Improved clinical and economic outcomes in severe bronchiolitis with pre-emptive nCPAP ventilatory strategy

Purpose

Severe bronchiolitis is the leading cause of admission to the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (nCPAP) has become the primary respiratory support, replacing invasive mechanical ventilation (MV). Our objective was to evaluate the economic and clinical consequences following implementation of this respiratory strategy in our unit.

Methods

This was a retrospective cohort analysis of 525 infants with bronchiolitis requiring respiratory support and successively treated during two distinct periods with invasive MV between 1996 and 2000, P1 (n = 193) and nCPAP between 2006 and 2010, P2 (n = 332). Costs were estimated using the hospital cost billing reports.

Results

Patients’ baseline characteristics were similar between the two periods. P2 is associated with a significant decrease in the length of ventilation (LOV) (4.1 ± 3.5 versus 6.9 ± 4.6 days, p < 0.001), PICU length of stay (LOS) (6.2 ± 4.6 versus 9.7 ± 5.5 days, p < 0.001) and hospital LOS. nCPAP was independently associated with a shorter duration of ventilatory support than MV (hazard ratio 1.8, 95 % CI 1.5–2.2, p < 0.001). nCPAP was also associated with a significant decrease in ventilation-associated complications, and less invasive management. The mean cost of acute viral bronchiolitis-related PICU hospitalizations was significantly decreased, from 17,451 to 11,205 € (p < 0.001). Implementation of nCPAP led to a reduction of the total annual cost of acute viral bronchiolitis hospitalizations of 715,000 €.

Conclusion

nCPAP in severe bronchiolitis is associated with a significant improvement in patient management as shown by the reduction in invasive care, LOV, PICU LOS, hospital LOS, and economic burden.     

Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study

Purpose

The use of noninvasive ventilation (NIV) to facilitate discontinuation of mechanical ventilation in patients with acute hypoxemic respiratory failure (hypoxemic ARF) has never been explored. This pilot study aims to assess the feasibility of early extubation followed by immediate NIV, compared conventional weaning, in patients with resolving hypoxemic ARF.

Methods

Twenty consecutive hypoxemic patients were randomly assigned to receive either conventional weaning or NIV. The changes in arterial blood gases and respiratory rate were compared between the two groups at 1, 12, 24 and 48?h. Differences in the rate of extubation failure, ICU and hospital mortality, number of invasive-ventilation-free-days at day 28, septic complications, number of tracheotomies, days and rates of continuous intravenous sedation, and ICU length of stay were also determined.

Results

No patient interrupted the study protocol. Arterial blood gases were similar during invasive mechanical ventilation, 1?h after NIV application following extubation, and after 12, 24 and 48?h. Respiratory rate was higher after 1?h in the NIV group, but no different after 12, 24 and 48?h. The number of invasive-ventilation-free-days at day 28 was 20?±?8 (min?=?0, max?=?25) days in the treatment group and 10?±?9 (min?=?0, max?=?25) days in the control group (p?=?0.014). The rate of extubation failure, ICU and hospital mortality, tracheotomies, septic complications, days and rates of continuous sedation, and ICU length of stay were not significantly different between the two groups.

Conclusions

In a highly experienced centre NIV may be used to facilitate discontinuation of mechanical ventilation in selected patients with resolving hypoxemic ARF.     

Impact of the humidification device on intubation rate during noninvasive ventilation with ICU ventilators: results of a multicenter randomized controlled trial

Purpose

The use of heat and moisture exchangers (HME) during noninvasive ventilation (NIV) can increase the work of breathing, decrease alveolar ventilation, and deliver less humidity in comparison with heated humidifiers (HH). We tested the hypothesis that the use of HH during NIV with ICU ventilators for patients with acute respiratory failure would decrease the rate of intubation (primary endpoint) as compared with HME.

Methods

We conducted a multicenter randomized controlled study in 15 centers. After stratification by center and type of respiratory failure (hypoxemic or hypercapnic), eligible patients were randomized to receive NIV with HH or HME.

Results

Of the 247 patients included, 128 patients were allocated to the HME group and 119 to the HH group. Patients were comparable at baseline. The intubation rate was not significantly different: 29.7 % in the HME group and 36.9 % in the HH group (p = 0.28). PaCO₂ did not significantly differ between the two arms, even in the subgroup of hypercapnic patients. No significant difference was observed for NIV duration, ICU and hospital LOS, or ICU mortality (HME 14.1 vs. HH 21.5 %, p = 0.18).

Conclusions

In this study, the short-term physiological benefits of HH in comparison with HME during NIV with ICU ventilators were not observed, and no difference in intubation rate was found. The physiologic effects may have been obscured by leaks or other important factors in the clinical settings. This study does not support the recent recommendation favoring the use of HH during NIV with ICU ventilators.     

Tracheal suction by closed system without daily change versus open system

Background

Tracheal suctioning costs are higher with a closed tracheal suction system (CTSS) than with an open system (OTSS), due to the need for complete daily change as recommended by the manufacturer. However, is it necessary to change the closed system daily?

Objective

To evaluate the tracheal suctioning costs and incidence of ventilator-associated pneumonia (VAP) using closed system without daily change vs OTSS.

Design

Prospective and randomised study.

Setting

An Intensive Care Unit in a university hospital.

Patients

Patients requiring mechanical ventilation.

Interventions

Patients were randomly assigned to CTSS without daily change or OTSS. We used a CTSS that allowed partial or complete change.

Measurements and results

There were no significant differences between both groups of patients (236 with CTSS and 221 with OTSS) in gender, age, diagnosis, APACHE-II score, mortality, number of aspirations per day, percentage of patients who developed VAP (13.9 vs 14.1%) or the number of ventilator-associated pneumonia per 1000 days of mechanical ventilation (14.1 vs 14.6). There were not significant differences in tracheal suctioning costs per patient/day between CTSS vs OTSS (2.3?±?3.7 vs 2.4?±?0.5 Euros; p?=?0.96); however, when length of mechanical ventilation was lower than 4?days, the cost was higher with CTSS than with OTSS (7.2?±?4.7 vs 1.9?±?0.6?Euros; p?p?Conclusion CTSS without daily change is the optimal option for patients needing tracheal suction longer than 4?days.     

An optimized set-up for helmet noninvasive ventilation improves pressure support delivery and patient�Cventilator interaction

Objective

To test the effects on mechanical performance of helmet noninvasive ventilation (NIV) of an optimized set-up concerning the ventilator settings, the ventilator circuit and the helmet itself.

Subjects and methods

In a bench study, helmet NIV was applied to a physical model. Pressurization and depressurization rates and minute ventilation (MV) were measured under 24 conditions including pressure support of 10 or 20?cmH₂O, positive end expiratory pressure (PEEP) of 5 or 10?cmH₂O, ventilator circuit with ??high??, ??intermediate?? or ??low?? resistance, and cushion deflated or inflated. In a clinical study pressurization and depressurization rates, MV and patient?Cventilator interactions were compared in six patients with acute respiratory failure during conventional versus an ??optimized?? set-up (PEEP increased to 10?cmH₂O, low resistance circuit and cushion inflated).

Results

In the bench study, all adjustments simultaneously applied (increased PEEP, inflated cushion and low resistance circuit) increased pressurization rate (46.7?±?2.8 vs. 28.3?±?0.6?%, p?<?0.05), depressurization rate (82.9?±?1.9 vs. 59.8?±?1.1?%, p????0.05) and patient MV (8.5?±?3.2 vs. 7.4?±?2.8?l/min, p?<?0.05), and decreased leaks (17.4?±?6.0 vs. 33.6?±?6.0?%, p?<?0.05) compared to the basal set-up. In the clinical study, the optimized set-up increased pressurization rate (51.0?±?3.5 vs. 30.8?±?6.9?%, p?<?0.002), depressurization rate (48.2?±?3.3 vs. 34.2?±?4.6?%, p?<?0.0001) and total MV (27.7?±?7.0 vs. 24.6?±?6.9?l/min, p?<?0.02), and decreased ineffective efforts (3.5?±?5.4 vs. 20.3?±?12.4?%, p?<?0.0001) and inspiratory delay (243?±?109 vs. 461?±?181?ms, p?<?0.005).

Conclusions

An optimized set-up for helmet NIV that limits device compliance and ventilator circuit resistance as much as possible is highly effective in improving pressure support delivery and patient?Cventilator interaction.     

Efficacy/Safety of Olmesartan Medoxomil Versus Losartan Potassium in Na?ve Versus Previously Treated Subjects With Hypertension

Introduction

A predefined exploratory analysis of a prospective, randomized, double-blind, forcedtitration study of olmesartan medoxomil (OM) versus losartan potassium (LOS) in subjects with hypertension not previously or previously treated with antihypertensive medication is reported.

Methods

The study included a 3?C4-week placebo run-in and an 8-week active treatment period: OM (weeks 1?C4, OM 20 mg; weeks 5?C8, OM 40 mg); placebo + OM (weeks 1?C2, placebo; weeks 3?C4, OM 20 mg; weeks 5?C8, OM 40 mg); and LOS (weeks 1?C4, LOS 50 mg; weeks 5?C8, LOS 100 mg). Analyses focused on comparison of OM and placebo + OM combined versus LOS. Efficacy endpoints were mean change from baseline in seated cuff diastolic blood pressure (SeDBP) at week 8 (primary); seated cuff systolic blood pressure (SeSBP) at weeks 4 and 8, and SeDBP at week 4 (secondary), and BP target achievement (tertiary).

Results

The randomized population (n = 941) had a mean ± SD age of 51.9 ± 9.7 years, 54.5% were male, and 20.1% were na?ve to antihypertensive medication. For treatmentna?ve subjects, baseline seated BP (SeBP) (±SD) was 157.4 (±10.9)/101.8 (±4.3) mmHg with OM and 156.3 (±10.8)/101.1 (±3.9) mmHg with LOS, while non-na?ve subjects had 158.4 (±10.2)/100.9 (±4.0) mmHg with OM and 158.8 (±10.1)/101.3 (±4.2) mmHg with LOS. OM monotherapy produced significantly greater changes in least-squares mean (±SE) SeDBP compared with LOS in both treatment-na?ve (?9.7 [1.0] vs. ?6.6 [1.0] mmHg; P = 0.0232 vs. LOS) and non-na?ve subjects (?9.6 [0.5] vs. ?7.3 [0.5] mmHg; P = 0.0013 vs. LOS). A significantly greater proportion of patients achieved the SeBP goal of <140/90 mmHg with OM compared with LOS in treatment-na?ve (34.1% vs. 19.0%, respectively; P = 0.0109) and non-na?ve subjects (31.0% vs. 19.6%; P = 0.0008).

Conclusion

Overall, OM monotherapy resulted in significantly greater SeBP reductions and greater SeBP goal achievement than LOS, irrespective of previous medication use. Both OM and LOS therapy were well tolerated.     

Early intermittent noninvasive ventilation for acute chest syndrome in adults with sickle cell disease: a pilot study

Purpose

Alveolar hypoxia and hypoxic vasoconstriction lead to trapping of sickle cells within the pulmonary vasculature. Improving alveolar ventilation and oxygenation may improve the outcome of acute chest syndrome (ACS).

Methods

Prospective randomized single-center open study from November 1998 to February 2002 to test whether noninvasive ventilation (NIV) was more effective than oxygen alone in improving oxygenation on day 3 in adults with ACS and to evaluate the effects on pain, transfusion requirements, and length of stay.

Results

Seventy-one consecutive ACS episodes in 67 patients were randomly allocated to oxygen (n = 36) or NIV (n = 35) for 3 days in a medical step-down unit. Baseline respiratory rate and pain score were higher in the NIV group. NIV promptly lowered the respiratory rate, raised $ {\text{Pa}}_{{\text{O}_{2}}} $ , and decreased alveolar–arterial oxygen gradient $ (({\text{A}} - {\text{a}})_{{{\text{O}}_{ 2} }} ) $ , which remained unchanged with oxygen alone. $ {\text{Pa}}_{{{\text{CO}}_{ 2} }} $ significantly worsened only in the oxygen group. On day 3, the groups did not differ regarding the proportion of episodes with normal $ {\text{Pa}}_{{{\text{O}}_{ 2} }} $ (35% with NIV and 25% with oxygen; P = 0.5) or $ (({\text{A}} - {\text{a}})_{{{\text{O}}_{ 2} }} ) $ . Patient satisfaction and compliance were lower with NIV. No differences were noted in pain relief, transfusions, or length of stay. In the subgroup of patients with severe hypoxemia $ ( {\text{Pa}}_{{{\text{O}}_{ 2} }} \le 6 5\,{\text{mmHg)}} $ , physiological variables also improved faster with NIV, the differences being slightly more pronounced.

Conclusions

Respiratory rate and gas exchange improved faster with NIV. However, NIV failed to significantly reduce the number of patients remaining hypoxemic at day 3, and was associated with greater patient discomfort.     

Small dead space heat and moisture exchangers do not impede gas exchange during noninvasive ventilation: a comparison with a heated humidifier

Objective

Adverse respiratory and gasometrical effects have been described in patients with acute respiratory failure (ARF) undergoing noninvasive ventilation (NIV) with standard heat and moisture exchangers (HME). We decided to evaluate respiratory parameters and arterial blood gases (ABG) of patients during NIV with small dead space HME compared with heated humidifier (HH).

Design

Prospective randomized crossover study.

Setting

A 16-bed medical intensive care unit (ICU).

Patients

Fifty patients receiving NIV for ARF.

Measurements

The effects of HME and HH on respiratory rate, minute ventilation, EtCO₂, oxygen saturation, airway occlusion pressure at 0.1 s, ABG, and comfort perception were compared during two randomly determined NIV periods of 30 min. The relative impact of HME and HH on these parameters was successively compared with or without addition of a flex tube (40 and 10 patients, respectively).

Main results

No difference was observed between HME and HH regarding any of the studied parameters, whether or not a flex tube was added.

Conclusion

If one decides to humidify patients’ airways during NIV, one may do so with small dead space HME or HH without altering respiratory parameters.     

High-flow nasal cannula (HFNC) support in interhospital transport of critically ill children

Purpose

Optimal respiratory support for interhospital transport of critically ill children is challenging and has been scarcely investigated. High-flow nasal cannula (HFNC) therapy has emerged as a promising support mode in the paediatric intensive care unit (PICU), but no data are available on HFNC used during interhospital transport. We aimed to assess the safety of HFNC during retrievals of critically ill children and its impact on the need for invasive ventilation (IV).

Methods

This was a retrospective, single-centre study of children under 2 years old transported by a specialized paediatric retrieval team to PICU. We compared IV rates before (2005–2008) and after introduction of HFNC therapy (2009–2012).

Results

A total of 793 infants were transported. The mean transport duration was 1.4 h (range 0.25–8), with a mean distance of 205 km (2–2,856). Before introduction of HFNC, 7 % (n = 23) were retrieved on non-invasive ventilation (NIV) and 49 % (n = 163) on IV. After introduction of HFNC, 33 % (n = 150) were retrieved on HFNC, 2 % (n = 10) on NIV, whereas IV decreased to 35 % (n = 162, p < 0.001). No patients retrieved on HFNC required intubation during retrieval, or developed pneumothorax or cardiac arrest. Using HFNC was associated with a significant reduction in IV initiated by the retrieval team (multivariate OR 0.51; 95 % CI 0.27–0.95; p = 0.032).

Conclusions

We report on a major change of practice in transport of critically ill children in our retrieval system. HFNC therapy was increasingly used and was not inferior to low-flow oxygen or NIV. Randomized trials are needed to assess whether HFNC can reduce the need for IV in interhospital transport of critically ill children.     

Noninvasive ventilation in chest trauma: systematic review and meta-analysis

Purpose

Single studies of Noninvasive Ventilation (NIV) in the management of acute respiratory failure in chest trauma patients have produced controversial findings. The aim of this study is to critically review the literature to investigate whether NIV reduces mortality, intubation rate, length of stay and complications in patients with chest trauma, compared to standard therapy.

Methods

We performed a systematic review and meta-analysis of randomized controlled trials, prospective and retrospective observational studies, by searching PubMed, EMBASE and bibliographies of articles retrieved. We screened for relevance studies that enrolled adults with chest trauma who developed mild to severe acute respiratory failure and were treated with NIV. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis.

Results

Ten studies (368 patients) met the inclusion criteria and were included for the meta-analysis. Five studies (219 patients) reported mortality and results were quite homogeneous across studies, with a summary relative risk for patients treated with NIV compared with standard care (oxygen therapy and invasive mechanical ventilation) of 0.26 (95 % confidence interval 0.09–0.71, p = 0.003). There was no advantage in mortality of continuous positive airway pressure over noninvasive pressure support ventilation. NIV significantly increased arterial oxygenation and was associated with a significant reduction in intubation rate, in the incidence of overall complications and infections.

Conclusions

These results suggest that NIV could be useful in the management of acute respiratory failure due to chest trauma.     

Automatic adjustment of pressure support by a computer-driven knowledge-based system during noninvasive ventilation: a feasibility study

Objective

To evaluate the feasibility of using a knowledge-based system designed to automatically titrate pressure support (PS) to maintain the patient in a “respiratory comfort zone” during noninvasive ventilation (NIV) in patients with acute respiratory failure.

Design and setting

Prospective crossover interventional study in an intensive care unit of a university hospital.

Patients

Twenty patients.

Interventions

After initial NIV setting and startup in conventional PS by the chest physiotherapist NIV was continued for 45?min with the automated PS activated.

Measurements and results

During automated PS minute-volume was maintained constant while respiratory rate decreased significantly from its pre-NIV value (20?±?3 vs. 25?±?3?bpm). There was a trend towards a progressive lowering of dyspnea. In hypercapnic patients PaCO₂ decreased significantly from 61?±?9 to 51?±?2?mmHg, and pH increased significantly from 7.31?±?0.05 to 7.35?±?0.03. Automated PS was well tolerated. Two system malfunctions occurred prompting physiotherapist intervention.

Conclusions

The results of this feasibility study suggest that the system can be used during NIV in patients with acute respiratory failure. Further studies should now determine whether it can improve patient-ventilator interaction and reduce caregiver workload.

     

Noninvasive mechanical ventilation in patients having declined tracheal intubation

Purpose

Noninvasive ventilation (NIV) is a treatment option in patients with acute respiratory failure who are good candidates for intensive care but have declined tracheal intubation. The aim of our study was to report outcomes after NIV in patients with a do-not-intubate (DNI) order.

Methods

Prospective observational cohort study in all patients who received NIV for acute respiratory failure in 54 ICUs in France and Belgium, in 2010/2011.

Results

Goals of care, comfort, and vital status were assessed daily. On day 90, a telephone interview with patients and relatives recorded health-related quality of life (HRQOL), posttraumatic stress disorder-related symptoms, and symptoms of anxiety and depression. Post-ICU burden was compared between DNI patients and patients receiving NIV with no treatment-limitation decisions (TLD). Of 780 NIV patients, 574 received NIV with no TLD, and 134 had DNI orders. Hospital mortality was 44 % in DNI patients and 12 % in the no-TLD group. Mortality in the DNI group was lowest in COPD patients compared to other patients in the DNI group (34 vs. 51 %, P = 0.01). In the DNI group, HRQOL showed no significant decline on day 90 compared to baseline; day-90 data of patients and relatives did not differ from those in the no-TLD group.

Conclusions

Do-not-intubate status was present among one-fifth of ICU patients who received NIV. DNI patients who were alive on day 90 experienced no decrease in HRQOL compared to baseline. The prevalences of anxiety, depression, and PTSD-related symptoms in these patients and their relatives were similar to those seen after NIV was used as part of full-code management (clinicaltrial.govNCT01449331).     

Use of tracheostomy in the PICU among patients requiring prolonged mechanical ventilation

Purpose

The purpose of the present study is to describe the use of tracheostomy, specifically frequency, timing (in relation to initiation of mechanical ventilation), and associated factors, in a large cohort of children admitted to North American pediatric intensive care units (PICUs) and requiring prolonged mechanical ventilation.

Methods

This was a retrospective cohort study. De-identified data were obtained from the VPS^LLC database, a multi-site, clinical PICU database. Admissions between 1 July 2009 and 30 June 2011 were enrolled in the study if the patient required mechanical ventilation for at least 72 h and did not have a tracheostomy tube at initiation of mechanical ventilation.

Results

A total of 13,232 PICU admissions from 82 PICUs were analyzed in the study; of these, 872 (6.6 %) had a tracheostomy tube inserted after initiation of mechanical ventilation. The rate varied significantly (0–13.4 %, p < 0.001) among the 45 PICUs that had 100 or more admissions included in the study. The median time to insertion of a tracheostomy tube was 14.4 days (IQR 7.4–25.7), and it also varied significantly by unit (4.3–30.4 days, p < 0.001) among those that performed at least ten tracheostomies included in the study.

Conclusions

There is significant variation in both the frequency and time to tracheostomy between the studied PICUs for patients requiring prolonged mechanical ventilation; among those who received a tracheostomy, the majority did so after two or more weeks of mechanical ventilation. Future studies examining tracheostomy benefits, disadvantages, outcomes, and resource utilization of this patient subgroup are indicated.     

Non-invasive ventilation as a strategy for weaning from invasive mechanical ventilation: a systematic review and Bayesian meta-analysis

Purpose

A systematic review and meta-analysis was conducted to answer the question ‘In adults with respiratory failure requiring invasive ventilation for more than 24 h, does a weaning strategy with early extubation to non-invasive ventilation (NIV) compared to invasive ventilation weaning reduce all-cause hospital mortality?’

Methods

We included randomised and quasi-randomised controlled trials that evaluated the use of non-invasive ventilation, compared to invasive ventilation, as a weaning strategy in adults mechanically ventilated for at least 24 h. The EMBASE, MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL) bibliographic databases were searched from inception to February 2018. Bayesian hierarchical models were used to perform the meta-analysis. The primary outcome was mortality at hospital discharge. Secondary outcomes included mortality (30, 60, 90 and 180 days), quality of life, duration of invasive ventilation, weaning failure, length of stay [intensive care unit (ICU) and hospital] and adverse events.

Results

Twenty-five relevant studies involving 1609 patients were included in the quantitative analysis. Studies had moderate to high risk of bias due to risk of performance and detection bias. Mortality at hospital discharge was lower in the NIV weaning group compared to the invasive weaning group [pooled odds ratio (OR) 0.58, 95% highest density interval (HDI) 0.29–0.89]. Subgroup analyses showed lower pooled mortality at hospital discharge rates in NIV weaning than those in the control group in chronic obstructive pulmonary disease (COPD) patients (pooled OR 0.43, 95% HDI 0.13–0.81) and the effect is less certain in the mixed ICU population (pooled OR 0.88, 95% HDI 0.25–1.48). NIV weaning reduced the duration of invasive ventilation in patients [standardised mean difference (SMD) ??1.34, 95% HDI ??1.92 to ??0.77] and ICU length of stay (SMD ??0.70, 95% HDI ??0.94 to ??0.46). Reported rates of ventilator associated pneumonia (VAP) were lower in the NIV group. NIV weaning did not reduce overall hospital length of stay or long-term mortality. There were insufficient data to compare other adverse events and health-related quality of life.

Conclusions

The use of NIV in weaning from mechanical ventilation decreases hospital mortality, the incidence of VAP and ICU length of stay. NIV as a weaning strategy appears to be most beneficial in patients with COPD.

     

Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilation

Purpose

To evaluate whether extracorporeal carbon dioxide removal by means of a pumpless extracorporeal lung-assist (PECLA) device could be an effective and safe alternative to invasive mechanical ventilation in patients with chronic pulmonary disease and acute hypercapnic ventilatory failure not responding to noninvasive ventilation (NIV).

Methods

In this multicentre, retrospective study, 21 PECLA patients were compared with respect to survival and procedural outcomes to 21 matched controls with conventional invasive mechanical ventilation. Matching criteria were underlying diagnosis, age, Simplified Acute Physiology Score II and pH at ICU admission.

Results

Of the 21 patients treated with PECLA, 19 (90?%) did not require intubation. Median PaCO₂ levels and pH in arterial blood prior to PECLA were 84.0?mmHg (54.2–131.0) and 7.28 (7.10–7.41), respectively. Within 24?h, median PaCO₂ levels and pH had significantly improved to 52.1 (33.0–70.1; p? p? p?=?0.056). There was no group difference in the 28-day (24?% vs. 19?%, adjusted p?=?0.845) or 6-month mortality (33?% vs. 33?%).

Conclusions

In this study the use of extracorporeal carbon dioxide removal allowed avoiding intubation and invasive mechanical ventilation in the majority of patients with acute on chronic respiratory failure not responding to NIV. Compared to conventional invasive ventilation, short- and long-term survivals were similar.     

Mortality in very long-stay pediatric intensive care unit patients and incidence of withdrawal of treatment

Background

The mortality for children with prolonged stay in pediatric intensive care units (PICU) is much higher than overall mortality. The incidence of withdrawal or limitation of therapy in this group is unknown.

Purpose

To assess mortality and characteristics of children admitted for ≥28 days to our ICU, and to describe the extent to which limitations of care were involved in the terminal phase preceding death.

Methods

For the period 2003 to 2005 clinical data were collected retrospectively for children with prolonged stay (defined as ≥28 days) in a medical/surgical PICU of a university children’s hospital.

Results

In the PICU, 4.4% of the children (116/2,607, equal gender, mean age 29 days) had a prolonged stay. Median (range) stay was 56 (28–546) days. These children accounted for 3% of total admissions and occupied 63% of total admission days. Mortality during admission for this group was five times higher (22%) than the average PICU mortality rate of 4.6%. Withdrawal or limitation of therapy preceded 70% of deaths.

Conclusions

Children with prolonged stay in the PICU have a significantly high risk of mortality. Death is typically preceded by limitation of care.     

Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial

Objective

To investigate the safety and effects of a restrictive red blood cell (RBC) transfusion strategy in pediatric cardiac surgery patients.

Design

Randomized controlled trial.

Setting

Pediatric ICU in an academic tertiary care center, Leiden University Medical Center, Leiden, The Netherlands.

Patients

One hundred seven patients with non-cyanotic congenital heart defects between 6 weeks and 6 years of age. One hundred three patients underwent corrective surgery on cardiopulmonary bypass.

Interventions

Prior to surgery patients were randomly assigned to one of two groups with specific RBC transfusion thresholds: Hb 10.8 g/dl (6.8 mmol/l) and Hb 8.0 g/dl (5.0 mmol/l).

Measurements

Length of stay in hospital (primary outcome), length of stay in PICU, duration of ventilation (secondary outcome), incidence of adverse events and complications related to randomization (intention to treat analysis).

Results

In the restrictive transfusion group, mean volume of transfused RBC was 186 (±70) ml per patient and in the liberal transfusion group 258 (±87) ml per patient, (95 % CI 40.6–104.6), p < 0.001. Length of hospital stay was shorter in patients with a restrictive RBC transfusion strategy: median 8 (IQR 7–11) vs. 9 (IQR 7–14) days, p = 0.047. All other outcome measures and incidence of adverse effects were equal in both RBC transfusion groups. Cost of blood products for the liberal transfusion group was 438.35 (±203.39) vs. 316.27 (±189.96) euros (95 % CI 46.61–197.51) per patient in the restrictive transfusion group, p = 0.002.

Conclusions

For patients with a non-cyanotic congenital heart defect undergoing elective cardiac surgery, a restrictive RBC transfusion policy (threshold of Hb 8.0 g/dl) during the entire perioperative period is safe, leads to a shorter hospital stay and is less expensive.     

Elevation of creatine kinase is associated with worse outcomes in 2009 pH1N1 influenza?A infection

Background

Current medical knowledge lacks specific information regarding creatine kinase (CK) elevation in influenza?A pH1N1 (2009) infection.

Objectives

Primary endpoints were correlation between CK at intensive care unit (ICU) admission and ICU mortality. Secondary endpoints were ICU length of stay (LOS), mechanical ventilation (MV), and requirement of renal replacement techniques (RRT).

Materials and methods

A prospective multicenter register included all adults admitted for severe acute respiratory insufficiency (SARI) with confirmed pH1N1 in 148 ICUs. Clinical data including demographics, comorbidities, laboratory information, organ involvement, and prognostic data were registered. Post?hoc classification of subjects was determined according to CK level. Data are expressed as median (interquartile range).

Results

Five hundred and five (505) patients were evaluable. Global ICU mortality was 17.8?% without documented differences between breakpoints. CK ≥500?UI/L was documented in 23.8?% of ICU admissions, being associated with greater renal dysfunction: acute kidney injury (AKI) was more frequent (26.1 versus 17.1?%, p?p?p?p?=?0.07) and duration of mechanical ventilation (median 15?days versus 11?days, p?Conclusions CK is a biomarker of severity in pH1N1 infection. Elevation of CK was associated with more complications and increased ICU LOS and healthcare resources.     

Alternative lipid emulsions in the critically ill: a systematic review of the evidence

Purpose

Parenteral lipid emulsions (LEs) are commonly rich in long-chain triglycerides derived from soybean oil (SO). SO-containing emulsions may promote systemic inflammation and therefore may adversely affect clinical outcomes. We hypothesized that alternative oil-based LEs (SO-sparing strategies) may improve clinical outcomes in critically ill adult patients compared to products containing SO emulsion only. The purpose of this systematic review was to evaluate the effect of parenteral SO-sparing strategies on clinical outcomes in intensive care unit (ICU) patients.

Methods

We searched computerized databases from 1980 to 2013. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated SO-sparing strategies versus SO-based LEs in the context of parenteral nutrition.

Results

A total of 12 RCTs met the inclusion criteria. When the results of these RCTs were statistically aggregated, SO-sparing strategies were associated with clinically important reductions in mortality (risk ratio, RR 0.83; 95 % confidence intervals, CI 0.62, 1.11; P = 0.20), in duration of ventilation (weighted mean difference, WMD ?2.57; 95 % CI ?5.51, 0.37; P = 0.09), and in ICU length of stay (LOS) (WMD ?2.31; 95 % CI ?5.28, 0.66; P = 0.13) but none of these differences were statistically significant. SO-sparing strategies had no effect on infectious complications (RR 1.13; 95 % CI 0.87, 1.46; P = 0.35).

Conclusion

Alternative oil-based LEs may be associated with clinically important reductions in mortality, duration of ventilation, and ICU LOS but lack of statistical precision precludes any clinical recommendations at this time. Further research is warranted to confirm these potential positive treatment effects.