Dexamethasone treatment during ventilator dependency: possible life threatening gastrointestinal complications.
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Corticosteroids in high doses have been used effectively to decrease the duration of ventilator dependency in very low birthweight infants at risk for chronic lung disease. Randomised prospective studies have shown benefit, with only minimal complications being reported. However, review of our experience over 2.5 years with high dose steroids in 80 premature neonates yielded three major complications: one case each of perforated duodenal ulcer, perforated gastric ulcer, and upper gastrointestinal haemorrhage. Two of the three patients died. Thus the use of steroids in neonates may not be without risk, and significant complications can occur. When high dose corticosteroids are to be used in very low birthweight neonates, H2 receptor antagonist treatment and gastric pH monitoring are recommended. The physician must remain alert to the possibilities of upper gastrointestinal bleeding and ulcer perforation in these patients. (+info)
The outcome of extubation failure in a community hospital intensive care unit: a cohort study.
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INTRODUCTION: Extubation failure has been associated with poor intensive care unit (ICU) and hospital outcomes in tertiary care medical centers. Given the large proportion of critical care delivered in the community setting, our purpose was to determine the impact of extubation failure on patient outcomes in a community hospital ICU. METHODS: A retrospective cohort study was performed using data gathered in a 16-bed medical/surgical ICU in a community hospital. During 30 months, all patients with acute respiratory failure admitted to the ICU were included in the source population if they were mechanically ventilated by endotracheal tube for more than 12 hours. Extubation failure was defined as reinstitution of mechanical ventilation within 72 hours (n = 60), and the control cohort included patients who were successfully extubated at 72 hours (n = 93). RESULTS: The primary outcome was total ICU length of stay after the initial extubation. Secondary outcomes were total hospital length of stay after the initial extubation, ICU mortality, hospital mortality, and total hospital cost. Patient groups were similar in terms of age, sex, and severity of illness, as assessed using admission Acute Physiology and Chronic Health Evaluation II score (P > 0.05). Both ICU (1.0 versus 10 days; P < 0.01) and hospital length of stay (6.0 versus 17 days; P < 0.01) after initial extubation were significantly longer in reintubated patients. ICU mortality was significantly higher in patients who failed extubation (odds ratio = 12.2, 95% confidence interval [CI] = 1.5-101; P < 0.05), but there was no significant difference in hospital mortality (odds ratio = 2.1, 95% CI = 0.8-5.4; P < 0.15). Total hospital costs (estimated from direct and indirect charges) were significantly increased by a mean of 33,926 US dollars (95% CI = 22,573 US dollars - 45,280 US dollars; P < 0.01). CONCLUSION: Extubation failure in a community hospital is univariately associated with prolonged inpatient care and significantly increased cost. Corroborating data from tertiary care centers, these adverse outcomes highlight the importance of accurate predictors of extubation outcome. (+info)
Extubation failure: an outcome to be avoided.
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Extubation failure is an outcome of increasing importance but nearly all studies have been conducted in academic settings. The article by Seymour and colleagues demonstrates that extubation failure is an outcome to be avoided in the community hospital setting as well. Patients failing extubation experience longer lengths of stay, experience higher intensive care unit mortality, and incur greater hospital costs. Investigators have identified tools for predicting extubated patients at highest risk for reintubation. The predictors focus on detecting upper airway obstruction, inadequate cough, excess respiratory secretions, and abnormal mental status. Systematic application of these predictors has the potential to improve outcome. (+info)
Pro/con clinical debate: tracheostomy is ideal for withdrawal of mechanical ventilation in severe neurological impairment.
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Most clinical trials on the topic of extubation have involved patients outside the neurological intensive care unit. As a result, in this area clinicians are left with little evidence on which to base their decision making. Although tracheostomies are increasingly common procedures, they are not without complications and costs, and hence a decision to perform them should not be taken lightly. In this issue of Critical Care two groups debate the merits of tracheostomy before extubation in a patient with neurological impairment. What becomes very clear is the need for more high quality data for this common clinical problem. (+info)
Risk factor screening scale to optimize treatment for potential heart transplant candidates under extracorporeal membrane oxygenation.
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We developed a risk factor-scaling score (RFSS) to select which patients supported by extracorporeal membrane oxygenation (ECMO) were suitable for ventricular assist device (VAD) implantation or heart transplantation (HTx). A total of 78 patients supported with ECMO for more than 48 h due to cardiac origin were included in this study. Patients were categorized into two groups based on the outcomes: the poor outcome group (n = 33) consisted of for those who later died or were later excluded from VAD or HTx; the favorable outcome group (n = 45) consisted of those who were weaned off ECMO finally and survived or were deemed suitable candidates for VAD or HTx. Seven risk factors were significant according to univariate analyses. Based on the regression coefficients of multivariate analysis, the RFSS was developed: (lung dysfunction x 7) + (systemic infection x 3) + (peak lactate > 3 mmole/L x 3) + (kidney dysfunction x 2) + (creatine kinase > 10,000 U/L x 1). Patients with an RFSS of 7 or more were be allocated to the poor outcome group. The RFSS was validated by another group of 30 patients with good correlation. The RFSS provides a way to predict which ECMO-supported patients are suitable candidates for VAD implantation or HTx. (+info)
High dose caffeine citrate for extubation of preterm infants: a randomised controlled trial.
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OBJECTIVE: To compare two dosing regimens for caffeine citrate in the periextubation period for neonates born at less than 30 weeks gestation in terms of successful extubation and adverse effects. DESIGN: A multicentre, randomised, double blind, clinical trial. SETTING: Four tertiary neonatal units within Australia. PATIENTS: Infants born less than 30 weeks gestation ventilated for more than 48 hours. INTERVENTIONS: Two dosing regimens of caffeine citrate (20 v 5 mg/kg/day) for periextubation management. Treatment started 24 hours before a planned extubation or within six hours of an unplanned extubation. MAIN OUTCOME MEASURE: Failure to extubate within 48 hours of caffeine loading or reintubation and ventilation or doxapram within seven days of caffeine loading. RESULTS: A total of 234 neonates were enrolled. A significant reduction in failure to extubate was shown for the 20 mg/kg/day dosing group (15.0% v 29.8%; relative risk 0.51; 95% confidence interval (CI) 0.31 to 0.85; number needed to treat 7 (95% CI 4 to 24)). A significant difference in duration of mechanical ventilation was shown for infants of less than 28 weeks gestation receiving the high dose of caffeine (mean (SD) days 14.4 (11.1) v 22.1 (17.1); p = 0.01). No difference in adverse effects was detected in terms of mortality, major neonatal morbidity, death, or severe disability or general quotient at 12 months. CONCLUSIONS: This trial shows short term benefits for a 20 mg/kg/day dosing regimen of caffeine citrate for neonates born at less than 30 weeks gestation in the periextubation period, without evidence of harm in the first year of life. (+info)
Are blood gases necessary in mechanically ventilated patients who have successfully completed a spontaneous breathing trial?
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BACKGROUND: The utility of routinely obtaining arterial blood gas analyses (ABGs) prior to extubation in patients who have successfully completed a spontaneous breathing trial is not known. OBJECTIVE: Review our practices and determine our extubation success rate with a policy of selective ABG utilization. METHODS: Retrospective chart review. RESULTS: We reviewed 54 extubations of 52 patients. Sixty-five percent of the extubations were performed without obtaining an ABG after the spontaneous breathing trial. The extubation success rate was 94% for the entire group and was the same regardless of whether an ABG measurement was obtained (94.7% vs 94.3%, respectively). CONCLUSION: ABG measurement does not appear to be a prerequisite to extubation following a clinically successful spontaneous breathing trial. (+info)
Combination of histopathological and electromyographic patterns can help to evaluate functional outcome of critical ill patients with neuromuscular weakness syndromes.
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INTRODUCTION: The aim of the study was to describe patterns of neuromuscular weakness using a combination of electromyography and histology, and to evaluate functional outcome in patients following complicated cardiovascular surgery. METHODS: Fifteen adults requiring long-term mechanical ventilation (>15 days) following cardiovascular surgery associated with postoperative complications were prospectively included. Electrophysiological and histological analyses (muscle and nerve) were performed when failure to wean from mechanical ventilation associated with peripheral neuromuscular weakness was noticed. Functional disability was evaluated 12 months after surgery. RESULTS: Six patients had a predominantly axonal neuropathy, six presented with myopathy, and three patients had a combination of axonal neuropathy and myopathy. All of them presented with acute tetraparesis and failure to wean from mechanical ventilation. All of the study patients who received corticosteroids exhibited a myopathic pattern (with or without axonopathic changes) but never an axonopathic pattern only. Only two of the eight survivors at 12 months were not ambulatory. These two patients had no detectable compound muscle action potential on electrophysiological examination. CONCLUSION: The combination of electromyographic evaluation and neuromuscular histological abnormalities could help to identify the type and severity of neuromuscular weakness, in turn helping to evaluate the patient's potential functional prognosis. (+info)