Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial

Background: There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. Methods: In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). Results: We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). Conclusions: Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

The role of ondansetron and gabapentin in subarachnoid anesthesia

Background. Ondansetron is a serotonin 5-HT3 receptor antagonist used mainly as an antiemetic. The aim of the study was to investigate a possible effect of ontansetron on the duration of motor and sensory block after intrathecal administration of ropivacaine.Methods. We studied 50 patients undergoing transurethral resection of prostate or/and resection of papillomas of the urinary bladder. In the evening before surgery all patients received either 8 mg oral ondansetron plus iv 8 mg ondansetron 15 min before subarachnoid anesthesia or placebo. Spinal anesthesia was induced with 2.2 ml of 0.75% plain ropivacaine. 30 min after the intrathecal injection of the local anesthetic and every other 30min, motor and sensory block were assessed. The endpoint of the measurements was the full recovery from the motor block.Results. The maximum level for sensory as well as for motor block was first assessed 30 min after spinal block induction by ropivacaine. The maximum level of the sensory block, defined as decreased sensation, was T8 in the control and T6 in the ondansetron group, and absence of sensation was defined as T11 and T9 for the control and the ondansetron groups, respectively. Block duration was also assessed 180 min after spinal anesthesia and motor block was detected in 1 of 22 and 0 of 24 in the control and ondansetron groups respectively.Conclusions. There was no clinical evidence of ondansetron on having any effect on the sensoy and motor block produced by ropivacain.Background. Gabapentin is an adjuvant analgesic and may enhance the spread of subarachnoid block. We investigated the effects of pretreatment with gabapentin on subarachnoid block characteristics and hemodynamics.Methods. Seventy patients undergoing transurethral procedures under subarachnoid anesthesia with 2.2 mL of 0.75% ropivacaine were randomly assigned to receive preoperatively 400 mg of gabapentin 6 hourly, up to a total dose of 1200 mg, or placebo. Sensory and motor blocks were assessed every 30 min until regression of sensory block to L4. At the same time intervals, systolic and diastolic arterial blood pressures and heart rate were recorded.Results. There were no differences between groups in the sensory block levels or degree of motor block. Sensory block 150 min after the subarachnoid injection had regressed to L4 in 26 of 32 patients in the gabapentin group and in 25 of the 33 patients in the control group. Systolic arterial blood pressure was decreased in the gabapentin group (p = 0.002 for the main effect of group, and p = 0.03 at 60 min between the groups). The diastolic arterial blood pressure did not differ between the groups, but overall, the heart rate was more rapid in the gabapentin group (p = 0.002, but only for baseline values between the groups, p = 0.036). Conclusions. Pretreatment with gabapentin had no effect on the spread of sensory block or the regression of motor block but was associated with lower systolic arterial blood pressure values in patients undergoing subarachnoid anesthesia with ropivacaine.Εισαγωγή. Σκοπός της μελέτης αυτής ήταν να μελετηθεί η επίδραση της οντανσετρόνης στη διάρκεια του αισθητικού και του κινητικού αποκλεισμού, που προκαλείται με τη χορήγηση του τοπικού αναισθητικού ροπιβακαίνη στη ραχιαία αναισθησία.Μέθοδος. Μελετήθηκαν 50 ασθενείς, που υποβλήθηκαν σε διουρηθρική προστατεκτομή ή / και σε αφαίρεση θηλωμάτων της ουροδόχου κύστης. Οι ασθενείς τυχαιοποιήθηκαν σε δύο ομάδες της οντανσετρόνης και στην ομάδα ελέγχου. Σε όλους τους ασθενείς έγινε ραχιαία αναισθησία με 2.2 ml ροπιβακαίνης 0.75%. Η ομάδα της οντανσετρόνης έλαβε 8mg per os το βράδυ της παραμονής του χειρουργείου και 8 mg ενδοφλεβίως 15 min πριν από τη ραχιαία αναισθησία. Στην ομάδα ελέγχου χορηγήθηκαν ταμπλέτα σακχαρίνης και φυσιολογικός ορός αντίστοιχα. Ακολούθησαν μετρήσεις ανά 30 min μετά τη ραχιαία αναισθησία για τον προσδιορισμό του κινητικού και του αισθητικού αποκλεισμού μέχρι την πλήρη αποκατάσταση της κίνησης των κάτω άκρων.Αποτελέσματα. Τριάντα λεπτά μετά τη ραχιαία καταγράφηκε και στις δύο ομάδες ο μέγιστος βαθμός αισθητικού και κινητικού αποκλεισμού, που ορίστηκε ως το δερμοτόμιο που υπήρχε μείωση της αίσθησης της αφής και της πίεσης. Όσο αφορά στην ομάδα της οντανσετρόνης ήταν το δερμοτόμιο Θ6 και το Θ8 για την ομάδα ελέγχου. Τα δερμοτόμια στα οποία καταγράφηκε πλήρης απουσία αίσθησης για την ομάδα της οντανσετρόνης ήταν το Θ9 και το Θ11 για την ομάδα ελέγχου αντίστοιχα. Η διάρκεια του αποκλεισμού αισθητικού και κινητικού δε διέφερε σημαντικά ανάμεσα στις δύο ομάδες σε όλη τη διάρκεια των μετρήσεων. Σε 11 από τους 22 και σε 16 από τους 24 ασθενείς υπήρχε αισθητικός αποκλεισμός στην ομάδα ελέγχου και οντανσετρόνης αντίστοιχα 180 min μετά τη ραχιαία αναισθησία. Κινητικός αποκλεισμός στο ίδιο χρονικό διάστημα δεν καταγράφηκε σε κανέναν από τους 24 στην ομάδα της οντανσετρόνης και σε 1 από τους 22 στην ομάδα ελέγχου.Συμπεράσματα. Η οντανσετρόνη, δεν είχε καμία συμμετοχή στον κινητικό ή αισθητικό αποκλεισμό, που προκλήθηκε μετά από ενδοραχιαία έγχυση ροπιβακαΐνης.Εισαγωγή. Η γκαμπαπεντίνη είναι ένα φάρμακο γνωστό για την αντιεπιλεπτική του δράση όσο και για την αναλγητική, ιδιαίτερα μετεγχειρητικά. Στερεοχημικά συγγενεύει με τον νευροδιανευροδιαβιβαστή GABA (γ-αμινοβουτυρικό οξύ) και αλληλεπιδρά με το GABA στις συνάψεις. Η αρχική υπόθεση ήταν, ότι είναι πιθανό να επιταχύνει την εγκατάσταση του υπαραχνοειδούς αποκλεισμού. Επιπρόσθετα, καταγράφηκε η επίδραση της γκαμπαπεντίνης στις αιμοδυναμικές παραμέτρους.Μέθοδος. 70 ασθενείς που θα υποβάλλονταν σε διουρηθρική προστατεκτομή ή σε αφαίρεση θηλωμάτων, υπό ραχιαία αναισθησία, τυχαιοποιήθηκαν σε δύο ομάδες. Στους ασθενείς της ομάδας της γκαμπαπεντίνης χορηγούνταν την παραμονή του χειρουργείου κάψουλες γκαμπαπεντίνης 400 mg από τις 18.00 μμ, στις 00.00 πμ και στις 06.00 πμ την ημέρα της επέμβασης, συνολικά 1200 mg. Οι ασθενείς στην ομάδα ελέγχου ελάμβαναν αντίστοιχα εικονικό φάρμακο. Η ραχιαία αναισθησία έγινε και στις δύο ομάδες των ασθενών ακολουθώντας την ίδια τεχνική, με ροπιβακαίνη 0.75%, 2.2 mL. 30 min μετά τη ραχιαία αναισθησία ακολουθούσε εκτίμηση του κινητικού και του αισθητικού αποκλεισμού με τη μέθοδο Bromage και με αισθητήρα πίεσης αντίστοιχα. Όταν η αποδρομή του αισθητικού αποκλεισμού εντοπιζόταν στο δερμοτόμιο Ο4, δεν πραγματοποιούνταν περαιτέρω μετρήσεις. Παράλληλα, κάθε 30 min, υπήρχε καταγραφή της συστολικής και της διαστολικής πίεσης ,καθώς και της καρδιακής συχνότητας. Αποτελέσματα. Σε 26 από τους 32 ασθενείς, στην ομάδα της γκαμπαπεντίνης, και σε 25 από τους 33, στην ομάδα ελέγχου ο αισθητικός αποκλεισμός είχε υποχωρήσει στο Ο4 δερμοτόμιο 150 min μετά τη ραχιαία αναισθησία. Οι τιμές της συστολικής αρτηριακής πίεσης, ήταν χαμηλότερες στην ομάδα της γκαμπαπεντίνης p = 0.002 και p = 0.03 στα 60 min μεταξύ των δύο ομάδων, ενώ οι τιμές της διαστολικής πίεσης δεν διέφεραν στατιστικά σημαντικά, ανάμεσα στις δύο ομάδες. Οι τιμές της καρδιακής συχνότητας, ήταν υψηλότερες στην ομάδα της γκαμπαπεντίνης, μόνο όμως σε αυτές τις τιμές που καταγράφηκαν πριν από τη ραχιαία αναισθησία p = 0.002 και p = 0.036 για τις δύο ομάδες.Συμπεράσματα. Η γκαμπαπεντίνη δεν είχε καμία επίδραση τόσο στην εγκατάσταση του αισθητικού αποκλεισμού, όσο και στην αποδρομή του κινητικού. Επιπλέον οι τιμές της συστολικής αρτηριακής πίεσης ήταν συνολικά χαμηλότερες στους ασθενείς που έλαβαν προεγχειρητικά γκαμπαπεντίνη

Relationship between biomarkers and subsequent clinical and angiographic restenosis after paclitaxel-eluting stents for treatment of STEMI: a HORIZONS-AMI substudy

Drug-eluting stents (DES) reduce the incidence of in-stent restenosis (ISR) after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Whether the use of biomarkers might be of utility to identify patients who remain at risk for DES ISR after primary PCI has never been examined. A total of 26 biomarkers were measured at enrollment and 30 days and analyzed at a central core laboratory in 501 STEMI patients from the HORIZONS-AMI trial. All patients underwent primary PCI with the TAXUS paclitaxel-eluting stent (PES), were scheduled for routine angiographic follow-up at 13 months, and were followed for 3 years. Mean in-stent late-loss was 0.28 +/- A 0.57 mm, and target lesion revascularization (TLR) at 3 years occurred in 9.1 % of patients. Low levels of interleukin-6 (IL-6) and placental growth factor (PLGF) at admission were associated with both higher in-stent late loss and ischemia-driven TLR. Additionally, low admission levels of cardiotrophin-1 (CT-1) were associated with higher rates of ischemia-driven TLR. At 30-day follow-up lower values of IL-1ra (IL-1ra), matrix metalloproteinase 9 (MMP9), and myeloperoxidase (MPO), and a decline relative to admission in IL-1ra, monocyte chemotactic protein-1 (MCP-1), and MMP9 were associated with higher in-stent late loss. Low values of IL-6 at 30 days were also associated with ischemia-driven TLR. After multivariate adjustment, only MPO at 30 days and a decline of MCP-1 between admission and 30 days were associated with in-stent late loss, and only CT-1 was associated with TLR. MPO at 30 days and a decline of MCP-1 between admission and 30 days were independently associated with in-stent late loss, and CT-1 was associated with TLR. Additional studies to confirm and validate the utility of these biomarkers are warrante

D-dimer levels predict ischemic and hemorrhagic outcomes after acute myocardial infarction: a HORIZONS-AMI biomarker substudy

D-dimer is a product of cross linked fibrin degradation and is a measure of the amount of fibrin turnover. As such, D-dimer might be of utility in the prediction of both thrombotic and hemorrhagic events. Therefore, the aim of the present study was to evaluate whether elevated D-dimer levels on admission and at discharge could predict subsequent ischemic and hemorrhagic events in patients with acute myocardial infarction (AMI). D-dimer was measured on admission and at discharge in 461 out of a total of 3,602 patients in the HORIZONS-AMI trial, as part of the formal prespecified biomarker substudy. The predictive value for major adverse cardiovascular events (MACE) and non-CABG major bleeding after 3 year follow up was investigated by stratifying patients in groups of D-dimer level and comparing event rates using Kaplan-Meier and calculating hazard ratios using Cox proportional hazards models. D-dimer levels ≥ 0.71 μg/mL on admission were associated with an adjusted hazard ratio of 2.58 for MACE (p = 0.0014) and 4.61 for major bleeding (p = 0.0018). A discharge D-dimer level ≥ 1.26 μg/mL was associated with a higher risk for MACE by univariate analysis (HR 1.88, p = 0.037), but lost its significance after multivariate adjustment (HR 1.77, p = 0.070). High D-dimer levels on admission were associated with a higher risk of MACE and non-CABG major bleeding in STEMI patients undergoing pPC

Impact of intravascular ultrasound imaging on early and late clinical outcomes following percutaneous coronary intervention with drug-eluting stents

This study sought to assess the impact of intravascular ultrasound (IVUS)-guided versus angiography-guided drug-eluting stent (DES) implantation. There are limited data on IVUS guidance in the DES era. Therefore, we investigated the impact of IVUS guidance on clinical outcomes in the MATRIX (Comprehensive Assessment of Sirolimus-Eluting Stents in Complex Lesions) registry. The MATRIX registry prospectively enrolled consecutive, unselected patients treated with sirolimus-eluting stents (SES) (n = 1,504); 631 patients (42%) underwent IVUS-guided stenting, and 873 (58%) had only angiographic guidance. We assessed 30-day, 1-year, and 2-year rates of death/myocardial infarction (MI), major adverse cardiac events (cardiac death, MI, or target vessel revascularization), and definite/probable stent thrombosis in 548 propensity-score matched patient pairs. After matching, baseline and angiographic characteristics were similar in IVUS and no-IVUS groups. Patients in the IVUS group had significantly less death/MI at 30 days (1.5% vs. 4.6%, p < 0.01), 1 year (3.3% vs. 6.5%, p < 0.01), and 2 years (5.0% vs. 8.8%, p < 0.01). Patients in the IVUS group had significantly less major adverse cardiac events at 30 days (2.2% vs. 4.8%, p = 0.04) and numerically less major adverse cardiac events at 1 year (9.1% vs. 13.5%, p = 0.07) and 2 years (12.9% vs. 16.7%, p = 0.18). Rates of MI were significantly lower in the IVUS group at 30 days (1.5% vs. 4.0%, p < 0.01), 1 year (1.8% vs. 4.8%, p < 0.01), and 2 years (2.1% vs. 5.7%, p < 0.01). IVUS-guided stent implantation appears to be associated with a reduction in both early and long-term clinical events. Further investigation in randomized controlled trials is warrante

Impact of intravascular ultrasound imaging on early and late clinical outcomes following percutaneous coronary intervention with drug-eluting stents

This study sought to assess the impact of intravascular ultrasound (IVUS)-guided versus angiography-guided drug-eluting stent (DES) implantation. There are limited data on IVUS guidance in the DES era. Therefore, we investigated the impact of IVUS guidance on clinical outcomes in the MATRIX (Comprehensive Assessment of Sirolimus-Eluting Stents in Complex Lesions) registry. The MATRIX registry prospectively enrolled consecutive, unselected patients treated with sirolimus-eluting stents (SES) (n = 1,504); 631 patients (42%) underwent IVUS-guided stenting, and 873 (58%) had only angiographic guidance. We assessed 30-day, 1-year, and 2-year rates of death/myocardial infarction (MI), major adverse cardiac events (cardiac death, MI, or target vessel revascularization), and definite/probable stent thrombosis in 548 propensity-score matched patient pairs. After matching, baseline and angiographic characteristics were similar in IVUS and no-IVUS groups. Patients in the IVUS group had significantly less death/MI at 30 days (1.5% vs. 4.6%, p < 0.01), 1 year (3.3% vs. 6.5%, p < 0.01), and 2 years (5.0% vs. 8.8%, p < 0.01). Patients in the IVUS group had significantly less major adverse cardiac events at 30 days (2.2% vs. 4.8%, p = 0.04) and numerically less major adverse cardiac events at 1 year (9.1% vs. 13.5%, p = 0.07) and 2 years (12.9% vs. 16.7%, p = 0.18). Rates of MI were significantly lower in the IVUS group at 30 days (1.5% vs. 4.0%, p < 0.01), 1 year (1.8% vs. 4.8%, p < 0.01), and 2 years (2.1% vs. 5.7%, p < 0.01). IVUS-guided stent implantation appears to be associated with a reduction in both early and long-term clinical events. Further investigation in randomized controlled trials is warrante