肌无力危象需要机械通气: 250 例多中心分析。
- 作者列表："Neumann B","Angstwurm K","Mergenthaler P","Kohler S","Schönenberger S","Bösel J","Neumann U","Vidal A","Huttner HB","Gerner ST","Thieme A","Steinbrecher A","Dunkel J","Roth C","Schneider H","Schimmel E","Fuhrer H","Fahrendorf C","Alberty A","Zinke J","Meisel A","Dohmen C","Stetefeld HR","German Myasthenic Crisis Study Group.
OBJECTIVE:To determine demographic characteristics, clinical features, treatment regimens, and outcome of myasthenic crisis (MC) requiring mechanical ventilation (MV). METHODS:Analysis of patients who presented with MC between 2006 and 2015 in a German multicenter retrospective study. RESULTS:We identified 250 cases in 12 participating centers. Median age at crisis was 72 years. Median duration of MV was 12 days. Prolonged ventilation (>15 days) depended on age (p = 0.0001), late-onset myasthenia gravis (MG), a high Myasthenia Gravis Foundation of America Class before crisis (p = 0.0001 for IVb, odds ratio [OR] = infinite), number of comorbidities (>3 comorbidities: p = 0.002, OR 2.99), pneumonia (p = 0.0001, OR 3.13), and resuscitation (p = 0.0008, OR 9.15). MV at discharge from hospital was necessary in 20.5% of survivors. Patients with early-onset MG (p = 0.0001, OR 0.21), thymus hyperplasia (p = 0.002, OR 0), and successful noninvasive ventilation trial were more likely to be ventilated for less than 15 days. Noninvasive ventilation in 92 cases was sufficient in 38%, which was accompanied by a significantly shorter duration of ventilation (p = 0.001) and intensive care unit (ICU) stay (p = 0.01). IV immunoglobulins, plasma exchange, and immunoadsorption were more likely to be combined sequentially if the duration of MV and the stay in an ICU extended (p = 0.0503, OR 2.05). Patients who received plasma exchange or immunoadsorption as first-line therapy needed invasive ventilation significantly less often (p = 0.003). In-hospital mortality was 12%, which was significantly associated with the number of comorbidities (>3) and complications such as acute respiratory distress syndrome and resuscitation. Main cause of death was multiorgan failure, mostly due to sepsis. CONCLUSION:Mortality and duration of MC remained comparable to previous reports despite higher age and a high disease burden in our study. Prevention and treatment of complications and specialized neurointensive care are the cornerstones in order to improve outcome.
目的: 确定需要机械通气 (MV) 的肌无力危象 (MC) 的人口统计学特征、临床特征、治疗方案和结局。 方法: 分析德国多中心回顾性研究中 2015 和 2006年就诊的 MC 患者。 结果: 我们确定了 12 个参与中心的 250 例病例。危机时的中位年龄为 72 岁。MV 的中位持续时间为 12 天。长时间通气 (> 15 天) 取决于年龄 (p = 0.0001) 、晚发性重症肌无力 (MG) 、 a 高重症肌无力美国基金会级 (IVb p = 0.0001，比值比 [或] = 无限)，合并症数量 (> 3 个合并症: p = 0.002, 或 2.99),肺炎 (p = 0.0001，或 3.13) 和复苏 (p = 0.0008，或 9.15)。20.5% 的幸存者出院时 MV 是必要的。早发性 MG (p = 0.0001，OR 0.21) 、胸腺增生 (p = 0.002，OR 0) 、成功的无创通气试验更有可能通气时间少于 15 天。无创通气 92 例，充分通气 38% 例，通气时间明显缩短 (p = 0.001)，ICU 住院时间明显缩短 (p = 0.01)。如果 MV 持续时间和 ICU 停留时间延长，IV 免疫球蛋白、血浆置换和免疫吸附更有可能依次合并 (p = 0.0503，或 2.05)。接受血浆置换或免疫吸附作为一线治疗的患者需要有创通气的频率显著降低 (p = 0.003)。住院死亡率为 12%，与合并症数 (> 3) 和并发症 (如急性呼吸窘迫综合征和复苏) 显著相关。主要死亡原因为多器官功能衰竭，多为脓毒症。 结论: 尽管我们研究中的年龄较高，疾病负担较高，但 MC 的死亡率和持续时间仍与以前的报告相当。预防和治疗并发症以及专门的神经重症监护是改善预后的基石。
METHODS:Background: The hospitalization of patients treated in the intensive care unit (ICU) in 5−15% of cases is associated with the occurrence of a complication in the form of ventilator-associated pneumonia (VAP). Purpose: Retrospective assessment of risk factors of VAP in patients treated at ICUs in the University Hospital in Krakow. Methods: The research involved the medical documentation of 1872 patients treated at the ICU of the University Hospital in Krakow between 2014 and 2017. The patients were mechanically ventilated for at least 48 h. The obtained data were presented by qualitative and quantitative analysis (%). The qualitative variables were compared using the Chi2 test. Statistically significant was the p < 0.05 value. Results: VAP was demonstrated in 23% of all patients treated in ICU during the analyzed period, and this infection occurred in 13% of men and 10% of women. Pneumonia associated with ventilation was found primarily in patients staying in the ward for over 15 days and subjected to intratracheal intubation (17%). A statistically significant was found between VAP and co-morbidities, e.g., chronic obstructive pulmonary disease, diabetes, alcoholism, obesity, the occurrence of VAP and multi-organ trauma, hemorrhage/hemorrhagic shock, and fractures as the reasons for admitting ICU patients. Conclusions: Patients with comorbidities such as chronic obstructive pulmonary disease, obesity, diabetes, and alcoholism are a high-risk group for VAP. Particular attention should be paid to patients admitted to the ICU with multi-organ trauma, fractures, and hemorrhage/hemorrhagic shock as patients predisposed to VAP. There is a need for further research into risk factors for non-modifiable VAP such as comorbidities and reasons for ICU admission in order to allow closer monitoring of these patients for VAP.
METHODS::Backgroud Severe pneumonia is one of the most common causes for mechanical ventilation. We aimed to early identify severe pneumonia patients with high risk of extubation failure in order to improve prognosis. Methods From April 2014 to December 2015, medical records of intubated patients with severe pneumonia in intensive care unit were retrieved from database. Patients were divided into extubation success and failure groups, and multivariate logistic regressions were performed to identify independent predictors for extubation failure. Results A total of 125 eligible patients were included, of which 82 and 43 patients had extubation success and failure, respectively. APACHE II score (odds ration (OR) 1.141, 95% confident interval (CI) 1.022-1.273, P = 0.019, cutoff at 17.5), blood glucose (OR 1.122, 95%CI 1.008-1.249, P = 0.035, cutoff at 9.87mmol/L), dose of fentanyl (OR 3.010, 95%CI 1.100-8.237, P = 0.032, cutoff at 1.135mg/d), and the need for red blood cell (RBC) transfusion (OR 2.774, 95%CI 1.062-7.252, P = 0.037) were independent risk factors for extubation failure. Conclusions In patients with severe pneumonia, APACHE II score > 17.5, blood glucose > 9.87mmol/L, fentanyl usage > 1.135mg/d, and the need for RBC transfusion might be associated with higher risk of extubation failure.
METHODS:PURPOSE:To assess the association between the duration of mechanical ventilation during post resuscitation care and 30-day survival after cardiac arrest. METHODS:We conducted a retrospective observational study using data from two national registries. Comatose cardiac arrest patients admitted to general intensive care in Swedish hospitals between 2011 and 2016 were eligible. Based on the median duration of mechanical ventilation for patients who did not survive to hospital discharge, used as a proxy for the endurance of post resuscitation care, the hospitals were divided into four ordered groups for which association with 30-day survival was analyzed. RESULTS:In total, 5.113 patients in 56 hospitals were included. Median duration of mechanical ventilation for patients who did not survive to hospital discharge ranged from 17 hours in hospital group 1 to 51 hours in hospital group 4. After adjustment for baseline characteristics, 30-day survival in the entire cohort was positively and independently associated with ordered hospital group: (adjusted odds ratio (95%CI); 1.12 (1.02,1.23); p = 0.02). Thus, hospitals with a longer duration of mechanical ventilation among non-survivors had better survival rate among patients admitted to ICU after a cardiac arrest. However, in a secondary analysis restricted to patients with length of stay in the intensive care unit ≥ 48 hours, there was no significant association between 30-day survival and ordered hospital group. CONCLUSION:A tendency for longer duration of post resuscitation care in the ICU was associated with higher 30-day survival in comatose patients admitted to intensive care after cardiac arrest.