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Antenatal magnesium sulfate and the need for mechanical ventilation in the first three days of life.Pediatrics and Neonatology Nov 2023Antenatal administration of magnesium sulfate (MgSO) to women in preterm labor has gained widespread use. This study examined the relationship between MgSO exposure with...
BACKGROUND
Antenatal administration of magnesium sulfate (MgSO) to women in preterm labor has gained widespread use. This study examined the relationship between MgSO exposure with neonatal respiratory outcomes.
METHODS
Very low birth weight (VLBW) infants exposed to antenatal MgSO were included. Infants who were intubated anytime during the first three days of life were compared to those who were not intubated regarding their demographic and clinical characteristics, MgSO therapy, immediate respiratory outcomes, and occurrence of intraventricular hemorrhage (IVH) using student t-test, chi square testing and logistic regression analysis to control for confounding variables. Correlation coefficient of MgSO cumulative dose given and duration of infusion with delivery room resuscitation and need for mechanical ventilation in the first 3 days of life were also calculated. Multilinear regression analysis was used to control for confounding factors.
RESULTS
Intubated group included 96 infants while non-intubated group included 171 infants. Although, intubated group has younger gestational age (26 vs. 29 weeks, p < 0.01) and lower birth weight (786 vs. 1115 g (g), p < 0.01), there were no significant differences between groups in regard to MgSO cumulative dose (24 vs. 27 g, p = 0.29), infusion time (14.6 vs. 18 h, p = 0.19) or infants' serum magnesium level (2.6 vs. 2.8 milliequivalents (mEq)/L p = 0.86). There was no correlation between cumulative MgSO4 dose with endotracheal intubation or cardiac resuscitation in the delivery room (cc: -0.03, p = 0.66; and 0.02, p = 0.79, respectively) or the need for mechanical ventilation in the first 3 days of life (cc: -0.04 to -0.07, p = 0.21-0.51). In addition, there was no relationship between MgSO dose, duration of infusion, or infant's serum magnesium level and occurrence of IVH.
CONCLUSION
Regardless of dose or duration of infusion, antenatal MgSO exposure is not associated with increased intubation or mechanical ventilation early in life.
Topics: Infant, Newborn; Humans; Female; Pregnancy; Magnesium Sulfate; Respiration, Artificial; Magnesium; Gestational Age; Obstetric Labor, Premature
PubMed: 37280122
DOI: 10.1016/j.pedneo.2022.10.008 -
Therapeutic Hypothermia and Temperature... Jun 2024Asphyxiated newborns often require both therapeutic hypothermia (TH) and mechanical ventilation (MV) and the complex interrelationship between these two therapeutic... (Review)
Review
Asphyxiated newborns often require both therapeutic hypothermia (TH) and mechanical ventilation (MV) and the complex interrelationship between these two therapeutic interventions is very interesting, which could not only have several synergistic positive effects but also some risks. Perinatal asphyxia is the leading cause of neonatal hypoxic-ischemic encephalopathy (HIE) and TH is the only approved neuroprotective treatment to limit brain injury, improving the mortality rate and long-term neurological outcomes. HIE is often associated with severe respiratory failure, requiring MV, due to different lung diseases or an impairment of the respiratory drive. The respiratory support management of asphyxiated newborns is very difficult, considering (a) various pathophysiological contexts, (b) the strong impact of TH on gas metabolism and (c) on lung mechanics, and (d) complex TH-MV interactions. Therefore, it is necessary to evaluate the real indications of MV for cooled newborns, considering the risks of respiratory overassistance (hypocapnia/hyperoxia), as well as the adequate monitoring systems. To date, specific randomized studies about the optimal respiratory approach for cooled newborns are lacking, and strategies for MV support vary from center to center. Moreover, there are many open questions about the real effects of cooling on lung mechanics and on surfactant, most appropriate method of blood gas analysis, and clear indications for pharmacological sedation. The aim of this review is to propose a reasoned approach for respiratory management of cooled newborns, considering the pathophysiological context, multiple actions of TH, and consequences of TH-MV matched action and its related risks.
Topics: Humans; Hypothermia, Induced; Infant, Newborn; Asphyxia Neonatorum; Respiration, Artificial; Hypoxia-Ischemia, Brain
PubMed: 37625025
DOI: 10.1089/ther.2023.0032 -
Orphanet Journal of Rare Diseases Mar 2024Patients with lymphangioleiomyomatosis (LAM) are considered high risk for most surgeries and require specific anesthetic considerations mainly because of the common...
Patients with lymphangioleiomyomatosis (LAM) are considered high risk for most surgeries and require specific anesthetic considerations mainly because of the common spontaneous pneumothorax (PTX). To explore whether intraoperative mechanical ventilation could increase the risk of PTX in those patients, we included 12 surgical patients with LAM in this study, of whom four (33.3%) experienced postoperative PTX. According to our results, patients with higher CT grade, poorer pulmonary function, and a history of preoperative PTX might be more likely to develop postoperative PTX. However, intraoperative mechanical ventilation did not show obvious influence, which might help clinicians reconsider the perioperative management of LAM patients.
Topics: Humans; Pneumothorax; Lymphangioleiomyomatosis; Incidence; Respiration, Artificial; Lung Neoplasms
PubMed: 38521962
DOI: 10.1186/s13023-024-03117-w -
Perfusion Apr 2024The impact of mechanical ventilation on the survival of patients supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) due to severe acute... (Review)
Review
BACKGROUND
The impact of mechanical ventilation on the survival of patients supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) due to severe acute respiratory distress syndrome (ARDS) remains still a focus of research.
METHODS
Recent guidelines, randomized trials, and registry data underscore the importance of lung-protective ventilation during respiratory and cardiac support on ECMO.
RESULTS
This approach includes decreasing mechanical power delivery by reducing tidal volume and driving pressure as much as possible, using low or very low respiratory rate, and a personalized approach to positive-end expiratory pressure (PEEP) setting. Notably, the use of ECMO in awake and spontaneously breathing patients is increasing, especially as a bridging strategy to lung transplantation. During respiratory support in V-V ECMO, native lung function is of highest importance and adjustments of blood flow on ECMO, or ventilator settings significantly impact the gas exchange. These interactions are more complex in veno-arterial (V-A) ECMO configuration and cardiac support. The fraction on delivered oxygen in the sweep gas and sweep gas flow rate, blood flow per minute, and oxygenator efficiency have an impact on gas exchange on device side. On the patient side, native cardiac output, native lung function, carbon dioxide production (VCO2), and oxygen consumption (VO2) play a role. Avoiding pulmonary oedema includes left ventricle (LV) distension monitoring and prevention, pulse pressure >10 mm Hg and aortic valve opening assessment, higher PEEP adjustment, use of vasodilators, ECMO flow adjustment according to the ejection fraction, moderate use of inotropes, diuretics, or venting strategies as indicated and according to local expertise and resources.
CONCLUSION
Understanding the physiological principles of gas exchange during cardiac support on femoro-femoral V-A ECMO configuration and the interactions with native gas exchange and haemodynamics are essential for the safe applications of these techniques in clinical practice. Proning during ECMO remains to be discussed until further data is available from prospective, randomized trials implementing individualized PEEP titration during proning.
Topics: Extracorporeal Membrane Oxygenation; Humans; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 38651573
DOI: 10.1177/02676591241232270 -
Noninvasive mechanical ventilation assistance in amyotrophic lateral sclerosis: a systematic review.Sao Paulo Medical Journal = Revista... 2023Respiratory failure is the most common cause of death in patients with amyotrophic lateral sclerosis (ALS), and morbidity is related to poor quality of life (QOL)....
BACKGROUND
Respiratory failure is the most common cause of death in patients with amyotrophic lateral sclerosis (ALS), and morbidity is related to poor quality of life (QOL). Non-invasive ventilation (NIV) may be associated with prolonged survival and QOL in patients with ALS.
OBJECTIVES
To assess whether NIV is effective and safe for patients with ALS in terms of survival and QOL, alerting the health system.
DESIGN AND SETTING
Systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards using population, intervention, comparison, and outcome strategies.
METHODS
The Cochrane Library, CENTRAL, MEDLINE, LILACS, EMBASE, and CRD databases were searched based on the eligibility criteria for all types of studies on NIV use in patients with ALS published up to January 2022. Data were extracted from the included studies, and the findings were presented using a narrative synthesis.
RESULTS
Of the 120 papers identified, only 14 were related to systematic reviews. After thorough reading, only one meta-analysis was considered eligible. In the second stage, 248 studies were included; however, only one systematic review was included. The results demonstrated that NIV provided relief from the symptoms of chronic hypoventilation, increased survival, and improved QOL compared to standard care. These results varied according to clinical phenotype.
CONCLUSIONS
NIV in patients with ALS improves the outcome and can delay the indication for tracheostomy, reducing expenditure on hospitalization and occupancy of intensive care unit beds.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO database: CRD42021279910 - https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=279910.
Topics: Humans; Amyotrophic Lateral Sclerosis; Noninvasive Ventilation; Quality of Life; Respiration, Artificial; Respiratory Insufficiency
PubMed: 37436254
DOI: 10.1590/1516-3180.2022.0470.R1.100423 -
BMC Pediatrics Oct 2023Respiratory support is crucial for newborns with underdeveloped lung. The clinical outcomes of patients depend on the clinician's ability to recognize the status...
Early prediction of need for invasive mechanical ventilation in the neonatal intensive care unit using artificial intelligence and electronic health records: a clinical study.
BACKGROUND
Respiratory support is crucial for newborns with underdeveloped lung. The clinical outcomes of patients depend on the clinician's ability to recognize the status underlying the presented symptoms and signs. With the increasing number of high-risk infants, artificial intelligence (AI) should be considered as a tool for personalized neonatal care. Continuous monitoring of vital signs is essential in cardiorespiratory care. In this study, we developed deep learning (DL) prediction models for rapid and accurate detection of mechanical ventilation requirements in neonates using electronic health records (EHR).
METHODS
We utilized data from the neonatal intensive care unit in a single center, collected between March 3, 2012, and March 4, 2022, including 1,394 patient records used for model development, consisting of 505 and 889 patients with and without invasive mechanical ventilation (IMV) support, respectively. The proposed model architecture includes feature embedding using feature-wise fully connected (FC) layers, followed by three bidirectional long short-term memory (LSTM) layers.
RESULTS
A mean gestational age (GA) was 36.61 ± 3.25 weeks, and the mean birth weight was 2,734.01 ± 784.98 g. The IMV group had lower GA, birth weight, and longer hospitalization duration than the non-IMV group (P < 0.05). Our proposed model, tested on a dataset from March 4, 2019, to March 4, 2022. The mean AUROC of our proposed model for IMV support prediction performance demonstrated 0.861 (95%CI, 0.853-0.869). It is superior to conventional approaches, such as newborn early warning score systems (NEWS), Random Forest, and eXtreme gradient boosting (XGBoost) with 0.611 (95%CI, 0.600-0.622), 0.837 (95%CI, 0.828-0.845), and 0.0.831 (95%CI, 0.821-0.845), respectively. The highest AUPRC value is shown in the proposed model at 0.327 (95%CI, 0.308-0.347). The proposed model performed more accurate predictions as gestational age decreased. Additionally, the model exhibited the lowest alarm rate while maintaining the same sensitivity level.
CONCLUSION
Deep learning approaches can help accurately standardize the prediction of invasive mechanical ventilation for neonatal patients and facilitate advanced neonatal care. The results of predictive, recall, and alarm performances of the proposed model outperformed the other models.
Topics: Infant; Humans; Infant, Newborn; Respiration, Artificial; Intensive Care Units, Neonatal; Birth Weight; Artificial Intelligence; Electronic Health Records
PubMed: 37872515
DOI: 10.1186/s12887-023-04350-1 -
British Journal of Anaesthesia Jul 2024Invasive mechanical ventilation is a key supportive therapy for patients on intensive care. There is increasing emphasis on personalised ventilation strategies. Clinical... (Review)
Review
Invasive mechanical ventilation is a key supportive therapy for patients on intensive care. There is increasing emphasis on personalised ventilation strategies. Clinical decision support systems (CDSS) have been developed to support this. We conducted a narrative review to assess evidence that could inform device implementation. A search was conducted in MEDLINE (Ovid) and EMBASE. Twenty-nine studies met the inclusion criteria. Role allocation is well described, with interprofessional collaboration dependent on culture, nurse:patient ratio, the use of protocols, and perception of responsibility. There were no descriptions of process measures, quality metrics, or clinical workflow. Nurse-led weaning is well-described, with factors grouped by patient, nurse, and system. Physician-led weaning is heterogenous, guided by subjective and objective information, and 'gestalt'. No studies explored decision-making with CDSS. Several explored facilitators and barriers to implementation, grouped by clinician (facilitators: confidence using CDSS, retaining decision-making ownership; barriers: undermining clinician's role, ambiguity moving off protocol), intervention (facilitators: user-friendly interface, ease of workflow integration, minimal training requirement; barriers: increased documentation time), and organisation (facilitators: system-level mandate; barriers: poor communication, inconsistent training, lack of technical support). One study described factors that support CDSS implementation. There are gaps in our understanding of ventilation practice. A coordinated approach grounded in implementation science is required to support CDSS implementation. Future research should describe factors that guide clinical decision-making throughout mechanical ventilation, with and without CDSS, map clinical workflow, and devise implementation toolkits. Novel research design analogous to a learning organisation, that considers the commercial aspects of device design, is required.
Topics: Humans; Respiration, Artificial; Decision Support Systems, Clinical; Clinical Decision-Making; Critical Care; Ventilator Weaning
PubMed: 38637268
DOI: 10.1016/j.bja.2024.03.011 -
Seminars in Fetal & Neonatal Medicine Dec 2023Non-invasive modes of respiratory support have been shown to be the preferable way of primary respiratory support of preterm infants with respiratory distress syndrome... (Review)
Review
Non-invasive modes of respiratory support have been shown to be the preferable way of primary respiratory support of preterm infants with respiratory distress syndrome (RDS). The avoidance of invasive mechanical ventilation can be beneficial for preterm infants in reduction of morbidity and even mortality. However, it is well-established that some infants managed with non-invasive respiratory support from the outset have symptomatic RDS to a degree that warrants surfactant administration. Infants for whom non-invasive respiratory support ultimately fails are prone to adverse outcomes, occurring at a frequency on par with the group intubated primarily. This raises the question how to combine non-invasive respiratory support with surfactant therapy. Several methods of less or minimally invasive surfactant therapy have been developed to address the dilemma between avoidance of mechanical ventilation and administration of surfactant. This paper describes the different methods of less invasive surfactant application, reports the existing evidence from clinical studies, discusses the limitations of each of the methods and the open and future research questions.
Topics: Infant; Infant, Newborn; Humans; Infant, Premature; Surface-Active Agents; Pulmonary Surfactants; Respiration, Artificial; Respiratory Distress Syndrome, Newborn; Lipoproteins
PubMed: 38040586
DOI: 10.1016/j.siny.2023.101496 -
Indian Journal of Gastroenterology :... Apr 2024The management of acute liver failure (ALF) in modern hepatology intensive care units (ICU) has improved patient outcomes. Critical care management of hepatic... (Review)
Review
The management of acute liver failure (ALF) in modern hepatology intensive care units (ICU) has improved patient outcomes. Critical care management of hepatic encephalopathy, cerebral edema, fluid and electrolytes; prevention of infections and organ support are central to improved outcomes of ALF. In particular, the pathogenesis of encephalopathy is multifactorial, with ammonia, elevated intra-cranial pressure and systemic inflammation playing a central role. Although ALF remains associated with high mortality, the availability of supportive care, including organ failure support such as plasma exchange, timely mechanical ventilation or continuous renal replacement therapy, either conservatively manages patients with ALF or offers bridging therapy until liver transplantation. Thus, appropriate critical care management has improved the likelihood of patient recovery in ALF. ICU care interventions such as monitoring of cerebral edema, fluid status assessment and interventions for sepsis prevention, nutritional support and management of electrolytes can salvage a substantial proportion of patients. In this review, we discuss the key aspects of critical care management of ALF.
Topics: Humans; Liver Failure, Acute; Critical Care; Hepatic Encephalopathy; Brain Edema; Plasma Exchange; Respiration, Artificial; Nutritional Support; Sepsis; Intensive Care Units; Renal Replacement Therapy; Liver Transplantation; Ammonia
PubMed: 38578565
DOI: 10.1007/s12664-024-01556-8 -
JAMA Network Open Jun 2024Guidelines recommend an analgesia-first strategy for sedation during mechanical ventilation, but associations between opioids provided during mechanical ventilation and...
IMPORTANCE
Guidelines recommend an analgesia-first strategy for sedation during mechanical ventilation, but associations between opioids provided during mechanical ventilation and posthospitalization opioid-related outcomes are unclear.
OBJECTIVE
To evaluate associations between an intravenous opioid dose received during mechanical ventilation and postdischarge opioid-related outcomes in medical (nonsurgical) patients.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study evaluated adults receiving mechanical ventilation lasting 24 hours or more for acute respiratory failure and surviving hospitalization. Participants from 21 Kaiser Permanente Northern California hospitals from January 1, 2012, to December 31, 2019, were included. Data were analyzed from October 1, 2020, to October 31, 2023.
EXPOSURES
Terciles of median daily intravenous fentanyl equivalents during mechanical ventilation.
MAIN OUTCOMES AND MEASURES
The primary outcome was the first filled opioid prescription in 1 year after discharge. Secondary outcomes included persistent opioid use and opioid-associated complications. Secondary analyses tested for interaction between opioid doses during mechanical ventilation, prior opioid use, and posthospitalization opioid use. Estimates were based on multivariable-adjusted time-to-event analyses, with death as a competing risk, and censored for hospice or palliative care referral, rehospitalization with receipt of opioid, or loss of Kaiser Permanente plan membership.
RESULTS
The study included 6746 patients across 21 hospitals (median age, 67 years [IQR, 57-76 years]; 53.0% male). Of the participants, 3114 (46.2%) filled an opioid prescription in the year prior to admission. The median daily fentanyl equivalent during mechanical ventilation was 200 μg (IQR, 40-1000 μg), with terciles of 0 to 67 μg, more than 67 to 700 μg, and more than 700 μg. Compared with patients who did not receive opioids during mechanical ventilation (n = 1013), a higher daily opioid dose was associated with opioid prescriptions in the year after discharge (n = 2942 outcomes; tercile 1: adjusted hazard ratio [AHR], 1.00 [95% CI, 0.85-1.17], tercile 2: AHR, 1.20 [95% CI, 1.03-1.40], and tercile 3: AHR, 1.25 [95% CI, 1.07-1.47]). Higher doses of opioids during mechanical ventilation were also associated with persistent opioid use after hospitalization (n = 1410 outcomes; tercile 3 vs no opioids: odds ratio, 1.44 [95% CI, 1.14-1.83]). No interaction was observed between opioid dose during mechanical ventilation, prior opioid use, and posthospitalization opioid use.
CONCLUSIONS AND RELEVANCE
In this retrospective cohort study of patients receiving mechanical ventilation, opioids administered during mechanical ventilation were associated with opioid prescriptions following hospital discharge. Additional studies to evaluate risks and benefits of strategies using lower opioid doses are warranted.
Topics: Humans; Male; Female; Analgesics, Opioid; Respiration, Artificial; Retrospective Studies; Middle Aged; Patient Discharge; Aged; California; Respiratory Insufficiency; Administration, Intravenous
PubMed: 38874921
DOI: 10.1001/jamanetworkopen.2024.17292