Ventilator-associated events: From surveillance to optimizing management

Mechanical ventilation (MV) is a life-support therapy that may predispose to morbid and lethal complications, with ventilator-associated pneumonia (VAP) being the most prevalent. In 2013, the Center for Disease Control (CDC) defined criteria for ventilator-associated events (VAE). Ten years later, a growing number of studies assessing or validating its clinical applicability and the potential benefits of its inclusion have been published. Surveillance with VAE criteria is retrospective and the focus is often on a subset of patients with higher than lower severity. To date, it is estimated that around 30% of ventilated patients in the intensive care unit (ICU) develop VAE. While surveillance enhances the detection of infectious and non-infectious MV-related complications that are severe enough to impact the patient's outcomes, there are still many gaps in its classification and management. In this review, we provide an update by discussing VAE etiologies, epidemiology, and classification. Preventive strategies on optimizing ventilation, sedative and neuromuscular blockade therapy, and restrictive fluid management are warranted. An ideal VAE bundle is likely to minimize the period of intubation. We believe that it is time to progress from just surveillance to clinical care. Therefore, with this review, we have aimed to provide a roadmap for future research on the subject.Copyright © 2022 The Author(s)

Lariat Loop

Insertion of nasogastric tube is one of the commonest clinical procedures. However, very rarely, the tube can coil on itself to form something called a Lariat loop. This is a knot that can cause the tube to get stuck inside the pharynx and can precipitate emergencies like laryngeal obstruction or esophageal rupture. A brief discussion of a case along with the causes and prevention of this complication has been done.

Arterial catheterization: is a new competence for internist?

Background: Arterial catheterization is frequently used in the management of critically ill patients, but their use in internal medicine is limited by the lack of monitoring systems and fewer nursing staff. The aim of our study is to demonstrate the safety of arterial catheters in the internal medicine ward. Materials and Methods: We conducted a retrospective cohort study between January 2018 and December 2021 at the Department of Internal Medicine 1 of the AOU Careggi. All patients with arterial catheters were enrolled. Patients with SARS-CoV2 infection were excluded. We conducted a univariate analysis on the association between self-removal of the device and complications. Results: We enrolled 488 patients. Mean age was 74.26±14.85 years. The main site of arterial access was radial artery (84.83%), followed by femoral artery (10.45%). The average length of stay of the device was 6.39±5.01 days, and in 3.48% there was an accidental self-removal of the device. The most frequent complication was mild bleeding (1.6%), followed by infection of the insertion site (0.8%) and distal embolization (0.3%). Delirium occurred in 20.3% of patients, and an association was found between delirium and self-removal of the arterial catheter (p <0.001, OR 5.35, CI 2.05-13-94). However, there was no association between delirium and any complications (p=1.000). Conclusions: arterial catheterization is a low-complication procedure;the internist should acquire this competence to deal with the presence of critically ill patients and the development of subintensive therapy units.