Should Benzodiazepine Sedation be Delivered by Infusion or Bolus?

Benzodiazepine sedation for mechanically ventilated patients in intensive care (ICU) is common practice worldwide. We performed a literature review to investigate whether benzodiazepine sedation is best delivered by continuous infusion or intermittent bolus. PubMed, Ovid and Cochrane databases were searched. Only four studies, involving 481 patients, were found. Three were randomised controlled trials and one was an observational cohort study; all used different benzodiazepines, sometimes in conjunction with opiates. The studies measured different outcomes including mechanical ventilation duration, length of ICU and hospital stay, quality and complications of sedation and mortality. Use of intermittent sedation or opiate boluses alone reduced mechanical ventilation duration, ICU and hospital length of stay. However such limited data means that the optimal mode of delivery for benzodiazepine sedation remains unresolved.

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Impact of Permissive Hypoxia and Hyperoxia Avoidance on Clinical Outcomes in Septic Patients Receiving Mechanical Ventilation: A Retrospective Single-Center Study

BioMed Research International ◽

10.1155/2021/7332027 ◽

2021 ◽

Vol 2021 ◽

pp. 1-10

Author(s):

Kota Nishimoto ◽

Takeshi Umegaki ◽

Sayaka Ohira ◽

Takehiro Soeda ◽

Natsuki Anada ◽

...

Keyword(s):

Mechanical Ventilation ◽

University Hospital ◽

Icu Mortality ◽

Respiratory Dysfunction ◽

Mechanically Ventilated ◽

Icu Stay ◽

Ventilation Duration ◽

Mechanical Ventilation Duration ◽

Before And After ◽

Clinical Records

Background. Septic patients often require mechanical ventilation due to respiratory dysfunction, and effective ventilatory strategies can improve survival. The effects of the combination of permissive hypoxia and hyperoxia avoidance for managing mechanically ventilated patients are unknown. This study examines these effects on outcomes in mechanically ventilated septic patients. Methods. In a retrospective before-and-after study, we examined adult septic patients (aged ≥18 years) requiring mechanical ventilation at a university hospital. On April 1, 2017, our mechanical ventilation policy changed from a conventional oxygenation target (SpO2: ≥96%) to more conservative targets with permissive hypoxia (SpO2: 88-92% or PaO2: 60 mmHg) and hyperoxia avoidance (reduced oxygenation for Pa O 2 > 110 mmHg ). Patients were divided into a prechange group (April 2015 to March 2017; n = 83 ) and a postchange group (April 2017 to March 2019; n = 130 ). Data were extracted from clinical records and insurance claims. Using a multiple logistic regression model, we examined the association of the postchange group (permissive hypoxia and hyperoxia avoidance) with intensive care unit (ICU) mortality after adjusting for variables such as Sequential Organ Failure Assessment (SOFA) score and PaO2/FiO2 ratios. Results. The postchange group did not have significantly lower adjusted ICU mortality (0.67, 0.33-1.43; P = 0.31 ) relative to the prechange group. However, there were significant intergroup differences in mechanical ventilation duration (prechange: 11.0 days, postchange: 7.0 days; P = 0.01 ) and ICU stay (prechange: 11.0 days, postchange: 9.0 days; P = 0.02 ). Conclusions. Permissive hypoxia and hyperoxia avoidance had no significant association with reduced ICU mortality in mechanically ventilated septic patients. However, this approach was significantly associated with shorter mechanical ventilation duration and ICU stay, which can improve patient turnover and ventilator access.

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“Difficult to Sedate”: Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children

Children ◽

10.3390/children8050348 ◽

2021 ◽

Vol 8 (5) ◽

pp. 348

Author(s):

Nataly Shildt ◽

Chani Traube ◽

Mary Dealmeida ◽

Ishaan Dave ◽

Scott Gillespie ◽

...

Keyword(s):

Mechanical Ventilation ◽

Length Of Stay ◽

Pediatric Intensive Care ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Opiate Withdrawal ◽

Successful Implementation ◽

Chromosomal Disorders ◽

Mechanically Ventilated ◽

Single Center Study

We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08–0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.

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Comparison of culture-negative and culture-positive sepsis or septic shock: a systematic review and meta-analysis

Critical Care ◽

10.1186/s13054-021-03592-8 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Yuting Li ◽

Jianxing Guo ◽

Hongmei Yang ◽

Hongxiang Li ◽

Yangyang Shen ◽

...

Keyword(s):

Septic Shock ◽

Mechanical Ventilation ◽

Length Of Stay ◽

Meta Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Icu Length Of Stay ◽

Mechanical Ventilation Duration ◽

Culture Positive ◽

Culture Negative

Abstract Background Mortality and other clinical outcomes between culture-negative and culture-positive septic patients have been documented inconsistently and are very controversial. A systematic review and meta-analysis was performed to compare the clinical outcomes of culture-negative and culture-positive sepsis or septic shock. Methods We searched the PubMed, Cochrane and Embase databases for studies from inception to the 1st of January 2021. We included studies involving patients with sepsis or septic shock. All authors reported our primary outcome of all-cause mortality and clearly compared culture-negative versus culture-positive patients with clinically relevant secondary outcomes (ICU length of stay, hospital length of stay, mechanical ventilation requirements, mechanical ventilation duration and renal replacement requirements). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). Results Seven studies including 22,655 patients were included. The primary outcome of this meta-analysis showed that there was no statistically significant difference in the all-cause mortality between two groups (OR = 0.95; 95% CI, 0.88 to 1.01; P = 0.12; Chi-2 = 30.71; I2 = 80%). Secondary outcomes demonstrated that there was no statistically significant difference in the ICU length of stay (MD = − 0.19;95% CI, − 0.42 to 0.04; P = 0.10;Chi-2 = 5.73; I2 = 48%), mechanical ventilation requirements (OR = 1.02; 95% CI, 0.94 to 1.11; P = 0.61; Chi2 = 6.32; I2 = 53%) and renal replacement requirements (OR = 0.82; 95% CI, 0.67 to 1.01; P = 0.06; Chi-2 = 1.21; I2 = 0%) between two groups. The hospital length of stay of culture-positive group was longer than that of the culture-negative group (MD = − 3.48;95% CI, − 4.34 to − 2.63; P < 0.00001;Chi-2 = 1.03; I2 = 0%). The mechanical ventilation duration of culture-positive group was longer than that of the culture-negative group (MD = − 0.64;95% CI, − 0.88 to − 0.4; P < 0.00001;Chi-2 = 4.86; I2 = 38%). Conclusions Culture positivity or negativity was not associated with mortality of sepsis or septic shock patients. Furthermore, culture-positive septic patients had similar ICU length of stay, mechanical ventilation requirements and renal replacement requirements as those culture-negative patients. The hospital length of stay and mechanical ventilation duration of culture-positive septic patients were both longer than that of the culture-negative patients. Further large-scale studies are still required to confirm these results.

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Comparison of Culture-Negative and Culture-Positive Sepsis or Septic Shock: A Systematic Review and Meta-Analysis

10.21203/rs.3.rs-220606/v1 ◽

2021 ◽

Author(s):

Yuting Li ◽

Jianxing Guo ◽

Hongmei Yang ◽

Hongxiang Li ◽

Yangyang Shen ◽

...

Keyword(s):

Septic Shock ◽

Mechanical Ventilation ◽

Length Of Stay ◽

Meta Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Icu Length Of Stay ◽

Mechanical Ventilation Duration ◽

Culture Positive ◽

Culture Negative

Abstract Background: Mortality and other clinical outcomes between culture-negative and culture-positive septic patients have been documented inconsistently and are very controversial. A systematic review and meta-analysis was performed to compare the clinical outcomes of culture-negative and culture-positive sepsis or septic shock.Methods: We searched the PubMed, Cochrane, and Embase databases for studies from inception to the 1st of January 2021. We included studies involving patients with sepsis or septic shock. All authors reported our primary outcome of all-cause mortality and clearly comparing culture-negative versus culture-positive patients with clinically relevant secondary outcomes (ICU length of stay, hospital length of stay, mechanical ventilation requirements, mechanical ventilation duration and renal replacement requirements). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI).Results: Seven studies including 22655 patients were included. The primary outcome of this meta-analysis showed that there was no statistically significant difference in the all-cause mortality between two groups (OR=0.95; 95% CI, 0.88 to 1.01; P=0.12; Chi2=30.71; I2=80%) . Secondary outcomes demonstrated that there was no statistically significant difference in the ICU length of stay(MD=-0.19;95% CI, -0.42 to 0.04; P=0.10;Chi2=5.73; I2=48%), mechanical ventilation requirements(OR=1.05; 95% CI, 0.93 to 1.18; P=0.41; Chi2=5.89; I2=66%) and renal replacement requirements(OR=0.82; 95% CI, 0.67 to 1.01; P=0.06; Chi2=1.21; I2=0%) between two groups. The hospital length of stay of culture-positive group was longer than that of the culture-negative group(MD=-3.48;95% CI, -4.34 to -2.63; P<0.00001;Chi2=1.03; I2=0%). The mechanical ventilation duration of culture-positive group was longer than that of the culture-negative group(MD=-0.64;95% CI, -0.88 to -0.4; P<0.00001;Chi2=4.86; I2=38%).Conclusions: Culture positivity or negativity was not associated with mortality of sepsis or septic shock patients. Furthermore, culture-positive septic patients had similar ICU length of stay, mechanical ventilation requirements and renal replacement requirements as those culture-negative patients. The hospital length of stay and mechanical ventilation duration of culture-positive septic patients were both longer than that of the culture-negative patients. Further large-scale studies are still required to confirm these results.

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Tracheostomy Practice in Mechanically Ventilated Patients With SARS-CoV-2 Induced Acute Respiratory Distress Syndrome: a Single-center Retrospective Study With Focus on Tracheomalacia

10.21203/rs.3.rs-150959/v1 ◽

2021 ◽

Author(s):

Marcello Guarnieri ◽

Patrizia Andreoni ◽

Hedwige Gay ◽

Riccardo Giudici ◽

Maurizio Bottiroli ◽

...

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Invasive Mechanical Ventilation ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Single Center ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Factors Associated ◽

Ventilated Patients

Abstract Background: The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare, but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. Aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence.Methods. Retrospective, single-center study performed in an Italian teaching hospital. All adult patients admitted to the Intensive Care Unit (ICU) between February 24 and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, while information regarding airway management was collected daily.Results. A total of 151 patients were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 39.7%. A tracheostomy was performed in 73 (48.3%) patients: open surgical technique in 54 patients (74%) and percutaneous Ciaglia technique in 19 patients (26%). Patients in whom a tracheostomy was performed had, compared to the other patients, a longer duration of mechanical ventilation and longer ICU and hospital length of stay. Tracheomalacia was diagnosed in 8 (5%) patients. The factors associated with tracheomalacia were female sex, obesity, and tracheostomy.Conclusions. In our population, approximately 50% of patients with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized patients had a longer ICU and hospital length of stay. Five percent of our population was diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature and the underlying mechanisms are not fully understood.

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Impact of Permissive Hypoxia and Hyperoxia Avoidance on Clinical Outcomes in Septic Patients Receiving Mechanical Ventilation: A Retrospective Single-Center Study

10.21203/rs.3.rs-146649/v1 ◽

2021 ◽

Author(s):

Kota Nishimoto ◽

Takeshi Umegaki ◽

Sayaka Ohira ◽

Takehiro Soeda ◽

Natsuki Anada ◽

...

Keyword(s):

Mechanical Ventilation ◽

University Hospital ◽

Icu Mortality ◽

Mechanically Ventilated ◽

Icu Stay ◽

Ventilation Duration ◽

Mechanical Ventilation Duration ◽

Single Center Study ◽

Before And After ◽

Improve Patient

Abstract Different ventilatory strategies may affect survival in septic patients requiring mechanical ventilation. In this retrospective before-and-after study, we examined the effects of permissive hypoxia and hyperoxia avoidance on mortality in mechanically ventilated adult (≥18 years) septic patients at a Japanese university hospital. In April 2017, our hospital’s mechanical ventilation policy changed from a conventional oxygenation target (SpO2: ≥96%.) to more conservative targets with permissive hypoxia (SpO2: 88-92% or PaO2: 60 mmHg) and hyperoxia avoidance (reduced oxygenation for PaO2 >110 mmHg). Patients were divided into a pre-change group (April 2015 to March 2017; n=83) or post-change group (April 2017 to March 2019; n=130). Using a multiple logistic regression model, we examined the association of the post-change group with intensive care unit (ICU) mortality. The post-change group did not have a significantly lower adjusted ICU mortality (odds ratio: 0.67, 95% confidence interval: 0.33-1.43; P=0.31) than the pre-change group. However, there were significant differences in mechanical ventilation duration (pre-change: 11.0 days, post-change: 7.0 days; P=0.01) and ICU stay (pre-change: 11.0 days, post-change: 9.0 days; P=0.02). Although the new ventilation policy did not affect ICU mortality, the reductions in mechanical ventilation duration and ICU stay may improve patient turnover and ventilator access.

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Effect of Early versus Late Tracheostomy Placement on Survival in Patients Receiving Mechanical Ventilation

50 Studies Every Intensivist Should Know ◽

10.1093/med/9780190467654.003.0026 ◽

2018 ◽

pp. 157-162

Author(s):

J. Michael Guthrie ◽

Vadim Gudzenko

Keyword(s):

Mechanical Ventilation ◽

Prolonged Mechanical Ventilation ◽

Controlled Trial ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Icu Patients ◽

Early Tracheostomy ◽

Mechanically Ventilated ◽

Study Intervention

The TracMan randomized controlled trial examined mortality among patients randomized to receive early (first 4 days) versus late (after 10 days) tracheostomy. This chapter describes the basics of the study, including funding, study location, who was studied, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. It briefly reviews other relevant studies and information, discusses implications, and concludes with a relevant clinical case. The study found that early tracheostomy did not improve mortality in mechanically ventilated ICU patients. Early tracheostomy did not improve important patient outcomes such as ICU or hospital length of stay. The study also demonstrated that clinicians’ ability to predict which ICU patients will require prolonged mechanical ventilation is severely limited.

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The impact of intensive care unit physician staffing change at a community hospital

SAGE Open Medicine ◽

10.1177/20503121211066471 ◽

2022 ◽

Vol 10 ◽

pp. 205031212110664

Author(s):

Christopher D Adams ◽

Luigi Brunetti ◽

Liza Davidov ◽

Jose Mujia ◽

Michael Rodricks

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Length Of Stay ◽

Patient Care ◽

Hospital Costs ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Mechanically Ventilated ◽

Unit Model

Objectives: A high-intensity staffing model has been defined as either mandatory intensivist consultation or a closed intensive care unit in which intensivists manage all aspects of patient care. In the current climate of limited healthcare resources, transitioning to a closed intensive care unit model may lead to significant improvements in patient care and resource utilization. Methods: This is a single-center, retrospective cohort study of all mechanically ventilated intensive care unit admissions in the pre-intensive care unit closure period of 1 October 2014 to 30 September 2015 as compared with the post-intensive care unit closure period of 1 November 2015 to 31 October 2016. Patient demographics as well as outcome data (duration of mechanical ventilation, length of stay, direct costs, complications, and mortality) were abstracted from the electronic health record. All data were analyzed using descriptive and inferential statistics. Regression analyses were used to adjust outcomes for potential confounders. Results: A total of 549 mechanically ventilated patients were included in our analysis: 285 patients in the pre-closure cohort and 264 patients in the post-closure cohort. After adjusting for confounders, there was no significant difference in mortality rates between the pre-closure (40.7%) and post-closure (38.6%) groups (adjusted odds ratio = 0.82; 95% confidence interval = 0.56–1.18; p = 0.283). The post-closure cohort was found to have significant reductions in duration of mechanical ventilation (3.71–1.50 days; p < 0.01), intensive care unit length of stay (5.8–2.7 days; p < 0.01), hospital length of stay (10.9–7.3 days; p < 0.01), and direct hospital costs (US $16,197–US $12,731; p = 0.009). Patient complications were also significantly reduced post-intensive care unit closure. Conclusion: Although a closed intensive care unit model in our analysis did not lead to a statistical difference in mortality, it did demonstrate multiple beneficial outcomes including reduced ventilator duration, decreased intensive care unit and hospital length of stay, fewer patient complications, and reduced direct hospital costs.

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Ethnicity and outcomes in patients hospitalised with COVID-19 infection in East London: an observational cohort study

BMJ Open ◽

10.1136/bmjopen-2020-042140 ◽

2021 ◽

Vol 11 (1) ◽

pp. e042140

Author(s):

Vanessa J Apea ◽

Yize I Wan ◽

Rageshri Dhairyawan ◽

Zudin A Puthucheary ◽

Rupert M Pearse ◽

...

Keyword(s):

Premature Death ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Organ Support ◽

Invasive Ventilation ◽

Black Patients ◽

Hospitalised Patients ◽

Observational Cohort ◽

The Impact ◽

To Receive

ObjectiveTo describe outcomes within different ethnic groups of a cohort of hospitalised patients with confirmed COVID-19 infection. To quantify and describe the impact of a number of prognostic factors, including frailty and inflammatory markers.SettingFive acute National Health Service Hospitals in east London.DesignProspectively defined observational study using registry data.Participants1737 patients aged 16 years or over admitted to hospital with confirmed COVID-19 infection between 1 January and 13 May 2020.Main outcome measuresThe primary outcome was 30-day mortality from time of first hospital admission with COVID-19 diagnosis during or prior to admission. Secondary outcomes were 90-day mortality, intensive care unit (ICU) admission, ICU and hospital length of stay and type and duration of organ support. Multivariable survival analyses were adjusted for potential confounders.Results1737 were included in our analysis of whom 511 had died by day 30 (29%). 538 (31%) were from Asian, 340 (20%) black and 707 (40%) white backgrounds. Compared with white patients, those from minority ethnic backgrounds were younger, with differing comorbidity profiles and less frailty. Asian and black patients were more likely to be admitted to ICU and to receive invasive ventilation (OR 1.54, (95% CI 1.06 to 2.23); p=0.023 and OR 1.80 (95% CI 1.20 to 2.71); p=0.005, respectively). After adjustment for age and sex, patients from Asian (HR 1.49 (95% CI 1.19 to 1.86); p<0.001) and black (HR 1.30 (95% CI 1.02 to 1.65); p=0.036) backgrounds were more likely to die. These findings persisted across a range of risk factor-adjusted analyses accounting for major comorbidities, obesity, smoking, frailty and ABO blood group.ConclusionsPatients from Asian and black backgrounds had higher mortality from COVID-19 infection despite controlling for all previously identified confounders and frailty. Higher rates of invasive ventilation indicate greater acute disease severity. Our analyses suggest that patients of Asian and black backgrounds suffered disproportionate rates of premature death from COVID-19.

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Evaluation of Delirium in Critically Ill Patients Prescribed Melatonin or Ramelteon

Annals of Pharmacotherapy ◽

10.1177/10600280211002054 ◽

2021 ◽

pp. 106002802110020

Author(s):

Natasha Romero ◽

Kevin M. Dube ◽

Kenneth E. Lupi ◽

Jeremy R. DeGrado

Keyword(s):

Clinical Outcomes ◽

Critically Ill ◽

Critically Ill Patients ◽

Receptor Agonist ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Melatonin Receptor ◽

Observational Cohort ◽

Impaired Sleep ◽

Retrospective Observational Cohort Study

Background: An impaired sleep-wake cycle may be one factor that affects the development of delirium in critically ill patients. Several small studies suggest that exogenous melatonin or ramelteon may decrease the incidence and/or duration of delirium. Objective: To compare the effect of prophylactic administration of melatonin, ramelteon, or no melatonin receptor agonist on the development of delirium in the intensive care unit (ICU). Methods: This was a single-center, retrospective, observational cohort study of nondelirious patients in the ICU who received melatonin, ramelteon, or no melatonin receptor agonist. The primary end point was the incidence of delirium. Secondary end points included assessments of daily level of sedation and daily utilization of antipsychotic, sedative, and opioid agents. Results: No difference was observed in the incidence of delirium among the melatonin, ramelteon, and placebo cohorts (18.7% vs 14.3% vs 13.8%; P = 0.77). A difference was observed in the rate of agitation and sedation among the 3 groups, with the greatest observed in the melatonin cohort. Additionally, there was a difference in the use of propofol, dexmedetomidine, and opioids. Overall, there was no difference in clinical outcomes, including duration of mechanical ventilation and ICU or hospital length of stay. Conclusion and Relevance: Therapy with melatonin, ramelteon, and no melatonin receptor agonist resulted in similar rates of delirium in a mixed ICU population. Despite significant differences in agitation, sedation, and medication utilization, there was no differences in the clinical outcomes evaluated.

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