scholarly journals High sedation needs of critically ill COVID-19 ARDS patients—A monocentric observational study

PLoS ONE ◽  
2021 ◽  
Vol 16 (7) ◽  
pp. e0253778
Author(s):  
Armin Niklas Flinspach ◽  
Hendrik Booke ◽  
Kai Zacharowski ◽  
Ümniye Balaban ◽  
Eva Herrmann ◽  
...  
Keyword(s):  
Critically Ill ◽  
Distress Syndrome ◽  
Demographic Data ◽  
Prone Positioning ◽  
Mixed Effect ◽  
Mechanically Ventilated ◽  
Global Pandemic ◽  
Potential Association ◽  
The Mean ◽  
Sedation Regimen

Background Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). Methods We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used. Results In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature. Conclusion The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.

scholarly journals Early conscious prone positioning in patients with COVID-19 receiving continuous positive airway pressure: a retrospective analysis

2020 ◽  
Vol 7 (1) ◽  
pp. e000711 ◽  
Author(s):  
Stuart Winearls ◽  
Ema L Swingwood ◽  
Charlotte L Hardaker ◽  
Amy M Smith ◽  
Fraser M Easton ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
Continuous Positive Airway Pressure ◽  
Airway Pressure ◽  
Positive Airway Pressure ◽  
Arterial Oxygen ◽  
Prone Positioning ◽  
Mechanically Ventilated ◽  
Global Pandemic ◽  
High Care ◽  
Randomised Controlled

The global pandemic of COVID-19 has challenged the management of hypoxaemic respiratory failure and strained intensive care unit resources. While prone positioning (PP) is an established therapy in mechanically ventilated patients with acute respiratory distress syndrome (ARDS), its role in conscious patients is less well defined. We retrospectively reviewed our experience of implementing early PP in a cohort of 24 patients with acute hypoxaemic respiratory failure due to COVID-19 who required support with continuous positive airway pressure (CPAP). The use of PP alongside CPAP significantly increased both the ROX index and arterial oxygen pressure:fractional inspired oxygen (PaO2:FiO2) ratio from baseline values (ROX index: 7.0±2.5 baseline vs 11.4±3.7 CPAP+PP, p<0.0001; PaO2:FiO2 ratio: 143±73 mm Hg baseline vs 252±87 mm Hg CPAP+PP, p<0.01), and the changes to both the ROX index and PaO2:FiO2 ratio remained significant 1 hour after cessation of proning. The mean duration of PP in the first 24 hours was 8±5 hours. Few complications were observed and PP was continued for a mean of 10±5 days. From our experience in a dedicated COVID-19 respiratory high care unit, PP alongside CPAP therapy was feasible, tolerated, safe and improved oxygenation. The use of conscious PP in ARDS warrants further investigation in randomised controlled trials.

scholarly journals Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome due to COVID-19: A Cohort Study and Analysis of Physiology

2020 ◽  
Author(s):  
Mehdi Shelhamer ◽  
Paul D. Wesson ◽  
Ian L. Solari ◽  
Deanna L. Jensen ◽  
William Alex Steele ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Competing Risks ◽  
Distress Syndrome ◽  
Saturation Index ◽  
Hospital Death ◽  
Prone Positioning ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Physiologic Parameters ◽  
Ventilated Patients

Abstract BACKGROUND: Coronavirus disease 2019 (COVID-19) can lead to acute respiratory distress syndrome (ARDS) but it is unknown whether prone positioning improves outcomes in mechanically ventilated patients with moderate to severe ARDS due to COVID-19.METHODS: A cohort study at a New York City hospital at the peak of the early pandemic in the United States, under crisis conditions. The aim was to determine the benefit of prone positioning in mechanically ventilated patients with ARDS due to COVID-19. The primary outcome was in-hospital death. Secondary outcomes included changes in physiologic parameters. Fine-Gray competing risks models with stabilized inverse probability treatment weighting (sIPTW) were used to determine the effect of prone positioning on outcomes. In addition, linear mixed effects models (LMM) were used to assess changes in physiology with prone positioning.RESULTS: Out of 335 participants who were intubated and mechanically ventilated, 62 underwent prone positioning, 199 met prone positioning criteria and served as controls and 74 were excluded. The intervention and control groups were similar at baseline. In multivariate-adjusted competing risks models with sIPTW, prone positioning was significantly associated with reduced mortality (SHR 0.61, 95% CI 0.46-0.80, P < 0.005). Using LMM to evaluate the impact of positioning maneuvers on physiological parameters, the oxygenation-saturation index was significantly improved during days 1-3 (P < 0.01) whereas oxygenation-saturation index (OSI), oxygenation-index (OI) and arterial oxygen partial pressure to fractional inspired oxygen (PaO2:FiO2) were significantly improved during days 4-7 (P < 0.05 for all). CONCLUSIONS: Prone positioning in patients with moderate to severe ARDS due to COVID-19 is associated with reduced mortality and improved physiologic parameters. One in-hospital death could be averted for every eight patients treated. Replicating results and scaling the intervention are important, but prone positioning may represented an additional therapeutic option in patients with ARDS due to COVID-19.

scholarly journals Association between early fluid overload and mortality in critically-ill mechanically ventilated children: a single-center retrospective cohort study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Xiangmei Kong ◽  
Yueniu Zhu ◽  
Xiaodong Zhu
Keyword(s):  
Hospital Mortality ◽  
Critically Ill ◽  
Fluid Overload ◽  
Pediatric Intensive Care ◽  
Multiple Organ ◽  
Mechanically Ventilated ◽  
The Mean ◽  
Severity Of The Disease ◽  
Early Fluid ◽  
The Relationship

Abstract Background Positive fluid overload (FO) may cause adverse effect. This study retrospectively analyzed the relationship between early FO and in-hospital mortality in children with mechanical ventilation (MV) in pediatric intensive care unit (PICU). Methods This study retrospectively enrolled 309 children (ages 28 days to 16 years) receiving invasive MV admitted to the PICU of Xinhua Hospital from March 2014 to March 2019. Children receiving MV for less than 48 h were excluded. The FO in the first 3 days of MV was considered to the early FO. Patients were divided into groups according to early FO and survival to evaluate the associations of early FO, percentage FO(%FO) > 10%, and %FO > 20% with in-hospital mortality. Results A total of 309 patients were included. The mean early FO was 8.83 ± 8.81%, and the mortality in hospital was 26.2% (81/309). There were no significant differences in mortality among different FO groups (P = 0.053) or in early FO between survivors and non-survivors (P = 0.992). Regression analysis demonstrated that use of more vasoactive drugs, the presence of multiple organ dysfunction syndrome, longer duration of MV, and a non-operative reason for PICU admission were related to increased mortality (P < 0.05). Although early FO and %FO > 10% were not associated with in-hospital mortality (β = 0.030, P = 0.090, 95% CI = 0.995–1.067; β = 0.479, P = 0.153, 95% CI = 0.837–3.117), %FO > 20% was positively correlated with mortality (β = 1.057, OR = 2.878, P = 0.029, 95% CI = 1.116–7.418). Conclusions The correlation between early FO and mortality was affected by interventions and the severity of the disease, but %FO > 20% was an independent risk factor for in-hospital mortality in critically ill MV-treated children.

Comparison of Bronchoscopy-Guided and Real-Time Ultrasound-Guided Percutaneous Dilatational Tracheostomy: Safety, Complications, and Effectiveness in Critically Ill Patients

2017 ◽  
Vol 34 (3) ◽  
pp. 191-196 ◽  
Author(s):  
Aykut Sarıtaş ◽  
Muhammed M. Kurnaz
Keyword(s):  
Real Time ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Demographic Data ◽  
Percutaneous Dilatational Tracheostomy ◽  
Apache Ii ◽  
Ultrasound Guided ◽  
Dilatational Tracheostomy ◽  
The Us ◽  
The Mean

Objective: To compare the efficacy, safety, and incidence of complications between fiber-optic bronchoscopy-guided percutaneous dilatational tracheostomy (FOB-PDT) and ultrasound-guided percutaneous dilatational tracheostomy (US-PDT) and to determine whether US-PDT is a viable alternative to FOB-PDT. Methods: This randomized prospective study was carried out in 80 patients who were randomly divided into US-PDT and FOB-PDT groups. Demographic data and Acute Physiology and Chronic Health Evaluation II (APACHE II), procedure duration, hemorrhage status, complications, procedure difficulty, displacement of entry location after US, and hemodynamic data were evaluated in both groups. Tracheal incision was performed with real-time US and a transverse probe position in the out-of-plane mode. Results: No significant differences were observed between the 2 groups in terms of demographic data, oral intubation time, APACHE II values, difficulty of the procedure, or the number of needle interventions ( P > .05). The mean hemorrhage ratio of the FOB-PDT group was significantly higher than that of the US-PDT group ( P < .05). The entry location was changed in 6 patients in the US-PDT group following neck examination with US. The mean duration of the procedure for the FOB-PDT group was significantly longer than that for the US-PDT group ( P < .05). Conclusion: Ultrasound-guided percutaneous dilatational tracheostomy is a safe procedure for critically ill patients and has the advantages of a low complication rate, short duration of procedure, being informative with regard to neck anatomy, and facilitating prevention of vascular puncture. Thus, US-PDT can be used as an alternative to FOB-PDT.

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.

scholarly journals ECMO/CRRT Combined Support in the Treatment of Critically Ill SARS-CoV-2 Pneumonia Patients

2021 ◽  
Author(s):  
Shengqing Li
Keyword(s):  
Critically Ill ◽  
Distress Syndrome ◽  
Pulmonary Ventilation ◽  
Combined Treatment ◽  
Severe Heart Failure ◽  
Kidney Injury ◽  
Inflammatory Factors ◽  
Treatment Technique ◽  
The Mean ◽  
Lung Ct

Objective: To explore the experience with and complications of extracorporeal membrane oxygenation (ECMO)combined with continuous renal replacement therapy (CRRT) for treatment of critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia.Methods: The data on critically ill COVID-19 patients who received ECMO/CRRT at Tongji Hospital, which is affiliated with Huazhong University of Science and Technology, in February and March 2020 were collected and analyzed. All three patients were male, and the mean age was 50.6 years (range 44–58 years). The indications for ECMO in critically ill SARS-CoV-2 pneumonia patients at our center were severe acute respiratory distress syndrome with Pao2/Fio2 below 100 mmHg under an effective protective pulmonary ventilation strategy and inflammatory stormaccompanied by acute kidney injury. One patient, with severe heart failure, was selected for venoarterial ECMO, andthe other two patients were selected for venovenous ECMO.Results: In the three patients who received ECMO combined with bedside CRRT, the mean duration was 9.7 days (range 7–13 days). Four complications occurred during ECMO/CRRT, especially thrombocytopenia. Laboratory testing showed increased counts of leukocytes and lymphocytes and decreased levels of inflammatory factors. Lung CT was suggestive of significantly absorbed and reduced lesions and interstitial fibrosis.Conclusions: The survival rate of patients with cardiopulmonary failure treated with ECMO/CRRT in whom conventional treatment failed in this group was 100%, which indicates that combined treatment with ECMO and CRRT is an important treatment technique.

Retrospective investigation of an association between high-dose buprenorphine and perpetuation of post-anesthesia hyperthermia in cats following ovariohysterectomy

2020 ◽  
pp. 1098612X2097620
Author(s):  
Cheyenne J Cannarozzo ◽  
Pati Kirch ◽  
Luis Campoy ◽  
Robin D Gleed ◽  
Augusto M Lorenzutti ◽  
...  
Keyword(s):  
Demographic Data ◽  
High Dose ◽  
Mixed Effect ◽  
Treatment Groups ◽  
Mixed Effect Models ◽  
Potential Association ◽  
Opioid Administration ◽  
Second Year ◽  
To Receive ◽  
Linear Mixed Effect Models

Objectives We evaluated a potential association between the administration of high-dose buprenorphine and perpetuation of hyperthermia in cats following ovariohysterectomy (OVH). We hypothesized that buprenorphine 0.24 mg/kg subcutaneously (SC) would result in longer-lasting postoperative hyperthermia in cats vs a group receiving morphine 0.1 mg/kg SC. Methods Anesthetic records from cats admitted for OVH as part of surgical exercises for second year veterinary medicine students in 2018 and 2019 were collected. All cats were sedated with dexmedetomidine 20 µg/kg and morphine 0.1 mg/kg intramuscularly. Anesthesia was induced with propofol and maintained with isoflurane in oxygen. At extubation, cats received morphine 0.1 mg/kg SC in 2018 and buprenorphine 0.24 mg/kg SC in 2019. Temperature was measured rectally prior to sedation, esophageally during anesthesia and rectally at 1, 4 and 16–20 h after extubation. Demographic data and temperature prior to administration of postoperative opioids were compared with t-tests. The effects of treatment (opioids) and time on postoperative rectal temperature and on the incidence of hyperthermia (temperature >39.2°C) were evaluated with mixed and generalized linear mixed-effect models. Significance was set at P <0.05. Results There were no differences in demographic characteristics between treatment groups (all P  ⩾0.2). Intraoperative esophageal temperature was lower in cats scheduled to receive morphine (mean ± SD 36.6 ± 0.2) than in those receiving buprenorphine (36.9 ± 1.0) ( P <0.0001). Postoperative temperature was higher for cats receiving buprenorphine than for those receiving morphine ( P <0.0001). The incidence of hyperthermia 16–20 h after opioid administration was 56% for morphine and 73% for buprenorphine ( P = 0.03). Conclusions and relevance Buprenorphine 0.24 mg/kg SC for postoperative analgesia in cats was associated with hyperthermia that persisted for 16–20 h after administration, and the incidence of hyperthermia for this group was higher than in the cats that received morphine 0.1 mg/kg SC.

scholarly journals 1039 Sleep And Daytime Activity Among Mechanically Ventilated Adults During Early Critical Illness

SLEEP ◽  
2020 ◽  
Vol 43 (Supplement_1) ◽  
pp. A395-A395
Author(s):  
Z Liang ◽  
M N Elias ◽  
M Ji ◽  
C L Munro
Keyword(s):  
Critical Illness ◽  
Critically Ill ◽  
Controlled Trial ◽  
Activity Patterns ◽  
Activity Count ◽  
Federal Grant ◽  
Mechanically Ventilated ◽  
Daytime Activity ◽  
The Mean ◽  
Rest Activity

Abstract Introduction The purpose of this study is to report 5 consecutive days’ descriptive data for sleep efficiency (SE), total sleep time (TST), and daytime activity ratio (DAR) among critically ill mechanically ventilated adults from 9 intensive care units (ICU) across two hospitals. To our knowledge, this is the first study to describe sleep and activity patterns among mechanically ventilated adults during the early critical illness period. Methods We enrolled 31 critically ill mechanically ventilated subjects within 48 hours of ICU admission. Daytime periods were defined as 06:00-21:59; nighttime periods were defined as 22:00-05:59. Actigraphy estimated nighttime SE, TST, and the DAR. We calculated mean DARs [DAR = (daytime activity count per minute / 24-hour activity count per minute) x 100], which may be an indicator of altered rest/activity cycles. In our study, a DAR of &gt;80% was used to define normal rest/activity patterns. Descriptive analyses were used for this sub-analysis of our parent randomized controlled trial. Results Among the 31 subjects included, the mean age was 59.6 ± 17.3 years, 41.9% were male, 80.6% were White, and 67.7% were Hispanic/Latino. The mean nighttime SE and TST over the 5-day ICU period were 83.1% ± 16.1 and 6.6 ± 1.3 hours, respectively. The mean DAR over the 5-day ICU period was 66.5% ± 19.2. Only 17.5% of subject days (14 days out of a total of 80 recorded days) met the definition of normal rest/activity patterns (DAR &gt;80%). Conclusion Throughout the early ICU period, among mechanically ventilated patients, both the sleep/wake as well as the rest/activity cycle were disturbed. Intervention studies targeting the optimization of nighttime sleep consolidation and daytime activity should be investigated. Support This project was supported by a federal grant from the National Institutes of Health/National Institute of Nursing Research (R01NR016702). This clinical trial is registered with ClinicalTrials.gov (NCT03128671).

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