PRactice of VENTilation in Middle-Income Countries (PRoVENT-iMIC): rationale and protocol for a prospective international multicentre observational study in intensive care units in Asia
Luigi PisaniAnna Geke AlgeraAry Serpa NetoAreef AhsanAbigail BeaneKaweesak ChittawatanaratAbul FaizRashan HaniffaReza HashemianMadiha HashmiHisham Ahmed ImadKanishka IndraratnaShivakumar IyerGyan KayasthaBhuvana KrishnaHassan MoosaBehzad NadjmRajyabardhan PattnaikSriram SampathLouise ThwaitesNi Ni TunNor’azim Mohd YunosSalvatore GrassoFrederique PaulusMarcelo Gama de AbreuPaolo PelosiArjen M. DondorpMarcus J. Schultz
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Current evidence on epidemiology and outcomes of invasively mechanically ventilated intensive care unit (ICU) patients is predominantly gathered in resource-rich settings. Patient casemix and patterns of critical illnesses, and probably also ventilation practices are likely to be different in resource-limited settings. We aim to investigate the epidemiological characteristics, ventilation practices and clinical outcomes of patients receiving mechanical ventilation in ICUs in Asia.PRoVENT-iMIC (study of PRactice of VENTilation in Middle-Income Countries) is an international multicentre observational study to be undertaken in approximately 60 ICUs in 11 Asian countries. Consecutive patients aged 18 years or older who are receiving invasive ventilation in participating ICUs during a predefined 28-day period are to be enrolled, with a daily follow-up of 7 days. The primary outcome is ventilatory management (including tidal volume expressed as mL/kg predicted body weight and positive end-expiratory pressure expressed as cm H2O) during the first 3 days of mechanical ventilation-compared between patients at no risk for acute respiratory distress syndrome (ARDS), patients at risk for ARDS and in patients with ARDS (in case the diagnosis of ARDS can be made on admission). Secondary outcomes include occurrence of pulmonary complications and all-cause ICU mortality.PRoVENT-iMIC will be the first international study that prospectively assesses ventilation practices, outcomes and epidemiology of invasively ventilated patients in ICUs in Asia. The results of this large study, to be disseminated through conference presentations and publications in international peer-reviewed journals, are of ultimate importance when designing trials of invasive ventilation in resource-limited ICUs. Access to source data will be made available through national or international anonymised datasets on request and after agreement of the PRoVENT-iMIC steering committee.NCT03188770; Pre-results.Abstract The impact of mechanical ventilation on the daily costs of intensive care unit (ICU) care is largely unknown. We thus conducted a systematic search for studies measuring the daily costs of ICU stays for general populations of adults (age ≥18 years) and the added costs of mechanical ventilation. The relative increase in the daily costs was estimated using random effects meta regression. The results of the analyses were applied to a recent study calculating the excess length-of-stay associated with ICU-acquired (ventilator-associated) pneumonia, a major complication of mechanical ventilation. The search identified five eligible studies including a total of 54 766 patients and ~238 037 patient days in the ICU. Overall, mechanical ventilation was associated with a 25.8% (95% CI 4.7%–51.2%) increase in the daily costs of ICU care. A combination of these estimates with standardised unit costs results in approximate daily costs of a single ventilated ICU day of €1654 and €1580 in France and Germany, respectively. Mechanical ventilation is a major driver of ICU costs and should be taken into account when measuring the financial burden of adverse events in ICU settings.
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Factors associated with survival in patients undergoing invasive mechanical ventilation in an intensive care unit in Colombia Objective: To determine the clinical characteristics and outcomes of critically ill patients who required invasive mechanical ventilation in an intensive care unit of a high-complexity hospital in Colombia. Methods: This was a retrospective follow-up study of a cohort of adult patients who required invasive mechanical ventilation in an intensive care unit. Sociodemographic, clinical, and pharmacological variables were identified. Using Cox regression, variables associated with survival and complications were identified. Results: A total of 357 patients were analyzed. They had an average age of 64.8±18.9 years, and 52.9% were male. The most frequent diagnoses were sepsis/septic shock (38.4%) and trauma (17.4%). The main factors associated with shorter survival were advanced age (HR:0.97, 95%CI:0.96–0.99), a diagnosis of septic shock (HR:0.29; 95%CI:0.18–0.48) or diabetes mellitus at admission (HR:0.57; 95%CI:0.33–0.98), suffering from a healthcare-associated infection (HR: HR:0.51; 95%CI:0.33–0.80), and the need for vasopressors (HR:0.36; 95%CI:0.22–0.59). The administration of systemic corticosteroids was associated with a higher probability of survival (HR:1.93; 95%CI:1.15–3.25). Conclusions: The use of systemic corticosteroids was associated with a greater probability of survival in critically ill patients who required invasive mechanical ventilation in an intensive care unit. The identification of the variables associated with a higher risk of dying should allow care protocols to be improved, thereby extending the life expectancy of these patients.
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To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit.Retrospective cohort analysis using data from NDCHealth's Hospital Patient Level Database.A total of 253 geographically diverse U.S. hospitals.The study included 51,009 patients >/=18 yrs of age admitted to an intensive care unit between October 1, 2002, and December 31, 2002.None.Days of intensive care and mechanical ventilation were identified using billing data, and daily costs were calculated as the sum of daily charges multiplied by hospital-specific cost-to-charge ratios. Cost data are presented as mean (+/-sd). Incremental daily cost of mechanical ventilation was calculated using log-linear regression, adjusting for patient and hospital characteristics. Approximately 36% of identified patients were mechanically ventilated at some point during their intensive care unit stay. Mechanically ventilated patients were older (63.5 yrs vs. 61.7 yrs, p < .0001) and more likely to be male (56.1% vs. 51.8%, p < 0.0001), compared with patients who were not mechanically ventilated, and required mechanical ventilation for a mean duration of 5.6 days +/- 9.6. Mean intensive care unit cost and length of stay were 31,574 +/- 42,570 dollars and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and 12,931 +/- 20,569 dollars and 8.5 days +/- 10.5 for those not requiring mechanical ventilation. Daily costs were greatest on intensive care unit day 1 (mechanical ventilation, 10,794 dollars; no mechanical ventilation, 6,667 dollars), decreased on day 2 (mechanical ventilation:, 4,796 dollars; no mechanical ventilation, 3,496 dollars), and became stable after day 3 (mechanical ventilation, 3,968 dollars; no mechanical ventilation, 3,184 dollars). Adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was 1,522 dollars per day (p < .001).Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter. Mechanical ventilation is associated with significantly higher daily costs for patients receiving treatment in the intensive care unit throughout their entire intensive care unit stay. Interventions that result in reduced intensive care unit length of stay and/or duration of mechanical ventilation could lead to substantial reductions in total inpatient cost.
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Mechanical ventilation is one of the important measures for the treatment of acute respiratory distress syndrome(ARDS).As in recent years,further study of the pathology of ARDS,mechanical ventilation strategy gradually developed from past tidal volume lung protective ventilation strategy.This paper described the new development of mechanical ventilation strategy for ARDS patients,provide a reference for clinical ventilation in the treatment of patients with ARDS.
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【Objective】 To investigate the effect of different fluid managements on the prognosis of patients with ARDS.【Methods】A total of 42 patients with ARDS were enrolled in the study and were divided randomly into 2 groups:liberal and limited strategy respectively.We monitored the death at 60 days,the days of using ventilator,days in the intensive care unit,the change of PaO2/FiO2,ARDS score,Peak pressure and so on.【Results】 The death at 60 days was lower in limited strategy than in liberal strategy.Oxygenation index improved,so do the lung injury score,the days of using ventilator and days in the intensive care unit decreased in the limited strategy as compared with the liberal strategy(P0.05).【Conclusion】 A limited strategy of fluid management may be better for ARDS patients than liberal strategy.
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This study aimed to characterize which are the early determinants of immediate failure of the use of noninvasive mechanical ventilation (NIMV) outside the ICU.This prospective study included patients who were admitted to the Military Hospital in Guayaquil, Ecuador. Each variable was analyzed independently by using a multiple logistic regression model toward establishing an association with the event.A total of 249 cases of NIMV over a 10 year period of its application outside the ICU was included in the study. Fifty-five (22.10%) patients were transferred to the ICU, A multivariate analysis showed that the determinants of immediate NIMV failure outside the ICU were the following: age (OR: 1.12; P = 0.03); SBP (OR: 1.04; P = 0.001); HR (OR: 1.66; P < 0.0001); pCO₂ (OR: 1.16; P = 0.007); pO2 (OR: 1.35; P = 0.003); levels of IPAP (OR: 1.35; P < 0.0001); and the number of quadrants affected, as shown in a chest X-ray (OR: 1.40; P < 0.0001).The number of affected quadrants in a chest X-ray, tachyarrhythmia and hypoxemia may be useful in the initial decision in the use of NIMV outside the ICU. High values of IPAP, the persistence of elevated pCO₂, arterial hypotension, and age could be useful as a second screening associated with immediate NIMV failure outside the ICU.
Noninvasive Ventilation
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The purpose of the study was to reveal the predictors of more than 24-hour intensive care unit stay for patients activated early (up to 5 hours) after surgery under extracorporeal circulation and to explore the possibilities of predicting the prolongation of postoperative intensive care in the clinical situation under examination. The protocols of anesthetic maintenance, early activation, and postoperative intensive care were analyzed in 83 patients (50 males and 33 females) aged 31 to 82 years, who had been operated on under extracorporeal circulation for various cardiosurgical diseases. The multiple regression analysis showed that the significant predictors of more prolonged intensive care after early activation were the level of arterial lactatemia (p = 0.0021), the dosages of adrenaline and/or noradrenaline (p = 0.0048), age (p = 0.0051), and female sex (p = 0.0142). It was shown that the multiple regression analysis could approximately predict the duration of intensive care after early activation. The predicted and actual durations of intensive care in patients with an intensive care unit stay length of more than 24 hours coincided in 52% of cases. In patients with an intensive care unit stay length of less than 24 hours, the estimated and actual durations of intensive care were in agreement in 92% of cases. It is concluded that it is expedient to take into account the results of the performed analysis in choosing the optimum postoperative management policy in cardiosurgical patients who are to undergo early activation.
Extracorporeal circulation
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Etiology
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