Temporary Diaphragm Pacing for Patients at Risk of Prolonged Mechanical Ventilation After Extensive Open Aortic Surgery

Background: During last decades mechanical ventilation has been an important support in the postoperative management of patients undergoing cardiac surgery. This study was designed to determine the predictors of prolonged mechanical ventilation (PMV) in patients undergoing heart valve surgery. Methods: This retrospective study considered of 1056 patients who underwent isolated valve surgery at Tehran Heart Center from March 2002 to March 2009. PMV is considered as mechanical ventilation period of ≥24 hours at postoperative hospital stay in this study. Results: PMV occurred in 6.6% of patients. Initial ventilation hours, atrial fibrillation, cardiac arrest and reintubation were the most prevalent postoperative complications. Preoperative renal failure, postoperative stroke, intra aortic balloon pump insertion, emergent operation, complete heart block, longer perfusion time were independent predictors of PMV in our patients. Conclusion: PMV is associated with significant comorbidities and increased hospital mortality. Strategies to delineate the patients at risk and to modify these risk factors by prophylactic measures should probably lead to a lower incidence of prolonged mechanical ventilation for patients undergoing isolated valve surgery.

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Neurally adjusted ventilatory assist versus pressure support ventilation: a randomized controlled feasibility trial performed in patients at risk of prolonged mechanical ventilation

Critical Care ◽

10.1186/s13054-020-02923-5 ◽

2020 ◽

Vol 24 (1) ◽

Cited By ~ 4

Author(s):

Daniel J. Hadfield ◽

Louise Rose ◽

Fiona Reid ◽

Victoria Cornelius ◽

Nicholas Hart ◽

...

Keyword(s):

Mechanical Ventilation ◽

Pressure Support Ventilation ◽

Pressure Support ◽

Prolonged Mechanical Ventilation ◽

Feasibility Trial ◽

Neurally Adjusted Ventilatory Assist ◽

Support Ventilation ◽

Randomized Controlled ◽

Ventilatory Assist ◽

Patients At Risk

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Identifying Patients at Risk for Diaphragm Atrophy During Mechanical Ventilation Using Routinely Available Clinical Data

Respiratory Care ◽

10.4187/respcare.08223 ◽

2020 ◽

pp. respcare.08223

Author(s):

Martin Urner ◽

Nicholas Mitsakakis ◽

Stefannie Vorona ◽

Lu Chen ◽

Michael C Sklar ◽

...

Keyword(s):

At Risk ◽

Mechanical Ventilation ◽

Clinical Data ◽

Patients At Risk ◽

Diaphragm Atrophy

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Endotracheal Tube Obstruction Among Patients Mechanically Ventilated for ARDS Due to COVID-19: A Case Series

Journal of Intensive Care Medicine ◽

10.1177/0885066620981891 ◽

2020 ◽

pp. 088506662098189

Author(s):

Samuel Wiles ◽

Eduardo Mireles-Cabodevila ◽

Scott Neuhofs ◽

Sanjay Mukhopadhyay ◽

Jordan P. Reynolds ◽

...

Keyword(s):

At Risk ◽

Mechanical Ventilation ◽

Endotracheal Tube ◽

Airway Resistance ◽

Prolonged Mechanical Ventilation ◽

Case Series ◽

Retrospective Chart Review ◽

Inflammatory Cells ◽

Pathological Examination ◽

Tube Obstruction

Background: Patients with COVID-19 and ARDS on prolonged mechanical ventilation are at risk for developing endotracheal tube (ETT) obstruction that has not been previously described in patients with ARDS due to other causes. The purpose of this report is to describe a case series of patients with COVID-19 and ARDS in which ETT occlusion resulted in significant clinical consequences and to define the pathology of the obstructing material. Methods: Incidents of ETT occlusion during mechanical ventilation of COVID-19 patients were reported by clinicians and retrospective chart review was conducted. Statistical analysis was performed comparing event rates between COVID-19 and non-COVID 19 patients on mechanical ventilation over the predefined period. Specimens were collected and submitted for pathological examination. Findings: Eleven COVID-19 patients experienced endotracheal tube occlusion over a period of 2 months. Average age was 69 (14.3, range 33-85) years. Mean APACHE III score was 73.6 (17.3). All patients had AKI and cytokine storm. Nine exhibited biomarkers for hypercoagulability. Average days on mechanical ventilation before intervention for ETT occlusion was 14 (5.18) days (range of 9 to 23 days). Five patients were discharged from the ICU, and 4 expired. Average documented airway resistance on admission was 14.2 (3.0) cm H2O/L/sec. Airway resistance before tube exchange was 28.1 (8.0) cm H2O /L/sec. No similar events of endotracheal tube occlusion were identified in non-COVID patients on mechanical ventilation during the same time period. Microscopically, the material consisted of mucin admixed with necrotic cell debris, variable numbers of degenerated inflammatory cells, oral contaminants and red blood cells. Interpretation: Patients with COVID-19 and ARDS on prolonged mechanical ventilation are at risk for developing ETT obstruction due to deposition of a thick, tenacious material within the tube that consists primarily of mucin and cellular debris. Clinicians should be aware of this dangerous but treatable complication.

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Pharmacologic Stress Gastropathy Prophylaxis May Not Be Necessary in At-Risk Surgical Trauma ICU Patients Tolerating Enteral Nutrition

Journal of Intensive Care Medicine ◽

10.1177/0885066616678385 ◽

2016 ◽

Vol 33 (7) ◽

pp. 424-429 ◽

Cited By ~ 6

Author(s):

Nicole M. Palm ◽

Brian McKinzie ◽

Pamela L. Ferguson ◽

Emily Chapman ◽

Margaret Dorlon ◽

...

Keyword(s):

Intensive Care Unit ◽

At Risk ◽

Mechanical Ventilation ◽

Enteral Nutrition ◽

Pharmacologic Stress ◽

Surgical Trauma ◽

Trauma Patients ◽

Patients At Risk ◽

Pharmacologic Prophylaxis ◽

Clinically Significant

Objective: Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis. Design: A retrospective cohort study of records from 2008 to 2013. Setting: Adult patients in a single-center STICU were included. Patients: Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention. Intervention: Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation. Measurements and Main Results: A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US$121/patient stay were realized. Conclusion: Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.

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