Volume 10, Issue 2, April 2024
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A Randomised Control Study Comparing Ultrasonography with Standard Clinical Methods in Assessing Endotracheal Tube Tip Positioning
DOI: 10.2478/jccm-2024-0019
Introduction: Airway ultrasound has been increasingly used in correct positioning of endotracheal tube. We hypothesize that a safe distance between endotracheal tube tip and carina can be achieved with the aid of ultrasound.
Aim of the study: Our primary objective was to determine whether ultrasound guided visualisation of proximal end of endotracheal tube cuff is better when compared to conventional method in optimal positioning of tube tip. The secondary objective was to find the optimal endotracheal tube position at the level of incisors in adult Indian population.
Materials and Methods: There were 25 patients each in the conventional group and the ultrasound group. Conventional method includes auscultation and end tidal capnography. In the ultrasound group the upper end of the endotracheal tube cuff was positioned with an intent to provide 4 cm distance from the tube tip to the carina. X ray was used in both groups for confirmation of tip position and comparison between the two groups. Further repositioning of the tube was done if indicated and the mean length of the tube at incisors was then measured.
Results: After x ray confirmation, endotracheal tube repositioning was required in 24% of patients in the USG group and 40 % of patients in the conventional group. However, this result was not found to be statistically significant (p = 0.364). The endotracheal tube length at the level of teeth was 19.4 ± 1.35 cm among females and 20.95 ± 1.37 cm among males.
Conclusions: Ultrasonography is a reliable method to determine ETT position in the trachea. There was no statistically significant difference when compared to the conventional method. The average length of ETT at the level of incisors was 19.5 cm for females and 21 cm for males.
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Characteristics of the Cerebrospinal Fluid in Septic Patients with Critical Illness Polyneuropathy – A Retrospective Cohort Study
DOI: 10.2478/jccm-2024-0018
Background: Critical illness polyneuropathy (CIP) is a complex disease commonly occurring in septic patients which indicates a worse prognosis. Herein, we investigated the characteristics of cerebrospinal fluid (CSF) in septic patients with CIP.
Methods: This retrospective study was conducted between Match 1, 2018, and July 1, 2022. Patients with sepsis who underwent a CSF examination and nerve electrophysiology were included. The levels of protein, glucose, lipopolysaccharide, white blood cell (WBC), interleukin (IL)-1, IL-6, IL-8, and tumor necrosis factor (TNF) α in CSF were measured. The fungi and bacteria in CSF were also assessed.
Results: Among the 175 septic patients, 116 (66.3%) patients were diagnosed with CIP. 28-day Mortality in CIP patients was higher than that in non-CIP patients (25.0% vs. 10.2%, P = 0.02) which was confirmed by survival analysis. The results of propensity score matching analysis (PSMA) indicated a significant difference in the level of protein, WBC, IL-1, IL-6, IL-8, and TNFα present in the CSF between CIP patients and non-CIP patients. The results of the receiver operating characteristic (ROC) analysis showed that IL-1, WBC, TNFα, and their combined indicator had a good diagnostic value with an AUC > 0.8.
Conclusion: The increase in the levels of WBC, IL-1, and TNFα in CSF might be an indicator of CIP in septic patients.
Keywords: sepsis, Acute Physiology and Chronic Health Evaluation II, cerebrospinal fluid, critical illness polyneuropathy, sequential organ failure assessment score
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Extracorporeal Membrane Oxygenation as Circulatory Support in Adult Patients with Septic Shock: A Systematic Review
DOI: 10.2478/jccm-2024-0017
Introduction: The utilization of extracorporeal membrane oxygenation (ECMO) in adult patients experiencing septic shock is a subject of ongoing debate within the medical community. This study aims to comprehensively address this issue through a systematic review conducted in accordance with the PRISMA guidelines.
Aim of Study: The primary objective of this study is to assess the outcomes of ECMO utilization in adult patients diagnosed with septic shock, thereby providing insights into the potential benefits and uncertainties associated with this treatment modality.
Materials and Methods: Our research encompassed a thorough search across electronic databases for relevant English-language articles published up until April 2023. The inclusion criteria were based on studies reporting on ECMO usage in adult patients with septic shock. Among the eligible studies meeting these criteria, a total of eleven were included in our analysis, involving a cohort of 512 patients. The mean age of the participants was 53.4 years, with 67.38% being male.
Results: In the pooled analysis, the mean survival rate following ECMO treatment was found to vary significantly across different ECMO modalities. Patients receiving venovenous-ECMO (VV-ECMO) and veno-venous-arterial ECMO (VVA-ECMO) demonstrated higher survival rates (44.5% and 44.4%, respectively) compared to those receiving venoarterial-ECMO (VA-ECMO) at 25% (p<0.05). A chi-square test of independence indicated that the type of ECMO was a significant predictor of survival (χ²(2) = 6.63, p=0.036). Additionally, patients with septic shock stemming from respiratory failure demonstrated survival rates ranging from 39% to 70%. Predictors of mortality were identified as older age and the necessity for cardiopulmonary resuscitation (CPR).
Conclusions: In septic shock patients, ECMO outcomes align with established indications like respiratory and cardiogenic shock. VV-ECMO and VVA-ECMO suggest better prognoses, though the optimal mode remains uncertain. Patient selection should weigh age and CPR need. Further research is vital to determine ECMO’s best approach for this population.
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Ventilator-Associated Events Cost in ICU Patients Receiving Mechanical Ventilation: A Multi-State Model
DOI: 10.2478/jccm-2024-0016
Introduction: Cost analysis is complicated by the fact that patients acquire infections during their hospital stay, having already spent time at risk without having an infection. Multi-state models (MSM) accounts for this time at risk treating infections as time-dependent exposures from ICU admission.
Aim of the study: To estimate ventilator-associated events (VAEs) direct additional cost in ICU patients.
Material and Methods: This was a prospective, observational study carried out for a two-year period in four medical-surgical ICUs of Athens, Greece. The sample consisted of adult patients who received mechanical ventilation for ≥4 days and were followed until discharge from the ICU or until death. CDC standard definitions were used to diagnose VAEs. To estimate VAEs additional length of stay (LOS), we used a four-state model that accounted for the time of VAEs. The direct hospital cost was calculated, consisting of the fixed and variable cost. The direct additional cost per VAEs episode was calculated by multiplying VAEs extra LOS by cost per day of ICU hospitalization.
Results: In the final analysis were included 378 patients with 9,369 patient-days. The majority of patients were male (58.7%) with a median age of 60 years. Of 378 patients 143 (37.8%) developed 143 episodes of VAEs. VAEs crude additional LOS was 17 days, while VAE mean additional LOS after applying MSM was 6.55±1.78 days. The direct cost per day of ICU hospitalization was € 492.80. The direct additional cost per VAEs episode was € 3,227.84, € 885.56 the fixed and € 2,342.28 the variable cost. Antibiotic cost was € 1,570.95 per VAEs episode. The total direct additional cost for the two-year period was € 461,581.12.
Conclusions: These results confirm the importance of estimating VAEs real cost using micro-costing for analytical cost allocation, and MSM to avoid additional LOS and cost overestimation.
Keywords: ventilator-associated events, mechanical ventilation, intensive care units, multi-state model, cost
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The Utility of Serial Lipid Measurements as a Potential Predictor of Sepsis Outcome: A Prospective Observational Study in a Tertiary Care Hospital
DOI: 10.2478/jccm-2024-0015
Background and aim: Sepsis is the major cause of morbidity and mortality for patients admitted to an intensive care unit worldwide. Currently, Procalcitonin (PCT) is a widely used prognostic marker for sepsis. The high cost of estimating Procalcitonin limits its utility in all health facilities. Lipid Profile, being a frequently done routine investigation, is studied in sepsis patients to predict the prognosis of sepsis. This study was aimed to assess the association between lipid profile parameters, procalcitonin and clinical outcomes in patients with sepsis.
Materials and methods: It is a prospective observational study conducted in a tertiary care hospital in the Department of Biochemistry in collaboration with the Intensive Care Unit (ICU). We included 80 sepsis patients from medical and surgical ICUs. Among them, 59 (74%) survived and 21 (26%) expired. Serum lipid profile, procalcitonin and variables required for APACHE II score are measured at two intervals, one during admission and on day 5. All the parameters were compared between the survivors and the non-survivors.
Results: Serum PCT levels were reduced on Day 5 [3.32 (1.27-11.86)] compared to Day 0 [13.42 (5.77-33.18)] in survivors. In survivors, Total Cholesterol, LDL-C and Non-HDL-C were significantly elevated on Day 5 compared to Day 0. In non-survivors, HDL-C significantly decreased on Day 5. Between survivors and non-survivors, HDL-C significantly decreased on Day 5 (23.88 ± 10.19 vs 16.67 ± 8.27 mg/dl). A Negative correlation was observed between HDL-C & PCT.
Conclusion: Serum Lipid profile levels, namely Total cholesterol, HDL-C and LDL-C, have possible associations with the severity of sepsis. HDL-C have a negative association with the clinical scoring system in sepsis patients. Overall, the findings from our study suggest that lipid profile parameters have possible implications in predicting the outcome of patients with sepsis.
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Weekend Effect and Mortality Outcomes in Aortic Dissection: A Prospective Analysis
DOI: 10.2478/jccm-2024-0014
Background: Aortic dissection (AD) is a critical heart condition with potentially severe outcomes. Our study aimed to investigate the existence of a “weekend effect” in AD by examining the correlation between patient outcomes and whether their treatment occurred on weekdays versus weekends.
Methods: Specifically, we prospectively analysed the effect of weekday and weekend treatment on acute AD patient outcomes, both before surgical intervention and during hospitalization, for 124 patients treated from 2019–2021, as well as during 6 months of follow-up.
Results: The mean age of the study population was 62.5 years, and patient age exhibited a high degree of variability. We recorded a mortality rate before surgery of 8.65% for the weekend group and 15% for the weekday group, but this difference was not statistically significant. During hospitalization, mortality was 50% in the weekend group and 25% in the weekday group, but this difference was not statistically significant. Discharge mortality was 9.61% in the weekend group and 5% in the weekday group.
Conclusions: Our findings suggest that there was no significant difference in mortality rates between patients admitted to the hospital on weekends versus weekdays. Therefore, the period of the week when a patient presents to the hospital with AD appears not to affect their mortality.
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Longitudinal Assessment of ROX and HACOR Scores to Predict Non-Invasive Ventilation Failure in Patients with SARS-CoV-2 Pneumonia
DOI: 10.2478/jccm-2024-0013
Introduction: NIV (Non-invasive ventilation) and HFNC (High Flow nasal cannula) are being used in patients with acute respiratory failure. HACOR score has been exclusively calculated for patients on NIV, on other hand ROX index is being used for patients on HFNC. This is first study where ROX index has been used in patients on NIV to predict failure.
Aim of the study: This study investigates the comparative diagnostic performance of HACOR score and ROX index to predict NIV failure.
Methods: We performed a retrospective cohort study of non-invasively ventilated Covid 19 patients admitted between 1st April 2020 to 15th June 2021 to ICU of a tertiary care teaching hospital located in Central India. We assessed factors responsible for NIV failure, and whether these scores HACOR/ ROX index have discriminative capacity to predict risk of invasive mechanical ventilation.
Results: Of the 441 patients included in the current study, 179 (40.5%) recovered, while remaining 262 (59.4%) had NIV failure. On multivariable analysis, ROX index > 4.47 was found protective for NIV-failure (OR 0.15 (95%CI 0.03-0.23; p<0.001). Age > 60 years and SOFA score were other significant independent predictors of NIV-failure. The AUC for prediction of failure rises from 0.84 to 0.94 from day 1 to day 3 for ROX index and from 0.79 to 0.92 for HACOR score in the same period, hence ROX score was non-inferior to HACOR score in current study. DeLong’s test for two correlated ROC curves had insignificant difference expect day-1 (D1: 0.03 to 0.08; p=3.191e-05 ,D2: -0.002 to 0.02; p = 0.2671, D3: -0.003 to 0.04; p= 0.1065).
Conclusion: ROX score of 4.47 at day-3 consists of good discriminatory capacity to predict NIV failure. Considering its non-inferiority to HACOR score, the ROX score can be used in patients with acute respiratory failure who are on NIV.
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Optimizing Nutrient Uptake in the Critically Ill: Insights into Malabsorption Management
DOI: 10.2478/jccm-2024-0012
It has already been stated that nutritional support represents a crucial component in the care of critically ill patients [1]. Prolonged negative energy balance during intensive care stay was confirmed as an independent risk factor for mortality. High metabolic demand encountered for critically ill patients may cause significant energy deficits responsible for increased risk of infection, prolonged mechanical ventilation and ICU stay [2-4].
Aditionally, providing nutritional support in ICU patients is often deemd challenging, as enteral feeding intolerance devolps secondary to gastrointestinal dysfunction [5]. Exccesive antimicrobial usage along with associated risk of nosocomial diarrhea may further exacerbate feeding intolerance. [More]
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Volume 10, Issue 1, January 2024
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