Sedation Depth is Associated with Increased Hospital Length of Stay in Mechanically Ventilated Air Medical Transport Patients: A Cohort Study.
- 作者列表："George BP","Vakkalanka JP","Harland KK","Faine B","Rewitzer S","Zepeski A","Fuller BM","Mohr NM","Ahmed A
:Background: Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods: A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results: Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions: Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.
背景: 镇痛药、镇静剂和神经肌肉阻滞剂是用于机械通气的空运医疗转运患者的常用药物。之前在急诊科 (ED) 和重症监护病房 (ICU) 的研究表明，镇静深度与机械通气时间延长、谵妄、增加住院时间 (LOS)，降低生存率。本研究的目的是评估院前环境中当前的镇静实践，并确定对临床结果的影响。方法: 对 2013年7月至 2018年5月经空中救护转送至单一 812 床中西部学术医学中心的机械通气患者进行回顾性队列研究。测量院前镇静药物和镇静深度 [Richmond 躁动-镇静量表评分 (RASS)]。主要结局为医院 LOS。次要结局是谵妄、机械通气时间、住院死亡率和需要神经外科手术。单变量分析用于测量镇静剂、镇静深度和临床结局之间的关联。调整潜在混杂协变量的多变量模型，以测量预测因子对临床结局的影响。结果: 共纳入 37 例患者。在这些患者中，79.2% 的患者接受镇静剂，其中 41% 的患者达到深度镇静 (RASS =-4)。在接受镇静的患者中，58.3% 接受了至少一剂苯二氮卓类药物。中度和深度镇静与 LOS 增加 59% (aRR: 1.59; 95% CI: 1.40-1.81) 和 24% (aRR: 1.24; 95% CI: 1.10-1.40) 相关, 分别。苯二氮卓类药物与住院平均增加 2.9 天相关 (95% CI，0.7-5.1)。特定药物或镇静深度与谵妄的发生之间不存在关联。结论: 院前中度和深度镇静，以及苯二氮卓类药物，与医院 LOS 增加有关。我们的研究结果指出镇静是一种可改变的风险因素，并提示在院前环境中需要进一步研究镇静实践。
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.