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

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.

Download Full-text

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.

Download Full-text

Effect of Nurse-Led Goal-Directed Lung Physical Therapy on the Prognosis of Pneumonia in Sepsis Patients in the ICU: A Prospective Cohort Study

Journal of Intensive Care Medicine ◽

10.1177/0885066620987200 ◽

2021 ◽

pp. 088506662098720

Author(s):

Jianhua Sun ◽

Wen Han ◽

Na Cui ◽

Qi Li ◽

Hao Wang ◽

...

Keyword(s):

Mechanical Ventilation ◽

Physical Therapy ◽

Confidence Interval ◽

Odds Ratio ◽

Phase 1 ◽

Phase 2 ◽

Icu Mortality ◽

Icu Stay ◽

Ventilation Duration ◽

Mechanical Ventilation Duration

Background: Pneumonia poses a significant burden on healthcare systems. However, few studies have focused on nurse-led goal-directed lung physical therapy (GDLPT) for pneumonia in sepsis patients in the intensive care unit (ICU). Objectives: This study aimed to investigate the effects of nurse-led GDLPT on the prognosis of pneumonia in sepsis patients in the ICU. Methods: We performed a prospective 2-phase (before-and-after) study over 3 years. After an observational phase (phase 1, n = 188), we designed, implemented, and evaluated a nurse-led GDLPT protocol (phase 2, n = 359) for pneumonia in sepsis patients in the ICU. The primary outcome was 28-day mortality. Results: We evaluated 742 critically ill patients with sepsis from January 2017 to January 2020. Among the 742 sepsis patients, 609 were diagnosed with pneumonia and 547 who met the inclusion criteria were enrolled in the study. Compared with patients in phase 1, patients in phase 2 had significantly shorter mechanical ventilation duration (5 [4, 6] days vs. 5 [4, 8] days, p = 0.037), shorter ICU stay (9 [4, 16] days vs. 9 [6, 20] days, p = 0.010), lower ICU mortality (15.0% [54/359] vs. 25.5% [48/188], p = 0.003), and lower 28-day mortality (16.7% [60/359] vs. 27.1% ([51/188], p = 0.004). Multivariate logistic regression analysis revealed that nurse-led GDLPT (odds ratio 0.540, 95% confidence interval 0.345–0.846, p = 0.007), clinical pulmonary infection score (odds ratio 1.111, 95% confidence interval 1.012–1.221, p = 0.028), and ventilation day (OR 1.160, 95% CI, 1.058–1.240, p<0.001)were independent predictors of 28-day mortality for pneumonia in sepsis patients, and that nurse-led GDLPT was a protective factor. Conclusions: Nurse-led GDLPT improved the outcomes of pneumonia in sepsis patients, and was particularly associated with shortened mechanical ventilation duration and ICU stay, and reduced ICU mortality and 28-day mortality.

Download Full-text

Relationship between Intracranial Pressure Monitoring and Outcomes in Severe Traumatic Brain Injury Patients

Anaesthesia and Intensive Care ◽

10.1177/0310057x1103900610 ◽

2011 ◽

Vol 39 (6) ◽

pp. 1043-1050 ◽

Cited By ~ 22

Author(s):

S. Haddad ◽

A. S. Aldawood ◽

A. Alferayan ◽

N. A. Russell ◽

H. M. Tamim ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Mechanical Ventilation ◽

Intracranial Pressure ◽

Hospital Mortality ◽

Icp Monitoring ◽

Icu Mortality ◽

Ventilation Duration ◽

Mechanical Ventilation Duration ◽

Significant Difference ◽

Severe Tbi

Intracranial pressure (ICP) monitoring is recommended in patients with a severe traumatic brain injury (TBI) and an abnormal computed tomography (CT) scan. However, there is contradicting evidence about whether ICP monitoring improves outcome. The purpose of this study was to examine the relationship between ICP monitoring and outcomes in patients with severe TBI. From February 2001 to December 2008, a total of 477 consecutive adult (>18 years) patients with severe TBI were included retrospectively in the study. Patients who underwent ICP monitoring (n=52) were compared with those who did not (n=425). The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, mechanical ventilation duration, the need for tracheostomy, and ICU and hospital length of stay (LOS). After adjustment for multiple potential confounding factors, ICP monitoring was not associated with significant difference in hospital or ICU mortality (odds ratio [OR]=1.71, 95% confidence interval [CI]=0.79 to 3.70, P=0.17; OR=1.01, 95% CI=0.41 to 2.45, P=0.99, respectively). ICP monitoring was associated with a significant increase in mechanical ventilation duration (coefficient=5.66, 95% CI=3.45 to 7.88, P <0.0001), need for tracheostomy (OR=2.02, 95% CI=1.02 to 4.03, P=0.04), and ICU LOS (coefficient=5.62, 95% CI=3.27 to 7.98, P <0.0001), with no significant difference in hospital LOS (coefficient=8.32, 95% CI=-82.6 to 99.25, P=0.86). Stratified by the Glasgow Coma Scale score, ICP monitoring was associated with a significant increase in hospital mortality in the group of patients with Glasgow Coma Scale 7 to 8 (adjusted OR=12.89, 95% CI=3.14 to 52.95, P=0.0004). In patients with severe TBI, ICP monitoring was not associated with reduced hospital mortality, however, with a significant increase in mechanical ventilation duration, need for tracheostomy, and ICU LOS.

Download Full-text

Should Benzodiazepine Sedation be Delivered by Infusion or Bolus?

Journal of the Intensive Care Society ◽

10.1177/175114371301400107 ◽

2013 ◽

Vol 14 (1) ◽

pp. 24-27

Author(s):

James Hutchinson ◽

Georgina Harlow ◽

David Sinton ◽

Tony Whitehouse

Keyword(s):

Mechanical Ventilation ◽

Mode Of Delivery ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Limited Data ◽

Mechanically Ventilated ◽

Ventilation Duration ◽

Mechanical Ventilation Duration ◽

Observational Cohort ◽

Randomised Controlled

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.

Download Full-text

A comparative study between effect of combined intravenous and nebulized amikacin versus intravenous amikacin alone in mechanically ventilated patients with ventilator-associated pneumonia (VAP)

Ain-Shams Journal of Anesthesiology ◽

10.1186/s42077-020-00098-3 ◽

2020 ◽

Vol 12 (1) ◽

Author(s):

Dalia M. El Fawy ◽

Azza Yousef Ibrahim ◽

Ahmed Mostafa Mohamed Abdulmageed ◽

Eman Abo Bakr El Seddek

Keyword(s):

Mechanical Ventilation ◽

Ventilator Associated Pneumonia ◽

Icu Mortality ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Icu Stay ◽

Drug Concentrations ◽

Group A ◽

Group B ◽

Ventilated Patients

Abstract Background Aerosolized antibiotic administration offers the theoretical advantages of achieving high drug concentrations at the infection site together with lower systemic absorption. This study aims to compare the effect of combining nebulized amikacin with intravenous amikacin to the effect of the usual intravenous route alone in the treatment of patients with ventilator-associated pneumonia and its impact on the duration of mechanical ventilation, laboratory, and clinical picture of the patients. Results This study was carried out on 64 mechanically ventilated patients with Gram-negative VAP. The patients were divided into 2 groups. Group A included 32 patients treated with nebulized amikacin plus IV amikacin, and group B included 32 patients treated with IV amikacin alone. The duration of treatment for both groups was 8 days with a daily assessment of Clinical Pulmonary Infection Score (CPIS) and monitoring of clinical and laboratory parameters. Sputum cultures were obtained thereafter. In our study, the CPIS score and overall ICU mortality were less in the nebulized than in the IV group but the difference failed to be statistically significant. Increase of oxygenation level (Pao2/Fio2 ratio), organism clearance, decrease in serum creatinine level, duration of mechanical ventilation, and length of ICU stay were significantly different in favor of group A than group B. Conclusion Nebulized and IV amikacin offered better oxygenation, organism clearance, less nephrotoxicity, and less duration of mechanical ventilation and ICU stay than the IV group. Combined and IV routes were comparable regarding the decrease in CPIS score and ICU mortality with no significant difference between them. However, we prefer to use the combined regimen for the mentioned reasons. Further large-scale studies are required to confirm these findings and to establish a definite conclusion.

Download Full-text

Early Versus Late Tracheostomy in Outcome of Patients Admitted in Neurosurgical Intensive Care Unit

Eastern Green Neurosurgery ◽

10.3126/egn.v2i2.29239 ◽

2020 ◽

Vol 2 (2) ◽

pp. 21-25

Author(s):

Shiwani Rai ◽

Prasansa Sharma ◽

Sofiya Makajoo ◽

Balgopal Karmacharya ◽

Nikunja Yogi

Keyword(s):

Mechanical Ventilation ◽

Intensive Care ◽

Tertiary Care ◽

Early Tracheostomy ◽

Icu Stay ◽

Ventilation Duration ◽

Mechanical Ventilation Duration ◽

Significant Difference ◽

Neurosurgical Intensive Care

Background: Tracheostomy is a commonly performed procedure in neurosurgical Intensive Care Units (ICU) performed to secure airway, aid in pulmonary toileting, and minimize ventilator-associated pneumonia (VAP) in cases requiring prolonged mechanical ventilation. Although early tracheostomy has been advocated rampantly in recent days, its benefit over late tracheostomy and the timing itself has been very controversial. In this study, we tried to study the effect of timing of tracheostomy in the outcome of patients in our ICU. Materials and methods: This is a retrospective study carried out over a period of one and a half years in a tertiary care center in western Nepal. Early tracheostomy was defined as those done within 4 days of endotracheal intubation and late were those done thereafter. Outcomes were studied in terms of length of ICU stay, hospital stay, mechanical ventilation, duration of tracheostomy in situ, VAP and mortality and complication over 90 days. Statistical analysis was done using SPSS 20.0. Results: There were 67 cases included in the study, out of which 27(40.3%) underwent early and 40 (59.7%) underwent late tracheostomy. The Mean duration of ICU stay, tracheostomy in situ duration, mechanical ventilation duration, and VAP were the parameters showing a significant difference between the two groups. There were 13 (19.4%) cases having complications in our series of which 6 (9%) of cases were from the early tracheostomy group and 7 (10.4%) of the cases were from the late tracheostomy group (p=0.63). Conclusion: Early tracheostomy is beneficial in a neurosurgical patient in terms of a decrease in ICU stay, duration of mechanical ventilation, duration of tracheostomy in situ, and VAP.

Download Full-text

Heterogeneity in the Definition of Mechanical Ventilation Duration and Ventilator-Free Days

American Journal of Respiratory and Critical Care Medicine ◽

10.1164/rccm.201308-1499le ◽

2014 ◽

Vol 189 (8) ◽

pp. 998-1002 ◽

Cited By ~ 30

Author(s):

Laetitia Contentin ◽

Stephan Ehrmann ◽

Bruno Giraudeau

Keyword(s):

Mechanical Ventilation ◽

Ventilation Duration ◽

Mechanical Ventilation Duration ◽

Definition Of

Download Full-text

2200 The effect of antipyretics and fever on the mortality of mechanically ventilated patients

Journal of Clinical and Translational Science ◽

10.1017/cts.2018.131 ◽

2018 ◽

Vol 2 (S1) ◽

pp. 30-31

Author(s):

Emily M. Evans ◽

Rebecca J. Doctor ◽

Brian M. Fuller ◽

Richard S. Hotchkiss ◽

Anne M. Drewry

Keyword(s):

Mechanical Ventilation ◽

Clinical Outcomes ◽

Severity Of Illness ◽

Primary Analysis ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Before And After ◽

Patients At Risk ◽

Forward Stepwise ◽

Ventilated Patients

OBJECTIVES/SPECIFIC AIMS: (1) To evaluate clinical outcomes in mechanically ventilated patients with and without fever. We hypothesize that, after adjusting for confounding factors such as age and severity of illness: (a) In septic patients, fever will be associated with improved clinical outcomes. (b) In nonseptic patients, fever will be associated with worse clinical outcomes. (2) To examine the relationship between antipyretics and mortality in mechanically ventilated patients at risk for an acute lung injury. We hypothesize that antipyretics will have no effect on clinical outcomes in mechanically ventilated patients with and without sepsis. METHODS/STUDY POPULATION: This is a retrospective study of a “before and after” observational cohort of 1705 patients with acute initiation of mechanical ventilation in the Emergency Department from September 2009 to March 2016. Data were collected retrospectively on the first 72 hours of temperature and antipyretic medication from the EHR. Temperatures measurements were adjusted based on route of measurement. Patients intubated for cardiac arrest or brain injury were excluded from our primary analysis due to the known damage of hyperthermia in these subsets. Cox proportional hazard models and multivariable linear regression analyzed time-to-event and continuous outcomes, respectively. Predetermined patient demographics were entered into each multivariable model using backward and forward stepwise regression. Models were assessed for collinearity and residual plots were used to assure each model met assumptions. RESULTS/ANTICIPATED RESULTS: Antipyretic administration is currently undergoing analysis. Initial temperature results are reported here. In the overall group, presence of hypothermia or fever within 72 hours of intubation compared with normothermia conferred a hazard ratio (HR) of 1.95 (95% CI: 1.48–2.56) and 1.31 (95% CI: 0.97–1.78), respectively. Presence of hypothermia and fever reduced hospital free days by 3.29 (95% CI: 2.15–4.42) and 2.34 (95% CI: 1.21–3.46), respectively. In our subgroup analysis of patients with sepsis, HR for 28-day mortality 2.57 (95% CI: 1.68–3.93) for hypothermia. Fever had no effect on mortality (HR 1.11, 95% CI: 0.694–1.76). Both hypothermia and fever reduced hospital free days by 5.39 (95% CI: 4.33–7.54) and 3.98 (95% CI: 2.46–5.32) days, respectively. DISCUSSION/SIGNIFICANCE OF IMPACT: As expected, both hypothermia and fever increased 28-day mortality and decreased hospital free days. In our sepsis subgroup, hypothermia again resulted in higher mortality and fewer hospital free days, while fever did not have a survival benefit or cost, but reduced hospital free days. Antipyretic administration complicates these findings, as medication may mask fever or exert an effect on survival. Fever may also affect mechanically ventilated septic patients differently than septic patients not on mechanical ventilation. Continued analysis of this data including antipyretic administration, ventilator free days and progression to ARDS will address these questions.

Download Full-text