Jia-Horng Wang

Assessment of myocardial injury in the emergency department independently predicts the short-term poor outcome in patients with severe carbon monoxide poisoning receiving mechanical ventilation and hyperbaric oxygen therapy.

OBJECTIVES Patients with severe carbon monoxide (CO) poisoning are often prone to unconsciousness and respiratory distress and as a result will receive mechanical ventilation and hyperbaric oxygen (MV-HBO) therapy. Factors associated with poor outcome at discharge are less defined in this patient population. This study was conducted to identify the prognostic predictors of short-term poor outcome in severely CO-poisoned patients receiving MV-HBO therapy. METHODS The departmental database and the medical records of 81 patients treated with MV-HBO therapy were reviewed. Demographic and clinical data were extracted for analysis. HBO therapy with 2.5 or 2.8 atmosphere absolute (ATA) was administered to these patients. Short-term poor outcome was defined as an in-hospital death or neurologic sequelae at discharge. All patients were divided into two groups: those with a poor outcome and those without a poor outcome. RESULTS Nine patients died while in the hospital, 32 patients had neurologic sequelae at discharge, and the incidence of poor outcome was 50.6%. Parameters that were assessed in the emergency department (ED) and highly associated with patients with a poor outcome included myocardial injury, typical findings on brain computed tomography related to CO poisoning, and higher serum levels of alanine transaminase, aspartate aminotransferase, blood urea nitrogen, creatinine, creatine kinase, creatine kinase-myocardial band, troponin-I, and C-reactive protein. These poor outcomes were also correlated with prolonged lag times from the end of CO exposure to ED arrival and from ED arrival to HBO therapy. In a multivariate analysis, myocardial injury was the only independent predictor of poor outcome (odds ratio, 8.2; 95% confidence interval, 1.012-67.610; p=0.049). CONCLUSIONS The results of this study indicate that myocardial injury assessed at ED arrival independently predicts the short-term poor outcome in severely CO-poisoned patients who receive MV-HBO therapy. Emergency physicians could use this objective marker to identify patients with an increased risk of poor outcome at discharge and refine the treatment protocol by shortening the time of patient transport and administering HBO therapy as soon as possible.

Acute kidney injury on ventilator initiation day independently predicts prolonged mechanical ventilation in intensive care unit patients

PURPOSE The purpose of this study is to identify the predictors for prolonged mechanical ventilation (PMV) of more than 21 days among intensive care unit (ICU) patients. MATERIAL AND METHODS A retrospective observational study was conducted in a respiratory ICU from December 2008 to November 2009. The outcome measurement was the occurrence of PMV. Acute kidney injury (AKI) was identified and defined as an increase in the serum creatinine level of 50% or greater from baseline. RESULTS Of 154 patients enrolled, 41 patients (26.6%) had PMV. Patients with PMV showed higher Acute Physiology and Chronic Health Evaluation II scores, lower serum albumin levels, and more AKI on mechanical ventilation (MV) initiation day compared with the non-PMV patients. Patients with PMV were significantly associated with longer MV duration before the day of readiness for weaning (DRW) and a higher rapid shallow breathing index on DRW. In a multivariate regression analysis, the independent risk factors for PMV were AKI on MV initiation day (odds ratio [OR], 5.630; 95% confidence interval [CI], 1.378-22.994; P = .016), longer MV duration before DRW (OR, 1.289; 95% CI, 1.158-1.435; P < .001), and higher rapid shallow breathing index on DRW (OR, 1.012; 95% CI, 1.003-1.021; P = .010). CONCLUSIONS Acute kidney injury on MV initiation day is an independent risk factor for PMV of more than 21 days, which may be helpful for clinicians to refine their management of these ICU patients early.

Intensive Care Unit-Acquired Bacteremia in Mechanically Ventilated Patients: Clinical Features and Outcomes

Intensive care unit (ICU)-acquired bacteremia (IAB) is associated with high medical expenditure and mortality. Mechanically ventilated patients represent one third of all patients admitted to ICU, but the clinical features and outcomes in mechanically ventilated patients who develop IAB remain unknown. We conducted a 3-year retrospective observational cohort study, and 1,453 patients who received mechanical ventilation on ICU admission were enrolled. Among patients enrolled, 126 patients who had developed IAB ≧48 hours after ICU admission were identified. The study patients were divided into IAB and no IAB groups, and clinical characteristics of IAB based on specific bacterial species were further analyzed. The multivariate Cox regression analysis showed that ventilator support for chronic obstructive pulmonary disease and congestive heart failure, and patients admitted from nursing home were the independent risk factors for developing IAB. Patients with IAB were significantly associated with longer length of ICU stay, prolonged ventilator use, lower rate of successful weaning, and higher rate of ventilator dependence and ICU mortality as compared to those without IAB. IAB was the independent risk factor for ICU mortality (HR, 1.510, 95% CI 1.054–1.123; p = 0.010). The clinical characteristics of IAB related to specific bacterial species included IAB due to Pseudomonas aeruginosa being likely polymicrobial, lung source and prior antibiotic use; Escherichia coli developing earlier and from urinary tract source; methicillin-resistant Staphylococcus aureus related to central venous catheter and multiple sets of positive hemoculture; and Elizabethkingia meningoseptica significantly associated with delayed/inappropriate antibiotic treatment. In summary, IAB was significantly associated with poor patient outcomes in mechanically ventilated ICU patients. The clinical features related to IAB and clinical characteristics of IAB based on specific bacterial species identified in our study may be utilized to refine the management of IAB.

Hyperbaric oxygen therapy as an adjunctive treatment for sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery

PurposeA retrospective study to evaluate the effect of hyperbaric oxygen (HBO2) therapy on sternal infection and osteomyelitis following median sternotomy.Materials and methodsA retrospective analysis of patients who received sternotomy and cardiothoracic surgery which developed sternal infection and osteomyelitis between 2002 and 2009. Twelve patients who received debridement and antibiotic treatment were selected, and six of them received additional HBO2 therapy. Demographic, clinical characteristics and outcome were compared between patients with and without HBO2 therapy.ResultsHBO2 therapy did not cause any treatment-related complication in patients receiving this additional treatment. Comparisons of the data between two study groups revealed that the length of stay in ICU (8.7 ± 2.7 days vs. 48.8 ± 10.5 days, p < 0.05), duration of invasive (4 ± 1.5 days vs. 34.8 ± 8.3 days, p < 0.05) and non-invasive (4 ± 1.9 days vs. 22.3 ± 6.2 days, p < 0.05) positive pressure ventilation were all significantly lower in patients with additional HBO2 therapy, as compared to patients without HBO2 therapy. Hospital mortality was also significantly lower in patients who received HBO2 therapy (0 case vs. 3 cases, p < 0.05), as compared to patients without the HBO2 therapy.ConclusionsIn addition to primary treatment with debridement and antibiotic use, HBO2 therapy may be used as an adjunctive and safe treatment to improve clinical outcomes in patients with sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery.

Synergistic impact of low serum albumin on intensive care unit admission and high blood urea nitrogen during intensive care unit stay on post-intensive care unit mortality in critically ill elderly patients requiring mechanical ventilation

Aims:  To identify intensive care unit (ICU) risk factors for post‐ICU 6‐month (PI6M) mortality in critically ill elderly patients requiring mechanical ventilation (MV).

Pneumothorax and mortality in the mechanically ventilated SARS patients: a prospective clinical study

IntroductionPneumothorax often complicates the management of mechanically ventilated severe acute respiratory syndrome (SARS) patients in the isolation intensive care unit (ICU). We sought to determine whether pneumothoraces are induced by high ventilatory pressure or volume and if they are associated with mortality in mechanically ventilated SARS patients.MethodsWe conducted a prospective, clinical study. Forty-one mechanically ventilated SARS patients were included in our study. All SARS patients were sedated and received mechanical ventilation in the isolation ICU.ResultsThe mechanically ventilated SARS patients were divided into two groups either with or without pneumothorax. Their demographic data, clinical characteristics, ventilatory variables such as positive end-expiratory pressure, peak inspiratory pressure, mean airway pressure, tidal volume, tidal volume per kilogram, respiratory rate and minute ventilation and the accumulated mortality rate at 30 days after mechanical ventilation were analyzed. There were no statistically significant differences in the pressures and volumes between the two groups, and the mortality was also similar between the groups. However, patients developing pneumothorax during mechanical ventilation frequently expressed higher respiratory rates on admission, and a lower PaO2/FiO2 ratio and higher PaCO2 level during hospitalization compared with those without pneumothorax.ConclusionIn our study, the SARS patients who suffered pneumothorax presented as more tachypnic on admission, and more pronounced hypoxemic and hypercapnic during hospitalization. These variables signaled a deterioration in respiratory function and could be indicators of developing pneumothorax during mechanical ventilation in the SARS patients. Meanwhile, meticulous respiratory therapy and monitoring were mandatory in these patients.

Characteristic features and outcomes of severe acute respiratory syndrome found in severe acute respiratory syndrome intensive care unit patients

Abstract Purpose The aim of the study was to identify characteristic clinical features and outcomes of critically ill patients with confirmed severe acute respiratory syndrome (SARS). Materials and Methods This retrospective study enrolled all patients admitted to a 12-bed SARS intensive care unit (ICU) in a tertiary care medical center in Taipei between May 15 and July 17, 2003. Patients with positive results of either reverse transcriptase–polymerase chain reaction or antibody to SARS coronavirus were defined as SARS cases and others with negative results as control cases. Results Of the 50 patients, 14 had confirmed SARS. Demographics were similar between the 2 groups. The highest leukocyte and neutrophil counts, lactate dehydrogenase, and creatine kinase; positive end-expiratory pressure; and use of corticosteroids, ribavirin, and intravenous immunoglobulin were higher in the SARS group. In contrast, the lowest lymphocyte count and the ratio of Pao 2 to the fraction of inspired oxygen were lower in the SARS group. Of the 15 deaths in the control group, 12 (80%) occurred during the first 2 weeks after ICU admission. However, in the confirmed SARS group, 5 (55.6%) of the 9 deaths occurred within the third or fourth week. This difference in timing between these 2 groups was significant (P = .004). Conclusions In a SARS ICU, patients with a confirmed diagnosis of SARS had significantly different clinical features and timing of mortality from those of the control group.

Hyperbaric oxygen therapy as an effective adjunctive treatment for chronic Lyme disease

Lyme disease is the most commonly reported vector-borne illness in the United States, but it is relatively rare in Taiwan. Lyme disease can be treated with antibiotic agents, but approximately 20% of these patients experience persistent or intermittent subjective symptoms, so-called chronic Lyme disease (CLD). The mechanisms of CLD remain unclear and the symptoms related to CLD are difficult to manage. Hyperbaric oxygen therapy (HBOT) was applied in CLD therapy in the 1990s. However, reported information regarding the effectiveness of HBOT for CLD is still limited. Here, we present a patient with CLD who was successfully treated with HBOT.

Impact and Predictors of Prolonged Chest Tube Duration in Mechanically Ventilated Patients with Acquired Pneumothorax

BACKGROUND: Prolonged chest tube duration is less well studied in patients who are supported by mechanical ventilation and have acquired pneumothorax. We investigated the impact of prolonged chest tube duration on patient outcomes and the risk factors associated with prolonged chest tube duration. METHODS: This retrospective observational study included 106 ventilated subjects who had been treated with thoracostomy for pneumothorax between May 2004 and December 2011. We analyzed 61 subjects and 63 events. The subjects were divided into a prolonged chest tube duration group (> 18 d) and a non-prolonged group (≤ 18 d). RESULTS: Subjects with prolonged chest tube duration had significantly higher ICU mortality (P = .006), longer ICU stay (P = .001), longer hospitalization (P = .004), longer mechanical ventilation after development of pneumothorax (P = .003), higher maximum peak inspiratory pressure (P = .03), and a higher rate of surgical emphysema (P = .009). High peak inspiratory pressure and surgical emphysema remained independent predictors of prolonged chest tube duration after multivariate logistic regression analysis. The probability of chest tube removal within 28 days was significantly lower in subjects with both high peak inspiratory pressure and surgical emphysema, compared to subjects without any risk factors (log rank P = .001). CONCLUSIONS: High peak inspiratory pressure and surgical emphysema are independent predictors of prolonged chest tube duration and negatively impact clinical outcomes in this patient group. These findings may provide information for better chest tube management.

Paroxysmal Sympathetic Hyperactivity: Two Case Reports

Paroxysmal sympathetic hyperactivity (PSH) is a syndrome characterized by episodes of hyperthermia, diaphoresis, agitation, dystonia, and increased blood pressure (BP), respiratory rate (RR), and heart rate (HR). Most cases are found after brain injury, although a few cases have had no brain injury. The exact mechanism is still not clear, but PSH can be treated by opioids, gabapentin, benzodiazepines, centrally acting α-agonists, and β-antagonists, bromocriptine, and intrathecal baclofen, instead of anti-epileptics, antibiotics, or antipyretics, in most cases. Delayed diagnosis and management of PSH may increase morbidity and mortality. We present 2 cases and review the literature on PSH. Accurate diagnosis and appropriate treatment can reduce the number of ventilator days and shorten the hospital course, and even improve the clinical outcome. Therefore, the differential diagnosis and management of patients presenting with hyperthermia, dystonia, tachypnea, and tachycardia are very important in daily practice in the intensive care unit.