Temperature Profile and Adverse Outcomes After Discharge From the Intensive Care Unit

Background A predictive model that uses the rhythmicity of core body temperature (CBT) could be an easily accessible clinical tool to ultimately improve outcomes among critically ill patients. Objectives To assess the relation between the 24-hour CBT profile (CBT-24) before intensive care unit (ICU) discharge and clinical events in the step-down unit within 7 days of ICU discharge. Methods This retrospective cohort study in a tertiary ICU at a single center included adult patients requiring acute invasive ventilation for more than 48 hours and assessed major clinical adverse events (MCAEs) and rapid response system activations (RRSAs) within 7 days of ICU discharge (MCAE-7 and RRSA-7, respectively). Results The 291 enrolled patients had a median mechanical ventilation duration of 139 hours (IQR, 50-862 hours) and at admission had a median Acute Physiology and Chronic Health Evaluation II score of 22 (IQR, 7-42). At least 1 MCAE or RRSA occurred in 64% and 22% of patients, respectively. Independent predictors of an MCAE-7 were absence of CBT-24 rhythmicity (odds ratio, 1.78 [95% CI, 1.07-2.98]; P = .03), Sequential Organ Failure Assessment score at ICU discharge (1.10 [1.00-1.21]; P = .05), male sex (1.72 [1.04-2.86]; P = .04), age (1.02 [1.00-1.04]; P = .02), and Charlson Comorbidity Index (0.87 [0.76-0.99]; P = .03). Age (1.03 [1.01-1.05]; P = .006), sepsis at ICU admission (2.02 [1.13-3.63]; P = .02), and Charlson Comorbidity Index (1.18 [1.02-1.36]; P = .02) were independent predictors of an RRSA-7. Conclusions Use of CBT-24 rhythmicity can assist in stratifying a patient’s risk of subsequent deterioration during general care within 7 days of ICU discharge.

Azithromycin and Septic Shock Outcomes

Introduction: Although there is evidence describing the immunomodulatory effects of macrolide antibiotics, there is little literature exploring the clinical effects these properties may have and their impact on measurable outcomes. Objective: The purpose of this study was to determine if empiric antimicrobial regimens containing azithromycin shorten time to shock resolution. Methods: A retrospective study was performed in adults with septic shock admitted to intensive care units (ICUs) of 3 university-affiliated, urban teaching hospitals between June 2012 and June 2016. Eligible patients with septic shock required treatment with norepinephrine as the first-line vasopressor for a minimum of 4 hours and received at least 48 hours of antimicrobial treatment from the time of shock onset. Propensity scores were utilized to match patients who received azithromycin to those who did not. Results: A total of 3116 patients met initial inclusion criteria. After propensity score matching, 258 patients were included, with 124 and 134 patients in the azithromycin and control groups, respectively. Median shock duration was similar in patients treated with or without azithromycin (45.6 hr vs 59.7 hr, P = .44). In-hospital mortality was also similar (37.9% vs 38.1%, P = .979). There were no significant differences in mechanical ventilation duration, ICU length of stay (LOS), or hospital LOS. Conclusions: In patients admitted to the ICU with septic shock, empiric azithromycin did not have a significant effect on shock duration, mechanical ventilation duration, ICU LOS, hospital LOS, or in-hospital mortality.

Pepsin A in Tracheal Secretions From Patients Receiving Mechanical Ventilation

Background In patients in the intensive care unit (ICU) receiving mechanical ventilation, aspiration of gastric contents may lead to ventilator-associated events and other adverse outcomes. Pepsin in pulmonary secretions is a biomarker of microaspiration of gastric contents. Objectives To evaluate the association between tracheal pepsin A and clinical outcomes related to ventilator use. Methods A subset of 297 patients from a larger clinical trial on aspiration of oral secretions in adults receiving mechanical ventilation consented to have pepsin A measured in their tracheal aspirate samples. A concentration ≥6.25 ng/mL indicated a positive result. Abundant microaspiration was defined as pepsin A in ≥30% of samples. Statistical analyses included analysis of variance, analysis of covariance, and χ2 tests. Results Most patients were White men, mean age 59.7 (SD, 18.8) years. Microaspiration was found in 43.8% of patients (n = 130), with abundant microaspiration detected in 17.5% (n = 52). After acuity was controlled for, patients with tracheal pepsin A had a longer mechanical ventilation duration (155 vs 104 hours, P < .001) and ICU stay (9.9 vs 8.2 days, P = .04), but not a longer hospital stay. Conclusions Microaspiration of gastric contents occurred in nearly half of patients and was associated with a longer duration of mechanical ventilation and a longer stay in the ICU. Additional preventative interventions beyond backrest elevation, oropharyngeal suctioning, and management of endotracheal tube cuff pressure may be needed. Also, the timing of pepsin measurements to capture all microaspiration events requires additional exploration.

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

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.

Driving Pressure is Not Predictive of ARDS Outcome in Chest Trauma Patients Under Mechanical Ventilation

Background: The relationship between the driving pressure of the respiratory system (ΔPrs) under mechanical ventilation and worse outcome has never been studied specifically in chest trauma patients. The objective of the present study was to assess in cases of chest trauma the relationship between ΔPrs and severity of acute respiratory distress syndrome (ARDS) or death and length of stay. Methods: A retrospective analysis of severe trauma patients (ISS >15) with chest injuries admitted to the Trauma Center from January 2010 to December 2018 was performed. Patients who received mechanical ventilation were included in our analysis. Mechanical ventilation parameters and ΔPrs were recorded during the stay in the intensive care unit. Association of ΔPrs and ARDS with mortality and outcomes was specifically studied at the onset of ARDS (ΔPrs-ARDS) by receiver operator characteristic curve analysis, Kaplan-Meier curves and multivariate analysis.Results: Among the 266 chest trauma patients studied, 194 (73%) developed ARDS. ΔPrs was significantly higher in the ARDS group versus in the no ARDS group (11.6±2.4 cm H2O vs 10.9±1.9 cm H2O, p=0.04). Among the patients with ARDS, no difference according to the duration of mechanical ventilation was found between the high ΔPrs group (ΔPrs-ARDS >14 cm H2O) and the low ΔPrs group (ΔPrs-ARDS ≤14 cm H2O), (p=0.75). ΔPrs-ARDS was not independently associated with the duration of mechanical ventilation (hazard ratio [HR], 1.006; 95% CI, 0.95–1.07; p=0.8) or mortality (HR, 1.07; 95% CI, 0.9–1.28; p=0.45).Conclusion: A high ΔPrs-ARDS was not significantly associated with an increase in mechanical ventilation duration or mortality risk in ARDS patients with chest trauma in contrast with medical patients.

Preoperative incentive spirometry for preventing postoperative pulmonary complications in patients undergoing coronary artery bypass graft surgery: a prospective, randomized controlled trial

Background Postoperative pulmonary complications (PPCs) often occur after cardiac operations and are a leading cause of morbidity, inhibit oxygenation, and increase hospital length of stay and mortality. Although clinical evidence for PPCs prevention is often unclear and crucial, measures occur to reduce PPCs. One device usually used for this reason is incentive spirometry (IS). The aim of the study is to evaluate the effect of preoperative incentive spirometry to prevent postoperative pulmonary complications, improve postoperative oxygenation, and decrease hospital stay following coronary artery bypass graft (CABG) surgery patients. Methods This was a clinical randomized prospective study. A total of 80 patients were selected as candidates for CABG at An-Najah National University Hospital, Nablus-Palestine. Patients had been randomly assigned into two groups: incentive spirometry group (IS), SI performed before surgery (study group) and control group, preoperative spirometry was not performed. The 40 patients in each group received the same protocol of anesthesia and ventilation in the operating room. Result The study findings showed a significant difference between the IS and control groups in the incidence of postoperative atelectasis. There were 8 patients (20.0%) in IS group and 17 patients (42.5%) in the control group (p = 0.03). Mechanical ventilation duration was significantly less in IS group. The median was four hours versus six hours in the control group (p < 0.001). Hospital length of stay was significantly less in IS group, and the median was six days versus seven days in the control group (p < 0.001). The median of the amount of arterial blood oxygen and oxygen saturation was significantly improved in the IS group (p < 0.005). Conclusion Preoperative incentive spirometry for two days along with the exercise of deep breathing, encouraged coughing, and early ambulation following CABG are in connection with prevention and decreased incidence of atelectasis, hospital stay, mechanical ventilation duration and improved postoperative oxygenation with better pain control. A difference that can be considered both significant and clinically relevant. Trial registration Thai Clinical Trials Registry: TCTR20201020005. Registered 17 October 2020—retrospectively registered.

Incidence, Predictors and Outcomes of Delirium in Critically Ill Patients With COVID-19

Background and Purpose: A variety of neurological manifestations have been attributed to COVID-19, but there is currently limited evidence regarding risk factors and outcomes for delirium in critically ill patients with COVID-19. The purpose of this study was to identify delirium in a large cohort of ICU patients with COVID-19, and to identify associated features and clinical outcomes at the time of hospital discharge. Methods: This is an observational cohort study of 213 consecutive patients admitted to an ICU for COVID-19 respiratory illness. Delirium was diagnosed by trained abstractors using the CHART-DEL instrument. The associations between key clinical features, sedation and delirium were examined, as were the impacts of delirium on clinical outcomes. Results: Delirium was identified in 57.3% of subjects. Delirious patients were more likely to receive mechanical ventilation, had lower P: F ratios, higher rates of renal replacement therapy and ECMO, and were more likely to receive enteral benzodiazepines. Only mechanical ventilation remained a significant predictor of delirium in a logistic regression model. Mortality was not significantly different, but delirious patients experienced greater mechanical ventilation duration, ICU/hospital lengths of stay, worse functional outcomes at discharge, and were less likely to be discharged home. Conclusions: Delirium is common in critically ill patients with COVID-19 and appears to be associated with greater disease severity. When present, delirium is associated with worse functional status at discharge, but not increased mortality. Additional studies are necessary to determine the generalizability of these results and the impact of delirium on longer-term cognitive and functional outcomes.

Association between mortality and highly antimicrobial-resistant bacteria in intensive care unit-acquired pneumonia

Data on the relationship between antimicrobial resistance and mortality remain scarce, and this relationship needs to be investigated in intensive care units (ICUs). The aim of this study was to compare the ICU mortality rates between patients with ICU-acquired pneumonia due to highly antimicrobial-resistant (HAMR) bacteria and those with ICU-acquired pneumonia due to non-HAMR bacteria. We conducted a multicenter, retrospective cohort study using the French National Surveillance Network for Healthcare Associated Infection in ICUs (“REA-Raisin”) database, gathering data from 200 ICUs from January 2007 to December 2016. We assessed all adult patients who were hospitalized for at least 48 h and presented with ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii. The association between pneumonia caused by HAMR bacteria and ICU mortality was analyzed using the whole sample and using a 1:2 matched sample. Among the 18,497 patients with at least one documented case of ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii, 3081 (16.4%) had HAMR bacteria. The HAMR group was associated with increased ICU mortality (40.3% vs. 30%, odds ratio (OR) 95%, CI 1.57 [1.45–1.70], P < 0.001). This association was confirmed in the matched sample (3006 HAMR and 5640 non-HAMR, OR 95%, CI 1.39 [1.27–1.52], P < 0.001) and after adjusting for confounding factors (OR ranged from 1.34 to 1.39, all P < 0.001). Our findings suggest that ICU-acquired pneumonia due to HAMR bacteria is associated with an increased ICU mortality rate, ICU length of stay, and mechanical ventilation duration.

Application Effect Analysis of Three Methods of Heating and Humidification for Weaning Patients in ICU

Objectives Adequate humidity and temperature of the inhaled mixed air are important for patients weaning from ventilators. It can not only prevent the damage of dry gas on respiratory tract, but also facilitate the discharge of sputum. We aim to investigate the humidification and heating effects of artificial nose, Venturi device plus thermostatic humidification T-tube (referred as VT), Venturi device plus thermostatic humidification T-tube and PEEP valve (referred as VTP) in critical ill patients with tracheotomy in ICU.Design:Retrospective cohort study.Setting: Tertiary academic medical center.Patients: A total of 166 patients were engaged in this study. Clinical and laboratory examination data were used to determine the heating and humidification performance of 3 different methods.Methods A retrospective, single-center cohort study was conducted in all critically ill patients ready to be weaned from mechanical ventilators. Three groups of patients were compared in terms of vital signs, the effect of artificial airway heating and humidification, and blood gas indicators. Basic patient data (age, gender, mechanical ventilation duration, ICU stay, disease type) were recorded. Vital signs include heart rate, blood pressure, respiratory rate, oxygen saturation; The performance of heating and humidifying the artificial airway were defined as the number of sputum suction and coughing within 24 hours, sputum characteristics, whether there is bloody sputum formation, whether there is phlegm callus formation; Blood gas indicators include pH, oxygen partial pressure, carbon dioxide partial pressure, lactic acid, residual base, and bicarbonate.Results In terms of the heating and humidification performance of patients in ICU, the VT method and the VTP method were significantly superior to those of artificial nasal method.SpO2 was significantly higher in patients treated with the VTP method than that in patients treated with VT.ConclusionCompared with the artificial nose method, the VTP method and VT methods are better. In terms of improving oxygenation, the VTP method could improve the patient's oxygen sum more than the VT mothod.

Risk Factors and Outcomes Associated with Community-Onset and Hospital-Acquired Co-infection in Patients Hospitalized for COVID-19: A Multi-Hospital Cohort Study

Background: We sought to determine the incidence of community-onset and hospital-acquired co-infection in patients hospitalized with COVID-19 and evaluate associated predictors and outcomes. Methods: Multicenter retrospective cohort study of patients hospitalized for COVID-19, 3/2020 to 8/2020, across 38 Michigan hospitals assessed for prevalence, predictors, and outcomes of community-onset or hospital-acquired co-infection. In-hospital and 60-day mortality, readmission, discharge to long-term care facility (LTCF), and mechanical ventilation duration, were assessed for patients with vs. without co-infection. Results: Of 2205 patients with COVID-19, 6.4% (N=141) had a co-infection (3.0% community-onset, 3.4% hospital-acquired). 64.9% of patients without co-infection received antibiotics. Community-onset co-infection predictors include admission from LTCF (OR 3.98, 95% CI 2.34-6.76, p<0.001) and admission to intensive care (OR 4.34, 95% CI 2.87-6.55, p<0.001). Hospital-acquired co-infection predictors include fever (OR 2.46, 95% CI 1.15-5.27, p=0.02) and advanced respiratory support (OR 40.72, 95% CI 13.49-122.93, p<0.001). Patients with (vs. without) community-onset co-infection had longer mechanical ventilation (OR 3.31, 95% CI 1.67-6.56, p=0.001) and higher in-hospital (OR 1.90, 95% CI 1.06-3.40 p=0.03) and 60-day mortality (OR 1.86, 95% CI 1.05-3.29 p=0.03). Patients with (vs. without) hospital-acquired co-infection had higher discharge to LTCF (OR 8.48, 95%CI 3.30-21.76 p<0.001), in-hospital (OR 4.17, 95% CI 2.37-7.33, p=<.001) and 60-day mortality (OR 3.66, 95% CI 2.11-6.33, p=<.001). Conclusion: Despite community-onset and hospital-acquired co-infection being uncommon, most patients hospitalized with COVID-19 received antibiotics. Admission from LTCF and to ICU were associated with increased risk of community-onset co-infection. Future work should prospectively validate predictors of COVID-19 co-infection to facilitate antibiotic reduction.