Cardiogenic oscillations to detect intratidal derecruitment and overdistension in a porcine model of healthy and atelectatic lungs.

BACKGROUND: Low positive end-expiratory pressure (PEEP) can result in alveolar derecruitment, and high PEEP or high tidal volume (VT) in lung overdistension. We investigated cardiogenic oscillations (COS) in the airway pressure signal to investigate whether these oscillations can assess unfavourable intratidal events. COS induce short instantaneous compliance increases within the pressure-volume curve, and consequently in the compliance-volume curve. We hypothesised that increases in COS-induced compliance reflect non-linear intratidal respiratory system mechanics. METHODS: In mechanically ventilated anaesthetised pigs with healthy (n=13) or atelectatic (n=12) lungs, pressure-volume relationships and the ECG were acquired at a PEEP of 0, 5, 10, and 15 cm H2O. During inspiration, the peak compliance of successive COS (CCOS) was compared with intratidal respiratory system compliance (CRS) within incremental volume steps up to the full VT of 12 ml kg-1. We analysed whether CCOS variation corresponded with systolic arterial pressure variation. RESULTS: CCOS-volume curves showed characteristic intratidal patterns depending on the PEEP level and on atelectasis. Increasing CRS- or CCOS-volume patterns were associated with intratidal derecruitment with low PEEP, and decreasing patterns above 6 ml kg-1 and high PEEP showed overdistension. CCOS was not associated with systolic arterial pressure variations. CONCLUSIONS: Heartbeat-induced oscillations within the course of the inspiratory pressure-volume curve reflect non-linear intratidal respiratory system mechanics. The analysis of these cardiogenic oscillations can be used to detect intratidal derecruitment and overdistension and, hence, to guide PEEP and VT settings that are optimal for respiratory system mechanics.

Impact of resuscitation fluid bag size availability on volume of fluid administration in the intensive care unit.

BACKGROUND: Iatrogenic fluid overload is associated with increased mortality in the intensive care unit (ICU). Decisions on fluid therapy may, at times, be based on other factors than physiological endpoints. We hypothesized that because of psychological factors volume of available fluid bags would affect the amount of resuscitation fluid administered to ICU patients. METHODS: We performed a prospective intervention cross-over study at 3 Swedish ICUs by replacing the standard resuscitation fluid bag of Ringer's Acetate 1000 mL with 500 mL bags (intervention group) for 5 separate months and then compared it with the standard bag size for 5 months (control group). Primary endpoint was the amount of Ringer's Acetate per patient during ICU stay. Secondary endpoints were differences between the groups in cumulative fluid balance and change in body weight, hemoglobin and creatinine levels, urine output, acute kidney failure (measured as the need for renal replacement therapy, RRT) and 90-day mortality. RESULTS: Six hundred and thirty-five ICU patients were included (291 in the intervention group, 344 in the control group). There was no difference in the amount of resuscitation fluid per patient during the ICU stay (2200 mL [1000-4500 median IQR] vs 2245 mL [1000-5630 median IQR]), RRT rate (11 vs 9%), 90-day mortality (11 vs 10%) or total fluid balance between the groups. The daily amount of Ringer's acetate administered per day was lower in the intervention group (1040 (280-2000) vs 1520 (460-3000) mL; P = .03). CONCLUSIONS: The amount of resuscitation fluid administered to ICU patients was not affected by the size of the available fluid bags. However, altering fluid bag size could have influenced fluid prescription behavior.

THAM administration reduces pulmonary carbon dioxide elimination in hypercapnia - an experimental porcine study.

BACKGROUND: In a previous study, we found a rebound of arterial carbon dioxide tension (PaCO2 ) after stopping THAM buffer administration. We hypothesized that this was due to reduced pulmonary CO2 elimination during THAM administration. The aim of this study was to investigate this hypothesis in an experimental porcine hypercapnic model. METHODS: In seven, initially normoventilated, anesthetized pigs (22-27 kg) minute ventilation was reduced by 66% for 7 h. Two hours after commencing hypoventilation, THAM was infused IV for 3 h in a dose targeting a pH of 7.35 followed by a 2 h observation period. Acid-base status, blood-gas content and exhaled CO2 were measured. RESULTS: THAM raised pH (7.07 ± 0.04 to 7.41 ± 0.04, P < 0.05) and lowered PaCO2 (15.2 ± 1.4 to 12.2 ± 1.1 kPa, P < 0.05). After the infusion, pH decreased and PaCO2 increased again. At the end of the observation period, pH and PaCO2 were 7.24 ± 0.03 and 16.6 ± 1.2 kPa, respectively (P < 0.05). Pulmonary CO2 excretion decreased from 109 ± 12 to 74 ± 12 ml/min (P < 0.05) during the THAM infusion but returned at the end of the observation period to 111 ± 15 ml/min (P < 0.05). The estimated reduction of pulmonary CO2 elimination during the infusion was 5800 ml. CONCLUSIONS: In this respiratory acidosis model, THAM reduced PaCO2 , but seemed not to increase the total CO2 elimination due to decreased pulmonary CO2 excretion, suggesting only cautious use of THAM in hypercapnic acidosis.

Editor's Choice - Prolonged ICU Length of Stay after AAA Repair: Analysis of Time Trends and Long-term Outcome.

OBJECTIVE: The aim of the study was to investigate the frequency and outcome of prolonged intensive care unit (ICU) length of stay (LOS) after abdominal aortic aneurysm (AAA) repair in the endovascular era. METHODS: All patients operated on for AAA between 1999 and 2013 at Uppsala University hospital were identified. Data were retrieved from the Swedish Vascular registry, the Swedish Intensive Care registry, the National Population registry, and case records. Prolonged ICU LOS was defined as ≥ 48 h during the primary hospital stay. Patients surviving ≥ 48 h after AAA surgery were included in the analysis. RESULTS: A total of 725 patients were identified, of whom 707 (97.5%) survived ≥ 48 h; 563 (79.6%) underwent intact AAA repair and 144 (20.4%) ruptured AAA repair. A total of 548 patients (77.5%) required < 48 h of intensive care, 115 (16.3%) 2-6 days and 44 (6.2%) ≥ 7 days. The rate of prolonged ICU LOS declined considerably over time, from 41.4% of all AAA repairs in 1999 to 7.3% in 2013 (p < .001) whereas the use of endovascular aortic repair (EVAR) increased from 6.9% in 1999 to 78.0% in 2013 (p < .001). The 30 day survival rate was 98.2% for those with < 48 h ICU stay versus 93.0% for 2-6 days versus 81.8% for ≥ 7 days (p < .001); the corresponding 90 day survival was 97.1% versus 86.1% versus 63.6% (p < .001) respectively. For patients surviving 90 days after repair, there was no difference in long-term survival between the groups. CONCLUSION: During the period of progressively increasing use of EVAR, a simultaneous significant reduction in frequency of prolonged ICU LOS occurred. Although prolonged ICU LOS was associated with a high short-term mortality, long-term outcome among those surviving the initial 90 days was less affected.

Malpositioning of fine bore feeding tube: a serious complication.

Feeding tubes are used frequently in the intensive care unit to provide enteral nutrition. For critically ill patients, enteral nutrition is preferable to parenteral in terms of cost, complication and gut mucosal maintenance. Fine bore feeding tubes are always preferred because their soft, flexible construction and narrow diameter enables these tubes to be well tolerated by patients and they rarely contribute to sinus infections or obstruction of breathing. On the other hand it is not uncommon that these tubes are misplaced in the tracheobronchial tree or the pleural cavity, especially in high-risk patients, i.e. sedated patients, patients with weak cough reflex, endotracheally intubated patients and agitated patients. Malpositioning in the peritoneal cavity or the mediastinum through gastric or esophageal perforation is also possible; even intravascular and intracranial misplacement have been reported. The incidence of misplacement of a feeding tube is difficult to estimate because few studies have been performed. The largest study of 1100 such tubes revealed an overall malposition rate of 1.3%, but it should be mentioned that this study included only radiographically detected misplacements. Other researchers estimate the occurrence of accidental misplacement and migration out of position as high as 13% to 20% in high-risk patients.

Good short-term agreement between measured and calculated tracheal pressure.

BACKGROUND: Tracheal pressure (P(tr)) is required to measure the resistance of the tracheal tube and the breathing circuit. P(tr) can either be measured with a catheter or, alternatively, calculated from the pressure-flow data available from the ventilator. METHODS: Calculated P(tr) was compared with measured P(tr) during controlled ventilation and assisted spontaneous breathing in 18 healthy and surfactant-depleted piglets. Their lungs were ventilated using different flow patterns, tidal volumes (V(T)) and levels of positive end-expiratory pressure. RESULTS: In terms of the root mean square error (RMS), indicating the average deviation of calculated from measured P(tr), the difference between calculated and measured P(tr) was 0.6 cm H(2)O (95%CI 0.58-0.65) for volume-controlled ventilation; 0.73 cm H(2)O (0.72-0.75) for pressure support ventilation; and 0.78 cm H(2)O (0.75-0.80) for bi-level positive airway pressure ventilation. CONCLUSION: The good agreement between calculated and measured P(tr) during varying conditions, suggests that calculating P(tr) could help setting the ventilator and choosing the appropriate level of support.