The Israel Medical Association journal : IMAJ, 2020
BACKGROUND The use of a high flow nasal cannula (HFNC) was examined for different clinical indica... more BACKGROUND The use of a high flow nasal cannula (HFNC) was examined for different clinical indications in the critically ill. OBJECTIVES To describe a single center experience with HFNC in post-extubation critical care patients by using clinical indices. METHODS In this single center study, the authors retrospectively evaluated the outcome of patients who were connected to the HFNC after their extubation in the intensive care unit (ICU). At 48 hours after the extubation, the patients were divided into three groups: the group weaned from HFNC, the ongoing HFNC group, and the already intubated group. RESULTS Of the 80 patients who were included, 42 patients were without HFNC support at 48 hours after extubation, 22 and 16 patients were with ongoing HFNC support and already intubated by this time frame, respectively. The mean ROX index (the ratio of SpO2 divided by fraction of inspired oxygen to respiratory rate) at 6 hours of the weaned group was 12.3 versus 9.3 in the ongoing HFNC gr...
Introduction: Concomitant experimental/compassionate drug administration has been all-pervasive i... more Introduction: Concomitant experimental/compassionate drug administration has been all-pervasive in the treatment of COVID-19 patients. The objective of this study was to study the relationship between patient severity, the number of experimental/compassionate medications received (main outcome measure),
Principles and Practice of Maternal Critical Care, 2020
Pregnancy is associated with significant anatomical and physiological changes in the airway and r... more Pregnancy is associated with significant anatomical and physiological changes in the airway and respiratory system. Reduction of functional residual capacity in parallel with increased oxygen consumption shortens the time available for airway manipulation before hypoxia becomes significant. Hormone-induced changes in respiratory drive cause a reduction of normal partial pressure of arterial carbon dioxide values during pregnancy, associated with compensatory metabolic acidosis. A thorough understanding of these changes is key for anesthesiologists and critical care providers managing obstetric patients with compromised oxygenation requiring airway manipulation and mechanical ventilation.
SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON... more SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM 02:00 PM OUTCOMES OF CARDIAC ARREST BETWEEN REALITY AND TELEVISION MEDICAL DRAMAS: RESULTS OF THE TVMD2 STUDY JOSEPH VARON MD, FCCP* ABBAS ALSHAMI LUZ RAMIREZ DARYELLE VARON AND SHARON EINAV PURPOSE: Outcomes of cardiopulmonary resuscitation (CPR) include: death, return of spontaneous circulation (ROSC), sustained ROSC, and discharge from hospital, among others. We aimed to assess if television medical dramas (TVMDs) depictions of CPR outcomes are representative of reality. METHODS: An instrument was created to address quality of CPR in TVMD. It was applied by advanced cardiac life support (ACLS) certified-health care providers, to assess and review CPR scenarios performance and outcomes from 32 different TVMDs from 2010 to 2018. Data was evaluated to explore CPR outcomes. RESULTS: A total of 836 episodes of TVMDs were reviewed with a total of 212 on-screen CPR attempts; of which, 202 revealed the outcome. CPR success rate was 61.9% (n1⁄4125). In 189 CPR scenes, patient’s condition was followed during the hospitalization, and 54% (n1⁄4102) survived to hospital discharge. Of the survivors, we were able to assess the cerebral performance category (CPC) score in 88 patients. 96.5% (n1⁄485) had favorable neurological outcome (CPC 1,2) and only 3.5% (n1⁄43) had unfavorable neurological outcome (CPC 3,4 and5). Moreover, we assessed if determination of ROSC in TVMDs complied with the Utstein Resuscitation Registry Templates (by spontaneously restoring a palpable pulse or a measurable blood pressure). We found that from 160 episodes, in which we could assess how ROSC was determined, only 30% (n1⁄448) depended on the pulse; while 56.3% (n1⁄490) used the monitor. Other methods to identify ROSC were echocardiography in 3.75% (n1⁄46), waking up in 9.38% (n1⁄415), breathing in 4.38% (n1⁄47), and coughing in 2.5% (n1⁄44) of the patients. CONCLUSIONS: The success rate of CPR and neurological outcomes for survivors in TVMDs are better than outcomes among real patients. ROSC identification also varied from common clinical practice. TVMDs portrayal of CPR outcomes significantly misrepresents outcomes in reality. CLINICAL IMPLICATIONS: TVMDs are a major source of medical education among lay people. Inadequate representation of CPR outcomes may give families false hope. DISCLOSURES: No relevant relationships by Abbas Alshami, source1⁄4Web Response Advisory Committee Member relationship with Zoll Please note: $5001 $20000 Added 03/14/2019 by Sharon Einav, source1⁄4Web Response, value1⁄4Travel<br Advisory Committee Member relationship with Medtronic Please note: $20001 $100000 Added 03/14/2019 by Sharon Einav, source1⁄4Web Response, value1⁄4Intellectual property rights Advisory Committee Member relationship with Diasorin Please note: $1001 $5000 Added 03/14/2019 by Sharon Einav, source1⁄4Web Response, value1⁄4Grant/Research Support No relevant relationships by Luz Ramirez, source1⁄4Web Response No relevant relationships by Joseph Varon, source1⁄4Web Response No relevant relationships by Daryelle Varon, source1⁄4Web Response DOI: https://doi.org/10.1016/j.chest.2019.08.899 Copyright a 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. 72A [ 1 5 6 # 4 S CHES T OC TO B E R 2 0 1 9 ]
BACKGROUND The annual congress of the European Society of Anaesthesiology (ESA) is one of the lar... more BACKGROUND The annual congress of the European Society of Anaesthesiology (ESA) is one of the largest anaesthesia congresses in the world and exhibits more than 1200 abstracts annually.
Supplemental Digital Content is available in the text. Objectives: Reintubation after failed extu... more Supplemental Digital Content is available in the text. Objectives: Reintubation after failed extubation is associated with increased mortality and longer hospital length of stay. Noninvasive oxygenation modalities may prevent reintubation. We conducted a systematic review and meta-analysis to determine the safety and efficacy of high-flow nasal cannula after extubation in critically ill adults. Data Sources: We searched MEDLINE, EMBASE, and Web of Science. Study Selection: We included randomized controlled trials comparing high-flow nasal cannula to other noninvasive methods of oxygen delivery after extubation in critically ill adults. Data Extraction: We included the following outcomes: reintubation, postextubation respiratory failure, mortality, use of noninvasive ventilation, ICU and hospital length of stay, complications, and comfort. Data Synthesis: We included eight randomized controlled trials (n = 1,594 patients). Compared with conventional oxygen therapy, high-flow nasal cannula decreased reintubation (relative risk, 0.46; 95% CI, 0.30–0.70; moderate certainty) and postextubation respiratory failure (relative risk, 0.52; 95% CI, 0.30–0.91; very low certainty), but had no effect on mortality (relative risk, 0.93; 95% CI, 0.57–1.52; moderate certainty), or ICU length of stay (mean difference, 0.05 d fewer; 95% CI, 0.83 d fewer to 0.73 d more; high certainty). High-flow nasal cannula may decrease use of noninvasive ventilation (relative risk, 0.64; 95% CI, 0.34–1.22; moderate certainty) and hospital length of stay (mean difference, 0.98 d fewer; 95% CI, 2.16 d fewer to 0.21 d more; moderate certainty) compared with conventional oxygen therapy, however, certainty was limited by imprecision. Compared with noninvasive ventilation, high-flow nasal cannula had no effect on reintubation (relative risk, 1.16; 95% CI, 0.86–1.57; low certainty), mortality (relative risk, 1.12; 95% CI, 0.82–1.53; moderate certainty), or postextubation respiratory failure (relative risk, 0.82; 95% CI, 0.48–1.41; very low certainty). High-flow nasal cannula may reduce ICU length of stay (moderate certainty) and hospital length of stay (moderate certainty) compared with noninvasive ventilation. Conclusions: High-flow nasal cannula reduces reintubation compared with conventional oxygen therapy, but not compared with noninvasive ventilation after extubation.
Objective: Inhalation of noble and other gases after cardiac arrest (CA) might improve neurologic... more Objective: Inhalation of noble and other gases after cardiac arrest (CA) might improve neurological and cardiac outcomes. This article discusses up-to-date information on this novel therapeutic intervention. Data Sources: CENTRAL, MEDLINE, online published abstracts from conference proceedings, clinical trial registry clinicaltrials.gov, and reference lists of relevant papers were systematically searched from January 1960 till March 2019. Study Selection: Preclinical and clinical studies, irrespective of their types or described outcomes, were included. Data Extraction: Abstract screening, study selection, and data extraction were performed by two independent authors. Due to the paucity of human trials, risk of bias assessment was not performed. Data Synthesis: After screening 281 interventional studies, we included an overall of 27. Only, xenon, helium, hydrogen, and nitric oxide have been or are being studied on humans. Xenon, nitric oxide, and hydrogen show both neuroprotective and cardiotonic features, while argon and hydrogen sulfide seem neuroprotective, but not cardiotonic. Most gases have elicited neurohistological protection in preclinical studies; however, only hydrogen and hydrogen sulfide appeared to preserve CA1 sector of hippocampus, the most vulnerable area in the brain for hypoxia. Conclusion: Inhalation of certain gases after CPR appears promising in mitigating neurological and cardiac damage and may become the next successful neuroprotective and cardiotonic interventions.
BACKGROUND Mediastinitis is a rare but severe infection, defined as an inflammation of the connec... more BACKGROUND Mediastinitis is a rare but severe infection, defined as an inflammation of the connective tissues and structures within the mediastinum. Due to its proximity with vital structures, mediastinitis represents a highly morbid pathological process associated with a high risk of mortality. In most cases mediastinitis requires treatment in the intensive care unit. OBJECTIVES The goal of this narrative review is to highlight to the reader the clinical features of mediastinitis, to attempt to define each clinical scenario, to describe the responsible pathogens and finally to depict both the medical and surgical treatment. SOURCES We performed a literature search of the PubMed and Cochrane libraries, limited for articles published between January 2003 and December 2018, reporting on acute mediastinitis. CONTENT The term covers different entities of different etiologies including deep sternal wound infection related to sternotomy; esophageal perforation or anastomosis leakage; and finally descending necrotizing mediastinitis often secondary to oropharyngeal abscess. The responsible pathogens and therefore subsequent management depends on the underlying etiology. Empirical antimicrobial therapy should cover the suspected microorganisms while surgery and supportive measures should aim to reduce the inoculum of pathogens by providing adequate drainage and debridement. IMPLICATIONS Literature concerning mediastinitis in the ICU is relatively scarce. Here we collated the evidence and reviewed the different causes and treatment options of acute mediastinitis with a particular focus on microbiological epidemiology. Future research in larger cohorts is needed to better understand the treatment of this difficult disease.
BACKGROUND: The use of in vitro fertilization is increasing. The incidence of adverse outcomes is... more BACKGROUND: The use of in vitro fertilization is increasing. The incidence of adverse outcomes is greater for women who undergo in vitro fertilization, potentially leading to intensive care unit admission. This study aimed to assess the etiology and course of intensive care unit admission in women who underwent in vitro fertilization compared to those who did not, with specific focus on intensive care unit admission due to postpartum hemorrhage. METHODS: In this retrospective study, medical records of patients admitted to the intensive care unit during pregnancy or the peripartum period at 2 medical centers (2005–2016 at Mount Sinai Hospital, New York, NY, and 2005–2013 at Shaare Zedek Medical Center, Jerusalem, Israel) were analyzed. Demographic, past medical and obstetric history, and details regarding delivery and intensive care unit stay were collected, as was information regarding mode of conception (in vitro fertilization versus non–in vitro fertilization) for the current pregnancy. The primary outcome measure was difference in etiology of intensive care unit admission between in vitro fertilization and non–in vitro fertilization groups. Secondary outcome measures included differences in prepregnancy characteristics, incidence, severity, and management of postpartum hemorrhage, as well as incidence of other clinical major morbidity events and delivery-related complications. Multivariable logistic regression was performed to study the relationship between in vitro fertilization and the odds of having been admitted to the intensive care unit due to hemorrhage. RESULTS: During the study period, there were nearly 192,000 deliveries, with 428 pregnant and peripartum women admitted to the intensive care unit. Of the 409 cases analyzed, 60 had conceived following in vitro fertilization and 349 had conceived without in vitro fertilization. The non–in vitro fertilization group was more likely to have multiple medical comorbidities, and the in vitro fertilization group was more likely to have multiple gestations. The groups also differed in etiology of intensive care unit admission; more women in the in vitro fertilization group were admitted due to a pregnancy-related complication. Intensive care unit admission for postpartum hemorrhage was more frequent in the in vitro fertilization group (60.0% vs 43.1%, P = .014), with a 2-fold increase in the incidence of hemorrhagic shock. Logistic regression analysis revealed a 2-fold increase in the odds that intensive care unit admission was due to hemorrhage in women undergoing in vitro fertilization, a finding that was not statistically significant when multiple gestation was added to the model. CONCLUSIONS: Among patients admitted to the intensive care unit, patients with different modes of conception had dissimilar etiologies for intensive care unit admission with intensive care unit admission due to hemorrhage greater in those with in vitro fertilization. Higher rates of multiple gestation pregnancies may explain this difference. Differences in pregnancies conceived via in vitro fertilization versus without in vitro fertilization may affect the obstetric intensive care unit case mix.
Disaster Medicine and Public Health Preparedness, 2015
ObjectiveData on best practices for evacuating an intensive care unit (ICU) during a disaster are... more ObjectiveData on best practices for evacuating an intensive care unit (ICU) during a disaster are limited. The impact of Hurricane Sandy on New York City area hospitals provided a unique opportunity to learn from the experience of ICU providers about their preparedness, perspective, roles, and activities.MethodsWe conducted a cross-sectional survey of nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy ICU evacuations.ResultsSixty-eight health care professionals from 4 evacuating hospitals completed surveys (35% ICU nurses, 21% respiratory therapists, 25% physicians-in-training, and 13% attending physicians). Only 21% had participated in an ICU evacuation drill in the past 2 years and 28% had prior training or real-life experience. Processes were inconsistent for patient prioritization, tracking, transport medications, and transport care. Respondents identified communication (43%) as the key barrier to effective evacuation. The equipment...
Amniotic fluid embolism (AFE) is an obstetrical catastrophe characterized by acute hypotension, h... more Amniotic fluid embolism (AFE) is an obstetrical catastrophe characterized by acute hypotension, hypoxia, and coagulopathy occurring during labor, cesarean section, post-delivery, or during amniocentesis. Thromboelastography (TEG) is a bedside test of global homeostasis and has seldom been used to study coagulation in AFE despite increasing popularity in other diseases. We report TEG usage as part of a treatment for patients with AFE.
In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive... more In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive care unit (ICU) because of the shortage of ICU beds. The aim of the study was to compare the outcome and ventilatory management of medical patients mechanically ventilated on the medical wards and in the ICU. This was a prospective, observational, noninterventional study over a 6-month period. The study was conducted in internal medicine wards and the ICU of a 500-bed community university-affiliated hospital. Ninety-nine mechanically ventilated medical patients in the ICU or on the medical wards because of shortage of ICU beds were included in the study. Baseline characteristics of the patients ventilated in the ICU (group 1) and in the medical wards (group 2) were collected. Thirty-four patients were ventilated in the ICU and 65 in the wards during the study period. In-hospital survival rate in group 1 was 38% vs 20% in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). The Acute Physiologic and Chronic Health Evaluation (APACHE) II score in group 1 was 24 +/- 7 vs 27 +/- 7 in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). Other prognostic factors were similar. The age of the survivors in the 2 groups was similar: 57 +/- 25 years in group 1 vs 69 +/- 13 years in group 2 (P = NS). Mean number of ventilatory changes in group 1 was 7.5 +/- 1.4 per day per patient, whereas it was 1.3 +/- 1.0 in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). The number of arterial blood gas analyses in group 1 was 7.7 +/- 1.2 per day per patient compared with 2.3 +/- 1.3 in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Twenty percent (20%) of the patients in group 1 had endotracheal tube-related inadvertent events compared with 62% of the patients in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). We conclude that in medical patients requiring mechanical ventilation, there is a higher in-hospital survival rate in ICU-ventilated patients as compared with ventilated patients managed on the medical wards. In addition, ICU provides a better monitoring associated with less endotracheal tube-related complications and more active ventilatory management.
The Israel Medical Association journal : IMAJ, 2020
BACKGROUND The use of a high flow nasal cannula (HFNC) was examined for different clinical indica... more BACKGROUND The use of a high flow nasal cannula (HFNC) was examined for different clinical indications in the critically ill. OBJECTIVES To describe a single center experience with HFNC in post-extubation critical care patients by using clinical indices. METHODS In this single center study, the authors retrospectively evaluated the outcome of patients who were connected to the HFNC after their extubation in the intensive care unit (ICU). At 48 hours after the extubation, the patients were divided into three groups: the group weaned from HFNC, the ongoing HFNC group, and the already intubated group. RESULTS Of the 80 patients who were included, 42 patients were without HFNC support at 48 hours after extubation, 22 and 16 patients were with ongoing HFNC support and already intubated by this time frame, respectively. The mean ROX index (the ratio of SpO2 divided by fraction of inspired oxygen to respiratory rate) at 6 hours of the weaned group was 12.3 versus 9.3 in the ongoing HFNC gr...
Introduction: Concomitant experimental/compassionate drug administration has been all-pervasive i... more Introduction: Concomitant experimental/compassionate drug administration has been all-pervasive in the treatment of COVID-19 patients. The objective of this study was to study the relationship between patient severity, the number of experimental/compassionate medications received (main outcome measure),
Principles and Practice of Maternal Critical Care, 2020
Pregnancy is associated with significant anatomical and physiological changes in the airway and r... more Pregnancy is associated with significant anatomical and physiological changes in the airway and respiratory system. Reduction of functional residual capacity in parallel with increased oxygen consumption shortens the time available for airway manipulation before hypoxia becomes significant. Hormone-induced changes in respiratory drive cause a reduction of normal partial pressure of arterial carbon dioxide values during pregnancy, associated with compensatory metabolic acidosis. A thorough understanding of these changes is key for anesthesiologists and critical care providers managing obstetric patients with compromised oxygenation requiring airway manipulation and mechanical ventilation.
SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON... more SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM 02:00 PM OUTCOMES OF CARDIAC ARREST BETWEEN REALITY AND TELEVISION MEDICAL DRAMAS: RESULTS OF THE TVMD2 STUDY JOSEPH VARON MD, FCCP* ABBAS ALSHAMI LUZ RAMIREZ DARYELLE VARON AND SHARON EINAV PURPOSE: Outcomes of cardiopulmonary resuscitation (CPR) include: death, return of spontaneous circulation (ROSC), sustained ROSC, and discharge from hospital, among others. We aimed to assess if television medical dramas (TVMDs) depictions of CPR outcomes are representative of reality. METHODS: An instrument was created to address quality of CPR in TVMD. It was applied by advanced cardiac life support (ACLS) certified-health care providers, to assess and review CPR scenarios performance and outcomes from 32 different TVMDs from 2010 to 2018. Data was evaluated to explore CPR outcomes. RESULTS: A total of 836 episodes of TVMDs were reviewed with a total of 212 on-screen CPR attempts; of which, 202 revealed the outcome. CPR success rate was 61.9% (n1⁄4125). In 189 CPR scenes, patient’s condition was followed during the hospitalization, and 54% (n1⁄4102) survived to hospital discharge. Of the survivors, we were able to assess the cerebral performance category (CPC) score in 88 patients. 96.5% (n1⁄485) had favorable neurological outcome (CPC 1,2) and only 3.5% (n1⁄43) had unfavorable neurological outcome (CPC 3,4 and5). Moreover, we assessed if determination of ROSC in TVMDs complied with the Utstein Resuscitation Registry Templates (by spontaneously restoring a palpable pulse or a measurable blood pressure). We found that from 160 episodes, in which we could assess how ROSC was determined, only 30% (n1⁄448) depended on the pulse; while 56.3% (n1⁄490) used the monitor. Other methods to identify ROSC were echocardiography in 3.75% (n1⁄46), waking up in 9.38% (n1⁄415), breathing in 4.38% (n1⁄47), and coughing in 2.5% (n1⁄44) of the patients. CONCLUSIONS: The success rate of CPR and neurological outcomes for survivors in TVMDs are better than outcomes among real patients. ROSC identification also varied from common clinical practice. TVMDs portrayal of CPR outcomes significantly misrepresents outcomes in reality. CLINICAL IMPLICATIONS: TVMDs are a major source of medical education among lay people. Inadequate representation of CPR outcomes may give families false hope. DISCLOSURES: No relevant relationships by Abbas Alshami, source1⁄4Web Response Advisory Committee Member relationship with Zoll Please note: $5001 $20000 Added 03/14/2019 by Sharon Einav, source1⁄4Web Response, value1⁄4Travel<br Advisory Committee Member relationship with Medtronic Please note: $20001 $100000 Added 03/14/2019 by Sharon Einav, source1⁄4Web Response, value1⁄4Intellectual property rights Advisory Committee Member relationship with Diasorin Please note: $1001 $5000 Added 03/14/2019 by Sharon Einav, source1⁄4Web Response, value1⁄4Grant/Research Support No relevant relationships by Luz Ramirez, source1⁄4Web Response No relevant relationships by Joseph Varon, source1⁄4Web Response No relevant relationships by Daryelle Varon, source1⁄4Web Response DOI: https://doi.org/10.1016/j.chest.2019.08.899 Copyright a 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. 72A [ 1 5 6 # 4 S CHES T OC TO B E R 2 0 1 9 ]
BACKGROUND The annual congress of the European Society of Anaesthesiology (ESA) is one of the lar... more BACKGROUND The annual congress of the European Society of Anaesthesiology (ESA) is one of the largest anaesthesia congresses in the world and exhibits more than 1200 abstracts annually.
Supplemental Digital Content is available in the text. Objectives: Reintubation after failed extu... more Supplemental Digital Content is available in the text. Objectives: Reintubation after failed extubation is associated with increased mortality and longer hospital length of stay. Noninvasive oxygenation modalities may prevent reintubation. We conducted a systematic review and meta-analysis to determine the safety and efficacy of high-flow nasal cannula after extubation in critically ill adults. Data Sources: We searched MEDLINE, EMBASE, and Web of Science. Study Selection: We included randomized controlled trials comparing high-flow nasal cannula to other noninvasive methods of oxygen delivery after extubation in critically ill adults. Data Extraction: We included the following outcomes: reintubation, postextubation respiratory failure, mortality, use of noninvasive ventilation, ICU and hospital length of stay, complications, and comfort. Data Synthesis: We included eight randomized controlled trials (n = 1,594 patients). Compared with conventional oxygen therapy, high-flow nasal cannula decreased reintubation (relative risk, 0.46; 95% CI, 0.30–0.70; moderate certainty) and postextubation respiratory failure (relative risk, 0.52; 95% CI, 0.30–0.91; very low certainty), but had no effect on mortality (relative risk, 0.93; 95% CI, 0.57–1.52; moderate certainty), or ICU length of stay (mean difference, 0.05 d fewer; 95% CI, 0.83 d fewer to 0.73 d more; high certainty). High-flow nasal cannula may decrease use of noninvasive ventilation (relative risk, 0.64; 95% CI, 0.34–1.22; moderate certainty) and hospital length of stay (mean difference, 0.98 d fewer; 95% CI, 2.16 d fewer to 0.21 d more; moderate certainty) compared with conventional oxygen therapy, however, certainty was limited by imprecision. Compared with noninvasive ventilation, high-flow nasal cannula had no effect on reintubation (relative risk, 1.16; 95% CI, 0.86–1.57; low certainty), mortality (relative risk, 1.12; 95% CI, 0.82–1.53; moderate certainty), or postextubation respiratory failure (relative risk, 0.82; 95% CI, 0.48–1.41; very low certainty). High-flow nasal cannula may reduce ICU length of stay (moderate certainty) and hospital length of stay (moderate certainty) compared with noninvasive ventilation. Conclusions: High-flow nasal cannula reduces reintubation compared with conventional oxygen therapy, but not compared with noninvasive ventilation after extubation.
Objective: Inhalation of noble and other gases after cardiac arrest (CA) might improve neurologic... more Objective: Inhalation of noble and other gases after cardiac arrest (CA) might improve neurological and cardiac outcomes. This article discusses up-to-date information on this novel therapeutic intervention. Data Sources: CENTRAL, MEDLINE, online published abstracts from conference proceedings, clinical trial registry clinicaltrials.gov, and reference lists of relevant papers were systematically searched from January 1960 till March 2019. Study Selection: Preclinical and clinical studies, irrespective of their types or described outcomes, were included. Data Extraction: Abstract screening, study selection, and data extraction were performed by two independent authors. Due to the paucity of human trials, risk of bias assessment was not performed. Data Synthesis: After screening 281 interventional studies, we included an overall of 27. Only, xenon, helium, hydrogen, and nitric oxide have been or are being studied on humans. Xenon, nitric oxide, and hydrogen show both neuroprotective and cardiotonic features, while argon and hydrogen sulfide seem neuroprotective, but not cardiotonic. Most gases have elicited neurohistological protection in preclinical studies; however, only hydrogen and hydrogen sulfide appeared to preserve CA1 sector of hippocampus, the most vulnerable area in the brain for hypoxia. Conclusion: Inhalation of certain gases after CPR appears promising in mitigating neurological and cardiac damage and may become the next successful neuroprotective and cardiotonic interventions.
BACKGROUND Mediastinitis is a rare but severe infection, defined as an inflammation of the connec... more BACKGROUND Mediastinitis is a rare but severe infection, defined as an inflammation of the connective tissues and structures within the mediastinum. Due to its proximity with vital structures, mediastinitis represents a highly morbid pathological process associated with a high risk of mortality. In most cases mediastinitis requires treatment in the intensive care unit. OBJECTIVES The goal of this narrative review is to highlight to the reader the clinical features of mediastinitis, to attempt to define each clinical scenario, to describe the responsible pathogens and finally to depict both the medical and surgical treatment. SOURCES We performed a literature search of the PubMed and Cochrane libraries, limited for articles published between January 2003 and December 2018, reporting on acute mediastinitis. CONTENT The term covers different entities of different etiologies including deep sternal wound infection related to sternotomy; esophageal perforation or anastomosis leakage; and finally descending necrotizing mediastinitis often secondary to oropharyngeal abscess. The responsible pathogens and therefore subsequent management depends on the underlying etiology. Empirical antimicrobial therapy should cover the suspected microorganisms while surgery and supportive measures should aim to reduce the inoculum of pathogens by providing adequate drainage and debridement. IMPLICATIONS Literature concerning mediastinitis in the ICU is relatively scarce. Here we collated the evidence and reviewed the different causes and treatment options of acute mediastinitis with a particular focus on microbiological epidemiology. Future research in larger cohorts is needed to better understand the treatment of this difficult disease.
BACKGROUND: The use of in vitro fertilization is increasing. The incidence of adverse outcomes is... more BACKGROUND: The use of in vitro fertilization is increasing. The incidence of adverse outcomes is greater for women who undergo in vitro fertilization, potentially leading to intensive care unit admission. This study aimed to assess the etiology and course of intensive care unit admission in women who underwent in vitro fertilization compared to those who did not, with specific focus on intensive care unit admission due to postpartum hemorrhage. METHODS: In this retrospective study, medical records of patients admitted to the intensive care unit during pregnancy or the peripartum period at 2 medical centers (2005–2016 at Mount Sinai Hospital, New York, NY, and 2005–2013 at Shaare Zedek Medical Center, Jerusalem, Israel) were analyzed. Demographic, past medical and obstetric history, and details regarding delivery and intensive care unit stay were collected, as was information regarding mode of conception (in vitro fertilization versus non–in vitro fertilization) for the current pregnancy. The primary outcome measure was difference in etiology of intensive care unit admission between in vitro fertilization and non–in vitro fertilization groups. Secondary outcome measures included differences in prepregnancy characteristics, incidence, severity, and management of postpartum hemorrhage, as well as incidence of other clinical major morbidity events and delivery-related complications. Multivariable logistic regression was performed to study the relationship between in vitro fertilization and the odds of having been admitted to the intensive care unit due to hemorrhage. RESULTS: During the study period, there were nearly 192,000 deliveries, with 428 pregnant and peripartum women admitted to the intensive care unit. Of the 409 cases analyzed, 60 had conceived following in vitro fertilization and 349 had conceived without in vitro fertilization. The non–in vitro fertilization group was more likely to have multiple medical comorbidities, and the in vitro fertilization group was more likely to have multiple gestations. The groups also differed in etiology of intensive care unit admission; more women in the in vitro fertilization group were admitted due to a pregnancy-related complication. Intensive care unit admission for postpartum hemorrhage was more frequent in the in vitro fertilization group (60.0% vs 43.1%, P = .014), with a 2-fold increase in the incidence of hemorrhagic shock. Logistic regression analysis revealed a 2-fold increase in the odds that intensive care unit admission was due to hemorrhage in women undergoing in vitro fertilization, a finding that was not statistically significant when multiple gestation was added to the model. CONCLUSIONS: Among patients admitted to the intensive care unit, patients with different modes of conception had dissimilar etiologies for intensive care unit admission with intensive care unit admission due to hemorrhage greater in those with in vitro fertilization. Higher rates of multiple gestation pregnancies may explain this difference. Differences in pregnancies conceived via in vitro fertilization versus without in vitro fertilization may affect the obstetric intensive care unit case mix.
Disaster Medicine and Public Health Preparedness, 2015
ObjectiveData on best practices for evacuating an intensive care unit (ICU) during a disaster are... more ObjectiveData on best practices for evacuating an intensive care unit (ICU) during a disaster are limited. The impact of Hurricane Sandy on New York City area hospitals provided a unique opportunity to learn from the experience of ICU providers about their preparedness, perspective, roles, and activities.MethodsWe conducted a cross-sectional survey of nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy ICU evacuations.ResultsSixty-eight health care professionals from 4 evacuating hospitals completed surveys (35% ICU nurses, 21% respiratory therapists, 25% physicians-in-training, and 13% attending physicians). Only 21% had participated in an ICU evacuation drill in the past 2 years and 28% had prior training or real-life experience. Processes were inconsistent for patient prioritization, tracking, transport medications, and transport care. Respondents identified communication (43%) as the key barrier to effective evacuation. The equipment...
Amniotic fluid embolism (AFE) is an obstetrical catastrophe characterized by acute hypotension, h... more Amniotic fluid embolism (AFE) is an obstetrical catastrophe characterized by acute hypotension, hypoxia, and coagulopathy occurring during labor, cesarean section, post-delivery, or during amniocentesis. Thromboelastography (TEG) is a bedside test of global homeostasis and has seldom been used to study coagulation in AFE despite increasing popularity in other diseases. We report TEG usage as part of a treatment for patients with AFE.
In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive... more In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive care unit (ICU) because of the shortage of ICU beds. The aim of the study was to compare the outcome and ventilatory management of medical patients mechanically ventilated on the medical wards and in the ICU. This was a prospective, observational, noninterventional study over a 6-month period. The study was conducted in internal medicine wards and the ICU of a 500-bed community university-affiliated hospital. Ninety-nine mechanically ventilated medical patients in the ICU or on the medical wards because of shortage of ICU beds were included in the study. Baseline characteristics of the patients ventilated in the ICU (group 1) and in the medical wards (group 2) were collected. Thirty-four patients were ventilated in the ICU and 65 in the wards during the study period. In-hospital survival rate in group 1 was 38% vs 20% in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). The Acute Physiologic and Chronic Health Evaluation (APACHE) II score in group 1 was 24 +/- 7 vs 27 +/- 7 in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). Other prognostic factors were similar. The age of the survivors in the 2 groups was similar: 57 +/- 25 years in group 1 vs 69 +/- 13 years in group 2 (P = NS). Mean number of ventilatory changes in group 1 was 7.5 +/- 1.4 per day per patient, whereas it was 1.3 +/- 1.0 in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). The number of arterial blood gas analyses in group 1 was 7.7 +/- 1.2 per day per patient compared with 2.3 +/- 1.3 in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Twenty percent (20%) of the patients in group 1 had endotracheal tube-related inadvertent events compared with 62% of the patients in group 2 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). We conclude that in medical patients requiring mechanical ventilation, there is a higher in-hospital survival rate in ICU-ventilated patients as compared with ventilated patients managed on the medical wards. In addition, ICU provides a better monitoring associated with less endotracheal tube-related complications and more active ventilatory management.
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