Emergency percutaneous tracheotomy in failed intubation

AbstractObjectiveCricothyrotomy is the emergency surgical means of gaining access to the airways. However it holds a lot of problems to the patient and is only a temporary measure until a definitive airway is reached. Griggs’ forceps technique for elective bedside percutaneous dilational tracheotomy (PDT) is safe, fast, and carries fewer complications in expert hands. This study aimed at comparing between emergency cricothyrotomy and emergency PDT in patients with failed intubation.DesignA comparative double blind study.SettingEmergency room of Alexandria main university hospitals.Patients169 failed to intubate, failed to ventilate patients.MethodsThey were serially randomized into group I (85 patients): percutaneous cricothyrotomy and group II (84 patients): PDT using Griggs’ forceps technique.ResultsSuccess rate was 95.3% in group I and 97.6% in group II. Procedure duration (in minutes) was 1.85±0.36 in group I versus 1.46±0.31 in group II. Lung atelectasis occurred to 8.2% of patients in group I only. Vocal cord injury occurred to 4.7% of patients in group I versus 1.2% in group II.ConclusionEmergency PDT is feasible and safe in expert hands

Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease

Background: Patients with COPD are frequently hospitalized for acute exacerbations (AECOPD), which may cause respiratory failure and death. Proportional assist ventilation (PAV) is a relatively new mode of ventilator-based, inspiratory support designed to assist spontaneous breathing in patients with intact neural drive. It is a form of synchronized partial ventilatory assistance with peculiar characteristic that ventilator generates pressure in proportion to patient’s instantaneous effort. Pressure support ventilation (PSV) is an attractive weaning mode, however at higher pressure support levels, many patients displayed expiratory muscle activation indicating that the patient is “fighting the ventilator”. Objective: To compare PAV and PSV in the weaning of AECOPD patients. Patients and methods: The study was conducted on 60 patients admitted to the Department of Critical Care Medicine, at the Alexandria Main University Hospital with the diagnosis of AECOPD. Exclusion criteria included those with severe cardiac or neurological disease, and those managed by non-invasive ventilation. All patients were subjected on admission to complete history taking, complete physical examination and laboratory investigations and were treated according to guidelines of treatment of AECOPD. At the time of weaning patients were randomly categorized into two equal groups; Group A: patients weaned using PAV and Group B: patients weaned using PSV and the two groups were assessed for weaning success, patient–ventilator dys-synchrony, MV days, ICU, and hospital stay. Results: The weaning success rate was 90% in group A, and 66.7% in group B. PAV was associated with less patient–ventilator dys-synchrony and was associated with 1.5 day reduction in the mean days of mechanical ventilation, 2 day reduction in the mean days of ICU stay, and 1.8 day reduction in the mean days of hospital stay in comparison to PSV group. Conclusion: PAV was associated with less patient–ventilator dys-synchrony and associated with reduction of days of mechanical ventilation, ICU, and hospital stay

Fluconazole and selective digestive decontamination for prevention of Candida infection in high risk critically ill patients

Objective: Invasive fungal infections are common in critically ill patients specially those on prolonged mechanical ventilation. Fungal prophylaxis has been proven effective in certain high-risk patients such as bone marrow transplant and other immunocompromized patients. This study aimed to evaluate prophylactic use of fluconazole and selective digestive decontamination (SDD) in the prevention of invasive Candida infections in high risk critically ill patients. Design: A prospective, randomized, placebo-controlled trial. Setting: Critical care department, Main Alexandria University Hospital. Patients: Seventy five critically ill patients with anticipated prolonged mechanical ventilation. Methods: They were randomly assigned to three groups; control group, SDD group, and SDD + fluconazole according to the type of the drug they had received. Cultures were obtained after 5, 10, and 15 days. End point was 15 days from admission or the occurrence of Candida infection. Results: In a time-to-event analysis, the SDD + fluconazole group showed an absolute risk reduction of 48% when compared to the control group, and 28% when compared to the SDD group. The number needed to treat was 2.08 in the SDD + Fluconazole group, while in the SDD group it was 5. Conclusion: SDD + fluconazole safely and effectively decreased the incidence of Candida infections in the high-risk, critically ill patients

Prognostic Role of Serum Adrenomedullin in Patients with Ventilator Associated Pneumonia

Objective: Ventilator associated pneumonia is a common type of sepsis that occurs to about 9–27% of all mechanically ventilated patients and 20–50% of them develop septic shock. Several clinical, laboratory, and radiological methods have been used for diagnosing VAP. Adrenomedullin (ADM) has been found to be elevated in the plasma of septic patients. The study aim was to explore the prognostic role of ADM in the VAP patients. Design: A prospective observational study. Setting: Intensive Care Department of Alexandria University Hospitals. Patients: A total of 140 patients with proven VAP after medical ICU admission were consecutively enrolled. Methods: APACHE II score, SOFA score, CRP, lactate, and serum ADM were measured at day 0 of VAP diagnosis and 5 days later. The results were correlated with the outcomes of patients. Results: APACHE II, lactate, and serum ADM on day 0 could predict an unfavorable outcome. ADM prediction power was significantly higher than APACHE II and lactate. Day 5 readings of all tested parameters could predict occurrence of the unfavorable outcome. ADM on day 0 showed the highest sensitivity (96.25%). Conclusions: Serum adrenomedullin when measured at days 0 and 5 of VAP diagnosis may serve as an early predictor of unfavorable outcome

Impact of implementing five-level triage system on patients outcomes and resource utilization in the emergency department of Alexandria main university hospital

ABSTRACTObjective To investigate impact of five-level triage system on Emergency Department (ED) patients’ outcome and resources’ utilization.Design A comparative observational study (pre-/post-intervention).Setting ED of Alexandria Main University Hospital.Patients All trauma patients and adult emergencies presented to ED from 1st of September 2021 to 31st of May 2022. Patients who were discharged or left against medical advice were excluded.Methods Five-level triage was implemented in 1st of December 2021 using Australasian Triage Scale. Primary outcome was ED mortality, while secondary outcomes were resources’ utilization and ED length of stay (LOS). Multivariate logistic regression model for predictors of ED mortality was used.Results Totally, 9766 and 22,936 patients were subjected to three- and five-level triaging, respectively. ED mortality dropped from 5.26% to 1.46%. All resources including human factors were less utilized. ED LOS has declined from 170.1 ± 88.7 to 72.00 ± 109.8 min. All changes were statistically significant, p  60 min, >5 differential diagnoses, more interventions, and longer ED LOS with different Odds ratios.Conclusion Five-level triaging reduced rates of mis-triaging, ED mortality, resources’ utilization, and ED LOS