Patients with sepsis have a wide range of respiratory disorders that can be treated with oxygen therapy. Experimental data in animal sepsis models show that oxygen therapy significantly increases survival, while clinical data on the use of different oxygen therapy protocols are ambiguous. Oxygen therapy, especially hyperbaric oxygenation, in patients with sepsis can aggravate existing oxidative stress and contribute to the development of disseminated intravascular coagulation. The purpose of this article is to compare experimental and clinical data on oxygen therapy in animals and humans, to discuss factors that can influence the results of oxygen therapy for sepsis treatment in humans, and to provide some recommendations for reducing oxidative stress and preventing disseminated intravascular coagulation during oxygen therapy.
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Background Data on pulmonary hemodynamic parameters in patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) are scarce.
Methods The associations between pulmonary artery catheter parameters for the first 7 days of ECMO, fluid balance, and hospital mortality were investigated in adult patients (aged ≥19 years) who received venovenous ECMO for refractory ARDS between 2015 and 2017.
Results Twenty patients were finally included in the analysis (median age, 56.0 years; interquartile range, 45.5–68.0 years; female, n=10). A total of 140 values were collected for each parameter (i.e., 7 days×20 patients). Net fluid balance was weakly but significantly correlated with systolic and diastolic pulmonary arterial pressures (PAPs; r=0.233 and P=0.011; r=0.376 and P<0.001, respectively). Among the mechanical ventilation parameters, above positive end-expiratory pressure was correlated with systolic PAP (r=0.191 and P=0.025), and static compliance was negatively correlated with diastolic PAP (r=−0.169 and P=0.048). Non-survivors had significantly higher systolic PAPs than in survivors. However, in multivariate analysis, there was no significant association between mean systolic PAP and hospital mortality (odds ratio, 1.500; 95% confidence interval, 0.937–2.404; P=0.091).
Conclusions Systolic PAP was weakly but significantly correlated with net fluid balance during the early ECMO period in patients with refractory ARDS receiving ECMO.
Background Coronavirus disease 2019 (COVID-19) is one of the biggest pandemic causing acute respiratory failure (ARF) in the last century. Seasonal influenza carries high mortality, as well. The aim of this study was to compare features and outcomes of critically-ill COVID-19 and influenza patients with ARF.
Methods Patients with COVID-19 and influenza admitted to intensive care unit with ARF were retrospectively analyzed.
Results Fifty-four COVID-19 and 55 influenza patients with ARF were studied. Patients with COVID-19 had 32% of hospital mortality, while those with influenza had 47% (P=0.09). Patients with influenza had higher Eastern Cooperative Oncology Group, Clinical Frailty Scale, Acute Physiology and Chronic Health Evaluation II and admission Sequential Organ Failure Assessment (SOFA) scores than COVID-19 patients (P<0.01). Secondary bacterial infection, admission acute kidney injury, procalcitonin level above 0.2 ng/ml were the independent factors distinguishing influenza from COVID-19 while prone positioning differentiated COVID-19 from influenza. Invasive mechanical ventilation (odds ratio [OR], 42.16; 95% confidence interval [CI], 9.45–187.97), admission SOFA score more than 4 (OR, 5.92; 95% CI, 1.85–18.92), malignancy (OR, 4.95; 95% CI, 1.13–21.60), and age more than 65 years (OR, 3.31; 95% CI, 0.99–11.03) were found to be independent risk factors for hospital mortality.
Conclusions There were few differences in clinical features of critically-ill COVID-19 and influenza patients. Influenza cases had worse performance status and disease severity. There was no significant difference in hospital mortality rates between COVID-19 and influenza patients.
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Background Anticoagulation during extracorporeal membrane oxygenation (ECMO) usually is required to prevent thrombosis. The aim of this study was to investigate the usefulness of nafamostat mesilate (NM) as a regional anticoagulant during veno-arterial ECMO (VA-ECMO) treatment. Methods: We retrospectively reviewed the medical records of 16 patients receiving VA-ECMO and NM from January 2017 to June 2020 at Haeundae Paik Hospital. We compared clinical and laboratory data, including activated partial thromboplastin time (aPTT), which was measured simultaneously in patients and the ECMO site, to estimate the efficacy of regional anticoagulation. Results: The median patient age was 68.5 years, and 56.3% of patients were men. Cardiovascular disease was the most common primary disease (75.0%) requiring ECMO treatment, followed by respiratory disease (12.5%). The median duration of ECMO treatment was 7.5 days. Among 16 patients, seven were switched to NM after first using heparin as an anticoagulation agent, and nine received only NM. When comparing aPTT values in the NM group between patients and the ECMO site, that in patients was significantly lower than that at the ECMO site (73.57 vs. 79.25 seconds; P=0.010); in contrast, no difference was observed in the heparin group. Conclusions: NM showed efficacy as a regional anticoagulation method by sustaining a lower aPTT value compared to that measured at the ECMO site. NM should be considered as a safer regional anticoagulation method in VA-ECMO for patients at high risk of bleeding.
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Background Acute kidney injury (AKI) commonly occurs in critically ill patients. Estimation of renal function and antibiotics dose adjustment in patients with AKI is a challenging issue.
Methods Urinary creatinine clearance was measured in a 6-hour urine collection from patients with acute kidney injuries. The correlations between different formulas including the modified Cockcroft-Gault, modification of diet in renal disease, chronic kidney disease-epidemiology collaboration, Jelliffe, kinetic-glomerular filtration rate (GFR), Brater, and Chiou formulas were considered. The pattern of the prescribed antimicrobial agents was also compared with the patterns in the available resources.
Results Ninety-five patients with acute kidney injuries were included in the research. The mean age of the participants was 63.11±17.58 years old. The most patients (77.89%) were in stage 1 of AKI according to the Acute Kidney Injury Network criteria, followed by stage 2 (14.73%) and stage 3 (7.36), respectively. None of the formulations had a high or very high correlation with the measured creatinine clearance. In stage 1, Chiou (r=0.26), and in stage 2 and 3, kinetic-GFR (r=0.76 and r=0.37) had the highest correlation coefficient. Antibiotic over- and under-dosing were frequently observed in the study.
Conclusions The results showed that none of the static methods can predict the measured creatinine clearance in the critically ill patients. The dynamic methods such as kinetic-GFR can be helpful for patients who do not receive diuretics and vasopressors. Further studies are needed to confirm our results.
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Background Limited research has explored early mortality among patients presenting with septic shock. The objective of this study was to determine the incidence and factors associated with early death following emergency department (ED) presentation of septic shock.
Methods A prospective registry of patients enrolled in an ED septic shock clinical pathway was used to identify patients. Patients were compared across demographic, comorbid, clinical, and treatment variables by death within 72 hours of ED presentation.
Results Among the sample of 2,414 patients, overall hospital mortality was 20.6%. Among patients who died in the hospital, mean and median time from ED presentation to death were 4.96 days and 2.28 days, respectively. Death at 24, 48, and 72 hours occurred in 5.5%, 9.5%, and 11.5% of patients, respectively. Multivariate regression analysis demonstrated that the following factors were independently associated with early mortality: age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03–1.05), malignancy (OR, 1.53; 95% CI, 1.11–2.11), pneumonia (OR, 1.39; 95% CI, 1.02–1.88), urinary tract infection (OR, 0.63; 95% CI, 0.44–0.89), first shock index (OR, 1.85; 95% CI, 1.27–2.70), early vasopressor use (OR, 2.16; 95% CI, 1.60–2.92), initial international normalized ratio (OR, 1.14; 95% CI, 1.07–1.27), initial albumin (OR, 0.55; 95% CI, 0.44–0.69), and first serum lactate (OR, 1.21; 95% CI, 1.16–1.26).
Conclusions Adult septic shock patients experience a high rate of early mortality within 72 hours of ED arrival. Recognizable clinical factors may aid the identification of patients at risk of early death.
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necessiBackground:
Nurses are at the forefront of patient care, and time management skills can increase their ability to make decisions faster. This study aimed to assess the effect of a time management workshop on prioritization and time management skills among nurses of emergency and intensive care units.
Methods This randomized clinical trial was performed with 215 nurses. The educational intervention about time management was held in the form of a workshop for the intervention group. The time management questionnaire was completed by both groups before, immediately after, and 3 months after the intervention.
Results Most participants were female (n=191, 88%), with a mean age of 31.82 years (range, 22–63 years). Additionally, the participants’ work experience ranged from 1 to 30 years (mean±standard deviation, 8.00±7.15 years). After the intervention, the mean score of time management increased significantly in the intervention group, but no significant difference was observed in this regard in the control group. The results also revealed a significant difference between the intervention and control groups regarding the mean score of time management 3 months after the intervention (P<0.001).
Conclusions Time management training helped nurses adjust the time required to perform and prioritize various tasks.
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Background Hearing loss is a potentially serious complication that can occur after surviving a critical illness. Study on screening for hearing problems in pediatric critical care survivors beyond the neonatal period is lacking. This study aimed to identify the prevalence of abnormal hearing screening outcomes using transitory evoked otoacoustic emission (TEOAE) screening in children who survived critical illness and to find possible associating factors for abnormal hearing screening results.
Methods This study was a single-center, prospective, observational study. All children underwent otoscopy to exclude external and middle ear abnormalities before undergoing TEOAE screening. The screening was conducted before hospital discharge. Descriptive statistics, chi-square, and logistic regression tests were used for data analysis.
Results A total of 92 children were enrolled. Abnormal TEOAE responses were identified in 26 participants (28.3%). Children with abnormal responses were significantly younger than those with normal responses with a median age of 10.0 months and 43.5 months, respectively (P<0.001). Positive association with abnormal responses was found in children younger than 12 months of age (adjusted odds ratio [OR], 3.07; 95% confidence interval [CI], 1.06–8.90) and children with underlying genetic conditions (adjusted OR, 6.95; 95% CI, 1.49–32.54).
Conclusions Our study demonstrates a high prevalence of abnormal TEOAE screening responses in children surviving critical illness, especially in patients younger than 12 months of age. More extensive studies should be performed to identify the prevalence and associated risk factors of hearing problems in critically ill children.
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Background Arrhythmias are known complication after surgery for congenital heart disease (CHD). This study aimed to identify and discuss their immediate prevalence, diagnosis and management at a tertiary care hospital in Pakistan. Methods: A retrospective study was conducted at a tertiary care hospital in Pakistan between January 2014 and December 2018. All pediatric (<18 years old) patients admitted to the intensive care unit and undergoing continuous electrocardiographic monitoring after surgery for CHD were included in this study. Data pertaining to the incidence, diagnosis, and management of postoperative arrhythmias were collected. Results: Amongst 812 children who underwent surgery for CHD, 185 (22.8%) developed arrhythmias. Junctional ectopic tachycardia (JET) was the most common arrhythmia, observed in 120 patients (64.9%), followed by complete heart block (CHB) in 33 patients (17.8%). The highest incidence of early postoperative arrhythmia was seen in patients with atrioventricular septal defects (64.3%) and transposition of the great arteries (36.4%). Patients were managed according to the Pediatric Advanced Life Support guidelines. JET resolved successfully within 24 hours in 92% of patients, while 16 (48%) patients with CHB required a permanent pacemaker. Conclusions: More than one in five pediatric patients suffered from early postoperative arrhythmias in our setting. Further research exploring predictive factors and the development of better management protocols of patients with CHB are essential for reducing the morbidity and mortality associated with postoperative arrhythmia.
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Background It is important to determine the proper location of tracheal tube for proper ventilation. In this study, we compared the diagnostic value of tracheal intubation with two methods of palpation and auscultation with chest X-ray (CXR) method in pediatric.
Methods In this interventional study, 80 patients under 6 years of age were included. After tracheal intubation appropriate depth of tracheal tube was determined by auscultation and recorded, then by palpation depth of tracheal tube determined and tube was fixed. The length of the tube was calculated with the standard formula based on age. After surgery, CXR was taken and, according to the landmark, the distance from the end of the tube to the anterior lower tooth was recorded.
Results Interclass correlation coefficient (ICC) between the palpation method and the standard method in the number of fixing tracheal intubation was 0.573, which shows the average and significant correlation between these two methods in determining the fixed number of tracheal intubation. ICC between the auscultation and the standard method in fixing tracheal intubation number was 0.430, which shows the average and significant agreement between these two methods in determining the fixed number of tracheal intubation. There is no significant relationship between sex and the average number of fixing tracheal intubation in all methods.
Conclusions This study has shown that both palpation and auscultation methods are appropriate, but with a slightly higher palpation ICC, the palpation can be considered relatively better.
Background Mechanically ventilated patients experience anxiety for many reasons. Pharmacological treatments such as benzodiazepines are commonly employed to manage anxiety; however, these therapies often cause undesired side effects. Additional therapies for anxiety management are needed. We sought to determine whether cell phone-based virtual reality therapy could feasibly be used for anxiety management in mechanically ventilated patients.
Methods Mechanically ventilated subjects underwent at least one session of virtual reality therapy in which they were shown a cinematic video of an outdoor green space or blue space with 360° visual range of motion. Goal session duration was 5 minutes. The primary outcome was incidence of predefined patient safety events, including self-extubation and accidental removal of tubes or lines.
Results Ten subjects underwent a total of 18 virtual reality sessions. Fifteen sessions lasted the planned 5 minutes, one session was extended at participant request, and two sessions were terminated early at participant request. There were no occurrences of the predefined safety events, and no occurrences of cybersickness. Use of a visual analog scale to measure anxiety level was feasible for this pilot study, demonstrating feasibility of this scale for future, larger scale studies.
Conclusions Virtual reality therapy shows potential as a means of managing anxiety in patients undergoing mechanical ventilation, and further rigorous exploration with this protocol is feasible.
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Background The Life-Sustaining Treatment (LST) Decisions Act allows withholding and withdrawal of LST, including cardiopulmonary resuscitation (CPR). In the present study, the incidence of CPR before and after implementation of the Act was compared.
Methods This was a retrospective review involving hospitalized patients who underwent CPR at a single center between February 2016 and January 2020 (pre-implementation period, February 2016 to January 2018; post-implementation period, February 2018 to January 2020). The primary outcome was monthly incidence of CPR per 1,000 admissions. The secondary outcomes were duration of CPR, return of spontaneous circulation (ROSC) rate, 24-hour survival rate, and survival-to-discharge rate. The study outcomes were compared before and after implementation of the Act.
Results A total of 867 patients who underwent CPR was included in the analysis. The incidence of CPR per 1,000 admissions showed no significant difference before and after implementation of the Act (3.02±0.68 vs. 2.81±0.75, P=0.255). The ROSC rate (67.20±0.11 vs. 70.99±0.12, P=0.008) and survival to discharge rate (20.24±0.09 vs. 22.40±0.12, P=0.029) were higher after implementation of the Act than before implementation.
Conclusions The incidence of CPR did not significantly change for 2 years after implementation of the Act. Further studies are needed to assess the changes in trends in the decisions of CPR and other LSTs in real-world practice.
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Background Several recent studies have shown that preperitoneal pelvic packing (PPP) effectively produces hemostasis in patients with unstable pelvic fractures. However, few studies have examined the rate of surgical site infections (SSIs) in patients undergoing PPP following an unstable pelvic fracture. The purpose of the present study was to evaluate factors associated with SSI in such patients.
Methods We retrospectively reviewed the medical charts of 188 patients who developed hemorrhagic shock due to pelvic fracture between April 2012 and May 2021. Forty-four patients were enrolled in this study.
Results SSI occurred in 15 of 44 patients (34.1%). The SSIs occurred more frequently in cases of repacking during the second-look surgery (0 vs. 4 [26.7%], P=0.010) and combined bladder-urethra injury (1 [3.4%] vs. 4 [26.7%], P=0.039). The incidence of SSIs was not significantly different between patients undergoing depacking within or after 48 hours (12 [41.4%] vs. 5 [33.3%], P=0.603). The mean time to diagnosis of SSI was 8.1±3.9 days from PPP. The most isolated organism was Staphylococcus epidermidis.
Conclusions Repacking and combined bladder-urethra injury are potential risk factors for SSI in patients with unstable pelvic fracture. Close observation is recommended for up to 8 days in patients with these risk factors. Further, 48 hours after PPP, removing the packed gauze on cessation of bleeding and not performing repacking can help prevent SSI. Additional analyses are necessary with a larger number of patients with the potential risk factors identified in this study.
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Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients with Pelvic Ring or Acetabulum Fractures Aaron Singh, Travis Kotzur, Ezekial Koslosky, Rishi Gonuguntla, Lorenzo Canseco, David Momtaz, Ali Seifi, Case Martin Journal of Orthopaedic Trauma.2024;[Epub] CrossRef
Factors Associated With Pelvic Infection After Pre-Peritoneal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures Jennifer E. Baker, Husayn A. Ladhani, Caitlyn McCall, Chelsea R. Horwood, Nicole L. Werner, Barry Platnick, Clay Cothren Burlew Surgical Infections.2024; 25(5): 399. CrossRef
Comparison of Conventional versus Modified Preperitoneal Pelvic Packing in Patients with Bleeding Pelvic Fractures: A Single-Center Retrospective Pilot Study Sebeom Jeon, Byungchul Yu, Gil Jae Lee, Min A Lee, Jungnam Lee, Kang Kook Choi Journal of Clinical Medicine.2024; 13(14): 4062. CrossRef
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