Enhancing Resident Skills in Mechanical Ventilation. What Do Residents Learn during Intensive Care Unit Rotations?
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ABSTRACT:
SUBMITTER: Maximous SI
PROVIDER: S-EPMC8043281 | biostudies-literature | 2021 Mar
REPOSITORIES: biostudies-literature
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Enhancing Resident Skills in Mechanical Ventilation. What Do Residents Learn during Intensive Care Unit Rotations?
Maximous Stephanie I SI Lee Burton W BW
ATS scholar 20210330 1
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Project description:ImportanceMechanical ventilation may be lifesaving, but in certain persons, such as those with advanced dementia, it may prolong patient suffering without a clear survival benefit.ObjectiveTo describe the use and outcomes of mechanical ventilation and its association with the increasing numbers of intensive care unit (ICU) beds in the United States for patients with advanced dementia residing in a nursing home 120 days before that hospital admission.Design, setting, and participantsThis retrospective cohort study evaluated Medicare beneficiaries with advanced dementia hospitalized from January 1, 2000, to December 31, 2013, using the Minimum Data Set assessments linked with Medicare part A claims. A hospital fixed-effect, multivariable logistic regression model examined the effect of changes in ICU beds within individual hospitals and the likelihood of receiving mechanical ventilation, controlling for patients' demographic characteristics, function, and comorbidities.Main outcomes and measuresMechanical ventilation.ResultsFrom 2000 to 2013, a total of 635 008 hospitalizations of 380 060 eligible patients occurred (30.5% male and 69.5% female; mean [SD] age, 84.4 [7.4] years). Use of mechanical ventilation increased from 39 per 1000 hospitalizations in 2000 to 78 per 1000 hospitalizations in 2013 (P < .001, test of linear trend). As the number of ICU beds in a hospital increased over time, patients with advanced dementia were more likely to receive mechanical ventilation (ie, adjusted odds ratio per 10 ICU bed increase, 1.06; 95% CI, 1.05-1.07). In 2013, hospitals in the top decile in the number of ICU beds were reimbursed $9611.89 per hospitalization compared with $8050.24 per hospitalization in the lower decile (P < .001) without an improvement in 1-year mortality (65.2% vs 64.6%; P = 54).Conclusions and relevanceAmong hospitalized nursing home residents with advanced dementia, we found an increase in the use of mechanical ventilation over time without substantial improvement in survival. This increase in the use of mechanical ventilation was associated with an increase in the number of ICU beds within a hospital.
| S-EPMC5138104 | biostudies-literature
Project description:AimsThe incidence of respiratory failure and use of invasive or non-invasive mechanical ventilation (MV) in the cardiac intensive care units (CICUs) is increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this volume-mortality relationship has not been characterized in the CICU.Methods and resultsNational population-based data were used to identify patients admitted to CICUs (2005-2015) requiring MV in Canada. CICUs were categorized into low (≤100), intermediate (101-300), and high (>300) volume centres based on spline knots identified in the association between annual MV volume and mortality. Outcomes of interest included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (>96 h) and CICU length of stay (LOS). Among 47 173 CICU admissions requiring MV, 89.5% (42 200) required invasive MV. The median annual CICU MV volume was 43 (inter-hospital range 1-490). Compared to low-volume centres (35.9%), in-hospital mortality was lower in intermediate [29.2%, adjusted odds ratio (aOR) 0.84, 95% confidence interval (CI) 0.72-0.97, P = 0.019] and high-volume (18.2%; aOR 0.82, 95% CI 0.66-1.02, P = 0.076) centres. Prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, aOR 0.70, 95% CI 0.55-0.89, P = 0.003) and intermediate-volume (23.0%, aOR 0.85, 95% CI 0.68-1.06, P = 0.14] centres. Mortality and prolonged MV were lower in percutaneous coronary intervention (PCI)-capable and academic centres, but a shorter CICU LOS was observed only in subgroup of PCI-capable intermediate- and high-volume hospitals.ConclusionsIn a national dataset, we observed that higher CICU MV volumes were associated with lower incidence of in-hospital mortality, prolonged MV, and CICU LOS. Our data highlight the need for minimum MV volume benchmarks for CICUs caring for patients with respiratory failure.
| S-EPMC9067446 | biostudies-literature
Project description:BackgroundIntensive care unit patients undergoing mechanical ventilation have traditionally been sedated to make them comfortable and to avoid pain and anxiety. However, this may lead to prolonged mechanical ventilation and a longer length of stay.ObjectiveThe aim of this retrospective study was to explore whether different sedation regimens influence the course and duration of the weaning process.Patients and methodsIntubated adult patients (n = 152) from 15 general intensive care units in Sweden were mechanically ventilated for ≥ 24 h. Patients were divided into three groups according to the sedative(s) received during the weaning period (i.e. from being assessed as 'fit for weaning' until extubation): dexmedetomidine alone (DEX group, n = 32); standard of care with midazolam and/or propofol (SOC group, n = 67); or SOC plus dexmedetomidine (SOCDEX group, n = 53).ResultsPatients receiving dexmedetomidine alone were weaned more rapidly than those in the other groups despite spending longer time on mechanical ventilation prior to weaning. Anxiety during weaning was present in 0, 9 and 24% patients in the DEX, SOC and SOCDEX groups, respectively. Anxiety after extubation was present in 41, 20 and 34% in the DEX, SOC and SOCDEX groups, respectively. Delirium during weaning was present in 1, 2 and 1 patient in the DEX, SOC and SOCDEX groups, respectively. Delirium at ICU discharge was present in 1, 0 and 3 patients in the DEX, SOC and SOCDEX groups, respectively. Few patients fulfilled criteria for post-traumatic stress disorder.ConclusionDexmedetomidine, used as a single sedative, may have contributed to a shorter weaning period than SOC or SOCDEX. Patients who received dexmedetomidine-only sedation tended to report better health-related quality of life than those receiving other forms of sedation.
| S-EPMC5951865 | biostudies-literature
Project description:IntroductionConsistent medical knowledge acquisition while caring for the critically ill can be challenging for learners and educators in the pediatric intensive care unit (PICU), a unit often distinguished by fluctuating acuity and severity. We implemented a standardized didactic curriculum for PICU residents to facilitate their acquisition and retention of knowledge in core PICU topics.MethodsWe developed a comprehensive standardized curriculum for PGY 2-PGY 4 PICU pediatric and internal medicine-pediatric residents. Thirteen core topics were administered as 30-minute didactic sessions during the rotation, using either PowerPoint slides or a dry-erase board. Residents were tested to assess knowledge acquisition and retention.ResultsSeventy-eight residents participated, 86% of whom completed posttests. Seventeen percent completed follow-up tests. Of the learners who participated, 60 (77%) completed pretests and posttests, indicating their confidence level each time. The pretest mean was 55% (SD = 14.4%), and the posttest mean was 64% (SD = 15.6%). This 9% increase was statistically significant (p = .001; CI, 3.9% to 14.8%). The follow-up test at 3 months, completed by 15% of this subgroup, demonstrated a mean score of 62% (SD = 14.5%). When matched with posttest scores (mean score of 64%, SD = 13.3%), there was no significant difference (p = .7398; CI, -11.7% to 16.2%), suggesting retention of previously acquired knowledge.DiscussionOur standardized didactic curriculum effectively facilitated the acquisition and retention of the medical knowledge of core PICU topics among PICU residents, in addition to their usual experiential learning.
| S-EPMC7566227 | biostudies-literature
Project description:BackgroundMechanical power (MP) has been reported to be associated with clinical outcomes. Because the original MP equation is derived from paralyzed patients under volume-controlled ventilation, its application in practice could be limited in patients receiving pressure-controlled ventilation (PCV). Recently, a simplified equation for patients under PCV was developed. We investigated the association between MP and intensive care unit (ICU) mortality.MethodsWe conducted a retrospective analysis of Korean data from the Fourth International Study of Mechanical Ventilation. We extracted data of patients under PCV on day 1 and calculated MP using the following simplified equation: MPPCV = 0.098 ∙ respiratory rate ∙ tidal volume ∙ (ΔPinsp + positive end-expiratory pressure), where ΔPinsp is the change in airway pressure during inspiration. Patients were divided into survivors and non-survivors and then compared. Multivariable logistic regression was performed to determine association between MPPCV and ICU mortality. The interaction of MPPCV and use of neuromuscular blocking agent (NMBA) was also analyzed.ResultsA total of 125 patients was eligible for final analysis, of whom 38 died in the ICU. MPPCV was higher in non-survivors (17.6 vs. 26.3 J/min, P<0.001). In logistic regression analysis, only MPPCV was significantly associated with ICU mortality (odds ratio, 1.090; 95% confidence interval, 1.029-1.155; P=0.003). There was no significant effect of the interaction between MPPCV and use of NMBA on ICU mortality (P=0.579).ConclusionsMPPCV is associated with ICU mortality in patients mechanically ventilated with PCV mode, regardless of NMBA use.
| S-EPMC11002610 | biostudies-literature
Project description:Among hospital-acquired infections (HAIs) in children, ventilator-associated pneumonia (VAP) is the most common after blood stream infection (BSI). VAP can prolong length of ventilation and hospitalization, increase mortality rate, and directly change a patient's outcome in Pediatric Intensive Care Units (PICU).The research on VAP in children is limited, especially in Iran; therefore, the identification of VAP incidence and mortality rate will be important for both clinical and epidemiological implications.Mechanically ventilated pediatric patients were assessed for development of VAP during hospital course on the basis of clinical, laboratory and imaging criteria. We matched VAP group with control group for assessment of VAP related mortality in the critically ill ventilated children.VAP developed in 22.9% of critically ill children undergoing mechanical ventilation. Early VAP and late VAP were found in 19.3% and 8.4% of VAP cases, respectively. Among the known VAP risk factors that were investigated, immunodeficiency was significantly greater in the VAP group (p = 0.014). No significant differences were found between the two groups regarding use of corticosteroids, antibiotics, PH (potential of hydrogen) modifying agents (such as ranitidine or pantoprazole), presence of nasogastric tube and total or partial parenteral nutrition administration. A substantial number of patients in the VAP group had more than four risk factors for development of VAP, compared to those without VAP (p = 0.087). Mortality rate was not statistically different between the VAP and control groups (p = 0.477).VAP is still one of the major causes of mortality in PICUs. It is found that altered immune status is a significant risk factor for acquiring VAP. Also, occurrence of VAP was high in the first week after admission in PICU.
| S-EPMC5532548 | biostudies-other
Project description:Outcomes in patients receiving invasive mechanical ventilation (IMV) are currently unclear. The present study aimed to explore the prognostic factors of the mortality rate on day 28 in patients treated in the intensive care unit (ICU) and undergoing IMV. The IMV Mortality Prediction Score (IMPRES) of 129 patients in the ICU receiving IMV after emergency (or selective) endotracheal intubation from March 2018 to August 2020 was calculated. The patients were divided into survival (n=73) and death groups (n=56) on day 28. The predictive factors of independent and combined mortality rates were determined using a receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC). The AUC of the IMPRES for predicting patient death on day 28 was 0.785 (95% confidence interval (CI): 0.704-0.864, P<0.01). When the IMPRES cut-off was 4.50, the Youden index was at its maximum (0.487) with a sensitivity of 85.7% and a specificity of 63.0%. The AUC of the ventilator use time (days) at 12.5 days cut-off was 0.653 (95% CI: 0.56-0.746, P<0.01), the Youden index was 0.235 with a sensitivity of 52.1% and a specificity of 71.4%. The AUC of the IMPRES combined with the duration of ventilator use was 0.856 (95% CI: 0.789-0.922, P<0.001), the Youden index was 0.635 with a sensitivity of 84.9% and a specificity of 78.6%. The IMPRES was observed to be the main factor influencing the mortality rate of patients receiving IMV at the ICU on day 28, and the IMPRES combined with the duration of ventilator use had a significant predictive value for the 28-day mortality rates of these patients.
| S-EPMC11332165 | biostudies-literature
Project description:Early recognition of risk factors for prolonged mechanical ventilation (PMV) could allow for early clinical interventions, prevention of secondary complications such as nosocomial infections, and effective triage of hospital resources. This study tested the hypothesis that an ensemble machine learning (ML) analysis of clinical data at time of intubation could identify patients at risk of PMV, using a COVID-19 dataset to classify patients into PMV (> 14 days) and non-PMV (≤ 14 days) groups. While several factors are known to cause PMV, including acid-base, weakness, and delirium, lesser-utilized but routinely measured parameters such as platelet count, glucose levels and fevers may also be relevant. Patient data from a single University Hospital were analyzed via the ML workflow to predict patients at risk of PMV and identify key clinical markers. Model performance was evaluated on a chronologically distinct cohort. The ML workflow identified patients at risk of PMV with AUROCTRAIN=0.960 (F1TRAIN = 0.935) and AUROCTEST=0.804 (F1TEST = 0.800). Top key features for classification included glucose, platelet count, temperature, LVEF, bicarbonate (arterial blood gas), and BMI. Data analysis at intubation time via the proposed workflow offers the potential to accurately predict patients at risk of PMV, with the goal to improve patient management and triage of hospital resources.
| S-EPMC11615281 | biostudies-literature
Project description:Introduction: Detection of early metabolic changes in critically-ill coronavirus disease 2019 (COVID-19) patients under invasive mechanical ventilation (IMV) at the intensive care unit (ICU) could predict recovery patterns and help in disease management. Methods: Targeted metabolomics of serum samples from 39 COVID-19 patients under IMV in ICU was performed within 48 h of intubation and a week later. A generalized linear model (GLM) was used to identify, at both time points, metabolites and clinical traits that predict the length of stay (LOS) at ICU (short ≤ 14 days/long >14 days) as well as the duration under IMV. All models were initially trained on a set of randomly selected individuals and validated on the remaining individuals in the cohort. Further validation in recently published metabolomics data of COVID-19 severity was performed. Results: A model based on hypoxanthine and betaine measured at first time point was best at predicting whether a patient is likely to experience a short or long stay at ICU [area under curve (AUC) = 0.92]. A further model based on kynurenine, 3-methylhistidine, ornithine, p-cresol sulfate, and C24.0 sphingomyelin, measured 1 week later, accurately predicted the duration of IMV (Pearson correlation = 0.94). Both predictive models outperformed Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and differentiated COVID-19 severity in published data. Conclusion: This study has identified specific metabolites that can predict in advance LOS and IMV, which could help in the management of COVID-19 cases at ICU.
| S-EPMC8387940 | biostudies-literature
