Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes.

OBJECTIVES: The epidemiology of unplanned extubations (UEs) and associated adverse outcomes in pediatric cardiac ICUs (CICU). DESIGN: Registry data (August 2014 to October 2020). SETTING: Forty-five Pediatric Cardiac Critical Care Consortium hospitals. PATIENTS: Patients receiving mechanical ventilation (MV) via endotracheal tube (ETT). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-six thousand five hundred eight MV courses occurred in 36,696 patients, with a crude UE rate of 2.8%. In cardiac surgical patients, UE was associated with longer duration of MV, but we failed to find such association in medical patients. In both cohorts, UE was associated with younger age, being underweight, and airway anomaly. In multivariable logistic regression, airway anomaly was associated with UE in all patients. Younger age, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category, longer duration of MV, and initial oral rather than nasal ETT are associated with UE in the surgical group, but we failed to find such associations in the medical group. UE was associated with a higher reintubation rate compared with elective extubation (26.8 vs 4.8%; odds ratio [OR], 7.35; 95% CI, 6.44-8.39; p < 0.0001) within 1 day of event. After excluding patients having redirection of care, UE was associated with at least three-fold greater odds for each of ventilator-associated pneumonia (VAP), cardiac arrest, and use of mechanical circulatory support (MCS). However, we failed to identify an association between UE and greater odds of mortality (1.2 vs 0.8%; OR, 1.48; 95% CI, 0.86-2.54; p = 0.15), but uncertainty remains. CONCLUSIONS: UE in CICU patients is associated with greater odds of cardiac arrest, VAP, and MCS. Cardiac medical and surgical patients in the CICU appear to have different explanatory factors associated with UE, and perhaps these may be modifiable and tested in future collaborative population research.

Short-term exposure to ambient fine particulate pollution aggravates ventilator-associated pneumonia in pediatric intensive care patients undergoing cardiovascular surgeries.

BACKGROUND: Ambient air pollutants can be hazardous to human health, especially for vulnerable children. The impact of ambient air pollutant exposure before and during intensive care unit (ICU) stays on the development of ventilator-associated pneumonia (VAP) in critically ill children has not been established. We aimed to determine the correlations between short-term exposures to ambient fine particulate matter (PM2.5) and VAP in pediatric cardiac surgery patients in the ICU, and explore the effect of delayed exposure. METHODS: The medical record of 1755 child patients requiring artificial ventilation in the ICU between December 2013 to December 2020, were analyzed. The daily average concentrations of particulate matters (PM2.5 and PM10), sulfur dioxide (SO2), and ozone (O3) were calculated from public data. Interactions between these pollutants and VAP were simulated with the distributed lag non-linear model. RESULTS: Three hundred forty-eight cases (19.829%) of VAP were identified in this study, while the average concentrations of PM2.5, PM10, O3 and SO2 were 58, 118, 98 and 26 µg/m3, respectively. Exposure to increased levels of PM2.5 two days prior (lag 2-day) to VAP diagnosis is significantly correlated with an enhanced risk for VAP development. Even a slight increase of 10 µg/m3 in PM2.5 can translate to a 5.4% increase in VAP incidence (95% CI: 1.4%-9.5%) while the VAP incidence increased to 11.1% (95%CI: 4.5-19.5%) when PM2.5 concentration is well below the National Ambient Air Quality standard (NAAQS) of 50 µg/m3. The association was more pronounced in those aged below 3-months, with low body mass index or suffered from pulmonary arterial hypertension. CONCLUSION: Short-term PM2.5 exposure is a significant risk for development of VAP in pediatric patients. This risk is present even with PM2.5 levels below the NAAQS. Ambient PM2.5 may represent a previously unrecognized risk factor for pneumonia and the current environmental pollution standards need to be reevaluated to consider susceptible populations. TRIAL REGISTRATION: The trial was registered with the National Clinical Trial Center: The correlation between ambient air pollution and the complications in ICU underwent cardiac surgery. TRIAL REGISTRATION NUMBER: ChiCTR2000030507. Date of registration: March 5, 2020. URL of trial registry record: http://www.chictr.org.cn/index.aspx .

Clinical predictors of mortality in patients with pseudomonas aeruginosa infection.

BACKGROUND: Infections caused by Pseudomonas aeruginosa are difficult to treat with a significant cost and burden. In Lebanon, P. aeruginosa is one of the most common organisms in ventilator-associated pneumonia (VAP). P. aeruginosa has developed widespread resistance to multiple antimicrobial agents such as fluoroquinolones and carbapenems. We aimed at identifying risk factors associated for P. aeruginosa infections as well as identifying independent risk factors for developing septic shock and in-hospital mortality. METHODS: We used a cross-sectional study design where we included patients with documented P. aeruginosa cultures who developed an infection after obtaining written consent. Two multivariable regression models were used to determine independent predictors of septic shock and mortality. RESULTS: During the observed period of 30 months 196 patients were recruited. The most common predisposing factor was antibiotic use for more than 48 hours within 30 days (55%). The prevalence of multi-drug resistant (MDR) P. aeruginosa was 10%. The strongest predictors of mortality were steroid use (aOR = 3.4), respiratory failure (aOR = 7.3), identified respiratory cultures (aOR = 6.0), malignancy (aOR = 9.8), septic shock (aOR = 18.6), and hemodialysis (aOR = 30.9). CONCLUSION: Understanding resistance patterns and risk factors associated with mortality is crucial to personalize treatment based on risk level and to decrease the emerging threat of antimicrobial resistance.

Risk factors of second ventilator-associated pneumonia in trauma patients: a retrospective cohort study.

BACKGROUND: Ventilator acquired pneumonia (VAP) is a frequent and serious complication in ICU. Second episodes of VAP are common in trauma patients and may be related to severity of underlying conditions, treatment or bacterial factors of the first VAP. The aim of this study was to identify risk factors of second VAP episodes in trauma injured patients (defined as the development of a new pulmonary infection during or remotely following the first episode). DESIGN: This is a single-center, retrospective cohort study of trauma injured patients who underwent a first episode of VAP between January 1, 2013 and December 31, 2020 at Beaujon Hospital. RESULTS: A total of 533 patients with a first episode of VAP were analyzed, mostly with head and/or thoracic traumatic injury. A second episode of VAP occurred in one hundred sixty-seven patients (31.3%). The main risk factors found was the degree of hypoxemia at the time of the first episode [PaO2/FiO2 ratio 100-200, OR 3.12 (1.77-5.69); < 100, OR 5.80 (2.70-12.8)] and severe traumatic brain injury characterized by an initial GCS ≤ 8 [OR 1.65 (1.01-2.74)]. CONCLUSION: Depth of hypoxemia during the first VAP episode and severity of the initial brain injury are the main risk factors for VAP second episode in trauma injured patients.

Do Antibiotics Prevent Infectious Complications in Critically Injured Patients With Blunt Nonoperative Midfacial Trauma?

BACKGROUND: While recent literature suggests antibiotics are not needed in patients with nonoperative facial fractures involving sinuses, the existing studies do not focus on critically injured patients who are known to be at higher risk for sinusitis and ventilator-associated pneumonia, which could be exacerbated by facial fractures. PURPOSE: The purpose of this study was to determine if antibiotics reduce the rate of infectious complications in critically injured patients who have blunt midfacial trauma treated nonoperatively. STUDY DESIGN, SETTING, SAMPLE: The authors conducted a retrospective cohort study consisting of patients admitted to the trauma intensive care unit who sustained blunt midfacial injuries managed nonoperatively at an urban Level 1 trauma center from August 13th, 2012, to July 30th, 2020. Adults who were critically injured on admission and sustained a midfacial fracture involving a sinus were included in the study. Patients who underwent operative repair of any facial fracture were excluded. PREDICTOR VARIABLE: The predictor variable was the use of antibiotics. MAIN OUTCOME VARIABLE: The primary outcome variable was the development of infectious complications, such as sinusitis, soft tissue infection, or any type of pneumonia, including ventilator-associated pneumonia (VAP). ANALYSES: The data were analyzed using Wilcoxon rank sum tests, Fisher exact tests, and multivariable logistic regression as appropriate for analysis type with significance level set at <0.05. RESULTS: The study included 307 patients, with a mean age of 40.6 years. Men accounted for 85.0% of the study population. Antibiotics were administered to 229 (74.6%) of the study population. Complications developed in 13.6% of the patients, which included sinusitis (0.3%), VAP (7.5%), and other types of pneumonia (5.9%). Clostridioides difficile colitis developed in 2 patients (0.6%). Antibiotics were not associated with a decrease in infectious complications in either the unadjusted analysis (13.1% in antibiotic group, 15.4% in no antibiotic group, RR = 0.85 [95% confidence interval = 0.5 to 1.6], P = .7) or the adjusted analysis (odds ratio 0.74 [0.34 to 1.62]). CONCLUSIONS AND RELEVANCE: Even in this critically injured patient population thought to be at elevated risk for infectious complications from their midfacial fractures, the rates of infectious complications in those who received antibiotics and those who did not were no different. These results suggest that consideration of more judicious use of antibiotics is warranted in critically ill patients with nonoperative midface fractures.

A prospective comparative study of the functional results associated with the use of Björk flap tracheostomy versus standard tracheostomy.

BACKGROUND: Placement of a tracheostomy for patients requiring prolonged mechanical ventilation (PMV) improves patients' comfort, decreases dead space ventilation, allows superior airway hygiene, and reduces the incidence of ventilator-associated pneumonia. Controversy still exists regarding the role of standard tracheostomy (ST) as opposed to the less frequently done Björk flap tracheostomy (BFT). This study compares the functional outcomes of these two techniques. STUDY DESIGN: Seventy-nine patients receiving tracheostomy in a 12-month period: 38 BFT vs. 41 ST. Data included demographics, indications for PMV, ventilator days before tracheostomy, time to and a number of patients who passed the fiberoptic endoscopic evaluation of swallowing (FEES), time to and a number of patients decannulated. RESULTS: Indications in both groups were PMV from trauma (18/38 vs 15/41), pneumonia (13/38 vs 13/41), and ARDS (7/38 vs 11/4), respectively (p > 0.05). Patients in both groups did not differ with regard to age, sex, GCS, duration of PMV before tracheostomy, the time to and a number of patients who passed the 1st FEES. However, the number of days and the number of FEES required before the next successful FEES in the 20 BFT and 21 ST patients who failed the 1st was 9 (4) vs. 16 (5), and 2 (1) vs. 4 (1), respectively (p < 0.05). Additionally, the number of intraoperative complications in aggregate were 0/38 in the BFT as opposed to 6/41 in the ST group (p < 0.05). CONCLUSION: We conclude that BFT may be associated with an overall shorter time to restoration of normal swallowing when compared to ST.

Construction and Validation of a Predictive Model for the Risk of Ventilator-Associated Pneumonia in Elderly ICU Patients.

Background: Ventilator-associated pneumonia (VAP) is among the most important hospital-acquired infections in an intensive-care unit setting. However, clinical practice lacks effective theoretical tools for preventing VAP in the elderly. Aim: To describe the independent factors associated with VAP in elderly intensive-care unit (ICU) patients on mechanical ventilation (MV) and to construct a risk prediction model. Methods: A total of 1851 elderly patients with MV in ICUs from January 2015 to September 2019 were selected from 12 tertiary hospitals. Study subjects were divided into a model group (n = 1219) and a validation group (n = 632). Two groups of patients were divided into a VAP group and a non-VAP group and compared. Univariate and logistic regression analyses were used to explore influencing factors for VAP in elderly ICU patients with MV, establish a risk prediction model, and draw a nomogram. We used the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test to evaluate the predictive effect of the model. Findings regarding the length of ICU stay, surgery, C-reactive protein (CRP), and the number of reintubations were independent risk factors for VAP in elderly ICU patients with MV. Predictive-model verification results showed that the area under the curve (AUC) of VAP risk after MV in the modeling and verification groups was 0.859 and 0.813 (P < 0.001), respectively, while P values for the Hosmer-Lemeshow test in these two groups were 0.365 and 0.485, respectively. Conclusion: The model could effectively predict the occurrence of VAP in elderly patients with MV in ICUs. This study is a retrospective study, so it has not been registered as a clinical study.

Early pneumonia diagnosis decreases ventilator-associated pneumonia rates in trauma population.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a source of morbidity and mortality for trauma patients. Aspiration events are also common because of traumatic brain injury, altered mental status, or facial trauma. In patients requiring mechanical ventilation, early pneumonias (EPs) may be erroneously classified as ventilator associated. METHODS: A prospective early bronchoscopy protocol was implemented from January 2020 to January 2022. Trauma patients intubated before arrival or within 48 hours of admission underwent bronchoalveolar lavage (BAL) within 24 hours of intubation. Patients with more than 100,000 colony-forming units on BAL were considered to have EP. RESULTS: A total of 117 patients underwent early BAL. Ninety-three (79.5%) had some growth on BAL with 36 (30.8%) meeting criteria for EP. For the total study population, 29 patients (24.8%) were diagnosed with VAP later in their hospital course, 12 of which had previously been diagnosed with EP. Of EP patients (n = 36), 21 (58.3%) were treated with antibiotics based on clinical signs of infection. Of EP patients who had a later pneumonia diagnosed by BAL (n = 12), seven (58.3%) grew the same organism from their initial BAL. When these patients were excluded from VAP calculation, the rate was reduced by 27.6%. Patients with EP had a higher rate of smoking history (41.7% vs. 19.8%, p < 0.001) compared with patients without EP. There was no difference in median hospital length of stay, intensive care unit length of stay, ventilator days, or mortality between the two cohorts. CONCLUSION: Early pneumonia is common in trauma patients intubated within the first 48 hours of admission and screening with early BAL identifies patients with aspiration or pretraumatic indicators of pneumonia. Accounting for these patients with early BAL significantly reduces reported VAP rates. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Nursing care and epidemiological profile of patients with ventilator-associated pneumonia / Cuidados de enfermagem e perfil epidemiológico de pacientes com pneumonia associada à ventilação mecânica / Cuidados de enfermería y perfil epidemiológico de pacientes con neumonía asociada a ventilador

Background and Objectives: to assess the epidemiological profile of patients diagnosed with ventilator-associated pneumonia (VAP) in an Intensive Care Unit (ICU) and to investigate nursing care adequacy. Methods: a quantitative retrospective cohort study, applied in the ICU of a hospital in the countryside of Rio Grande do Sul. It involved 100% of medical records of patients over 20 years of age, in the year 2019, who developed VAP. Results: a total of 3,215 patients were on invasive mechanical ventilation (IMV), and of these 13 developed VAP (2.47%). Most were men (76.92%), with a mean age of 60.3 years, whose main causes of hospitalization were heart problems (30.77%), multiple trauma (30.77%) and stroke (15.39%). The main pathogens found in tracheal aspirates were Acinetobacter sp. (15%) and Pseudomonas aeruginosa (15%). The mean ICU stay was 30.61 days, and 61.53% died. For nursing care assessment, the mean checklist of the VAP bundle applied was calculated, according to the number of days in VMI. The result was 2.62 checklists per day, with the institution recommending four. Conclusion: the study made it possible to know the epidemiological profile of patients with VAP, in addition to observing the need for improvement in nursing care, considering that the checklist completion was below the recommended.(AU)

Justificativa e Objetivos: avaliar o perfil epidemiológico de pacientes diagnosticados com pneumonia associada à ventilação mecânica (PAVM) em Unidade de Terapia Intensiva (UTI) e investigar a adequação dos cuidados de enfermagem. Métodos: estudo quantitativo de coorte, retrospectivo, aplicado na UTI de um hospital do interior do Rio Grande do Sul. Envolveu 100% dos prontuários de pacientes com mais de 20 anos de idade, no ano de 2019, que desenvolveram PAVM. Resultados: estiveram em ventilação mecânica invasiva (VMI) 3.215 pacientes e, desses, 13 desenvolveram PAVM (2,47%). A maioria era homens (76,92%), com média de idade de 60,3 anos, cujas principais causas de internação foram problemas cardíacos (30,77%), politraumatismo (30,77%) e acidente vascular cerebral (15,39%). Os principais patógenos encontrados nos aspirados traqueais foram Acinetobacter sp (15%) e Pseudomonas aeruginosa (15%). A média de permanência na UTI foi de 30,61 dias, e foram a óbito 61,53%. Para avaliação dos cuidados de enfermagem, foi calculada a média de checklist do bundle de PAVM, aplicados, conforme a quantidade de dias em VMI. O resultado foi de 2,62 checklists por dia, sendo que a instituição preconiza quatro. Conclusão: o estudo permitiu conhecer o perfil epidemiológico dos pacientes com PAVM, além de observar a necessidade de melhora nos cuidados de enfermagem, considerando que a realização do checklist ficou abaixo do recomendado.(AU)

Justificación y Objetivos: evaluar el perfil epidemiológico de pacientes con diagnóstico de neumonía asociada a ventilación mecánica (NAVM) en una Unidad de Cuidados Intensivos (UCI) e investigar la adecuación de los cuidados de enfermería. Métodos: estudio de cohorte cuantitativo, retrospectivo, aplicado en el UCI de un hospital del interior de Rio Grande do Sul. Involucró el 100% de las historias clínicas de pacientes mayores de 20 años, en el año 2019, que desarrollaron NAVM. Resultados: un total de 3.215 pacientes estaban en ventilación mecánica invasiva (VMI), y, de estos, 13 desarrollaron NAVM (2,47%). La mayoría eran hombres (76,92%), con una edad media de 60,3 años, cuyas principales causas de hospitalización fueron problemas cardíacos (30,77%), politraumatismos (30,77%) y accidentes cerebrovasculares (15,39%). Los principales patógenos encontrados en los aspirados traqueales fueron Acinetobacter sp (15%) y Pseudomonas aeruginosa (15%). La estancia media en UCI fue de 30,61 días, y falleció el 61,53%. Para la evaluación de la atención de enfermería, se calculó el checklist promedio del bundle VAP aplicado, de acuerdo con el número de días en VMI. El resultado fue de 2,62 checklists por día, y la institución recomendó cuatro. Conclusión: el estudio posibilitó conocer el perfil epidemiológico de los pacientes con NAVM, además de observar la necesidad de mejoría en la atención de enfermería, considerando que el llenado del checklist estuvo por debajo de lo recomendado.(AU)

Major infections following pediatric cardiac surgery pre- and post-CLABSI bundle implementation.

Background: Postoperative infection contributes to the worsening of congenital cardiac surgery (CCS) outcomes. Surgical site infection (SSI), bloodstream infection (BSI) and ventilator associated pneumonia (VAP) are common. An additional bundle of preventive measures against central-line associated bloodstream infection (CLABSI) bundle was implemented in April 2019. Objectives: To compare the incidence of major infections after pediatric CCS before and after the implementation of the CLABSI bundle and to identify risk factors for major infections. Methods: We conducted a single-center, retrospective study to assess the incidence of major infections including bloodstream infection (BSI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP) after pediatric CCS one year before and after implementation of the CLABSI bundle during April 2018-March 2020. The demographics and outcomes of the patients were explored, and risk factors for major infections were identified using multivariate analysis. Results: A total of 548 children (53% male) underwent CCS with a median age of 1.9 years (range 0.01-17.5 years). The median Aristotle Basic Complexity score was 7.1 (range 3-14.5). The CLABSI bundle was applied in 262 patients. Overall mortality was 5.5%. 126 patients (23%) experienced major postoperative infections. During the year after the implementation of the CLABSI bundle, BSI was reduced from 8.4% to 3.1% (p = 0.01), with a smaller reduction in VAP (21% to 17.6%; p = 0.33). The incidence of SSI was unchanged (1.7% to 1.9%; p = 0.77). The independent risk factors for major infections were age at surgery <6 months (p = 0.04), postoperative ventilator usage >2 days (p < 0.01), central line usage >4 days (p = 0.04), and surgery during the pre-CLABSI bundle period (p = 0.01). Conclusion: Following the implementation of the CLABSI prevention package in our pediatric CCS unit, the incidence of BSI was significantly reduced. The incidence of VAP tended to decrease, while the SSI was unchanged. Sustainability of the prevention package through nurse empowerment and compliance audits is an ongoing challenge.

Risk factors for ventilator-associated pneumonia due to multi-drug resistant organisms after cardiac surgery in adults.

BACKGROUND: Ventilator-associated pneumonia (VAP) is one of the most common intensive care unit (ICU)-acquired infections, which can cause multiple adverse events. Due to bacterial mutation and overuse of antimicrobial drugs, multidrug-resistant organisms (MDRO) has become one of the major causes of postoperative VAP infections in cardiac patients. Therefore, this study aims to explore the risk factors for VAP with MDRO following cardiac surgery in adults. METHODS: The clinical data of adult VAP patients following cardiac surgery in the hospital from Jan 2017 to May 2021 were analyzed retrospectively, and the patients were divided into the MDRO VAP group and the non-MDRO VAP group. Univariable and multivariable logistic regression analyses were performed on risk factors in patients with MDRO VAP. The species and drug sensitivity of pathogens isolated from the VAP patients were also analyzed. RESULTS: A total of 61 VAP cases were involved in this study, with 34 cases in the MDRO VAP group (55.7%) and 27 cases in the non-MDRO VAP group (44.3%). Multivariable logistic regression analysis showed that independent risk factors for MDRO VAP included preoperative creatinine clearance rate (CCR) ≥ 86.6ml, intraoperative cardiopulmonary bypass (CPB) time ≥ 151 min, postoperative acute kidney injury (AKI) and nasal feeding. Gram-negative bacilli were the main pathogens in VAP patients (n = 54, 90.0%), with the highest rate of Acinetobacter baumannii (n = 24, 40.0%). Additionally, patients with MDRO VAP had a significantly longer postoperative intensive care unit (ICU) duration and higher hospitalization costs than non-MDRO VAP patients, but there was no notable difference in the 28-day mortality rate between the two groups. CONCLUSION: Based on implementing measures to prevent VAP, clinicians should pay more attention to patients with kidney disease, longer intraoperative CPB time, and postoperative nasal feeding to avoid MDRO infections.

Multidimensional machine learning models predicting outcomes after trauma.

BACKGROUND: An emerging body of literature supports the role of individualized prognostic tools to guide the management of patients after trauma. The aim of this study was to develop advanced modeling tools from multidimensional data sources, including immunological analytes and clinical and administrative data, to predict outcomes in trauma patients. METHODS: This was a prospective study of trauma patients at Level 1 centers from 2015 to 2019. Clinical, flow cytometry, and serum cytokine data were collected within 48 hours of admission. Sparse logistic regression models were developed, jointly selecting predictors and estimating the risk of ventilator-associated pneumonia, acute kidney injury, complicated disposition (death, rehabilitation, or nursing facility), and return to the operating room. Model parameters (regularization controlling model sparsity) and performance estimation were obtained via nested leave-one-out cross-validation. RESULTS: A total of 179 patients were included. The incidences of ventilator-associated pneumonia, acute kidney injury, complicated disposition, and return to the operating room were 17.7%, 28.8%, 22.5%, and 12.3%, respectively. Regarding extensive resource use, 30.7% of patients had prolonged intensive care unit stay, 73.2% had prolonged length of stay, and 23.5% had need for prolonged ventilatory support. The models were developed and cross-validated for ventilator-associated pneumonia, acute kidney injury, complicated dispositions, and return to the operating room, yielding predictive areas under the curve from 0.70 to 0.91. Each model derived its optimal predictive value by combining clinical, administrative, and immunological analyte data. CONCLUSION: Clinical, immunological, and administrative data can be combined to predict post-traumatic outcomes and resource use. Multidimensional machine learning modeling can identify trauma patients with complicated clinical trajectories and high resource needs.

Neumonía asociada a ventilación mecánica en pacientes con neumonía grave por SARS-CoV-2 / Ventilation associated pneumonia in patients with severe SARS-CoV-2 pneumonia

Introducción: Los pacientes con COVID-19 pueden evolucionar hacia una falla respiratoria aguda grave y requerir ventilación mecánica invasiva (VMI). La complicación más frecuente en estos pacientes es la neumonía asociada a ventilación mecánica (NAVM), con incidencias reportadas más altas que en la época pre-COVID. El objetivo de este estudio es reportar la incidencia, tasa de incidencia y microbiología de la NAVM en pacientes en VMI con COVID-19. Métodos: Se incluyeron a todos los pacientes con neumonía grave y PCR (+) para SARS-CoV-2 que ingresaron y requirieron VMI entre marzo y julio del 2021 en el Instituto Nacional del Tórax (INT). Se recolectaron datos demográficos, clínicos y de laboratorio de la ficha electrónica. Se registraron y caracterizaron los casos de neumonía asociado a la ventilación mecánica. Resultados: Se incluyeron 112 pacientes de los cuales el 42,8% presentó NAVM, con una tasa de incidencia de 28,8/1.000 días de VMI. Los microorganismos aislados más frecuentes fueron Klebsiella pneumoniae (29,6%), Staphylococcus aureus (21,8%) y Pseudomonas aeruginosa (12,5%). Los pacientes que cursaron NAVM estuvieron casi el doble de tiempo en VMI, pero sin presentar aumento de la mortalidad. Conclusión: La NAVM es una complicación frecuente en los pacientes con neumonía grave asociada a COVID-19. La microbiología de estas entidades no ha cambiado respecto a la era pre-pandémica. Estos resultados cobran relevancia en el inicio y suspensión de antibióticos en este grupo de pacientes.

Introduction: Patients with COVID-19 can progress to severe acute respiratory failure and require invasive mechanical ventilation (IMV). The most frequent complication in these patients is ventilator-associated pneumonia (VAP), with higher reported incidences than in the pre-COVID era. The objective of this study is to report the prevalence, incidence rate and microbiology of VAP in patients on IMV with COVID-19. Methods: Patients with severe pneumonia and PCR (+) for SARS-CoV-2 who were admitted to IMV between march and july 2021 at the Instituto Nacional del Tórax (Chile) were included. Demographic, clinical and laboratory data from electronic records were collected. Cases of pneumonia associated with mechanical ventilation were recorded and characterized. Results: 112 patients were included, 42.8% of them presented VAP with an incidence rate of 28.8/1,000 IMV days. The most frequent isolated microorganisms were Klebsiella pneumoniae (29.6%), Staphylococcus aureus (21.8%) and Pseudomonas aeruginosa (12.5%). Patients who underwent VAP spent almost twice as long on IMV, although they had not increase in mortality. Conclusion: VAP is a common complication in patients with severe pneumonia associated with COVID-19. The microbiology of these entities has not changed from the pre-pandemic era. These results become relevant in the initiation and suspension of antibiotics in this group of patients.

Time to Look for Another Infectious Source? White Blood Cell Trends during Ventilator-Associated Pneumonia.

Background: Ventilator-associated pneumonia (VAP) continues to plague patients in intensive care units (ICUs) throughout the world. Persistent leukocytosis despite antibiotic treatment for VAP can have many etiologies including normal inflammatory response, inadequate VAP antimicrobial therapy, and the presence of additional infectious diagnoses. Hypothesis: Surgical patients with VAP and a second infectious source have a different white blood cell count (WBC) trend than patients with VAP alone. Patients and Methods: Retrospective, single-center study of surgical ICU patients diagnosed with VAP (>104 CFU/mL on semi-quantitative culture) between January 2019 and June 2020. Chart review identified additional infections diagnosed during VAP treatment. White blood cell count values were compared between patients treated for VAP alone (VAP-alone) and those with additional infections (VAP-plus) using a Wilcoxon test. Univariable analysis compared admission type, surgeries, and steroid use between cohorts. Results: Eighty-eight VAPs were included for analysis; 61 (69%) were VAP-alone and 27 (31%) VAP-plus. Average age was 47.1 ± 16.7 years, 78% were male, and 93% were trauma admissions. Median hospital day of VAP diagnosis was six (interquartile range [IQR], 4-10). Nearly all patients (99%) were started on initial antibiotic agents to which the VAP organism was sensitive. Daily WBC was higher for VAP-plus compared with VAP-alone on days five, six, and seven of treatment. The maximum WBC was higher for VAP-plus (21.6 k/mcL vs. 16.1 k/mcL; p = 0.02). There were no differences in admission types, number of surgeries, or steroid use between groups. Conclusions: Providers should have increased suspicion for additional sources of infection when ICU patients with a VAP continue to have elevated WBC despite appropriate antibiotic therapy.

Comparison of Ventilator-Associated Pneumonia and Surgical Site Infection between Two Methods of Tracheostomy.

Objective: To compare the incidence of ventilator-associated pneumonia (VAP) and surgical site infection (SSI) between percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST). Methods: Data on 487 patients undergoing tracheostomy between 1st January 2014 and 30th September 2020 were reviewed. Patients were divided according to the surgical techniques. Clinical characteristics and postoperative care were compared to explore the risk factors for SSI and VAP. All tracheostomies were performed by intensivists who had completed at least ten tracheostomies. ST was performed using standard techniques. PDT was performed according to a modification technique described by Ciaglia. All procedures were performed at the bedside in the ICU. Results: Of all, 344 patients (70.6%) were men and 143 (29.4%) were women, and the mean age was 56 years (standard derivation [SD] 12 years). Two hundred and sixty-six patients (54.6%) received PDT, and 221 (45.4%) received SY. Patients in the PDT group had a significantly lower rate of SSI (3.4% vs. 8.5%, P = 0.01) compared with the ST group. Multivariate analysis revealed that comorbidities (P = 0.003), surgical type (P = 0.01), and cluster nursing (P < 0.001) were independent risk factors for SSI; age (P = 0.005), comorbidities (P < 0.001), smoking (P = 0.008), and cluster nursing (P = 0.01) were independent risk factors for VAP. Conclusion: PDT significantly reduces the risk of SSI. Proper care should be administrated in patients with one or more risk factors of SSI or VAP to prevent the occurrence of complications.

Ventilator-associated pneumonia and intubation location in adults with traumatic injuries: Systematic review and meta-analysis.

BACKGROUND: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality among critically ill patients, particularly those who present with traumatic injuries. This review aims to determine whether patients with traumatic injuries who are intubated in the prehospital setting are at higher risk of developing VAP compared with those intubated in the hospital. METHODS: A systematic review of Medline, Scopus, and Cochrane electronic databases was conducted from inception to January 2021. Inclusion criteria were patients with traumatic injuries who were intubated in the prehospital or hospital settings with VAP as an outcome. Using a random-effects model, the risk of VAP across study arms was compared by calculating a summary relative risk with 95% confidence intervals. The results of individual studies were also summarized qualitatively. RESULTS: The search identified 754 articles of which 6 studies (N = 2,990) met the inclusion criteria. All studies were good quality based on assessment with the Newcastle Ottawa scale. Prehospital intubation demonstrated an increased risk of VAP development in two of the six studies. Among the six studies, the overall quality weighted risk ratio was 1.09 (95% confidence interval, 0.90-1.31). CONCLUSION: Traumatically injured patients who are intubated in the prehospital setting have a similar risk of developing VAP compared with those that are intubated in the hospital setting. LEVEL OF EVIDENCE: Systematic review and meta-analysis; Level IV.

Association between cuffed tracheal tube use and reduced ventilator-associated pneumonia and conditions after elective cardiac surgery in infants and young children.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a serious complication in children after cardiac surgery that may result from micro-aspiration. However, the current recommendation to use cuffed tracheal tubes (TTs) versus uncuffed TTs in children is still uncertain. Our main aim was to evaluate the incidence of VAP, ventilator-associated tracheobronchitis (VAT) and ventilator-associated conditions (VAC) in children up to five years old who underwent elective cardiac surgery. METHODS: Single-center, prospective before-and-after study at a tertiary pediatric intensive care unit (PICU) in Italy. 242 patients (121 in each group) through the following periods: phase I (from Jan 2017 to 20th Feb 2018), during which children were intubated with uncuffed TTs; phase II (from 21th Feb 2018 to Feb 2019), during which children were intubated with cuffed TTs. RESULTS: Data were collected using an electronic dedicated database. Median age was five months. The use of cuffed tubes reduced the risk of VAC and VAP respectively 15.8 times (95% CI 3.4-73.1, P=0.0008) and 14.8 times (95% CI 3.1-71.5, P=0.002). No major related airway complications were observed in the cuffed TTs group. Average treatment effect, calculated after propensity score matching, confirmed the significant effect of cuffed TTs on VAC and VAP. CONCLUSIONS: Our study suggests a marked reduction of VAP and VAC associated with use of a cuffed versus uncuffed TT in infants and children ≤5 years of age after elective cardiac surgery. A randomized clinical trial is needed to confirm these results and define the impact of use of a cuffed versus uncuffed TT across other relevant ICU outcomes and non-cardiac PICU patients.

Invasive Pulmonary Aspergillosis in Hospital and Ventilator-Associated Pneumonias.

Pneumonia is the commonest nosocomial infection complicating hospital stay, with both non-ventilated hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) occurring frequently amongst patients in intensive care. Aspergillus is an increasingly recognized pathogen amongst patients with HAP and VAP, and is associated with significantly increased mortality if left untreated.Invasive pulmonary aspergillosis (IPA) was originally identified in patients who had been profoundly immunosuppressed, however, this disease can also occur in patients with relative immunosuppression such as critically ill patients in intensive care unit (ICU). Patients in ICU commonly have several risk factors for IPA, with the inflamed pulmonary environment providing a niche for aspergillus growth.An understanding of the true prevalence of this condition amongst ICU patients, and its specific rate in patients with HAP or VAP is hampered by difficulties in diagnosis. Establishing a definitive diagnosis requires tissue biopsy, which is seldom practical in critically ill patients, so imperfect proxy measures are required. Clinical and radiological findings in ventilated patients are frequently non-specific. The best-established test is galactomannan antigen level in bronchoalveolar lavage fluid, although this must be interpreted in the clinical context as false positive results can occur. Acknowledging these limitations, the best estimates of the prevalence of IPA range from 0.3 to 5% amongst all ICU patients, 12% amongst patients with VAP and 7 to 28% amongst ventilated patients with influenza.Antifungal triazoles including voriconazole are the first-line therapy choice in most cases. Amphotericin has excellent antimold coverage, but a less advantageous side effect profile. Echinocandins are less effective against IPA, but may play a role in rescue therapy, or as an adjuvant to triazole therapy.A high index of suspicion for IPA should be maintained when investigating patients with HAP or VAP, especially when they have specific risk factors or are not responding to appropriate empiric antibacterial therapy.

Correlation between Legionella pneumophila serogroups isolated from patients with ventilator-associated pneumonia and water resources: a study of four hospitals in Tehran, Iran.

Legionella pneumophila (L. pneumophila) is one of the main pathogens, causing pneumonia and respiratory tract infections, especially in patients with ventilator-associated pneumonia (VAP). This study aimed to approve the hypothesis that the serogroup distribution of L. pneumophila isolates from patients is correlated with Legionella strains in the environment. A total of 280 bronchoalveolar lavage (BAL) samples from VAP patients admitted to the intensive care unit (ICU) as well as 116 water samples from different sources in four hospitals in Tehran, Iran, were evaluated for the presence of L. pneumophila infection by culture, nested polymerase chain reaction (PCR), real-time PCR, and sequencing for genetic diversity. The molecular and culture methods found 24 (8.6%) and 5 (1.8%) samples to be positive for L. pneumophila in VAP patients, while they found 23 (19.8%) and 8 (6.9%) positive samples in water resources, respectively. The sequencing results indicated that all positive clinical samples and 14 (60.8%) environmental samples were belonged to L. pneumophila serogroup 1. Smoking, age, length of ICU stay, and duration of ventilator use had strong relationship with L. pneumophila infectivity. In conclusion, this is the first report from Iran to determine minor differences in the serogroup distribution of environmental and clinical strains. However, further studies are needed to confirm this relationship in different regions of Iran.

Continuous Endotracheal Tube Cuff Pressure Control Decreases Incidence of Ventilator-Associated Pneumonia in Patients with Traumatic Brain Injury.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common cause of morbidity and mortality in intensive care unit (ICU), and among the several preventative strategies described to reduce the incidence of VAP, the most important is the endotracheal tube cuff (ETC) pressure. The present study was conducted on 60 patients who required mechanical ventilation (MV) in the ICU with traumatic brain injury (TBI). METHODS: The patients were randomized into two groups of 30, in which ETC pressure was regulated using a smart cuff manager (SCM) (Group II), or manual measurement approach (MMA) (Group I). Demographic data, MV duration, length of ICU stay and mortality rates were recorded. The clinical pulmonary infection scores (CPISs), C-reactive protein (CRP) values, and the fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP) values of the groups were compared at baseline, and at hours 48, 72 and 96. RESULTS: In Group I, CPIS values significantly higher than Group II in 48th, 72nd and 96th hours (p < 0.05). In Group I, PEEP values and deep tracheal aspirate (DTA) culture growth rates significantly higher than Group II in 72nd and 96th hours (p < 0.05). CONCLUSION: The continuous maintenance of ETC pressure using SCM reduced the incidence of VAP.