Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p<0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p<0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding

Ketamine has no preemptive analgesic effect in patients undergoing abdominal hysterectomy

WOS: 00045921590067

Intensive Care Unit

Objective: To determine the characteristics and outcomes of patients with prolonged stay in a tertiary-care ICU. Method: Electronic database records of patients 18 years or older and hospitalized in the ICU from March 2010 to March 2013 were enrolled. Age, gender, main reason for ICU admission, length of mechanical ventilation and ICU stay, in-hospital and one year mortality were noted. Results: The records of 1,908 patients from their initial ICU stays were analyzed. The mean Length Of Stay (LOS) for patients with a LOS >= 28 days (n: 215) was 85.6+/-81.9 days. The main disease category necessitating prolonged stays was neurologic disorders according to the diagnosis by the admission to ICU, while the main disease category necessitating a LOS< 28 days stays was elective surgery. Among the prolonged stay patients, 37 (17.2%) were alive one year post-discharge and only 13 (6%) were living independently. Conclusion: Patients with a prolonged ICU stay constituted a small percentage of all ICU admissions but they proportionally used many more ICU bed days than short-stay patients. The mortality of prolonged ICU stay patients was very high. Very few survivors were living independently at one year. Thus, development of intermediate care units, palliative care and home care services are emerging necessities, to decrease the LOS in ICUs

Black Hairy Tongue After Allogeneic Stem Cell Transplantation: An Unrecognized Cutaneous Presentation of Graft-Versus-Host Disease

Black hairy tongue (BHT) is an unusual condition in adults characterized by marked accumulation of keratin on the dorsum of the tongue, resulting in a hair-like appearance. Herein, we have described 15 patients developing BHT after allogeneic stem cell transplantation (allo-SCT). BHT was generally accompanied by other cutaneous manifestations of cutaneous graft-versus-host disease (GVHD) or a precursor of GVHD. Our experience in this series emphasized that histopathologic evaluation is required for seemingly harmless eruptions like BHT in the posttransplantation period. Given the important prognostic implications of GVHD, physicians should be careful when confronted with BHT

Black Hairy Tongue After Allogeneic Stem Cell Transplantation: An Unrecognized Cutaneous Presentation of Graft-Versus-Host Disease

Black hairy tongue (BHT) is an unusual condition in adults characterized by marked accumulation of keratin on the dorsum of the tongue, resulting in a hair-like appearance. Herein, we have described 15 patients developing BHT after allogeneic stem cell transplantation (allo-SCT). BHT was generally accompanied by other cutaneous manifestations of cutaneous graft-versus-host disease (GVHD) or a precursor of GVHD. Our experience in this series emphasized that histopathologic evaluation is required for seemingly harmless eruptions like BHT in the posttransplantation period. Given the important prognostic implications of GVHD, physicians should be careful when confronted with BHT