Self-Extubation Revisited: A Case-Control Study.

BACKGROUND: To increase the understanding of the self-extubation phenomena, we assessed its rate in our medical ICU and aimed to identify the risk factors of self-extubation and the risk factors for re-intubation. METHODS: We prospectively identified subjects who self-extubated. Their baseline characteristics, including the Richmond Agitation Severity Scale score, reason for intubation, shift, distance of the endotracheal tube tip to the carina, and outcomes were collected retrospectively. For every subject who self-extubated, a control subject was selected from the mechanical ventilation database. RESULTS: During the study period, there were 2,578 admissions with 4,072 mechanical ventilation days. Fifty-three cases of self-extubation were recorded, which resulted in a self-extubation event rate of 1.3 per 100 days of mechanical ventilation. Forty-five controls were identified. The most common reason for intubation was hypoxic respiratory failure, followed by the need for airway protection and hypercapnic respiratory failure. Sedation was administered continuously in 34% of the subjects. Thirty-seven percent received no sedation. At the time of the event, the subjects who self-extubated had a higher Richmond Agitation Severity Scale score, a longer distance from the endotracheal tip to carina on the chest radiograph preceding the event, and a shorter duration of mechanical ventilation, and were more likely to be on volume-controlled mechanical ventilation. ICU mortality was lower in the self-extubation group, despite having a trend toward a higher Simplified Acute Physiology Score II. Sixteen subjects required re-intubation. Independent predictors of re-intubation were hypoxic respiratory failure as the reason for the initial intubation and self-extubation that occurred at night. The need for re-intubation was not associated with higher mortality. CONCLUSIONS: Results of our study showed that, in the era of reduced use of sedatives in the ICU, clinicians must be vigilant of the risk of self-extubation in the first 2 d of mechanical ventilation in patients who are agitated and with a longer endotracheal tube to carina distance on chest radiograph.

Ultrasound-Assessed Gastric Antral Area Correlates With Aspirated Tube Feed Volume in Enterally Fed Critically Ill Patients.

BACKGROUND: Enteral tube feed (ETF) intolerance occurs frequently in hospitalized patients and more so in critically ill patients. Most critical care nurses continue to assess gastric residual volume (GRV), especially among those with a history of ETF intolerance. We hypothesized that ultrasound assessment of GRV correlates directly with aspirated tube feed volume. METHODS: This was a prospective cohort study of a convenience sample of critically ill mechanically ventilated patients admitted to an intensive care unit receiving ETF. The gastric antrum was imaged using the aorta and inferior vena cava (IVC) as landmarks concurrently and simultaneously using a curvilinear probe in the midline. All ultrasound measurements were performed at 30 degrees head up, in the supine position, and prior to the assessment of GRV by nursing staff blinding the ultrasonographer to gastric volume aspirated. Gastric antral area was determined by assessing anteroposterior (AP) and craniocaudal (CC) diameters of the gastric antrum. RESULTS: Gastric cross-sectional area (CSA) using IVC as a landmark ( R2 = 0.92, P < .0001) and aorta as a landmark ( R2 = 0.86, P < .0001) correlated with aspirated volume. CC diameter of the stomach measured using the aorta as a landmark correlated with aspirated volume and increased linearly with increasing GRV ( R2 = 0.78, P < .0001). A CC diameter of <10 cm using the aorta as a landmark predicted a gastric volume of <500 mL. CONCLUSIONS: Ultrasound assessment provides accurate assessment of gastric volume in real-life settings, and the CC diameter of the gastric antrum provides a simple surrogate of GRV.

Therapeutic hypothermia at an urban public hospital: Development, implementation, experience and outcomes.

BACKGROUND: Therapeutic hypothermia (TH) improves the outcome of comatose patients suffering an out-of-hospital sudden cardiac arrest (SCA) with shockable rhythm and return of spontaneous circulation (ROSC). Evidence supporting its use in other circumstances is weak and the adoption of TH remains limited. OBJECTIVE: Describe the development and implementation of a TH program at an urban public hospital and report outcomes of out-of-hospital and in-hospital SCA and important quality measures. METHODS: The protocol was developed at 464-bed urban public hospital. We assembled historical and prospective samples of patients suffering an SCA. We measured the neurologic outcome of patients at the time of hospital discharge who underwent TH after SCA. We compared outcomes and important quality measures (duration of arrest, time to cooling, and time to target temperature) to existing literature. We determined reasons for not using TH in patients with in-hospital SCA. RESULTS: We described the development of our TH program and the challenges we faced implementing it. Of 45 patients treated with TH after SCA, 23 (51%) survived to discharge, 14 (31%) with good neurologic outcomes. In comparison to historical controls, TH did not improve outcome of in-hospital SCA. SCA from a shockable rhythm was associated with the best outcome. The time from return of spontaneous circulation to initiation of TH was consistently within 8 h. CONCLUSIONS: Despite logistical and financial constraints, we were able to rapidly implement a TH program with quality and outcomes similar to published data. TH did not improve outcomes for patients with an in-hospital SCA.

Interrater Reliability of Surveillance for Ventilator-Associated Events and Pneumonia.

OBJECTIVE To compare interrater reliabilities for ventilator-associated event (VAE) surveillance, traditional ventilator-associated pneumonia (VAP) surveillance, and clinical diagnosis of VAP by intensivists. DESIGN A retrospective study nested within a prospective multicenter quality improvement study. SETTING Intensive care units (ICUs) within 5 hospitals of the Centers for Disease Control and Prevention Epicenters. PATIENTS Patients who underwent mechanical ventilation. METHODS We selected 150 charts for review, including all VAEs and traditionally defined VAPs identified during the primary study and randomly selected charts of patients without VAEs or VAPs. Each chart was independently reviewed by 2 research assistants (RAs) for VAEs, 2 hospital infection preventionists (IPs) for traditionally defined VAP, and 2 intensivists for any episodes of pulmonary deterioration. We calculated interrater agreement using κ estimates. RESULTS The 150 selected episodes spanned 2,500 ventilator days. In total, 93-96 VAEs were identified by RAs; 31-49 VAPs were identified by IPs, and 29-35 VAPs were diagnosed by intensivists. Interrater reliability between RAs for VAEs was high (κ, 0.71; 95% CI, 0.59-0.81). Agreement between IPs using traditional VAP criteria was slight (κ, 0.12; 95% CI, -0.05-0.29). Agreement between intensivists was slight regarding episodes of pulmonary deterioration (κ 0.22; 95% CI, 0.05-0.39) and was fair regarding whether episodes of deterioration were attributable to clinically defined VAP (κ, 0.34; 95% CI, 0.17-0.51). The clinical correlation between VAE surveillance and intensivists' clinical assessments was poor. CONCLUSIONS Prospective surveillance using VAE criteria is more reliable than traditional VAP surveillance and clinical VAP diagnosis; the correlation between VAEs and clinically recognized pulmonary deterioration is poor. Infect Control Hosp Epidemiol 2017;38:172-178.

The Accuracy of Portable Monitoring in Diagnosing Significant Sleep Disordered Breathing in Hospitalized Patients.

BACKGROUND: Polysomnograms are not always feasible when sleep disordered breathing (SDB) is suspected in hospitalized patients. Portable monitoring is a practical alternative; however, it has not been recommended in patients with comorbidities. OBJECTIVE: We evaluated the accuracy of portable monitoring in hospitalized patients suspected of having SDB. DESIGN: Prospective observational study. SETTING: Large, public, urban, teaching hospital in the United States. PARTICIPANTS: Hospitalized patients suspected of having SDB. METHODS: Patients underwent portable monitoring combined with actigraphy during the hospitalization and then polysomnography after discharge. We determined the accuracy of portable monitoring in predicting moderate to severe SDB and the agreement between the apnea hypopnea index measured by portable monitor (AHIPM) and by polysomnogram (AHIPSG). RESULTS: Seventy-one symptomatic patients completed both tests. The median time between the two tests was 97 days (IQR 25-75: 24-109). Forty-five percent were hospitalized for cardiovascular disease. Mean age was 52±10 years, 41% were women, and the majority had symptoms of SDB. Based on AHIPSG, SDB was moderate in 9 patients and severe in 39. The area under the receiver operator characteristics curve for AHIPM was 0.8, and increased to 0.86 in patients without central sleep apnea; it was 0.88 in the 31 patients with hypercapnia. For predicting moderate to severe SDB, an AHIPM of 14 had a sensitivity of 90%, and an AHIPM of 36 had a specificity of 87%. The mean±SD difference between AHIPM and AHIPSG was 2±29 event/hr. CONCLUSION: In hospitalized, symptomatic patients, portable monitoring is reasonably accurate in detecting moderate to severe SDB.

The validity and reliability of the clinical assessment of increased work of breathing in acutely ill patients.

BACKGROUND: Mechanical ventilation is frequently indicated to reduce the work of breathing. Because it cannot be measured easily at the bedside, physicians rely on surrogate measurements such as patient appearance of distress and increased breathing effort. OBJECTIVE: We determined the validity and reliability of subjectively rating the appearance of respiratory distress and the reliability of 11 signs of increased breathing effort. SUBJECTS: The study included consecutive, acutely ill patients requiring various levels of respiratory support. METHODS: Blinded to each other's observations, a fellow and a critical care consultant rated the severity of distress (absent, slight, moderate, severe) after observing subjects for 10 seconds and then determined the presence of the signs of increased breathing effort. RESULTS: A total of 149 paired examinations occurred 6±6 minutes apart. The rating of respiratory distress correlated with oxygenation, respiratory rate, and 9 signs of increased work of breathing. It had the highest intraclass correlation coefficient (0.69; 95% confidence interval, 0.59-0.78). Rating distress as moderate to severe had a sensitivity of 70%, specificity of 92%, and positive likelihood ratio of 8 for the presence of 3 or more of hypoxia, tachypnea, and any sign of increased breathing effort. Agreement was moderate (κ = 0.53-0.47) for rating of distress, nasal flaring, scalene contraction, gasping, and abdominal muscle contraction, and fair (κ = 0.36-0.23) for sternomastoid contraction, tracheal tug, and thoracoabdominal paradox. CONCLUSION: Assessing the increased work of breathing by rating the severity of respiratory distress based on subject appearance is a valid and moderately reliable sign that predicts the presence of serious respiratory dysfunction. The reliability of the individual signs of increased breathing effort is moderate at best.

Association between rating of respiratory distress and vital signs, severity of illness, intubation, and mortality in acutely ill subjects.

BACKGROUND: When deciding whether mechanical ventilation is indicated, physicians integrate their findings on physical examination in a gestalt known as respiratory distress. Despite its importance, this gestalt is poorly understood. This study aims to describe the association between the rating of the severity of respiratory distress and vital signs, severity of illness, use of mechanical ventilation, and death. A prospective observational study with 1,134 consecutive subjects with uncertain triage evaluated by a critical care consult team was carried out in a public inner city teaching hospital. METHODS: After the initial evaluation of each patient, a critical care physician rated the level of respiratory distress. We recorded vital signs, diagnosis, and laboratory results and calculated the Acute Physiology and Chronic Health Evaluation (APACHE) II score. We recorded if mechanical ventilation was initiated by 72 h and if the subject died during the hospitalization. RESULTS: The most common diagnoses were respiratory illnesses. Higher distress levels were associated with higher breathing frequency (20, 22, 27, and 30 breaths/min, P < .001) and heart rate (96, 101, 109, and 116 beats/min, P < .001) and lower S(pO2) (97, 95, 93, and 92%, P < .001). These variables explain only a small portion of the variance of distress. Distress correlated weakly with the APACHE II score (r = 0.22, P = .001). Blood pressure, temperature, Glasgow coma scale score, and laboratory data were unrelated to the levels of distress. However, higher levels of distress correlated with intubation rates (5, 13, 27, and 41%, P < .001). The area under the receiver operating characteristic curve for respiratory distress predicting intubation (0.72) was larger than that for breathing frequency (0.65). Distress was an independent predictor of intubation but not of death. CONCLUSIONS: A physician's rating of respiratory distress is independently predictive of intubation in 72 h. Vital signs explain only a small proportion of variance in distress; the other observations contributing to a physician's rating of distress must be determined.