Weaning Readiness and Fluid Balance in Older Critically Ill Surgical Patients

2006 ◽  
Vol 15 (1) ◽  
pp. 54-64 ◽  
Author(s):  
Carol Diane Epstein ◽  
Joel R. Peerless
Keyword(s):  
Mechanical Ventilation ◽  
Fluid Balance ◽  
Older Patients ◽  
Prolonged Mechanical Ventilation ◽  
Venous Pressure ◽  
Surgical Patients ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
In The Beginning

• BackgroundFew studies address predictors for successful weaning of older adults from mechanical ventilation. • ObjectiveTo develop a clinical profile of older patients who are successfully weaned from long-term mechanical ventilation. • MethodsForty patients in the trauma and surgical intensive care unit who were at least 60 years old were enrolled in the study after 3 days of active weaning and were monitored daily until successfully weaned or until the end of the 14-day study. Hemodynamic and gas exchange variables, fluid balance, oxygen cost of breathing, and scores on the Burns Weaning Assessment Program were analyzed. • ResultsCompared with patients who were not weaned, successfully weaned patients required mechanical ventilation for 5.3 days, started active weaning earlier (mean 10.7 vs 14.5 days, P = .04), had lower mean negative daily fluid balances in the beginning (−0.394 vs 1.107 L, P = .004), and had lower mean net cumulative fluid balances (6.856 vs 16.212 L) at the time of enrollment. They also maintained both a lower mean net cumulative fluid balance (10.753 vs 25.049 L, P= .02) and a negative daily fluid balance (−0.389 vs 1.904 L, P = .03) throughout. Their mean central venous pressure decreased over time and was significantly lower (P<.001). • ConclusionPersistent positive fluid balance in older surgical patients is associated with prolonged mechanical ventilation. Estimates of fluid balance might be useful in weaning older patients from long-term mechanical ventilation.

scholarly journals Tracheostomy in Postoperative Pediatric Cardiac Surgical Patients—The Earlier, the Better

2021 ◽  
Author(s):  
Chalattil Bipin ◽  
Manoj K. Sahu ◽  
Sarvesh P. Singh ◽  
Velayoudam Devagourou ◽  
Palleti Rajashekar ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Cardiac Surgery ◽  
Hospital Stay ◽  
Pediatric Patients ◽  
Tertiary Care ◽  
Surgical Patients ◽  
Surgical Intensive Care Unit ◽  
Care Hospital ◽  
Surgical Intensive Care ◽  
Nutrition Supplementation

Abstract Objectives This study was aimed to assess the benefits of early tracheostomy (ET) compared with late tracheostomy (LT) on postoperative outcomes in pediatric cardiac surgical patients. Design Present one is a prospective, observational study. Setting The study was conducted at a cardiac surgical intensive care unit (ICU) of a tertiary care hospital. Participants All pediatric patients below 10 years of age, who underwent tracheostomy after cardiac surgery from January2019 to december2019, were subdivided into two groups according to the timing of tracheostomy: “early” if done before 7 days or “late” if done after 7 days postcardiac surgery. Interventions ET versus LT was measured in the study. Results Out of all 1,084 pediatric patients who underwent cardiac surgery over the study period, 41 (3.7%) received tracheostomy. Sixteen (39%) patients underwent ET and 25 (61%) underwent LT. ET had advantages by having reduced risk associations with the following variables: preoperative hospital stay (p = 0.0016), sepsis (p = 0.03), high risk surgery (p = 0.04), postoperative sepsis (p = 0.001), C-reactive protein (p = 0.04), ventilator-associated pneumonia (VAP; p = 0.006), antibiotic escalation (p = 0.006), and antifungal therapy (p = 0.01) requirement. Furthermore, ET was associated with lesser duration of mechanical ventilation (p = 0.0027), length of ICU stay (LOICUS; p = 0.01), length of hospital stay (LOHS; p = 0.001), lesser days of feed interruption (p = 0.0017), and tracheostomy tube change (p = 0.02). ET group of children, who had higher total ventilation-free days (p = 0.02), were decannulated earlier (p = 0.03) and discharged earlier (p = 0.0089). Conclusion ET had significant benefits in reduction of postoperative morbidities with overall shorter mechanical ventilation, LOICUS, and LOHS, better nutrition supplementation, lesser infection, etc. These benefits may promote faster patient convalescence and rehabilitation with reduced hospital costs.

Risk factors for poor outcome in older patients admitted in a surgical intensive care unit

2021 ◽  
Author(s):  
Emilie Occhiali ◽  
Pierre Prolange ◽  
Florence Cassiau ◽  
Frédéric Roca ◽  
Benoit Veber ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Older Patients ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Poor Outcome

Chronic Comorbid Illnesses Predict the Clinical Course of 866 Patients Requiring Prolonged Mechanical Ventilation in a Long-Term, Acute-Care Hospital

2018 ◽  
Vol 35 (8) ◽  
pp. 745-754 ◽  
Author(s):  
J. Dermot Frengley ◽  
Giorgio R. Sansone ◽  
Robert J. Kaner
Keyword(s):  
Mechanical Ventilation ◽  
Acute Care ◽  
Clinical Course ◽  
Prolonged Mechanical Ventilation ◽  
Acute Care Hospital ◽  
Care Hospital ◽  
Term Survival ◽  
Group A ◽  
Chronically Critically Ill

Objective: To determine whether burdens of chronic comorbid illnesses can predict the clinical course of prolonged mechanical ventilation (PMV)patients in a long-term, acute-care hospital (LTACH). Methods: Retrospective study of 866 consecutive PMV patients whose burdens of chronic comorbid illnesses were quantified using the Cumulative Illness Rating Scale (CIRS). Based on increasing CIRS scores, 6 groups were formed and compared: group A (≤25; n = 97), group B (26-28; n = 105), group C (29-31; n = 181), group D (32-34; n = 208), group E (35-37; n = 173), and group F (>37; n = 102). Results: As CIRS scores increased from group A to group F, rates of weaning success, home discharges, and LTACH survival declined progressively from 74% to 17%, 48% to 0%, and 79% to 21%, respectively (all P < .001). Negative correlations between the mean score of each CIRS group and correspondent outcomes also supported patients’ group allocation and an accurate prediction of their clinical course (all P < .01). Long-term survival progressively declined from a median survival time of 38.9 months in group A to 3.2 months in group F ( P < .001). Compared to group A, risk of death was 75% greater in group F ( P = .03). Noteworthy, PMV patients with CIRS score <25 showed greater ability to recover and a low likelihood of becoming chronically critically ill. Diagnostic accuracy of CIRS to predict likelihood of weaning success, home discharges, both LTACH and long-term survival was good (area under the curves ≥0.71; all P <.001). Conclusions: The burden of chronic comorbid illnesses was a strong prognostic indicator of the clinical course of PMV patients. Patients with lower CIRS values showed greater ability to recover and were less likely to become chronically critically ill. Thus, CIRS can be used to help guide clinicians caring for PMV patients in transfer decisions to and from postacute care setting.

Weaning Analgosedation in Patients Requiring Prolonged Mechanical Ventilation

2021 ◽  
pp. 088506662110487
Author(s):  
Stephanie Parks Taylor ◽  
John M. Hammer ◽  
Brice T. Taylor
Keyword(s):  
Mechanical Ventilation ◽  
Prolonged Mechanical Ventilation ◽  
Multidisciplinary Care ◽  
Potential Harm ◽  
Mechanically Ventilated ◽  
Multidisciplinary Care Team ◽  
Clinical Trial Evidence ◽  
Adults And Children ◽  
Trial Evidence

Although research supports the minimization of sedation in mechanically ventilated patients, many patients with severe acute respiratory distress syndrome (ARDS) receive prolonged opioid and sedative infusions. ICU teams face the challenge of weaning these medications, balancing the risks of sedation with the potential to precipitate withdrawal symptoms. In this article, we use a clinical case to discuss our approach to weaning analgosedation in patients recovering from long-term mechanical ventilation. We believe that a protocolized, multimodal weaning strategy implemented by a multidisciplinary care team is required to reduce potential harm from both under- and over-sedation. At present, there is no strong randomized clinical trial evidence to support a particular weaning strategy in adult ICU patients, but appraisal of the existing literature in adults and children can guide decision-making to enhance the recovery of these patients.

scholarly journals Sonographic Assessment of Intravascular Fluid Estimate (SAFE) Score by Using Bedside Ultrasound in the Intensive Care Unit

2020 ◽  
Vol 2020 ◽  
pp. 1-9 ◽  
Author(s):  
Keith Killu ◽  
Victor Coba ◽  
Dionne Blyden ◽  
Semeret Munie ◽  
Darlene Dereczyk ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Scoring System ◽  
Venous Pressure ◽  
Tertiary Care ◽  
Bedside Ultrasound ◽  
Volume Status ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Volume Score

Objective. The objective of the study was to use an ultrasound-based numerical scoring system for assessment of intravascular fluid estimate (SAFE) and test its validity. Methods. A prospective, observational study was carried out in the surgical intensive care unit (ICU) of an urban tertiary care teaching hospital. Patient’s intravascular volume status was assessed using the standard methods of heart rate, blood pressure, central venous pressure, cardiac output, lactate and saturation of venous oxygen, and others. This was compared with assessment using bedside ultrasound evaluation of the cardiac function, inferior vena cava, lungs, and the internal jugular vein. Applying a numerical scoring system was evaluated by Fisher’s exact testing and multinomial logistic model to predict the volume status based on ultrasound scores and the classification accuracy. Results. 61 patients in the ICU were evaluated. 21 (34.4% of total) patients diagnosed with hypovolemia, and their ultrasound volume score was −4 in 14 (66.7%) patients, −3 in 5 (23.8%) patients, and 0 in 2 (9.5%) patients (p<0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and −1 in 1 (5.6%) patient (p<0.001). 22 (36.1% of total) patients diagnosed with hypervolemia, and their ultrasound volume score was +4 in 4 (18.2%) patients, +3 in 15 (68.2%) patients, and  + 1 in 1 (4.6%) patient (p<0.001). We found a strong association between standard measures and the ultrasound score (p<0.001). Conclusion. Using the SAFE scoring system to identify the IVV status in critically ill patients significantly correlates with the standard measures. A SAFE score of −4 to −2 more likely represents hypovolemia, −1 to +1 more likely represents euvolemia, and +2 to +4 more likely to be hypervolemia.

scholarly journals Low hematocrit levels: a risk factor for long-term outcomes in patients requiring prolonged mechanical ventilation after cardiovascular surgery. A retrospective study

2019 ◽  
Vol 68 (2) ◽  
pp. 392-396 ◽  
Author(s):  
Akito Tsukinaga ◽  
Shunsuke Takaki ◽  
Takahiro Mihara ◽  
Kenta Okamura ◽  
Susumu Isoda ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Risk Factor ◽  
Cardiovascular Surgery ◽  
Cox Regression ◽  
Prolonged Mechanical Ventilation ◽  
Cox Regression Analysis ◽  
Icu Admission ◽  
Risk Patients ◽  
Long Term Mortality

While low-risk patients who undergo elective surgery can tolerate low hematocrit levels, the benefits of higher hematocrit levels might outweigh the risk of transfusion in high-risk patients. Therefore, this study aimed to evaluate the effects of perioperative hematocrit levels on mortality in patients requiring prolonged mechanical ventilation (PMV) after a cardiovascular surgery. This single-center retrospective cohort study was conducted on 172 patients who underwent cardiovascular surgery with cardiopulmonary bypass or off-pump coronary artery bypass grafting and required PMV for ≥72 hours in the intensive care unit (ICU) from 2008 to 2012 at the Yokohama City University Medical Center in Yokohama, Japan. Patients were classified according to hematocrit levels on ICU admission: high (≥30%) and low (<30%) groups. Of 172 patients, 86 were included to each of the low-hematocrit and high-hematocrit groups, with median hematocrit levels (first to third quartiles) of 27.4% (25.4%–28.7%) and 33.0% (31.3%–35.5%), respectively. The difference in survival rates was significant between the two groups using the log-rank test (HR 0.55, 95% CI 0.32 to 0.95, p=0.033). Cox regression analysis revealed that ≥30% increase in hematocrit levels on ICU admission was significantly associated with decreased long-term mortality (HR 0.40, 95% CI 0.20 to 0.80, p=0.0095). Lower hematocrit levels on ICU admission was a risk factor for increased long-term mortality, and higher hematocrit levels might outweigh the risk of transfusion in patients requiring PMV after a cardiovascular surgery.

scholarly journals A Technique to Minimize Aerosolization During Percutaneous Tracheostomy in COVID-19 Patients

2020 ◽  
Vol 86 (8) ◽  
pp. 904-906
Author(s):  
Alejandro Betancourt-Ramirez ◽  
Jay A. Yelon ◽  
Paul Boland ◽  
Michael Amaturo
Keyword(s):  
Prolonged Mechanical Ventilation ◽  
Percutaneous Tracheostomy ◽  
Percutaneous Dilatational Tracheostomy ◽  
Case Series ◽  
Surgical Intensive Care Unit ◽  
Surgical Team ◽  
Surgical Intensive Care ◽  
Level Of Evidence ◽  
Dilatational Tracheostomy ◽  
And Performance

Background The SARS-CoV-2 pandemic has caused respiratory failure in many patients. With no effective treatment or vaccine, prolonged mechanical ventilation is common in survivors. Timing and performance of tracheostomy, for both patient and surgical team safety, remains a question. Here within, we report our experience with percutaneous dilatational tracheostomy with modification to minimize aerosolization. Methods A modified percutaneous dilatational tracheostomy technique is described. The technique was performed on 10 patients in the surgical intensive care unit. Results Ten patients underwent percutaneous dilatational tracheostomy. There were 7 males, and the average age for the group was 60.8 years. The average number of ventilator days before the operation was 26.3. All procedures were successful, and no patient had any procedure-related complications. Conclusions The procedure described was successful in our patient population. We believe that this approach is safe for patients with coronavirus disease 2019 and limits aerosolization during the operation. Level of evidence Level IV, case series.

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