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Tsumura H, Brandon D, Vacchiano C, Krishnamoorthy V, Bartz R, Pan W. Exploring phenotype-based ventilator parameter optimization to mitigate postoperative pulmonary complications: a retrospective observational cohort study. Surg Today 2024; 54:722-733. [PMID: 38095709 PMCID: PMC11176264 DOI: 10.1007/s00595-023-02785-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 11/01/2023] [Indexed: 06/15/2024]
Abstract
PURPOSE To identify tidal volume (VT) and positive end-expiratory pressure (PEEP) associated with the lowest incidence and severity of postoperative pulmonary complications (PPCs) for each phenotype based on preoperative characteristics. METHODS The subjects of this retrospective observational cohort study were 34,910 adults who underwent surgery, using general anesthesia with mechanical ventilation. Initially, the least absolute shrinkage and selection operator regression was employed to select relevant preoperative characteristics. Then, the classification and regression tree (CART) was built to identify phenotypes. Finally, we computed the area under the receiver operating characteristic curves from logistic regressions to identify VT and PEEP associated with the lowest incidence and severity of PPCs for each phenotype. RESULTS CARTs classified seven phenotypes for each outcome. A probability of the development of PPCs ranged from the lowest (3.51%) to the highest (68.57%), whereas the probability of the development of the highest level of PPC severity ranged from 3.3% to 91.0%. Across all phenotypes, the VT and PEEP associated with the most desirable outcomes were within a small range of VT 7-8 ml/kg predicted body weight with PEEP of between 6 and 8 cmH2O. CONCLUSIONS The ranges of optimal VT and PEEP were small, regardless of the phenotypes, which had a wide range of risk profiles.
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Affiliation(s)
- Hideyo Tsumura
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA.
- Duke University Health System, 2301 Erwin Road, Durham, NC, 27710, USA.
| | - Debra Brandon
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
- Department of Pediatrics, Duke University School of Medicine, DUMC 3352, Durham, NC, 27710, USA
| | - Charles Vacchiano
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, DUMC 309427710, USA
- Department of Population Health Sciences Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
| | - Raquel Bartz
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Wei Pan
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
- Department of Population Health Sciences Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
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Lin HZ, Lin YF, Zheng YR. Comparison of neurally adjusted ventilatory assist and synchronized intermittent mandatory ventilation in preterm infants after patent ductus arteriosus ligation: a retrospective study. BMC Pediatr 2024; 24:277. [PMID: 38678190 PMCID: PMC11055325 DOI: 10.1186/s12887-024-04727-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/27/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVE This study aimed to compare the efficacy of neurally adjusted ventilatory assist (NAVA) to synchronized intermittent mandatory ventilation (SIMV) in preterm infants requiring mechanical ventilation after patent ductus arteriosus (PDA) ligation. METHODS A retrospective analysis was conducted on intubated preterm infants who underwent PDA ligation at our hospital from July 2021 to January 2023. Infants were divided into NAVA or SIMV groups based on the ventilation mode after surgery. RESULTS Fifty preterm infants were included. During treatment, peak inspiratory pressure (PIP) and mean airway pressure (MAP) were lower with NAVA compared to SIMV (PIP: 19.1 ± 2.9 vs. 22.4 ± 3.6 cmH2O, P < 0.001; MAP: 9.1 ± 1.8 vs. 10.9 ± 2.7 cmH2O, P = 0.002). PaO2 and PaO2/FiO2 were higher with NAVA (PaO2: 94.0 ± 11.7 vs. 84.8 ± 15.8 mmHg, P = 0.031; PaO2/FiO2: 267 [220-322] vs. 232 [186-290] mmHg, P = 0.025). Less sedation was required with NAVA (midazolam: 1.5 ± 0.5 vs. 1.1 ± 0.3 μg/kg/min, P < 0.001). CONCLUSION Compared to SIMV, early use of NAVA post PDA ligation in preterm infants was associated with decreased PIP and MAP. Early NAVA was also associated with reduced sedation needs and improved oxygenation. However, further studies are warranted to quantify the benefits of NAVA ventilation.
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Affiliation(s)
- Hui-Zi Lin
- Department of Neonatology, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China
| | - Yun-Feng Lin
- Department of Neonatology, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China.
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China.
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China.
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China.
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Wilson MG, Adams CN, Turnbull MD, Falyar CR, Harris EM, Thompson JA, Simmons VC. Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol. J Perianesth Nurs 2023; 38:845-850. [PMID: 37589630 DOI: 10.1016/j.jopan.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 08/18/2023]
Abstract
PURPOSE The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. DESIGN This quality improvement project was conducted using a pre- and postimplementation design. METHODS Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). FINDINGS Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. CONCLUSIONS Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.
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Affiliation(s)
- Megan G Wilson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Cara N Adams
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Matthew D Turnbull
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Christian R Falyar
- Middle Tennesee Acute Surgical Pain Management Fellowship, Middle Tennesee School of Anesthesia, Madison, TN
| | - Erica M Harris
- Duke University Anesthesia Department, Duke University Medical Center, Durham, NC
| | - Julie A Thompson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Virginia C Simmons
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC.
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Murugan R, Kashani K, Palevsky PM. Precision net ultrafiltration dosing in continuous kidney replacement therapy: a practical approach. Intensive Care Med Exp 2023; 11:83. [PMID: 38015332 PMCID: PMC10684837 DOI: 10.1186/s40635-023-00566-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.
- The Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Paul M Palevsky
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
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Hansen-Flaschen J, Ackrivo J. Practical Guide to Management of Long-Term Noninvasive Ventilation for Adults With Chronic Neuromuscular Disease. Respir Care 2023; 68:1123-1157. [PMID: 36922023 PMCID: PMC10353174 DOI: 10.4187/respcare.10349] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 12/19/2022] [Indexed: 03/17/2023]
Abstract
Recent technological advances in respiratory support and monitoring have dramatically enhanced the utility of long-term noninvasive ventilation (NIV). Improved quality of life and prolonged survival have been demonstrated for several common chronic neuromuscular diseases. Many adults with progressive neuromuscular respiratory disease can now comfortably maintain normal ventilation at home to near total respiratory muscle paralysis without needing a tracheostomy. However, current practice in many communities falls short of that potential. Mastery of the new technology calls for detailed awareness of the respiratory cycle; expert knowledge of mechanical devices, facial interfaces, and quantitative monitoring tools for home ventilation; and a willingness to stay current in a rapidly expanding body of clinical research. The depth and breadth of the expertise required to manage home assisted ventilation has given rise to a new focused medical subspecialty in chronic respiratory failure at the interface between pulmonology, critical care, and sleep medicine. For clinicians seeking pragmatic "how to" guidance, this primer presents a comprehensive, physician-directed management approach to long-term NIV of adults with chronic neuromuscular respiratory disease. Bi-level devices, portable ventilators, ventilation modalities, terminology, and monitoring strategies are reviewed in detail. Building on that knowledge base, we present a step-by-step guide to initiation, refinement, and maintenance of home NIV tailored to patient-centered goals of therapy. The quantitative approach recommended incorporates routine monitoring of home ventilation using technologies that have only recently become widely available including cloud-based device telemonitoring and noninvasive measurements of blood gases. Strategies for troubleshooting and problem solving are included.
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Affiliation(s)
- John Hansen-Flaschen
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jason Ackrivo
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Self M, Mun C, Goodrich A, Schmidt U. A NOVEL EQUATION SUCCESSFULLY CALCULATES TIDAL VOLUMES FOR LUNG PROTECTIVE VENTILATION. J Emerg Med 2023:S0736-4679(23)00233-0. [PMID: 37355422 DOI: 10.1016/j.jemermed.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/22/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Early application of low-tidal-volume ventilation (LTVV) has been associated with improved outcomes in the emergency department (ED) and intensive care unit (ICU), but is not consistently applied. The perceived complexity of calculating an ideal body weight (IBW)-based tidal volume (Vt) may contribute to this disparity. We hypothesized that a simplified equation could successfully predict LTVV. OBJECTIVE To create a memorable, single-step, sex-independent equation to estimate LTVV based on height. METHODS We conducted a retrospective observational cohort study of patients who received mechanical ventilation (MV) at 2 EDs from January 2016 to June 2019. Data were abstracted by automatic query. Patients < 18 years old, < 60 inches in height, and with implausible or incomplete data were excluded. LTVV was defined as ≤ 8 mL/kg IBW. We created a formula predicting a 6-8-mL/kg IBW Vt. We applied this formula to a population of ICU patients in the same health care system who received MV from January 2017 to December 2019 using the same exclusion criteria. The outcome was whether the equation predicted a 6-8-mL/kg IBW Vt. RESULTS A total of 982 ED patients were included; 753 (76.7%) had an initial Vt < 8 mL/kg IBW. The equation Vt = 20*(Ht-60) + 300 was derived. A total of 3720 ICU patients were included. The Vt equation successfully predicted a Vt of 6-8 mL/kg IBW in 3720 (100%) of ICU patients. CONCLUSIONS A novel equation successfully predicted a 6-8-mL/kg IBW Vt in a cohort of patients with height ≥ 60 inches.
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Affiliation(s)
- Michael Self
- Department of Emergency Medicine; Department of Anesthesiology, Division of Critical Care Anesthesia, University of California, San Diego, San Diego, California
| | - Christie Mun
- Department of Anesthesiology, Division of Critical Care Anesthesia, University of California, San Diego, San Diego, California
| | - Andrew Goodrich
- Critical Care Medicine, Memorial Healthcare System, Hollywood, Florida
| | - Ulrich Schmidt
- Department of Anesthesiology, Division of Critical Care Anesthesia, University of California, San Diego, San Diego, California
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Manrique S, Ruiz-Botella M, Rodríguez A, Gordo F, Guardiola JJ, Bodí M, Gómez J. Secondary use of data extracted from a clinical information system to assess the adherence of tidal volume and its impact on outcomes. Med Intensiva 2022; 46:619-629. [PMID: 36344013 DOI: 10.1016/j.medine.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/09/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To extract data from clinical information systems to automatically calculate high-resolution quality indicators to assess adherence to recommendations for low tidal volume. DESIGN We devised two indicators: the percentage of time under mechanical ventilation with excessive tidal volume (>8mL/kg predicted body weight) and the percentage of patients who received appropriate tidal volume (≤8mL/kg PBW) at least 80% of the time under mechanical ventilation. We developed an algorithm to automatically calculate these indicators from clinical information system data and analyzed associations between them and patients' characteristics and outcomes. SETTINGS This study has been carried out in our 30-bed polyvalent intensive care unit between January 1, 2014 and November 30, 2019. PATIENTS All patients admitted to intensive care unit ventilated >72h were included. INTERVENTION Use data collected automatically from the clinical information systems to assess adherence to tidal volume recommendations and its outcomes. MAIN VARIABLES OF INTEREST Mechanical ventilation days, ICU length of stay and mortality. RESULTS Of all admitted patients, 340 met the inclusion criteria. Median percentage of time under mechanical ventilation with excessive tidal volume was 70% (23%-93%); only 22.3% of patients received appropriate tidal volume at least 80% of the time. Receiving appropriate tidal volume was associated with shorter duration of mechanical ventilation and intensive care unit stay. Patients receiving appropriate tidal volume were mostly male, younger, taller, and less severely ill. Adjusted intensive care unit mortality did not differ according to percentage of time with excessive tidal volume or to receiving appropriate tidal volume at least 80% of the time. CONCLUSIONS Automatic calculation of process-of-care indicators from clinical information systems high-resolution data can provide an accurate and continuous measure of adherence to recommendations. Adherence to tidal volume recommendations was associated with shorter duration of mechanical ventilation and intensive care unit stay.
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Affiliation(s)
- S Manrique
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain.
| | - M Ruiz-Botella
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - A Rodríguez
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Spain
| | - F Gordo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Grupo de Investigación en Patología Crítica, Grado de Medicina, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | | | - M Bodí
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Spain
| | - J Gómez
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain
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Modeling surgical patients’ tidal volumes set by anesthesiologists – A successful regression approach based on 6 body parameters. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2022.103801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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9
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Secondary use of data extracted from a clinical information system to assess the adherence of tidal volume and its impact on outcomes. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Proulx F, Emeriaud G, François T, Joyal JS, Nardi N, Kawaguchi A, Jouvet P, Sauthier M. Oxygenation Defects, Ventilatory Ratio, and Mechanical Power During Severe Pediatric Acute Respiratory Distress Syndrome: Longitudinal Time Sequence Analyses in a Single-Center Retrospective Cohort. Pediatr Crit Care Med 2022; 23:22-33. [PMID: 34593741 DOI: 10.1097/pcc.0000000000002822] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Our understanding of pediatric acute respiratory distress syndrome is based on information from studies reporting intermittent, serial respiratory data. We have analyzed a high-resolution, longitudinal dataset that incorporates measures of hypoxemia severity, metrics of lung mechanics, ventilatory ratio, and mechanical power and examined associations with survival after the onset of pediatric acute respiratory distress syndrome. DESIGN Single-center retrospective cohort, 2013-2018. SETTING Tertiary surgical/medical PICU. PATIENTS Seventy-six cases of severe pediatric acute respiratory distress syndrome, determined according to the Pediatric Acute Lung Injury Consensus Conference criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The high-resolution database included continuous monitoring of ventilatory data (0.03 Hz) for up to 14 days after the diagnosis of pediatric acute respiratory distress syndrome or until extubation or death (n = 26). In the 12,128 hours of data during conventional mechanical ventilation, we used generalized estimating equations to compare groups, accounting for any effect of time. We identified an association between survival and faster rate of improvement in delta pressure (peak inspiratory pressure minus positive end-expiratory pressure; p = 0.028). Nonsurvival was associated with higher daily Pediatric Logistic Organ Dysfunction-2 scores (p = 0.005) and more severe hypoxemia metrics (p = 0.005). Mortality was also associated with the following respiratory/pulmonary metrics (mean difference [95% CI]): positive end-expiratory pressure level (+2.0 cm H2O [0.8-3.2 cm H2O]; p = 0.001), peak inspiratory pressure level (+3.0 cm H2O [0.5-5.5 cm H2O]; p = 0.022), respiratory rate (z scores +2.2 [0.9-3.6]; p = 0.003], ventilatory ratio (+0.41 [0.28-0.55]; p = 0.0001], and mechanical power (+5 Joules/min [1-10 Joules/min]; p = 0.013). Based on generalized linear mixed modeling, mechanical power remained associated with mortality after adjustment for normal respiratory rate, age, and daily Pediatric Logistic Organ Dysfunction-2 score (+3 Joules/breath [1-6 Joules/breath]; p = 0.009). CONCLUSIONS Mortality after severe pediatric acute respiratory distress syndrome is associated with the severity of organ dysfunction, oxygenation defects, and pulmonary metrics including dead space and theoretical mechanical energy load.
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Affiliation(s)
- François Proulx
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Guillaume Emeriaud
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Tine François
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Jean-Sébastien Joyal
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Nicolas Nardi
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Atsushi Kawaguchi
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Philippe Jouvet
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Michaël Sauthier
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
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Acute Hypoxemic Respiratory Failure in Children at the Start of COVID-19 Outbreak: A Nationwide Experience. J Clin Med 2021; 10:jcm10194301. [PMID: 34640318 PMCID: PMC8509571 DOI: 10.3390/jcm10194301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022] Open
Abstract
Study design: This is a prospective, multicenter, and observational study with the aim of describing physiological characteristics, respiratory management, and outcomes of children with acute hypoxemic respiratory failure (AHRF) from different etiologies receiving invasive mechanical ventilation (IMV) compared with those affected by SARS-CoV-2. Methods and Main Results: Twenty-eight patients met the inclusion criteria: 9 patients with coronavirus disease 2019 (COVID-19) and 19 patients without COVID-19. Non-COVID-19 patients had more pre-existing comorbidities (78.9% vs. 44.4%) than COVID-19 patients. At AHRF onset, non-COVID-19 patients had worse oxygenation (PaO2/FiO2 = 95 mmHg (65.5–133) vs. 150 mmHg (105–220), p = 0.04), oxygenation index = 15.9 (11–28.4) vs. 9.3 (6.7–10.6), p = 0.01), and higher PaCO2 (48 mmHg (46.5–63) vs. 41 mmHg (40–45), p = 0.07, that remained higher at 48 h: 54 mmHg (43–58.7) vs. 41 (38.5–45.5), p = 0.03). In 12 patients (5 COVID-19 and 7 non-COVID-19), AHRF evolved to pediatric acute respiratory distress syndrome (PARDS). All non-COVID-19 patients had severe PARDS, while 3 out of 5 patients in the COVID-19 group had mild or moderate PARDS. Overall Pediatric Intensive Care Medicine (PICU) mortality was 14.3%. Conclusions: Children with AHRF due to SARS-CoV2 infection had fewer comorbidities and better oxygenation than patients with non-COVID-19 AHRF. In this study, progression to severe PARDS was rarely observed in children with COVID-19.
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Bendavid I, Lobo DN, Barazzoni R, Cederholm T, Coëffier M, de van der Schueren M, Fontaine E, Hiesmayr M, Laviano A, Pichard C, Singer P. The centenary of the Harris-Benedict equations: How to assess energy requirements best? Recommendations from the ESPEN expert group. Clin Nutr 2021; 40:690-701. [PMID: 33279311 DOI: 10.1016/j.clnu.2020.11.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/18/2020] [Accepted: 11/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS The year 2019 marked the centenary of the publication of the Harris and Benedict equations for estimation of energy expenditure. In October 2019 a Scientific Symposium was organized by the European Society for Clinical Nutrition and Metabolism (ESPEN) in Vienna, Austria, to celebrate this historical landmark, looking at what is currently known about the estimation and measurement of energy expenditure. METHODS Current evidence was discussed during the symposium, including the scientific basis and clinical knowledge, and is summarized here to assist with the estimation and measurement of energy requirements that later translate into energy prescription. RESULTS In most clinical settings, the majority of predictive equations have low to moderate performance, with the best generally reaching an accuracy of no more than 70%, and often lead to large errors in estimating the true needs of patients. Generally speaking, the addition of body composition measurements did not add to the accuracy of predictive equations. Indirect calorimetry is the most reliable method to measure energy expenditure and guide energy prescription, but carries inherent limitations, greatly restricting its use in real life clinical practice. CONCLUSIONS While the limitations of predictive equations are clear, their use is still the mainstay in clinical practice. It is imperative to recognize specific patient populations for whom a specific equation should be preferred. When available, the use of indirect calorimetry is advised in a variety of clinical settings, aiming to avoid under-as well as overfeeding.
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Affiliation(s)
- Itai Bendavid
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Israel
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Tommy Cederholm
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden; Theme Ageing, Karolinska University Hospital, Stockholm, Sweden
| | - Moïse Coëffier
- Department of Nutrition, CIC1404, Rouen University Hospital and Normandie University, UNIROUEN, Inserm UMR1073, Rouen, France
| | - Marian de van der Schueren
- Department of Nutrition and Dietetics, HAN University of Applied Sciences, School of Allied Health, Nijmegen, the Netherlands
| | - Eric Fontaine
- Université Grenoble Alpes, LBFA, INSERM U1055, Grenoble, France
| | - Michael Hiesmayr
- Division of Cardiac, Thoracic, Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Claude Pichard
- Clinical Nutrition, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Israel.
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Lebossé M, Kern D, De Queiroz M, Bourdaud N, Veyckemans F, Chassard D, Baudin F. Ventilation in pediatric anesthesia: A French multicenter prospective observational study (PEDIAVENT). Paediatr Anaesth 2020; 30:912-921. [PMID: 32500930 DOI: 10.1111/pan.13909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Protective ventilation is now a standard of care in adults. However, management of ventilation is heterogeneous in children and little is known regarding the mechanical ventilation parameters actually used during pediatric anesthesia. AIM The aim of the study was to assess current ventilatory practices during pediatric anesthesia in France and to compare them with pediatric experts' statements, with a specific focus on tidal volume. PATIENTS AND METHODS We conducted a prospective multicenter observational study, regarding the ventilatory management and the mechanical ventilation parameters, over two days (21 and 22 June 2017) in 29 pediatric centers in France. All children undergoing general anesthesia during these 2 days were eligible; those who required extracorporeal circulation or one-lung ventilation were excluded. RESULTS A total of 701 children were included; median [IQR] age was 60 [24-120] months. Among the patients in whom controlled ventilation was used, 254/515 (49.3%) had an expired tidal volume >8 mL/kg and 44 children (8.8%) an expired tidal volume ≥10 mL/kg. Lower weight and use of a supraglottic airway device were significantly associated with provision of a tidal volume ≥10 mL/kg (odds ratio 0.94, 95% confidence interval [0.92; 0.97], P < .001 and 2.28 [1.20; 4.31], P = .012, respectively). The positive end-expiratory pressure was set at a median [IQR] of 4 [3-5] cmH2 O; it was <3 cmH2 O in 15.7% of children and not used in 56/499 (9.3%). Among intubated children, 57 (18.3%) received a tidal volume < 10 mL/kg with a positive end-expiratory pressure ≥3 cmH2 O in association with recruitment maneuvers. CONCLUSIONS Ventilatory practices in children were heterogenous, and a large proportion of children were not ventilated as it is currently recommended by some experts.
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Affiliation(s)
- Marion Lebossé
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Delphine Kern
- Pôle Anesthésie-Réanimation, Hôpitaux de Toulouse, Hôpital des enfants, Toulouse, France
| | - Mathilde De Queiroz
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Nathalie Bourdaud
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Francis Veyckemans
- Département d'Anesthésie-Réanimation, Clinique d'Anesthésie-Réanimation pédiatrique, Hôpital Jeanne de Flandre, CHRU Lille, Lille, France
| | - Dominique Chassard
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France.,Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, Université de Lyon, Lyon, France
| | - Florent Baudin
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France.,Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, Université de Lyon, Lyon, France
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Evaluating Delivery of Low Tidal Volume Ventilation in Six ICUs Using Electronic Health Record Data. Crit Care Med 2019; 47:56-61. [PMID: 30308549 DOI: 10.1097/ccm.0000000000003469] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Mechanical ventilation with low tidal volumes is recommended for all patients with acute respiratory distress syndrome and may be beneficial to other intubated patients, yet consistent implementation remains difficult to obtain. Using detailed electronic health record data, we examined patterns of tidal volume administration, the effect on clinical outcomes, and alternate metrics for evaluating low tidal volume compliance in clinical practice. DESIGN Observational cohort study. SETTING Six ICUs in a single hospital system. PATIENTS Adult patients who received invasive mechanical ventilation more than 12 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Tidal volumes were analyzed across 1,905 hospitalizations. Although mean tidal volume was 6.8 mL/kg predicted body weight, 40% of patients were exposed to tidal volumes greater than 8 mL/kg predicted body weight, with 11% for more than 24 hours. At a patient level, exposure to 24 total hours of tidal volumes greater than 8 mL/kg predicted body weight was associated with increased mortality (odds ratio, 1.82; 95% CI, 1.20-2.78), whereas mean tidal volume exposure was not (odds ratio, 0.87/1 mL/kg increase; 95% CI, 0.74-1.02). Initial tidal volume settings strongly predicted exposure to volumes greater than 8 mL/kg for 24 hours; the adjusted rate was 21.5% when initial volumes were greater than 8 mL/kg predicted body weight and 7.1% when initial volumes were less than 8 mL/kg predicted body weight. Across ICUs, correlation of mean tidal volume with alternative measures of low tidal volume delivery ranged from 0.38 to 0.66. CONCLUSIONS Despite low mean tidal volume in the cohort, a significant percentage of patients were exposed to a prolonged duration of high tidal volumes which was correlated with higher mortality. Detailed ventilator records in the electronic health record provide a unique window for evaluating low tidal volume delivery and targets for improvement.
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Lee JH, Bae JI, Jang YE, Kim EH, Kim HS, Kim JT. Lung protective ventilation during pulmonary resection in children: a prospective, single-centre, randomised controlled trial. Br J Anaesth 2019; 122:692-701. [DOI: 10.1016/j.bja.2019.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 01/20/2019] [Accepted: 02/05/2019] [Indexed: 11/16/2022] Open
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