OBJECTIVE:To estimate the prevalence of, the risk factors associated with, and the outcome of tracheostomy in a heterogeneous population of mechanically ventilated patients.
DESIGN:Prospective, ...observational cohort study.
SETTING:A total of 361 intensive care units from 12 countries.
PATIENTS:A cohort of 5,081 patients mechanically ventilated for >12 hrs.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:A total of 546 patients (10.7%) had a tracheostomy during their stay in the intensive care unit. Tracheostomy was performed at a median time of 12 days (interquartile range, 7–17) from the beginning of mechanical ventilation. Variables associated with the performance of tracheostomy were duration of mechanical ventilation, need for reintubation, and neurologic disease as the primary reason of mechanical ventilation. The intensive care unit stay of patients with or without tracheostomy was a median of 21 days (interquartile range, 12–32) vs. 7 days (interquartile range, 4–12; p < .001), respectively, and the hospital stay was a median 36 days (interquartile range, 23–53) vs. 15 days (interquartile range, 8–26; p < .001), respectively. Adjusting by other variables, tracheostomy was independently related with survival in the intensive care unit (odds ratio, 2.22; 95% confidence interval, 1.72–2.86). Mortality in the hospital was similar in both groups (39% vs. 40%, p = .65).
CONCLUSIONS:Tracheostomy is a common surgical procedure in the intensive care unit that is associated with a lower mortality in the unit but with a longer stay and a similar mortality in the hospital than in patients without tracheostomy.
To assess the factors associated with reintubation in patients who had successfully passed a spontaneous breathing trial.
We used logistic regression and recursive partitioning analyses of ...prospectively collected clinical data from adults admitted to ICUs of 37 hospitals in eight countries, who had undergone invasive mechanical ventilation for > 48 h and were deemed ready for extubation.
Extubation failure occurred in 121 of the 900 patients (13.4%). The logistic regression analysis identified the following associations with reintubation: rapid shallow breathing index (RSBI) odds ratio (OR), 1.009 per unit; 95% confidence interval (CI), 1.003 to 1.015; positive fluid balance (OR, 1.70; 95% CI, 1.15 to 2.53); and pneumonia as the reason for initiating mechanical ventilation (OR, 1.77; 95% CI, 1.10 to 2.84). The recursive partitioning analysis allowed the separation of patients into different risk groups for extubation failure: (1) RSBI of > 57 breaths/L/min and positive fluid balance (OR, 3.0; 95% CI, 1.8 to 4.8); (2) RSBI of < 57 breaths/L/min and pneumonia as reason for mechanical ventilation (OR, 2.0; 95% CI, 1.1 to 3.6); (3) RSBI of > 57 breaths/L/min and negative fluid balance (OR, 1.4; 95% CI, 0.8 to 2.5); and (4) RSBI of < 57 breaths/L/min (OR, 1 reference value).
Among routinely measured clinical variables, RSBI, positive fluid balance 24 h prior to extubation, and pneumonia at the initiation of ventilation were the best predictors of extubation failure. However, the combined predictive ability of these variables was weak.
Device-associated healthcare-acquired infections (DA-HAI) pose a threat to patient safety in the intensive care unit (ICU).
A DA-HAI surveillance study was conducted by the International Nosocomial ...Infection Control Consortium (INICC) in two adult medical/surgical ICUs at two hospitals in Caracas, Venezuela, in different periods from March 2008 to April 2015, using the US Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC/NHSN) definitions and criteria, and INICC methods.
We followed 1041 ICU patients for 4632 bed days. Central line-associated bloodstream infection (CLABSI) rate was 5.1 per 1000 central line days, ventilator-associated pneumonia (VAP) rate was 7.2 per 1000 mechanical ventilator days, and catheter-associated urinary tract infection (CAUTI) rate was 3.9 per 1000 urinary catheter days, all similar to or lower than INICC rates (4.9 CLABSI; 16.5 VAP; 5.3 CAUTI), and higher than CDC/NHSN rates (0.8 CLABSI; 1.1 VAP; and 1.3 CAUTI). Device utilization ratios were higher than INICC and CDC/NHSN rates, except for urinary catheter, which was similar to INICC. Extra length of stay was 8 days for patients with CLABSI, 9.6 for VAP and 5.7 days for CAUTI. Additional crude mortality was 3.0% for CLABSI, 4.4% for VAP, and 16.9% for CAUTI.
DA-HAI rates in our ICUs are higher than CDC/NSHN's and similar to or lower than INICC international rates.
Baseline characteristics and management have changed over time in patients requiring mechanical ventilation; however, the impact of these changes on patient outcomes is unclear.
To estimate whether ...mortality in mechanically ventilated patients has changed over time.
Prospective cohort studies conducted in 1998, 2004, and 2010, including patients receiving mechanical ventilation for more than 12 hours in a 1-month period, from 927 units in 40 countries. To examine effects over time on mortality in intensive care units, we performed generalized estimating equation models.
We included 18,302 patients. The reasons for initiating mechanical ventilation varied significantly among cohorts. Ventilatory management changed over time (P < 0.001), with increased use of noninvasive positive-pressure ventilation (5% in 1998 to 14% in 2010), a decrease in tidal volume (mean 8.8 ml/kg actual body weight SD = 2.1 in 1998 to 6.9 ml/kg SD = 1.9 in 2010), and an increase in applied positive end-expiratory pressure (mean 4.2 cm H2O SD = 3.8 in 1998 to 7.0 cm of H2O SD = 3.0 in 2010). Crude mortality in the intensive care unit decreased in 2010 compared with 1998 (28 versus 31%; odds ratio, 0.87; 95% confidence interval, 0.80-0.94), despite a similar complication rate. Hospital mortality decreased similarly. After adjusting for baseline and management variables, this difference remained significant (odds ratio, 0.78; 95% confidence interval, 0.67-0.92).
Patient characteristics and ventilation practices have changed over time, and outcomes of mechanically ventilated patients have improved. Clinical trials registered with www.clinicaltrials.gov (NCT01093482).
Purpose
To analyze the relationship between hypercapnia developing within the first 48 h after the start of mechanical ventilation and outcome in patients with acute respiratory distress syndrome ...(ARDS).
Patients and methods
We performed a secondary analysis of three prospective non-interventional cohort studies focusing on ARDS patients from 927 intensive care units (ICUs) in 40 countries. These patients received mechanical ventilation for more than 12 h during 1-month periods in 1998, 2004, and 2010. We used multivariable logistic regression and a propensity score analysis to examine the association between hypercapnia and ICU mortality.
Main outcomes
We included 1899 patients with ARDS in this study. The relationship between maximum PaCO
2
in the first 48 h and mortality suggests higher mortality at or above PaCO
2
of ≥50 mmHg. Patients with severe hypercapnia (PaCO
2
≥50 mmHg) had higher complication rates, more organ failures, and worse outcomes. After adjusting for age, SAPS II score, respiratory rate, positive end-expiratory pressure, PaO
2
/FiO
2
ratio, driving pressure, pressure/volume limitation strategy (PLS), corrected minute ventilation, and presence of acidosis, severe hypercapnia was associated with increased risk of ICU mortality odds ratio (OR) 1.93, 95% confidence interval (CI) 1.32 to 2.81;
p
= 0.001. In patients with severe hypercapnia matched for all other variables, ventilation with PLS was associated with higher ICU mortality (OR 1.58, CI 95% 1.04–2.41;
p
= 0.032).
Conclusions
Severe hypercapnia appears to be independently associated with higher ICU mortality in patients with ARDS.
Trial registration
Clinicaltrials.gov identifier, NCT01093482.
Purpose
There are limited data available about the role of sedation and analgesia during noninvasive positive pressure ventilation (NPPV). The objective of study was to estimate the effect of ...analgesic or sedative drugs on the failure of NPPV.
Methods
We studied patients who received at least 2 h of NPPV as first-line therapy in a prospective observational study carried out in 322 intensive care units from 30 countries. A marginal structural model (MSM) was used to analyze the association between the use of analgesic or sedative drugs and NPPV failure (defined as need for invasive mechanical ventilation).
Results
842 patients were included in the analysis. Of these, 165 patients (19.6 %) received analgesic or sedative drugs at some time during NPPV; 33 of them received both. In the adjusted analysis, the use of analgesics (odds ratio 1.8, 95 % confidence interval 0.6–5.4) or sedatives (odds ratio 2.8, 95 % CI 0.85–9.4) alone was not associated with NPPV failure, but their combined use was associated with failure (odds ratio 5.7, 95 % CI 1.8–18.4).
Conclusions
Slightly less than 20 % of patients received analgesic or sedative drugs during NPPV, with no apparent effect on outcome when used alone. However, the simultaneous use of analgesics and sedatives may be associated with failure of NPPV.
The effect of prethymectomy plasma exchange on postoperative mechanical ventilation requirement and length of stay in the intensive care unit were studied retrospectively in 37 patients with ...myasthenia gravis. We found a significantly decreased time on mechanical ventilation (mean 1.02 +/- 0.40 versus 3.43 +/- 0.60 days) and a shorter stay in the intensive care unit (mean 3.09 +/- 0.99 versus 5.15 +/- 0.66 days) for 11 patients with respiratory weakness who were treated with preoperative plasma exchange compared with 26 patients who did not receive plasma exchange. Patients with respiratory weakness who received prethymectomy plasma exchange required less time on mechanical ventilation (mean 1.02 +/- 0.40 versus 2.73 +/- 0.88 days) and a shorter stay in the intensive care unit (mean 3.09 +/- 0.99 versus 4.46 +/- 1.08 days) than those patients without respiratory weakness who did not receive plasma exchange. Eleven patients met the criteria for plasma exchange but did not receive it. They required significantly more time on mechanical ventilation (mean 4.43 +/- 0.94 versus 1.02 +/- 0.40 days) and in the intensive care unit (mean 6.09 +/- 0.86 versus 3.09 +/- 0.99 days) than patients who received plasma exchange. Our results indicate that patients with severe forms of myasthenia gravis treated with prethymectomy plasma exchange require less mechanical ventilation and less time in the intensive care unit postoperatively.
PDF
