and pharmacologic therapies to maintain patient safety in the intensive care unit.