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Intensity of Renal Replacement Therapy and Duration of Mechanical Ventilation: Secondary Analysis of the Acute Renal Failure Trial Network Study.
Sharma, S, Kelly, YP, Palevsky, PM, Waikar, SS
Chest. 2020;(4):1473-1481
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Abstract
BACKGROUND Randomized clinical trials have failed to show benefit from increasing intensity of renal replacement therapy (RRT) for acute kidney injury, but continue to be frequently used. In addition, intensive RRT is associated with an increase in adverse events potentially secondary to small solute losses, such as phosphate. We hypothesized that, compared with less-intensive RRT, intensive RRT would lead to longer duration of mechanical ventilation. RESEARCH QUESTION Does more-intensive renal replacement therapy in critically ill patients with acute kidney injury increase time to extubation from mechanical ventilation when compared with less-intensive therapy? STUDY DESIGN AND METHODS The Acute Renal Failure Trial Network study was a randomized multicenter trial of more-intensive (hemodialysis or sustained low-efficiency dialysis six times per week or continuous venovenous hemodiafiltration at 35 mL/kg per hour) vs less-intensive (hemodialysis or sustained low-efficiency dialysis three times per week or continuous venovenous hemodiafiltration at 20 mL/kg per hour) RRT in critically ill patients with acute kidney injury. Of 1124 patients, 907 who were supported by mechanical ventilation on study initiation were included in this Cox-proportional hazards analysis. The primary outcome was the time to first successful extubation off mechanical ventilation. RESULTS Patients who were assigned randomly to more-intensive RRT had a 33.3% lower hazard rate of successful extubation (hazard ratio, 0.67; 95% CI, 0.52-0.88; P < .001) when compared with patients who were assigned to less-intensive RRT. Patients who were assigned to more-intensive RRT had, on average, 2.07 ventilator-free days, compared with 3.08 days in those who were assigned to less-intensive RRT (P < .001) over 14 days from start of the study. INTERPRETATION Critically ill mechanically ventilated patients who were assigned randomly to more-intensive RRT had longer duration of mechanical ventilation compared with those who were assigned to less-intensive RRT. The reasons for this, such as excessive phosphate loss from more-intensive RRT, deserve further study to optimize the safety and effectiveness of CRRT delivery. This was a post hoc analysis of the Acute Renal Failure Trial Network study; clinical trial registration of the original trial is NCT00076219.
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Neonatal Caffeine Treatment and Respiratory Function at 11 Years in Children under 1,251 g at Birth.
Doyle, LW, Ranganathan, S, Cheong, JLY
American journal of respiratory and critical care medicine. 2017;(10):1318-1324
Abstract
RATIONALE Caffeine in the newborn period shortens the duration of assisted ventilation and reduces the incidence of bronchopulmonary dysplasia, but its effects on respiratory function in later childhood are unknown. OBJECTIVES To determine if children born with birth weight less than 1,251 g who were treated with neonatal caffeine had improved respiratory function at 11 years of age compared with children treated with placebo. METHODS Children enrolled in the CAP (Caffeine for Apnea of Prematurity) randomized controlled trial and assessed at the Royal Women's Hospital in Melbourne at 11 years of age had expiratory flow rates measured according to the standards of the American Thoracic Society. Values were converted to z-scores predicted for age, height, ethnicity, and sex. Parents completed questionnaires related to their child's respiratory health. MEASUREMENTS AND MAIN RESULTS A total of 142 children had expiratory flows measured. Expiratory flows were better in the caffeine group, by approximately 0.5 SD for most variables (e.g., FEV1; mean z-score, -1.00 vs. -1.53; mean difference, 0.54; 95% confidence interval, 0.14-0.94; P = 0.008). Fewer children in the caffeine group had values for FVC below the fifth centile (11% vs. 28%; odds ratio, 0.31; 95% confidence interval, 0.12-0.77; P = 0.012). When adjusted for bronchopulmonary dysplasia, the difference in flow rates between groups diminished. CONCLUSIONS Caffeine treatment in the newborn period improves expiratory flow rates in midchildhood, which seems to be achieved by improving respiratory health in the newborn period. Follow-up lung function testing in adulthood is vital for these individuals. Future placebo-controlled randomized trials of neonatal caffeine are unlikely. Clinical trial registered with www.clinicaltrials.gov (NCT00182312).
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[Enteral nutrition during prone positioning in mechanically ventilated patients].
Lucchini, A, Bonetti, I, Borrelli, G, Calabrese, N, Volpe, S, Gariboldi, R, Minotti, D, Cannizzo, L, Elli, S, Fumagalli, R, et al
Assistenza infermieristica e ricerca : AIR. 2017;(2):76-83
Abstract
UNLABELLED . Enteral nutrition during prone positioning in mechanically ventilated patients. INTRODUCTION The Enteral Nutrition (EN) tends to be stopped during prone positioning to prevent the risk of acid reflux and vomiting. AIMS To compare the gastric residual volume during continuous enteral nutrition in patients in prone and supine position. METHODS Observational restrospective study on Acute Respiratory Distress Syndrome patients, mechanically ventilated, with continuous enteral nutrition implemented according to the same protocol, in prone and supine position. RESULTS The 25 patients included had a mean age of 51.13±15.93 (range: 16-80) years. Gastic residual volume was checked on 656 occasions (408 in supine and 248 in prone position). Mean infusion rate was 63.3±18.5 ml/h: 62.1±18.9 ml/h in supine and 66.2±16.5 ml/h in prone position. The mean overall gastric residual volume was 24.4±54.2 ml: 20.6±18.9 ml in supime and 23.6±50.0 ml in prone posizion. In 4 occasions (2 in prone and 2 in supine position9, the gastric residual volume was > 300ml; EN was interrupted on 1 occasion with a gastric residual volume >500ml. CONCLUSIONS No clinically relevant differences of gastric residual volume were observed in prone and supine position. A protocol for the management of gastric residual volume allows a safe and effective administration of EN also in patients positioned for several hours in prone position.
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Early neonatal outcomes of volume guaranteed ventilation in preterm infants with respiratory distress syndrome.
Guven, S, Bozdag, S, Saner, H, Cetinkaya, M, Yazar, AS, Erguven, M
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2013;(4):396-401
Abstract
BACKGROUND Volume guaranteed (VG) synchronized intermittent mandatory ventilation (SIMV) is a novel mode of SIMV that provides automatic adjustment of the peak inspiratory pressure for ensuring a minimum set tidal volume and there are limited data about the effects of VG ventilation on short term neonatal outcomes in preterm infants with respiratory distress syndrome (RDS). OBJECTIVE The main objective of this study was to evaluate the effect of VG ventilation on duration of ventilation and total supplemental oxygen. We also aimed to compare the early neonatal outcomes of VG ventilation versus conventional SIMV on short-term outcomes in preterm babies with RDS who were given surfactant. METHODS In this randomized controlled study, preterm infants who were admitted with RDS and given surfactant were divided into 2 groups: group 1 included infants ventilated on conventional SIMV (n = 30) and group 2 included infants ventilated on VG ventilation (n = 42). Neonatal morbidities such as air leak, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC) and duration of mechanical ventilation and total oxygen supplementation were all recorded. RESULTS There were no significant differences between two groups in terms of demographic features. Infants ventilated with VG mode had significantly shorter duration of ventilation and need of total supplemental oxygen. The incidences of oxygen related short term complications including BPD, ROP, and IVH were also significantly lower in these infants compared with those ventilated with conventional SIMV. No significant differences were found between two groups with respect to NEC and air leak. CONCLUSION In conclusion, VG ventilation in combination with surfactant treatment significantly reduced both duration of mechanical ventilation and early neonatal oxygen related morbidities including BPD, ROP and IVH in preterm infants with RDS. This data favors the use of VG ventilation in respiratory support of premature infants.
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[Correction of energy homeostasis in the acute period of concomitant brain injury].
Nikonov, VV, Pavlenko, AIu, Beletskiĭ, AV
Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2013;(7):32-6
Abstract
A randomized prospective study of 191 patients with concomitant brain injury (CBI) of different severity has been carried out. All patients underwent surgery and received treatment in reanimation and intensive care departments. The main group consisted of 100 (52.4%) patients treated with cytoflavin in dosage 20-40 ml daily intravenously in drops during 10 days in addition to standard treatment. The comparison group included 91 (47.6%) patients who received standard treatment only. A positive effect of cytoflavin on clinical symptoms and laboratory characteristics of patients with CBI was identified. The decrease in severity measured with the APACHE II, higher activation of consciousness and improvement in the dynamics of neurological symptoms in these patients have resulted in the reduction in the duration of artificial lung ventilation and total hospital stay.
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Negative- versus positive-pressure ventilation in intubated patients with acute respiratory distress syndrome.
Raymondos, K, Molitoris, U, Capewell, M, Sander, B, Dieck, T, Ahrens, J, Weilbach, C, Knitsch, W, Corrado, A
Critical care (London, England). 2012;(2):R37
Abstract
INTRODUCTION Recent experimental data suggest that continuous external negative-pressure ventilation (CENPV) results in better oxygenation and less lung injury than continuous positive-pressure ventilation (CPPV). The effects of CENPV on patients with acute respiratory distress syndrome (ARDS) remain unknown. METHODS We compared 2 h CENPV in a tankrespirator ("iron lung") with 2 h CPPV. The six intubated patients developed ARDS after pulmonary thrombectomy (n = 1), aspiration (n = 3), sepsis (n = 1) or both (n = 1). We used a tidal volume of 6 ml/kg predicted body weight and matched lung volumes at end expiration. Haemodynamics were assessed using the pulse contour cardiac output (PiCCO) system, and pressure measurements were referenced to atmospheric pressure. RESULTS CENPV resulted in better oxygenation compared to CPPV (median ratio of arterial oxygen pressure to fraction of inspired oxygen of 345 mmHg (minimum-maximum 183 to 438 mmHg) vs 256 mmHg (minimum-maximum 123 to 419 mmHg) (P < 0.05). Tank pressures were -32.5 cmH2O (minimum-maximum -30 to -43) at end inspiration and -15 cmH2O (minimum-maximum -15 to -19 cmH2O) at end expiration. NO Inspiratory transpulmonary pressures decreased (P = 0.04) and airway pressures were considerably lower at inspiration (-1.5 cmH2O (minimum-maximum -3 to 0 cmH2O) vs 34.5 cmH2O (minimum-maximum 30 to 47 cmH2O), P = 0.03) and expiration (4.5 cmH2O (minimum-maximum 2 to 5) vs 16 cmH2O (minimum-maximum 16 to 23), P =0.03). During CENPV, intraabdominal pressures decreased from 20.5 mmHg (12 to 30 mmHg) to 1 mmHg (minimum-maximum -7 to 5 mmHg) (P = 0.03). Arterial pressures decreased by approximately 10 mmHg and central venous pressures by 18 mmHg. Intrathoracic blood volume indices and cardiac indices increased at the initiation of CENPV by 15% and 20% (P < 0.05), respectively. Heart rate and extravascular lung water indices remained unchanged. CONCLUSIONS CENPV with a tank respirator improved gas exchange in patients with ARDS at lower transpulmonary, airway and intraabdominal pressures and, at least initially improving haemodynamics. Our observations encourage the consideration of further studies on the physiological effects and the clinical effectiveness of CENPV in patients with ARDS.
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Comparison between measured and predicted resting energy expenditure in mechanically ventilated patients with COPD.
Rao, ZY, Wu, XT, Wang, MY, Hu, W
Asia Pacific journal of clinical nutrition. 2012;(3):338-46
Abstract
The aim of this study was to compare resting energy expenditure (REE) obtained by indirect calorimetry (IC) and Harris-Benedict (H-B) equations, and to examine whether hypocaloric nutrition support could improve protein nutritional status in mechanically ventilated patients with chronic obstructive pulmonary disease (COPD). Thirtythree COPD patients (20 males, 13 females) were recruited and REE was measured by IC. Measured REE (REEm) was compared to predictive REE by H-B equations (REEH-B) and its corrected values. Correlation between REEm and APACHE II score was also analyzed. Patients were randomly divided into hypocaloric energy group (50%-90% of REEm, En-low) and general energy group (90%-130% of REEm, En-gen) for nutrition support. The differences of albumin, prealbumin, transferrin, hemoglobin, and lymphocyte count before and after 7 days nutrition support were observed. Results show that REEH-B and REEH-B×1.2 were significantly lower than REEm (p<0.01). REEm positively correlated with APACHE II score (p<0.05 or p<0.01). After nutrition support, hemoglobin decreased significantly in En-gen group (p<0.05); lymphocyte count in both groups, and transferrin and prealbumin in the En-low group increased significantly (p<0.05 or p<0.01). Our data suggest that 1) these patients' REE were increased; 2) since IC is the best method to determine REE, in the absence of IC, H-B equations (with standard body weight) can be used to calculate REE, but the value should be adjusted by correction coefficients derived from APACHE II; 3) low energy nutrition support during mechanical ventilation in COPD patients might have better effects on improving protein nutritional status than high energy support.
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[Comparison of SmartCare and spontaneous breathing trials for weaning old patients with chronic obstructive pulmonary diseases].
Jiang, H, Yu, SY, Wang, LW
Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases. 2006;(8):545-8
Abstract
OBJECTIVE To compare the outcome of the SmartCare and spontaneous breathing trials (SBT) for weaning old patients with chronic obstructive pulmonary diseases (COPD). METHODS Thirty-eight COPD patients were enrolled in Department of Respiratory Medicine on the South Building, General Hospital of People's Liberation Army from January, 2003 to April, 2005. They mechanically ventilated for at least 3 d (age: 70 - 91 year, average: 83.3 +/- 4.3), randomly assigned to receive SmartCare (SC group, n = 13) or SBT (SBT group, n = 25). All patients were considered clinically and biologically stable, and therefore ready to be weaned from mechanical ventilation. In SC group, patients were ventilated with an inspiratory pressure (IPAP) support adjusted to achieve pH value > or = 7.35, saturation of oxygen in arterial blood (SaO2) > or = 90%, respiratory frequency (RR) > or = 10 and < or = 30 breaths/min, and fraction of inspired oxygen (FiO2) < or = 45%. In SBT group, the patients were placed in a weaning protocol utilizing increasing duration of spontaneous breathing. The following data were recorded at weaning: the acute physiology and chronic health evaluation II (APACHE II) score, arterial blood gases under mechanical ventilation, serum calcium, magnesium, and phosphorus, the days of ventilation before weaning and the duration of weaning. The patients of both groups were considered as successfully weaned when they were able to tolerate at least 48 consecutive hours of spontaneous breathing. Failure was defined in a patient who died during the weaning process or who still needed mechanical ventilation after at least 40 consecutive days of weaning. RESULTS No significant differences were found between the groups at the onset of weaning from mechanical ventilation regarding APACHE II, serum albumin, calcium, magnesium, phosphorus, partial pressure of carbon dioxide in arterial blood (PaCO2), and the days of mechanical ventilation (t = 0.834, 0.696, 1.384, 0.682, 0.467, 0.816, 0.384, all P > 0.05). The pH value of the SBT group (7.45 +/- 0.05) was higher than the SC group (7.40 +/- 0.04, t = 3.263, P < 0.05). Although patients in the SC group spent less time in weaning than those in the SBT group, the difference was not significant [(8.54 +/- 2.09), (13.32 +/- 2.19) d for the SC and SBT groups, respectively, t = 1.320, P = 0.251]. The 7-d weaning success rate was greater in the SC group than the SBT group (77%, 40%, chi(2) = 4.677, P = 0.031). No significant difference was found in 14-d weaning success rate (77%, 64% in the SC and SBT groups, chi(2) = 0.661, P = 0.416). Fewer arterial blood analyses were performed in the SC group (3.5 +/- 3.1, 6.6 +/- 3.7, t = 2.710, P = 0.011). CONCLUSION The SmartCare is better than SBT in weaning patients with COPD within 7 days.