Electrophysiological features and prognosis of Guillain-Barré syndrome in Israel: A single-center's 20 years' experience.

INTRODUCTION: We previously reported on 40 patients with Guillain-Barré syndrome (GBS) identified 1999-2005 at our center, and showed that a higher proportion had an axonal pattern, compared to Europe and North America. METHODS: Retrospective chart review of 100 adult patients with GBS between 2006 and 2018 at Shamir Medical Center. RESULTS: 46.8% of those with an abnormal EMG had an axonal pattern. Of the 60 patients who presented with mild disease (defined as Hughes score 1-2), walking deteriorated in 35 (58%, considering any worsening of Hughes score). 20 patients (33%) lost the ability to walk independently (Hughes score 3), 8 reached a point they could not walk (Hughes 4), and 2 needed mechanical ventilation. Ninety-four of 100 patients (94%) were treated with intravenous immunoglobulins (IVIg). Using ECG monitoring and DVT prophylaxis, IVIg-related adverse reactions were rare. CONCLUSIONS: This study demonstrated a higher proportion of axonal GBS patients in Israel, compared to European and North American patients, replicating the findings in the 1999-2005 patients. Due to the progressive nature of the disease, with more than half of patients presenting with mild disease deteriorating and needing inpatient rehabilitation - we advocate initiation of treatment once a clinical diagnosis of GBS is made.

Predictors of successful weaning in patients requiring extremely prolonged mechanical ventilation.

INTRODUCTION: For patients on prolonged mechanical ventilation (PMV; > 21 days), successful weaning has been attributed to various factors. The aim of this study is to determine the usefulness of the rapid shallow breathing index(RSBI) and other potential predictors of successful weaning in patients unable to wean and requiring extreme PMV at a hospital-based long-term ventilator facility in Israel. Material and ethods: Retrospective analysis of prospectively collected data over 5 years. RESULTS: A total of 150 subjects on PMV, ready to undergo a weaning process, were included in the study. Of them, 60 (40.0%) were males. The mean age of the whole study population was 76.5 years (SD = 13.6; range 22.0-96.0 years). The subjects were on MV for a mean period of 170.1 days (SD = 237.6; range 25.0-1624.0 days). Sixty patients (40%) were successfully weaned. The mean RSBI in the successfully weaned population was 41.9 breaths/min/L (SD = 12.3; range 13.0-80.4 breaths/min/L), in the population where weaning failed, it was 114.8 breaths/min/L (SD = 69.2; range 47.5-450.0 breaths/min/L). By univariate logistic regression analysis, younger age (p < 0.007), female gender (p < 0.001), decreased duration of MV (p < 0.023), re-spiratory rate (p < 0.001) and RSBI (p < 0.001), increased tidal volume/ideal body weight (p < 0.001) and minute ventilation (p < 0.01) were found to be factors that significantly predict successful weaning. By multivariate analysis, increased tidal volume/ /ideal body weight (p < 0.007) and decreased RSBI (p < 0.046) were found to be independent predictors of successful weaning (p < 0.001; R2 Nagelkerke = 0.90). CONCLUSIONS: Factors independently predicting successful weaning in patients requiring extreme PMV included increased tidal volume/ideal body weight and decreased RSBI.

Active surveillance cultures in critically ill patients: pathogens, patterns, and correlation with eventual bloodstream infections.

BACKGROUND: The role of routine active surveillance cultures (ASCs) in predicting consequent bloodstream infections is unclear. OBJECTIVES: To determine prospectively whether routine screening ASCs obtained on admission to the intensive care unit (ICU) can predict the causative agent of subsequent bloodstream infections. METHODS: We prospectively studied a cohort of 100 mechanically ventilated patients admitted consecutively to a 16-bed ICU. On admission, ASCs were obtained from four sites: skin cultures (swabs) from the axillary region, rectal swabs, nasal swabs, and deep tracheal aspirates. Thereafter, cultures were obtained from all four sites daily for the next 5 days of the ICU stay. RESULTS: Of the 100 recruited patients 31 (31%) had culture-proven bacteremia; the median time to development of bacteremia was 5 days (range 1-18). Patients with bacteremia had a longer median ICU stay than patients without bacteremia: 14 days (range 2-45) vs. 5 days (1-41) (P < 0.001). ICU and 28 day mortality were similar in patients with and without bacteremia. Most ASCs grew multiple organisms. However, there was no association between pathogens growing on ASCs and eventual development of bacteremia. CONCLUSIONS: ASCs obtained on ICU admission did not identify the causative agents of most subsequent bacteremia events. Therefore, bloodstream infections could not be related to ASCs.

A simplified approach to the management of gastric residual volumes in critically ill mechanically ventilated patients: a pilot prospective cohort study.

BACKGROUND: Enteral nutrition in the critically ill patient is often complicated by gastrointestinal intolerance, manifested by a large gastric residual volume. The frequency of GRV assessment and the intolerant level above which feeding is stopped is controversial. OBJECTIVES: To evaluate a novel approach to EN by allowing high GRV and once-daily assessment that was correlated with the paracetamol absorption test. METHODS: We conducted a pilot prospective study in an 18 bed general intensive care unit. The study group comprised 52 consecutive critically ill mechanically ventilated patients. Enteral nutrition was started at full delivery rate. Once-daily assessment of GRV with three consecutively repeated threshold volumes of 500 ml was performed before stopping EN. The paracetamol absorption test was performed and correlated to GRV. Patients were divided into two groups: low GRV (< 500 ml) and high GRV (at least one measurement of GRV > 500 ml). Clinical outcome included maximal calories delivered, incidence of pneumonia, ICU length of stay, and ICU and hospital mortality. RESULTS: There were 4 patients (9.5%) with ventilator-associated pneumonia in the low GRV group and 3 (30%) in the high GRV group (P = 0.12). GRV was inversely correlated to paracetamol absorption; however, neither GRV nor paracetamol absorption was associated with the development of pneumonia. Both groups had similar ICU length of stay (11.0 +/- 8.2 vs. 13.8 +/- 14.4 days, P = 0.41), and similar ICU (21% vs. 40%, P = 0.24) and hospital mortality (35% vs. 40%, P = 1.0). CONCLUSIONS: In critically ill mechanically ventilated patients, allowing larger gastric residual volumes, measured once daily, enables enteral feeding with fewer interruptions which results in high calorie intake without significant complications or side effects.

Optimization of endotracheal tube cuff filling by continuous upper airway carbon dioxide monitoring.

UNLABELLED: Inappropriate cuff filling is responsible for various complications related to the use of an endotracheal tube (ETT). In this study, we evaluated an objective, noninvasive method for continuous assessment of leak around the ETT cuff by monitoring carbon dioxide pressure (P(CO2) in the upper airway. P(CO2) levels were measured by capnography simultaneously between the ETT cuff and the vocal cords, at the oropharynx, and in the nares of the nose. Cuff filling was regulated by an electronic controller to achieve the minimal pressure needed to prevent CO2 leak. Feasibility of the method was assessed in a human simulator and in a porcine model. Clinical function was evaluated in 60 patients undergoing surgery, comparing the method to the standard anesthesiologist evaluation. Linear correlations were observed between the ETT cuff pressure and P(CO2) level in the human simulator (R2 = 0.954, P < 0.0001) and in the porcine model (R2 > 0.98, P < 0.0001). Iodine leak around the ETT cuff, in the porcine model, occurred only when P(CO2) levels were >2 mm Hg. In the surgery patients, the mean ETT cuff pressure determined clinically by the anesthesiologist was significantly higher than the optimal cuff pressure assessed by P(CO2) (25.2 +/- 3.6 versus 18.2 +/- 7.8 mm Hg, respectively; P < 0.001). According to these findings, optimal ETT cuff filling pressure can be identified by monitoring P(CO2) at the nares or the oropharynx. IMPLICATIONS: A new, objective, noninvasive method for optimizing endotracheal tube cuff filling based on monitoring carbon dioxide levels in the upper airways can be used to identify the minimal cuff pressure necessary to eliminate leak and prevent aspiration.

Extending the golden hour of hemorrhagic shock tolerance with oxygen plus hypothermia in awake rats. An exploratory study.

In a previous study of volume-controlled hemorrhagic shock (HS) in awake rats, without fluid resuscitation, either breathing of 100% oxygen or moderate hypothermia while breathing air, increased survival time. We hypothesized that combining oxygen and hypothermia can maximally extend the "golden hour" of HS from which resuscitation can be successful in terms of survival rate. Rats were prepared under light general anesthesia, breathing spontaneously via face mask, and then awakened for 2 h. Then, 3.25 ml arterial blood/100 g were withdrawn over 20 min. At the end of HS of 30, 60, 90 or 180 min duration, the shed blood was reinfused. Breathing was spontaneous. Survival endpoint was 24 h or earlier death. HS of 30 or 60 min was used for preliminary experiments; HS of 90 or 180 min for 35 definitive experiments. Control groups A-1 and B-1 had normothermia (rectal temperature 37.5 degrees C) and were breathing air. Treatment groups A-2 and B-2 had total body surface cooling during HS to rectal temperature 32 degrees C and were breathing 100% O(2). Arterial pressure during HS was higher in the hypothermia-O(2) groups. With HS of 90 min, in the normothermia-air group A-1 (n=10), none of the 10 rats survived to 3 h; while in the hypothermia-O(2) group A-2 (n=5), all rats survived to 24 h (P<0.001). With HS of 180 min, in the normothermia-air group B-1 (n=10), three of 10 rats survived to 3 h and 24 h (hypotension during HS in these three survivors was less severe than in the non-survivors); and in the hypothermia-O(2) group B-2 (n=10) all 10 rats survived to 24 h (P<0.003). We conclude that moderate hypothermia (32 degrees C) plus 100% oxygen inhalation during volume-controlled HS in awake rats mitigates hypotension and increases the chance of survival. It enables survival even after 3 h of moderate HS.