Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES).

OBJECTIVE: To study if protocolized monitoring of endotracheal tube (ETT) cuff pressure every 6 hours is better than adjusting endotracheal tube cuff inflation by the only bedside clinical assessment. MATERIALS AND METHODS: This was a single-center prospective randomized controlled study done between July 1, 2017 and March 31, 2019. Children between 1 month and 18 years, intubated with cuffed ETT by our trained doctors were included. After obtaining consent, patients were randomized into two groups, standard group (SG) and cuff pressure monitoring group (MG). Sample size was calculated with 80 patients in each group with a power of 80%, significance level (alpha 0.05 and beta 0.2). In the SG, ETT cuff inflation was adjusted by clinical assessment (bedside minimal leak technique and monitoring the percentage of leak displayed on ventilator display) at 6 hours interval. In the MG, cuff pressures were monitored by the device every 6 hours to maintain between 20 and 25 mm Hg. RESULTS: Out of 543 mechanically ventilated children during the study period, 266 were eligible and randomized for study. During the study, 89 patients died and 17 were left against medical advice, leaving 80 patients in each group. Incidence of post-extubation stridor (PES), re-intubation rate, ventilator-associated pneumonia (VAP) rate, ventilator days, and length of pediatric intensive care unit (PICU) stay were analyzed and found no advantage of protocolized monitoring of cuff pressures in the reduction of any of the above variables. CONCLUSION: Our findings if confirmed by large multicentric studies can bring an end to routine ETT cuff pressure measurements and emphasize more on clinical assessment. Clinical trial registry (CTRI/2019/05/019098).Indian Journal of Critical Care Medicine (2021): 10.5005/jp-journals-10071-23737. HOW TO CITE THIS ARTICLE: Shaikh F, Janaapureddy YR, Mohanty S, Reddy PK, Sachane K, Dekate PS, et al. Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES). Indian J Crit Care Med 2021;25(2):181-184.

Electromagnetic device-device interaction between a new generation implantable pacemaker and left ventricular assist device: recognition and potential solutions.

An electromagnetic interaction between St. Jude Medical Inc. (St. Paul, MN, USA) permanent pacemakers and HeartMate II left ventricular assist devices (LVADs) (Thoratec Inc., Pleasanton, CA, USA) has been reported before, but the problem was thought to be resolved in the St. Jude Medical's most recently released pacemaker platform. We report a case of interference between the HeartMate II LVAD and the most recently released St. Jude Medical pacemaker (model no. PM3210; Anthem) and review new developments to overcome the electromagnetic interference problem in this setting.

Meta-analysis: effect of patient self-testing and self-management of long-term anticoagulation on major clinical outcomes.

BACKGROUND: Anticoagulation with vitamin K antagonists reduces major thromboembolic complications in at-risk patients. With portable monitoring devices, patients can conduct their own international normalized ratio testing and dose adjustment at home. PURPOSE: To determine whether patient self-testing (PST), alone or in combination with self-adjustment of doses (patient self-management [PSM]), is associated with a reduction in thromboembolic complications and all-cause mortality without an increase in major bleeding events compared with usual care. DATA SOURCES: MEDLINE and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Studies published in English from 1966 to October 2010 that enrolled outpatient adults receiving long-term (>3 months) oral anticoagulant therapy and that compared PST or PSM with care in a physician's office or an anticoagulation clinic were included. DATA EXTRACTION: Two investigators reviewed each article. Three investigators extracted data from articles that met inclusion criteria by using standardized data abstraction forms. Studies were assessed for quality, and the overall strength of evidence was rated for each clinical outcome. DATA SYNTHESIS: Twenty-two trials, with a total of 8413 patients, were included. In one half of the trials, fewer than 50% of potentially eligible persons successfully completed the training and agreed to be randomly assigned. Patients randomly assigned to PST or PSM had lower total mortality (Peto odds ratio [OR], 0.74 [95% CI, 0.63 to 0.87]), lower risk for major thromboembolism (Peto OR, 0.58 [CI, 0.45 to 0.75]), and no increased risk for a major bleeding event (Peto OR, 0.89 [CI, 0.75 to 1.05]). The strength of evidence was moderate for the bleeding and thromboembolism outcomes but low for mortality. Eight of 11 trials reported that patient satisfaction, quality of life, or both was better with PST or PSM than with usual care. LIMITATIONS: In one half of the trials, fewer than 50% of the potentially eligible patients were randomly assigned. Only 5 trials were considered high quality, and only 2 were conducted in the United States. No studies addressed whether PST or PSM is safe during the high-risk initiation phase. CONCLUSION: Compared with usual care, PST with or without PSM is associated with significantly fewer deaths and thromboembolic events, without increased risk for a serious bleeding event, for a highly selected group of motivated adult patients requiring long-term anticoagulation with vitamin K antagonists. Whether this care model is cost-effective and can be implemented successfully in typical U.S. health care settings requires further study. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs Health Services Research and Development Service.

Serum Procalcitonin Concentration and Its Relationship with Local Manifestations after Snakebites.

The local signs and symptoms following snakebites are similar to those of cellulitis caused by bacterial infections. This leads to empirical treatment with antibiotics, which however is not supported by evidence. Procalcitonin (PCT) is a biomarker with good diagnostic accuracy for bacterial infection. We studied serum PCT concentration in 100 patients aged 13 years or more, presenting to the hospital with significant local manifestations (crossing the joint proximal to the bitten wound) within 24 hours after snakebite. The extent and progression of local manifestations were monitored 12 hourly. Baseline PCT measurement was carried out for all patients and measurement was repeated 12 hourly only in those patients with progressive local manifestations. The median interqartile range PCT concentration did not differ significantly by the severity of local manifestation at presentation (Grade 2 = 0.28 [0.26-0.30]; Grade 3 = 0.28 [0.26-0.32]; Grade 4 = 0.27 [0.26-0.32] ng/mL; P = 0.15). Furthermore, we did not observe an increase in PCT concentration on serial estimation in those with progressive local manifestation (0.28, 0.29, and 0.29 ng/mL) over 36 hours. These observations suggest that the local manifestations following snakebites were not caused by bacterial infection.

Management of severe rheumatological disease in the burn center.

In recent years, Burn Center has evolved to become a "wound intensive care unit" treating disease processes other than those due to thermal injury. Recent data have shown that more than 16% of admissions to Burn Centers are for nonburn injuries, particularly severe dermatologic diseases. The role of the Burn Center has been expanded to include treatment of patients with severe cutaneous manifestations of rheumatologic diseases. This approach has not been described before. All collagen vascular disease admissions to the Burn Center from 2005 to 2010 have been reviewed. There were 16 admissions where intensive wound management was a major component of the disease management. Disease processes included systemic lupus erythematosus, progressive systemic sclerosis, Raynaud's phenomenon, antiphospholipid syndrome, and dermatomyositis, among others. The authors describe five of these cases in detail. Comanagement of these patients by the Rheumatology and Burn services led to outstanding, successful outcomes. Collagen vascular diseases represent another area where the Burn Center may be the appropriate site for therapy.