Sedatives and anti-anxiety agents in critical illness

2016 ◽  
Author(s):  
Curtis N. Sessler ◽  
Katie M. Muzevich
Keyword(s):  
Mechanical Ventilation ◽  
Early Mobilization ◽  
Patient Characteristics ◽  
Initial Therapy ◽  
Mechanically Ventilated ◽  
Icu Length Of Stay ◽  
Level Of Consciousness ◽  
Continuous Drug Delivery ◽  
Spontaneous Breathing Trials ◽  
Light Sedation

Sedative and anti-anxiety agents are administered to many mechanically-ventilated intensive care unit (ICU) patients. While commonly considered supportive care, suboptimal administration of sedatives has been linked to longer duration of mechanical ventilation and longer ICU length of stay. The use of a structured multidisciplinary approach can help improve outcomes. The level of consciousness, as well as the presence and severity of agitation should be routinely evaluated using a validated sedation–agitation scale. The approach to delivery of sedation should be based upon specific goals, particularly mechanical ventilation, while maintaining the lightest possible level of sedation. Selection should be based upon clinical circumstances and patient characteristics, however, when continuous infusion sedation is required, experts suggest using non-benzodiazepine agents. A variety of strategies for sedation management have been demonstrated to be effective in clinical trials including use of protocols, targeting light sedation, preference of analgesics for initial therapy, use of intermittent, rather than continuous drug delivery when possible, and daily interruption of sedation. Finally, light sedation should be linked to performance of spontaneous breathing trials, as well as early mobilization.

scholarly journals Effect of gastric residual volume monitoring on incidence of ventilator-associated pneumonia in mechanically ventilated patients admitted to intensive care unit

2019 ◽  
Vol 36 (1) ◽  
Author(s):  
Elnaz Faramarzi ◽  
Ata Mahmoodpoor ◽  
Hadi Hamishehkar ◽  
Kamran Shadvar ◽  
Afshin Iranpour ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Ventilator Associated Pneumonia ◽  
Residual Volume ◽  
Gastric Residual Volume ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Icu Length Of Stay ◽  
Ventilated Patients

Objectives: The value of gastric residual volume (GRV) monitoring in ventilator-associated pneumonia (VAP) has frequently been questioned in the past years. In this trial, the effect of GRV on the frequency of VAP was evaluated in critically ill patients under mechanical ventilation. Methods: This descriptive study was carried out on 150 adult patients admitted to the intensive care unit over a 14-month period, from October 2015 to January 2017. GRV was measured every three hours, and gastric intolerance was defined as GRV>250 cc. The incidence of vomiting and VAP, GRV, length of mechanical ventilation and ICU stay, APACHE II and SOFA scores, and mortality rate were noted. Results: The mean APACHEII and SOFA scores, ICU length of stay, and duration of mechanical ventilation in the GRV>250ml group were significantly higher than in the GRV≤250 ml group (P<0.05). Also, a significantly higher number of patients in the GRV>250ml group experienced infection (62.3%) and vomiting (71.7%) compared with the GRV≤250 group (P<0.01). The highest OR was observed for SOFA score >15 and APACHE II >30, which increased the risk of GVR>250 ml by 10.09 (1.01-99.97) and 8.78 (1.49-51.58), respectively. Moreover, the increase in GVR was found to be higher in the non-survivor than in the survivor group. Conclusion: Increased GRV did not result in increased rates of VAP, ICU length of stay, and mortality. Therefore, the routine measurement of GRV as an important element of the VAP prevention bundle is not recommended in critically ill patients. How to cite this: Faramarzi E, Mahmoodpoor A, Hamishehkar H, Shadvar K, Iranpour A, Sabzevari T, et al. Effect of gastric residual volume monitoring on incidence of ventilator-associated pneumonia in mechanically ventilated patients admitted to intensive care unit. Pak J Med Sci. 2020;36(1):---------. doi: https://doi.org/10.12669/pjms.36.1.1321 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

scholarly journals Effect of gastric residual volume monitoring on incidence of ventilator-associated pneumonia in mechanically ventilated patients admitted to intensive care unit

2019 ◽  
Vol 36 (2) ◽  
Author(s):  
Elnaz Faramarzi ◽  
Ata Mahmoodpoor ◽  
Hadi Hamishehkar ◽  
Kamran Shadvar ◽  
Afshin Iranpour ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Ventilator Associated Pneumonia ◽  
Residual Volume ◽  
Gastric Residual Volume ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Icu Length Of Stay ◽  
Ventilated Patients

Objectives: The value of gastric residual volume (GRV) monitoring in ventilator-associated pneumonia (VAP) has frequently been questioned in the past years. In this trial, the effect of GRV on the frequency of VAP was evaluated in critically ill patients under mechanical ventilation. Methods: This descriptive study was carried out on 150 adult patients admitted to the intensive care unit over a 14-month period, from October 2015 to January 2017. GRV was measured every three hours, and gastric intolerance was defined as GRV>250 cc. The incidence of vomiting and VAP, GRV, length of mechanical ventilation and ICU stay, APACHE II and SOFA scores, and mortality rate were noted. Results: The mean APACHEII and SOFA scores, ICU length of stay, and duration of mechanical ventilation in the GRV>250ml group were significantly higher than in the GRV≤250 ml group (P<0.05). Also, a significantly higher number of patients in the GRV>250ml group experienced infection (62.3%) and vomiting (71.7%) compared with the GRV≤250 group (P<0.01). The highest OR was observed for SOFA score >15 and APACHE II >30, which increased the risk of GVR>250 ml by 10.09 (1.01-99.97) and 8.78 (1.49-51.58), respectively. Moreover, the increase in GVR was found to be higher in the non-survivor than in the survivor group. Conclusion: Increased GRV did not result in increased rates of VAP, ICU length of stay, and mortality. Therefore, the routine measurement of GRV as an important element of the VAP prevention bundle is not recommended in critically ill patients. doi: https://doi.org/10.12669/pjms.36.2.1321 How to cite this: Faramarzi E, Mahmoodpoor A, Hamishehkar H, Shadvar K, Iranpour A, Sabzevari T, et al. Effect of gastric residual volume monitoring on incidence of ventilator-associated pneumonia in mechanically ventilated patients admitted to intensive care unit. Pak J Med Sci. 2020;36(2):48-53. doi: https://doi.org/10.12669/pjms.36.2.1321 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

scholarly journals Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Gaetano Scaramuzzo ◽  
◽  
Lorenzo Gamberini ◽  
Tommaso Tonetti ◽  
Gianluca Zani ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Critically Ill ◽  
Lung Ventilation ◽  
Clinical History ◽  
Complication Rates ◽  
Prone Positioning ◽  
Mechanically Ventilated ◽  
Physiological Variables ◽  
Icu Length Of Stay ◽  
Severity Scores

Abstract Background Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. Results The median PaO2/FiO2 variation after the first PP cycle was 49 [19–100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. Conclusions Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.

Pressure Support Versus T-Piece Trial For Weaning From Mechanical Ventilation

2021 ◽  
Vol 15 (11) ◽  
pp. 2932-2933
Author(s):  
Khayyam Farid ◽  
Imran Ul Haq ◽  
Aqsa Saleema ◽  
Ambareen Sifatullah ◽  
Fazal Wfdood ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Pressure Support Ventilation ◽  
Pressure Support ◽  
The Other ◽  
Support Pressure ◽  
Weaning From Mechanical Ventilation ◽  
Mechanically Ventilated ◽  
Support Ventilation ◽  
Surgical Icu ◽  
Spontaneous Breathing Trials

Aim: To compare pressure support versus T-piece trial for weaning from mechanical ventilation Methodology: Randomized clinical trial in Surgical ICU, Khyber Teaching hospital Peshawar. 48 patients who had been mechanically ventilated for at least 24 hours and were deemed suitable for weaning took part in the study. SBT with pressure support ventilation of 8cm of H2O was performed on one group of patients for two hours while the other group received a 30-minute SBT with pressure support ventilation. It was successful when extubation process is completed, (being able to go 72 hours without mechanical ventilation after the first SBT). Results: Extubation was successful in 83.3% who received pressure support ventilation and in 75% who employed a T-piece. The patients who required reintubation were 12% with support pressure and 16.7% with T piece ventilation. Mortality rate in support pressure group is 16.7% while 25% in T piece ventilation group. Conclusion: Pressure support ventilation for 30 minutes had a much higher success rate when it came to extubation. For spontaneous breathing trials, a shorter, less taxing ventilation approach should be used rather than the traditional one. Keywords: Extubation, Support pressure, T piece

scholarly journals Neurological Complications and Noninvasive Multimodal Neuromonitoring in Critically Ill Mechanically Ventilated COVID-19 Patients

2020 ◽  
Vol 11 ◽  
Author(s):  
Denise Battaglini ◽  
Gregorio Santori ◽  
Karthikka Chandraptham ◽  
Francesca Iannuzzi ◽  
Matilde Bastianello ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Critically Ill ◽  
Invasive Mechanical Ventilation ◽  
Optic Nerve Sheath Diameter ◽  
Neurological Complications ◽  
Hemodynamic Changes ◽  
Mechanically Ventilated ◽  
Icu Length Of Stay ◽  
Common Manifestation

Purpose: The incidence and the clinical presentation of neurological manifestations of coronavirus disease-2019 (COVID-19) remain unclear. No data regarding the use of neuromonitoring tools in this group of patients are available.Methods: This is a retrospective study of prospectively collected data. The primary aim was to assess the incidence and the type of neurological complications in critically ill COVID-19 patients and their effect on survival as well as on hospital and intensive care unit (ICU) length of stay. The secondary aim was to describe cerebral hemodynamic changes detected by noninvasive neuromonitoring modalities such as transcranial Doppler, optic nerve sheath diameter (ONSD), and automated pupillometry.Results: Ninety-four patients with COVID-19 admitted to an ICU from February 28 to June 30, 2020, were included in this study. Fifty-three patients underwent noninvasive neuromonitoring. Neurological complications were detected in 50% of patients, with delirium as the most common manifestation. Patients with neurological complications, compared to those without, had longer hospital (36.8 ± 25.1 vs. 19.4 ± 16.9 days, p &lt; 0.001) and ICU (31.5 ± 22.6 vs. 11.5±10.1 days, p &lt; 0.001) stay. The duration of mechanical ventilation was independently associated with the risk of developing neurological complications (odds ratio 1.100, 95% CI 1.046–1.175, p = 0.001). Patients with increased intracranial pressure measured by ONSD (19% of the overall population) had longer ICU stay.Conclusions: Neurological complications are common in critically ill patients with COVID-19 receiving invasive mechanical ventilation and are associated with prolonged ICU length of stay. Multimodal noninvasive neuromonitoring systems are useful tools for the early detection of variations in cerebrovascular parameters in COVID-19.

scholarly journals Presentation, characteristics, treatments and outcomes of mechanically ventilated patients with COVID-19 in Bulgaria

2021 ◽  
Author(s):  
Neda Bakalova ◽  
Ivats Natsev ◽  
Hristo Damov ◽  
Irina Yatsenko ◽  
Stefanija Jovinska ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Heart Disease ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Medical Personnel ◽  
Patient Characteristics ◽  
University Hospital ◽  
Mechanically Ventilated ◽  
Cardiovascular Comorbidities

Background: The first surge of coronavirus disease 2019 (COVID-19) cases in Bulgaria occurred in the fall of 2020. To accommodate the rising number of critically ill patients, new intensive care units were formed in several hospitals. Here we describe the clinical presentation, patient characteristics, treatments and outcomes of mechanically ventilated COVID-19 patients in a newly formed COVID-19 ICU at a tertiary cardiac center in Sofia, Bulgaria. Methods: This is a retrospective observational study of mechanically ventilated COVID-19 patients admitted to Sveta Ekaterina University Hospital in Sofia, Bulgaria, between November 4th, 2020 and January 6th, 2021. Data were collected from electronic and written patient records and charts. Results: We identified 38 critical care patients admitted with respiratory failure and treated with mechanical ventilation at our COVID-19 ICU during this period. The median age was 66 (IQR 57-76, range 27-89) and 74% were male. Most patients, 36 (95%), had at least one comorbidity. The most common comorbidities were hypertension, valvular heart disease, ischemic heart disease and diabetes mellitus. Overall, 27 (71%) patients had a concomitant cardiac disease other than hypertension and 24% were recent cardiac surgical patients. Inotropic support was required in 29 (76%) patients, renal replacement therapy in 12 (32%) patients and prone positioning and ECMO were used in 5 (13%) and 2 (5%) patients respectively. The median duration of mechanical ventilation was 7.5 (IQR 5-14) days overall and 9 (IQR 6-13) days for survivors. At 30-days 28 (74%) of patients had died. Overall, 32 (84%) patients died in hospital and only 6 (16%) patients were discharged home. Conclusions: During the first major surge of COVID-19 cases in Bulgaria, despite the wave arriving later than in other countries, the healthcare system was largely unprepared. In our setting, mortality in critically ill patients requiring mechanical ventilation was very high at 85%. There may be several factors contributing to these results, namely the predominance of cardiovascular comorbidities in our patient population, the strained ICU capacity and the lack of medical personnel to provide adequate intensive care to such complex patients.

scholarly journals Determinants of gait independence after mechanical ventilation in the intensive care unit: a Japanese multicenter retrospective exploratory cohort study

2019 ◽  
Vol 7 (1) ◽  
Author(s):  
Shinichi Watanabe ◽  
Toru Kotani ◽  
Shunsuke Taito ◽  
Kohei Ota ◽  
Kenzo Ishii ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Length Of Stay ◽  
Hospital Discharge ◽  
Early Mobilization ◽  
Factors Affecting ◽  
Icu Length Of Stay ◽  
Sum Score ◽  
Icu Discharge

Abstract Purpose Gait independence is one of the most important factors related to returning home from the hospital for patients treated in the intensive care unit (ICU), but the factors affecting gait independence have not been clarified. This study aimed to determine the factors affecting gait independence at hospital discharge using a standardized early mobilization protocol that was shared by participating hospitals. Materials and methods Patients who entered the ICU from January 2017 to March 2018 were screened. The exclusion criteria were mechanical ventilation < 48 hours, age < 18, loss of gait independence before hospitalization, being treated for neurological issues, unrecoverable disease, unavailability of continuous data, and death during ICU stay. Basic attributes, such as age, ICU length of stay, information on early mobilization while in the ICU, Medical Research Council (MRC) sum-score at ICU discharge, incidence of ICU-acquired weakness (ICU-AW) and delirium, and the degree of gait independence at hospital discharge, were collected. Gait independence was determined using a mobility scale of the Barthel Index, and the factors that impaired gait independence at hospital discharge were investigated using a Cox proportional hazard regression analysis. Results One hundred thirty-two patients were analyzed. In the univariate analysis, age, APACHE II score, duration of mechanical ventilation, ICU length of stay, incidence of delirium, and MRC sum-score at ICU discharge were extracted as significant. In the multivariate analysis, age (p = 0.014), MRC sum-score < 48 (p = 0.021), and delirium at discharge from ICU (p < 0.0001) were extracted as significant variables. Conclusions We found that age and incidence of ICU-AW and delirium were significantly related to impaired gait independence at hospital discharge.

scholarly journals Early mobilization is associated with decreased mechanical ventilation and ICU length of stay following cardiac surgery

2021 ◽  
Vol 7 (4) ◽  
pp. 184
Author(s):  
Vasiliki Raidou ◽  
Stavros Dimopoulos ◽  
Foteini Chatzivasiloglou ◽  
Christos Kourek ◽  
Vasiliki Tsagari ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Length Of Stay ◽  
Medical Records ◽  
Early Mobilization ◽  
Icu Stay ◽  
Icu Length Of Stay ◽  
Icu Discharge

Background: Early mobilization of the Intensive Care Unit (ICU) patients improves muscle strength and functional capacity. It has been demonstrated that prevents Intensive Care Unit Acquired Weakness (ICUAW) and accelerates ICU discharge. However, data on mobilization early after cardiac surgery are inadequate. This study aimed to record early mobilization and investigates the association with ICU findings in cardiac surgery patients.Material and Methods: In this observational study, 165 patients after cardiac surgery were enrolled. Of these, 159 were assessed for early mobilization and mobilization status during ICU stay. Mobilization practices were recorded from 1st post ICU admission and every 48 h until 7th day. The duration of mechanical ventilation (MV) support, ICU length of stay and clinical outcome were recorded from medical records registration. Results: Early mobilization consisted of active and passive limb mobilization, sitting in bed and transferring from bed to chair. The proportion of patients mobilized, was 18% (n = 29/159) on day 1, 53% (n = 46/87) on day 3, 54% (n = 22/41) on day 5 and 62% (n = 15/24) on day 7. ICU length of stay was reduced for mobilized patients (n = 29) on day 1 compared to non-mobilized ones (24 ± 10 vs 47 ± 73 h respectively, P = 0.001). The duration of MV was shorter in mobilized patients on day 3 (n =46) compared to bedridden, (18 ± 9 vs 23 ± 30 h respectively, P = 0.01).Conclusions: Early mobilization after cardiac surgery was found to be low with a significant trend to increase over ICU stay. It is also associated with a reduced duration of MV and ICU length of stay.

scholarly journals Preemptive ganciclovir for mechanically ventilated patients with cytomegalovirus reactivation

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Laurent Papazian ◽  
◽  
Samir Jaber ◽  
Sami Hraiech ◽  
Karine Baumstarck ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Invasive Mechanical Ventilation ◽  
Double Blind ◽  
Intravenous Ganciclovir ◽  
Subdistribution Hazard ◽  
Mechanically Ventilated ◽  
Cytomegalovirus Reactivation ◽  
Secondary Outcomes ◽  
To Receive ◽  
Cmv Reactivation

Abstract Background The effect of cytomegalovirus (CMV) reactivation on the length of mechanical ventilation and mortality in immunocompetent ICU patients requiring invasive mechanical ventilation remains controversial. The main objective of this study was to determine whether preemptive intravenous ganciclovir increases the number of ventilator-free days in patients with CMV blood reactivation. Methods This double-blind, placebo-controlled, randomized clinical trial involved 19 ICUs in France. Seventy-six adults ≥ 18 years old who had been mechanically ventilated for at least 96 h, expected to remain on mechanical ventilation for ≥ 48 h, and exhibited reactivation of CMV in blood were enrolled between February 5th, 2014, and January 23rd, 2019. Participants were randomized to receive ganciclovir 5 mg/kg bid for 14 days (n = 39) or a matching placebo (n = 37). Results The primary endpoint was ventilator-free days from randomization to day 60. Prespecified secondary outcomes included day 60 mortality. The trial was stopped for futility based on the results of an interim analysis by the DSMB. The subdistribution hazard ratio for being alive and weaned from mechanical ventilation at day 60 for patients receiving ganciclovir (N = 39) compared with control patients (N = 37) was 1.14 (95% CI from 0.63 to 2.06; P = 0.66). The median [IQR] numbers of ventilator-free days for ganciclovir-treated patients and controls were 10 [0–51] and 0 [0–43] days, respectively (P = 0.46). Mortality at day 60 was 41% in patients in the ganciclovir group and 43% in the placebo group (P = .845). Creatinine levels and blood cells counts did not differ significantly between the two groups. Conclusions In patients mechanically ventilated for ≥ 96 h with CMV reactivation in blood, preemptive ganciclovir did not improve the outcome.

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