Te-Cheng Lien

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.

High expression of high‐mobility group box 1 in the blood and lungs is associated with the development of chronic obstructive pulmonary disease in smokers

High‐mobility group box 1 (HMGB1) is an important mediator in multiple pathological conditions, but the expression of HMGB1 in chronic obstructive pulmonary disease (COPD) has not yet been completely investigated. We aimed to analyze the relationship between HMGB1 expression in blood and lung tissue and the development of COPD.

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.

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.

Acute Kidney Injury on Ventilator Initiation Day Independently Predicts Prolonged Mechanical Ventilation in Intensive Care Unit Patients

The adverse outcomes associated with prolonged mechanical ventilation (PMV), defined as 21 days lasting 6 h/d or more, include increased length of stay in the intensive care unit (ICU), increased need for tracheostomy, a higher incidence of hospital death, and greater hospital costs. Early predictors for PMV could allow physicians to optimize their management of these patients. Risk factors associated with the duration of mechanical ventilation (MV) are advanced age, the APACHE II (Acute Physiology and Chronic Health Evaluation II) score, albumin level, presence of shock on admission, refractory acidosis, nonthyroidal illness syndrome, and renal dysfunction. Reports on the differences between PMVand non-PMV patients in terms of the indicators of the weaning process are scarce. The aim of this retrospective observational study was to identify the predictors of PMVamong ICU patients, especially the relationship between renal dysfunction and PMV. The study was conducted in a 35-bed respiratory ICU, and data on all consecutive patients admitted (2008Y2009) who received invasive MV because of acute respiratory failure were reviewed. Strict protocols were developed for weaning with criteria for the day of readiness for weaning (DRW), respiratory distress during the spontaneous trial of breathing, extubation or disconnection from the ventilator, and performing tracheostomy for laryngeal-intubated patients. Acute kidney injury (AKI) was defined as an increase of 50% or greater in the serum creatinine level from premorbid baseline level according to the glomerular filtration rate criteria of the RIFLE (Risk, Injury, Failure, Loss, and End-stage Kidney Disease) classification. If the baseline serum creatinine level was not available, the RIFLE urine output criteria were used (output G0.5 mL/kg per hour for 6 hours). Weaning failure was defined as the need to reintubate or to reconnect tracheotomized patients to the ventilator within 72 hours after weaning from MV. Of 511 patients admitted to the ICU, 154 (30.1%; mean age, 78.7 years) were enrolled in the study. The mean APACHE II score at ICU admission was 18.2, and the median duration of MV before ICU discharge was 12 days. Acute kidney injury was identified by premorbid creatine values in 122 patients and in 32 patients using the urine output criteria. The incidences of AKI on MV initiation, before MV day 21, and over the entire MV course were 14.9%, 29.9%, and 33.1%, respectively. Forty-one patients (26.6%) and 113 (73.4%) were in the PMVand non-PMV groups, respectively, according to the occurrence of PMV. Patients with PMV presented with notably more serious illness and higher APACHE II scores, lower serum albumin levels, and more AKI on MV initiation day compared with non-PMV patients. During the MV course, the PMVgroup hadmore AKI, more need for diuretic therapy, and greater need for renal replacement therapy beforeMV day 21. The PMV group had a longer length of MV before DRW, higher rapid shallow breathing index on DRW, and a greater likelihood of an unfavorable outcome, including need for tracheostomy, longer length of MV before ICU discharge, longer ICU stay, and higher ICUmortality rate. In the non-PMV group, 100% of patients met the criteria for readiness to wean before day 21 compared with 70.7% of those in the PMV group. Onmultivariate stepwise logistic regression analysis, AKI on MV initiation day and AKI before MV day 21 were independent factors predicting PMV. Patients with PMValso showed an independent association with a longer duration of MV before DRW and a higher rapid shallow breathing index on DRW. On MV initiation day, patients with AKI had higher APACHE II scores at admission, higher serum urea nitrogen and creatinine levels, longer duration of MV before ICU discharge, longer ICU stay, higher ICU mortality, and higher ratio of PMV compared with patients without AKI. The presence of AKI on MV initiation day is an independent risk factor for PMVof longer than 21 days. With awareness of this association, clinicians may be able to refine management of these patients early in the course of their illness and ICU stay.