Objective To evaluate the effect of oral decontamination on the incidence of ventilator associated pneumonia and mortality in mechanically ventilated adults.Design Systematic review and ...meta-analysis.Data sources Medline, Embase, CINAHL, the Cochrane Library, trials registers, reference lists, conference proceedings, and investigators in the specialty.Review methods Two independent reviewers screened studies for inclusion, assessed trial quality, and extracted data. Eligible trials were randomised controlled trials enrolling mechanically ventilated adults that compared the effects of daily oral application of antibiotics or antiseptics with no prophylaxis.Results 11 trials totalling 3242 patients met the inclusion criteria. Among four trials with 1098 patients, oral application of antibiotics did not significantly reduce the incidence of ventilator associated pneumonia (relative risk 0.69, 95% confidence interval 0.41 to 1.18). In seven trials with 2144 patients, however, oral application of antiseptics significantly reduced the incidence of ventilator associated pneumonia (0.56, 0.39 to 0.81). When the results of the 11 trials were pooled, rates of ventilator associated pneumonia were lower among patients receiving either method of oral decontamination (0.61, 0.45 to 0.82). Mortality was not influenced by prophylaxis with either antibiotics (0.94, 0.73 to 1.21) or antiseptics (0.96, 0.69 to 1.33) nor was duration of mechanical ventilation or stay in the intensive care unit.Conclusions Oral decontamination of mechanically ventilated adults using antiseptics is associated with a lower risk of ventilator associated pneumonia. Neither antiseptic nor antibiotic oral decontamination reduced mortality or duration of mechanical ventilation or stay in the intensive care unit.
IMPORTANCE: Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice. OBJECTIVE: To describe practice ...variation in IMV discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs). DESIGN, SETTING, AND PARTICIPANTS: Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US). EXPOSURES: Receiving IMV. MAIN OUTCOMES AND MEASURES: Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes. RESULTS: Among 1868 patients (median interquartile range age, 61.8 48.9-73.1 years; 1173 62.8% men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT (761 81.8% successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 4.7% vs 96 10.3%; absolute difference, 5.6% 95% CI, 2.6%-8.6%), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days 95% CI, 0.7-1.6), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days 95% CI, 0.8-2.4). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 17.2% vs 67 8.8%; absolute difference, 8.4% 95% CI, 2.0%-14.7%), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days 95% CI, 1.6-3.6), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days 95% CI, 1.1-5.2). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days 95% CI, 3.7-4.5), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days 95% CI, 4.0-6.3), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days 95% CI, 6.0-11.0). CONCLUSIONS AND RELEVANCE: In this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016, weaning practices varied internationally. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03955874
Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic ...review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles.
In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546.
We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1–13·3) in the conventional needle group to 4·2% (3·3–5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34–0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29–0·64; p<0·0001), need for epidural blood patch (0·50, 0·33–0·75; p=0·001), any headache (0·50, 0·43–0·57; p<0·0001), mild headache (0·52, 0·38–0·70; p<0·0001), severe headache (0·41, 0·28–0·59; p<0·0001), nerve root irritation (0·71, 0·54–0·92; p=0·011), and hearing disturbance (0·25, 0·11–0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation.
Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture.
None.
OBJECTIVE:To update the 2002 version of “Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient.”
DESIGN:A Task Force comprising 17 members of the ...Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided.
METHODS:Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions.
RESULTS:The Task Force developed a single strong recommendationwe recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents. The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn. In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents. Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death.
Previous trials of higher positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) failed to demonstrate mortality benefit, possibly because of differences in lung ...recruitability among patients with ARDS.
To determine whether the physiological response to increased PEEP is associated with mortality.
In a secondary analysis of the Lung Open Ventilation Study (LOVS, n = 983), we examined the relationship between the initial response to changes in PEEP after randomization and mortality. We sought to corroborate our findings using data from a different trial of higher PEEP (ExPress, n = 749).
The oxygenation response (change in ratio of arterial partial pressure of oxygen to fraction of inspired oxygen: P/F) after the initial change in PEEP after randomization varied widely (median, 9.5 mm Hg; interquartile range, -16 to 47) and was only weakly related to baseline P/F or the magnitude of PEEP change. Among patients in whom PEEP was increased after randomization, an increase in P/F was associated with reduced mortality (multivariable logistic regression; adjusted odds ratio, 0.80 95% confidence interval, 0.72-0.89 per 25-mm Hg increase in P/F), particularly in patients with severe disease (baseline P/F less-than-or-equal-to 150 mm Hg). Changes in compliance and dead space were not associated with mortality. These findings were confirmed by a similar analysis of data from the ExPress trial.
Patients with ARDS who respond to increased PEEP by improved oxygenation have a lower risk of death. The oxygenation response to PEEP might be used to predict whether patients will benefit from higher versus lower PEEP.
Recent literature in mechanical ventilation includes strong evidence from randomized trials. Little information is available regarding the influence of these trials on usual clinical practice.
To ...describe current mechanical ventilation practices and to assess the influence of interval randomized trials when compared with findings from a 1998 cohort.
A prospective international observational cohort study, with a nested comparative study performed in 349 intensive care units in 23 countries. We enrolled 4,968 consecutive patients receiving mechanical ventilation over a 1-month period. We recorded demographics and daily data related to mechanical ventilation for the duration of ventilation. We systematically reviewed the literature and developed 11 practice-change hypotheses for the comparative cohort study before seeing these results. In assessing practice changes, we only compared data from the 107 intensive care units (1,675 patients) that also participated in the 1998 cohort (1,383 patients).
In 2004 compared with 1998, the use of noninvasive ventilation increased (11.1 vs. 4.4%, P < 0.001). Among patients with acute respiratory distress syndrome, tidal volumes decreased (7.4 vs. 9.1 ml/kg, P < 0.001) and positive end-expiratory pressure levels increased slightly (8.7 vs. 7.7 cm H(2)O, P = 0.02). More patients were successfully extubated after their first attempt of spontaneous breathing (77 vs. 62%, P < 0.001). Use of synchronized intermittent mandatory ventilation fell dramatically (1.6 vs. 11%, P < 0.001). Observations confirmed 10 of our 11 practice-change hypotheses.
The strong concordance of predicted and observed practice changes suggests that randomized trial results have advanced mechanical ventilation practices internationally.
IMPORTANCE: The efficacy and safety of prone positioning is unclear in nonintubated patients with acute hypoxemia and COVID-19. OBJECTIVE: To evaluate the efficacy and adverse events of prone ...positioning in nonintubated adult patients with acute hypoxemia and COVID-19. DESIGN, SETTING, AND PARTICIPANTS: Pragmatic, unblinded randomized clinical trial conducted at 21 hospitals in Canada, Kuwait, Saudi Arabia, and the US. Eligible adult patients with COVID-19 were not intubated and required oxygen (≥40%) or noninvasive ventilation. A total of 400 patients were enrolled between May 19, 2020, and May 18, 2021, and final follow-up was completed in July 2021. INTERVENTION: Patients were randomized to awake prone positioning (n = 205) or usual care without prone positioning (control; n = 195). MAIN OUTCOMES AND MEASURES: The primary outcome was endotracheal intubation within 30 days of randomization. The secondary outcomes included mortality at 60 days, days free from invasive mechanical ventilation or noninvasive ventilation at 30 days, days free from the intensive care unit or hospital at 60 days, adverse events, and serious adverse events. RESULTS: Among the 400 patients who were randomized (mean age, 57.6 years SD, 12.83 years; 117 29.3% were women), all (100%) completed the trial. In the first 4 days after randomization, the median duration of prone positioning was 4.8 h/d (IQR, 1.8 to 8.0 h/d) in the awake prone positioning group vs 0 h/d (IQR, 0 to 0 h/d) in the control group. By day 30, 70 of 205 patients (34.1%) in the prone positioning group were intubated vs 79 of 195 patients (40.5%) in the control group (hazard ratio, 0.81 95% CI, 0.59 to 1.12, P = .20; absolute difference, −6.37% 95% CI, −15.83% to 3.10%). Prone positioning did not significantly reduce mortality at 60 days (hazard ratio, 0.93 95% CI, 0.62 to 1.40, P = .54; absolute difference, −1.15% 95% CI, −9.40% to 7.10%) and had no significant effect on days free from invasive mechanical ventilation or noninvasive ventilation at 30 days or on days free from the intensive care unit or hospital at 60 days. There were no serious adverse events in either group. In the awake prone positioning group, 21 patients (10%) experienced adverse events and the most frequently reported were musculoskeletal pain or discomfort from prone positioning (13 of 205 patients 6.34%) and desaturation (2 of 205 patients 0.98%). There were no reported adverse events in the control group. CONCLUSIONS AND RELEVANCE: In patients with acute hypoxemic respiratory failure from COVID-19, prone positioning, compared with usual care without prone positioning, did not significantly reduce endotracheal intubation at 30 days. However, the effect size for the primary study outcome was imprecise and does not exclude a clinically important benefit. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04350723
The question stem is the statement or question to which a response is sought. Each question should focus on a single construct. Question stems should contain fewer than 20 words and be easy to ...understand and interpret,5,13 nonjudgmental and unbiased.13 Investigators should phrase questions in a socially and culturally sensitive manner. They should avoid absolute terms (e.g., "always," "none" or "never"),11 abbreviations and complex terminology.2 Investigators should specify the perspective from which questions should be addressed, particularly for questions about attitudes that may elicit different responses depending on how they are worded.14 The language used influences the response formats used, which may affect the response rate. Demonstrative questions are often followed by binary responses, whereas question stems requesting respondents to rank items or elicit their opinions should adopt a neutral tone. The wording of the question and the order of response categories can influence the responses obtained.3,15 Moreover, the manner in which question stems and responses are synthesized and presented can influence potential respondents' decisions to initiate and complete a questionnaire.3 * "Other" response options: Providing an "other" response option or requesting "any other comments" allows for unanticipated answers, alters the power balance between investigators and respondents,18 and may enhance response rates to self-administered questionnaires.3 During questionnaire testing, "other" response options can help to identify new issues or elaborate on closed response formats.18 Members of the ACCADEMY (Academy of Critical Care: Development, Evaluation and Methodology) Group: Dr. Neill K.J. Adhikari, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute and Interdepartmental Division of Critical Care, Toronto, Ont.; Donald Arnold, Department of Medicine, McMaster University, Hamilton, Ont.; Dr. Karen E.A. Burns, St. Michael's Hospital, the Interdepartmental Division of Critical Care, Keenan Research Centre and the Li Ka Shing Knowledge Institute, Toronto, Ont.; Dr. Karen Choong, Department of Pediatrics and Division of Critical Care, McMaster Children's Hospital, Hamilton, Ont.; Dr. Deborah J. Cook MD MSc, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Dr. Cynthia Cupido, Department of Pediatrics and Division of Critical Care, McMaster Children's Hospital, Hamilton, Ont.; Ines De Campos RN, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont., and St. Michael's Hospital, Toronto, Ont.; Dr. Mark Duffett BScPharm, Department of Pharmacy and Division of Critical Care, McMaster Children's Hospital, and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Dr. Francois Lamontagne, Department of Clinical Epidemiology and Biostatics, McMaster University, Hamilton, Ont.; Dr. Wendy Lim, Department of Medicine, McMaster University, Hamilton, Ont.; and Dr. Maureen O. Meade MD MSc, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
Noninvasive ventilation has been studied as a means of reducing complications among patients being weaned from invasive mechanical ventilation. We sought to summarize evidence comparing noninvasive ...and invasive weaning and their effects on mortality.
We identified relevant randomized and quasirandomized trials through searches of databases, conference proceedings and grey literature. We included trials comparing extubation and immediate application of noninvasive ventilation with continued invasive weaning in adults on mechanical ventilation. Two reviewers each independently screened citations, assessed trial quality and abstracted data. Our primary outcome was mortality.
We identified 16 trials involving 994 participants, most of whom had chronic obstructive pulmonary disease (COPD). Compared with invasive weaning, noninvasive weaning significantly reduced mortality (risk ratio RR 0.53, 95% confidence interval CI 0.36 to 0.80), weaning failures (RR 0.63, 95% CI 0.42 to 0.96), ventilator-associated pneumonia (RR 0.25, 95% CI 0.15 to 0.43), length of stay in the intensive care unit (mean difference MD -5.59 d, 95% CI -7.90 to -3.28) and in hospital (MD -6.04 d, 95% CI -9.22 to -2.87), and total duration of mechanical ventilation (MD -5.64 d, 95% CI -9.50 to -1.77). Noninvasive weaning had no significant effect on the duration of ventilation related to weaning, but significantly reduced rates of tracheostomy (RR 0.19, 95% CI 0.08 to 0.47) and reintubation (RR 0.65, 95% CI 0.44 to 0.97). Mortality benefits were significantly greater in trials enrolling patients with COPD than in trials enrolling mixed patient populations (RR 0.36 95% CI 0.24 to 0.56 v. RR 0.81 95% CI 0.47 to 1.40).
Noninvasive weaning reduces rates of death and pneumonia without increasing the risk of weaning failure or reintubation. In subgroup analyses, mortality benefits were significantly greater in patients with COPD.
Host-associated microbial communities have important roles in tissue homeostasis and overall health. Severe perturbations can occur within these microbial communities during critical illness due to ...underlying diseases and clinical interventions, potentially influencing patient outcomes. We sought to profile the microbial composition of critically ill mechanically ventilated patients, and to determine whether microbial diversity is associated with illness severity and mortality.
We conducted a prospective, observational study of mechanically ventilated critically ill patients with a high incidence of pneumonia in 2 intensive care units (ICUs) in Hamilton, Canada, nested within a randomized trial for the prevention of healthcare-associated infections. The microbial profiles of specimens from 3 anatomical sites (respiratory, and upper and lower gastrointestinal tracts) were characterized using 16S ribosomal RNA gene sequencing.
We collected 65 specimens from 34 ICU patients enrolled in the trial (29 endotracheal aspirates, 26 gastric aspirates and 10 stool specimens). Specimens were collected at a median time of 3 days (lower respiratory tract and gastric aspirates; interquartile range IQR 2-4) and 6 days (stool; IQR 4.25-6.75) following ICU admission. We observed a loss of biogeographical distinction between the lower respiratory tract and gastrointestinal tract microbiota during critical illness. Moreover, microbial diversity in the respiratory tract was inversely correlated with APACHE II score (r = - 0.46, p = 0.013) and was associated with hospital mortality (Median Shannon index: Discharged alive; 1.964 vs. Deceased; 1.348, p = 0.045).
The composition of the host-associated microbial communities is severely perturbed during critical illness. Reduced microbial diversity reflects high illness severity and is associated with mortality. Microbial diversity may be a biomarker of prognostic value in mechanically ventilated patients.
ClinicalTrials.gov ID NCT01782755 . Registered February 4 2013.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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