Mechanical ventilation for older medical patients in a large tertiary medical care center.

BACKGROUND: The development of technologies for the prolongation of life has resulted in an increase in the number of older ventilated patients in internal medicine and chronic care wards. Our study aimed to determine the factors influencing the outcomes of older ventilated medical patients in a large tertiary medical center. METHODS: We performed a prospective observational cohort study including all newly ventilated medical patients aged 65 years and older over a period of 18 months. Data were acquired from computerized medical records and from an interview of the medical personnel initiating mechanical ventilation. RESULTS: A total of 554 patients underwent mechanical ventilation for the first time during the study period. The average age was 79 years, and 80% resided at home. Following mechanical ventilation, 8% died in the emergency room, and the majority of patients (351; 63%) were hospitalized in internal medicine wards. In-hospital mortality was 64.1%, with 48% dying during the first week of hospitalization. Overall 6-months survival was 26%. We found that a combination of age 85 years and older, functional status prior to ventilation, and associated morbidity (diabetes with target organ injury and/or oncological solid organ disease) were the strongest negative predictors of survival after discharge from the hospital. CONCLUSION: Mechanical ventilation at older age is associated with poor survival and it is possible to identify factors predicting survival. In the midst of the COVID-19 pandemic, the findings of this study may help in the decision-making process regarding mechanical ventilation for older people.

Optimization of Endotracheal Tube Cuff Pressure by Monitoring CO2 Levels in the Subglottic Space in Mechanically Ventilated Patients: A Randomized Controlled Trial.

BACKGROUND: Many of the complications of mechanical ventilation are related to inappropriate endotracheal tube (ETT) cuff pressure. The aim of the current study was to evaluate the effectiveness of automatic cuff pressure closed-loop control in patients under prolonged intubation, where presence of carbon dioxide (CO2) in the subglottic space is used as an indicator for leaks. The primary outcome of the study is leakage around the cuff quantified using the area under the curve (AUC) of CO2 leakage over time. METHODS: This was a multicenter, prospective, randomized controlled, noninferiority trial including intensive care unit patients. All patients were intubated with the AnapnoGuard ETT, which has an extra lumen used to monitor CO2 levels in the subglottic space.The study group was connected to the AnapnoGuard system operating with cuff control adjusted automatically based on subglottic CO2 (automatic group). The control group was connected to the AnapnoGuard system, while cuff pressure was managed manually using a manometer 3 times/d (manual group). The system recorded around cuff CO2 leakage in both groups. RESULTS: Seventy-two patients were recruited and 64 included in the final analysis. The mean hourly around cuff CO2 leak (mm Hg AUC/h) was 0.22 ± 0.32 in the manual group and 0.09 ± 0.04 in the automatic group (P = .01) where the lower bound of the 1-sided 95% confidence interval was 0.05, demonstrating noninferiority (>-0.033). Additionally, the 2-sided 95% confidence interval was 0.010 to 0.196, showing superiority (>0.0) as well. Significant CO2 leakage (CO2 >2 mm Hg) was 0.027 ± 0.057 (mm Hg AUC/h) in the automatic group versus 0.296 ± 0.784 (mm Hg AUC/h) in the manual group (P = .025). In addition, cuff pressures were in the predefined safety range 97.6% of the time in the automatic group compared to 48.2% in the automatic group (P < .001). CONCLUSIONS: This study shows that the automatic cuff pressure group is not only noninferior but also superior compared to the manual cuff pressure group. Thus, the use of automatic cuff pressure control based on subglottic measurements of CO2 levels is an effective method for ETT cuff pressure optimization. The method is safe and can be easily utilized with any intubated patient.

Vaccination as primary prevention? The effect of anti-pneumococcal vaccination on the outcome of patients suffering traumatic skull base fractures.

BACKGROUND: As many as 360,000 people suffer yearly from skull base fractures (SBF). These may be associated with a dural tear, hemosinus, otorrhea or rhinorrhea. The most common causative agent of post-traumatic meningitis is Streptococcus Pneumonia (Pneumococcus). PNEUMOVAX 23 is a potent vaccine against Pneumococcus, but head trauma involving any skull fractures are not defined indications for its use. Our aim was to identify the effect of PNEUMOVAX on the natural course and incidence of infections and infectious prognosis following SBF. METHODS: A retrospective review of patients suffering a traumatic SBF who were admitted to the Department of Neurosurgery at a single tertiary hospital referred from the entire north of Israel during 2002-2009 were characterized. Six hundred and two patients patients were included in the study; 99 patients received the PNEUMOVAX in the first few days of hospitalization, while 503 patients did not. Demographic data, presenting symptoms, chronic illnesses and radiologic features were logged. Treatment regimens were logged as well, including the use of PNEUMOVAX vaccine. Outcome parameters including infectious complications and functional state were logged at different set time points after admission. RESULTS: The group receiving the vaccine had a significantly older mean age, higher incidence of obesity, higher rate of headache or confusion on presentation, and a significantly higher incidence of additional cranial injuries. All these factors, known to worsen the outcome of SBF patients did not manifest in the vaccinated group. There was no statistically significant differences between the groups in the outcome parameters measured (fever, meningitis, mortality or length of hospitalization). CONCLUSIONS: We suggest that patients with a more severe status upon admission may benefit from a prophylactic treatment with the PNEUMOVAX vaccine.

Why mortality is still high with modern care of 613 evacuated mass lesions presented as severe head injuries 1999-2009.

Of 1,949 successive acute severe head injuries (SHI) over a period of 11 years 1999-2009, 613 (31.5%) underwent evacuation of mass lesions. Mortality at 3 months of evacuated mass (EM) lesions was higher over 10 years compared with that of non-EM lesions (it was overall 22%). The reduction of mortality was significantly less in EM compared with that for non-surgical cases (14.4-9.4% recently) and for the cases that were operated but not for mass evacuation (18.1-12.1%). A few explanations are: first, more SDH (60.5% of the EM recently compared with 45.9% in the first few years); second, more severe cases and older patients with co-morbidities were treated surgically; third, advances in prehospital care brought more severe patients to operative care - the rate of referrals decreased from 61.5% to 52.8% recently; fourth, part of the significant shortening of the injury to NT admission time (163-141 min) vanished owing to the parallel elongation of admission to operation time (95-100 min), thus, the threshold recommendation of 4 h to mass evacuation was achieved in only 52%; fifth, introducing decompressive craniectomy was not associated with outcome improvement.

Effect of infections on 30-day mortality among critically ill patients hospitalized in and out of the intensive care unit.

BACKGROUND: This analysis is part of a multicenter study conducted in Israel to evaluate survival of critically ill patients treated in and out of intensive care units (ICUs). OBJECTIVE: To assess the role of infection on 30-day survival among critically ill patients hospitalized in ICUs and regular wards. DESIGN: All adult inpatients were screened on four rounds for patients meeting ICU admission criteria. Retrospective chart review was used to detect presence and type of infection. Mortality was ascertained from day of meeting study criteria to 30 days thereafter. ANALYSIS: The effect of infection on mortality among patients, treated in and out of the ICU, was compared using Kaplan Meier survival curves. Multivariate Cox models were constructed to adjust interdepartmental comparisons for case-mix differences. RESULTS: Of 641 critically ill patients identified, 36.8% already had an infection on day 0. An additional 40.2% subsequently developed a new infection during the follow-up period, ranging from 64.6% in the ICU to 31.5% in regular wards (p < .001). Resistant infections were more prevalent in ICUs. Infection was independently associated with an increase in mortality, regardless of whether the patient was admitted to the ICU. There was no difference in the adjusted risk of mortality associated with an infection diagnosed on day 0 vs. an infection diagnosed later. Risk of dying was similar in resistant and nonresistant infections. Adjusting for infections, survival of ICU patients was better relative to patients in regular wards (adjusted hazard ratio = 0.7). Among the different types of infection, risk of mortality from pneumonia was significantly lower in ICUs relative to regular wards. There was a protective effect in ICUs among noninfected patients. CONCLUSION: The risk of acquiring a new infection is greater in the ICU. However, risk of mortality among ICU patients was lower for the most serious infections and for those without any infection.

Effect measure modification and confounding of severe head injury mortality by age and multiple organ injury severity.

PURPOSE: The study aim is to assess confounding and effect measure modification of the relationship between head injury severity (measured using the Glasgow Coma Scale [GCS]) and mortality by age and multiple organ injury (measured using the Injury Severity Score [ISS]). Head injury-related mortality is affected by head injury severity, as well as age and multiple organ injury. However, little is known about the effect modification of these relationships. METHODS: Stratifications and multiple logistic regression analyses examined the association of mortality with GCS score less than 9, controlled for ISS of 16 and higher or age of 55 years and older. Receiver operating curve (ROC) analyses were used to explore the relationship of GCS cutoff values and prediction of death by the ISS and age categories mentioned. RESULTS: Both age and ISS modified head injury mortality in a similar direction: there was a negative interaction between age and ISS and more severe head injury. Lower GCS values (indicating more severe head injury) related more strongly to mortality in younger persons. Lower GCS values related more strongly to mortality when extracranial injuries were less severe. These data indicate effect modification. Data indicate negative confounding of the association between GCS and mortality by age and positive confounding by ISS. Multivariate analyses indicate that only younger age modifies the effect of more severe head injury with statistical significance when both age and multiple organ injury are considered. ROC analyses conducted with stratified and logistic regression analyses indicate that GCS is a better predictor of death in those with younger age. CONCLUSIONS: The relationship of head injury severity and mortality is modified and confounded by age and ISS. GCS is a better predictor of death in younger patients.

Survival of critically ill patients hospitalized in and out of intensive care.

OBJECTIVE: A lack of intensive care units beds in Israel results in critically ill patients being treated outside of the intensive care unit. The survival of such patients is largely unknown. The present study's objective was to screen entire hospitals for newly deteriorated patients and compare their survival in and out of the intensive care unit. DESIGN: A priori developed intensive care unit admission criteria were used to screen, during 2 wks, the patient population for eligible incident patients. A screening team visited every hospital ward of five acute care hospitals daily. Eligible patients were identified among new admissions in the emergency department and among hospitalized patients who acutely deteriorated. Patients were followed for 30 days for mortality regardless of discharge. SETTING: Five acute care hospitals. PATIENTS: A total of 749 newly deteriorated patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Crude survival of patients in and out of the intensive care unit was compared by Kaplan-Meier curves, and Cox models were constructed to adjust the survival comparisons for residual case-mix differences. A total of 749 newly deteriorated patients were identified among 44,000 patients screened (1.7%). Of these, 13% were admitted to intensive care unit, 32% to special care units, and 55% to regular departments. Intensive care unit patients had better early survival (0-3 days) relative to regular departments (p=.0001) in a Cox multivariate model. Early advantage of intensive care was most pronounced among patients who acutely deteriorated while on hospital wards rather than among newly admitted patients. CONCLUSIONS: Only a small proportion of eligible patients reach the intensive care unit, and early admission is imperative for their survival advantage. As intensive care unit benefit was most pronounced among those deteriorating on hospital wards, intensive care unit triage decisions should be targeted at maximizing intensive care unit benefit by early admitting patients deteriorating on hospital wards.

Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds.

OBJECTIVE: The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for critically ill patients and compare their 30-day survival in and out of the intensive care unit. DESIGN: Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records. SETTING: Five acute care Israeli hospitals. PATIENTS: All patients fitting a priori developed study criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various confounding factors. The effect of intensive care unit vs. other departments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular departments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p =.018). There was no additional survival advantage for intensive care unit patients (p =.9) during the remaining follow-up time. CONCLUSIONS: The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treatment in the intensive care unit, may be advantageous.

Simulation and management games for training command and control in emergencies.

The aim of our project was to introduce and implement simulation techniques in a problematic field of increasing health care system preparedness for disasters. This field was chosen as knowledge is gained by few experienced staff members who need to disperse it to others during the busy routine work of the system personnel. Knowledge management techniques ranging from classifying the current data, centralized organizational knowledge storage and using it for decision making and dispersing it through the organization--were used in this project. In the first stage we analyzed the current system of building a preparedness protocol (set of orders). We identified the pitfalls of changing personnel and loosing knowledge gained through lessons from local and national experience. For this stage we developed a database of resources and objects (casualties) to be used in the simulation in different possibilities. One of those was the differentiation between drills with trainer and those in front of computers enable to set the needed solution. The model rules for different scenarios of multi-casualty incidents from conventional warfare trauma to combined chemical/toxicological as well as, levels of care pre and inside hospitals--were incorporated to the database management system (we used Microsoft Access' DBMS). The hardware for management game was comprised of serial computers with network and possibility of projection of scenes. For prehospital phase the possibility of portable PC's and connections to central server was used to assess bidirectional flow of information. Simulation software (ARENA) and graphical interfase (Visual Basic, GUI) as shown in the attached figure. We hereby conclude that our system provides solutions which are in use in different levels of healthcare system to assess and improve management command and control for different scenarios of multi-casualty incidents.

Role of the anaesthetist in developing and implementing readiness of hospital to mass casualty incidents.

PURPOSE OF REVIEW: A mass casualty incident is usually short and resolves itself. To minimize the risks to patients during mass casualty incidents, planning is essential. We hereby provide our experience with a recent literature review of the steps to provide the hospital with an efficient plan to overcome mass casualty situations of a traumatic nature, with special implications for the anaesthetist's role. RECENT FINDINGS: Preparation of the hospital starts with an accepting master plan and guidelines for creating local standing orders for this scenario. The hospital should work step by step in adjusting the master plan to its local requirements and infrastructure. During this work, one will find that it is not only technical or logistic but should address medical issues, with pertinent information from clinicians of different specialities. After authorization of the preparedness plan, it should be tested in limited scale drills, and then implemented in the hope that it will never need to be used. Periodic adjustments according to threats and new concepts and equipment should be made. SUMMARY: As a result of recent events, a major effort is considered to improve the preparedness plan of the hospital for mass casualty incidents. However, common surveyors report their unease with the current ability to cope with disasters. The involvement of medical teams in the process is mandatory to lessen the effects of the first wave of casualties and to be able to cope with the second wave.

National strategy for mass casualty situations and its effects on the hospital.

A mass-casualty situation (MCS) usually is short in duration and resolves itself. To minimize the risks to patients during MCS, planning is essential. This article summarizes the preparations needed at the hospital level, for a local MCS involving numerous trauma victims arriving to the Emergency Department at a short notice. Experiences and conclusions related to the implementation of the Israeli strategy in one hospital that combines the responsibilities of both the military and civilians are summarized. The Ministry of Health distributes the master MCS plan to each hospital where a local committee adapts it to the specific situation in a format of standing orders. After its approval by the Ministry of Health, an annual inspection is conducted to check the ability of the staff to manage a MCS. A full-scale drill is conducted every second year during which each site's readiness level and the continuity of the flow of care are tested. In building the strategy for treating trauma victims during a MCS, a few assumptions were taken into account. The goal of treatment in a MCS is to deliver an acceptable quality of care while preserving as many lives as is possible. In theory, the capacity of the hospital is its ability to manage a load of patients in the range of 20% of the hospital bed capacity. Planning and drilling are the ways to minimize deviations from the guidelines and to avoid management mistakes. Special attention should be paid to problems related to the initial phase of receiving the first message, outside communication, inside hospital communication, and staff recruitment. Other issues include: free access to the hospital; opening a public information center; and dealing with the media and very important persons (VIPs). A new method for creating the needed MCS plan in the hospital is suggested. It is based upon knowledge of management techniques that used multi-level documents, which are spread via Intranet between the different key figures. Using this method, it is possible to keep the strategy, the source documentation, and reasons for choosing it, as well as immediate release of checklists for each functions. This detailed, time consuming work is worthwhile in the long run, when the benefits of easy updating and better preparedness are apparent.

Dexanabinol (HU-211) in the treatment of severe closed head injury: a randomized, placebo-controlled, phase II clinical trial.

OBJECTIVE: To establish the safety of intravenous dexanabinol in severe head injury. DESIGN: Prospective, randomized, double-blind, placebo- (vehicle) controlled, multicenter, escalating dose study of a single administration of drug (48 or 150 mg) or vehicle (1 or 3 mL). SETTING: All Israeli neurosurgical intensive care units (a total of six units). PATIENTS: Sixty-seven patients, aged 16-65 yrs, Glasgow Coma Scale score of 4-8, injured within 6 hrs of treatment. MEASUREMENTS AND MAIN RESULTS: Intracranial pressure, cerebral perfusion pressure, blood pressure, and heart rate were measured continuously in the intensive care unit. Adverse medical events were recorded and clinical outcome was assessed by the Glasgow outcome scale throughout a 6-month follow-up period. A highly significant reduction in the percentage of time with intracranial pressure >25, cerebral perfusion pressure <50, and systolic blood pressure <90 mm Hg was observed in the drug-treated group. The nature and incidence of adverse medical events were similar in the two groups. The percentage of patients achieving good neurologic outcome on the Glasgow outcome scale was 21% and 14% higher in the drug-treated group at 3 and 6 months, respectively. Statistical analysis of these differences by a logistic model using dose, entry Glasgow coma scale score, and computed tomograph as covariates yielded p values for the effect of treatment of .03 and .14 at 3 and 6 months, respectively. CONCLUSIONS: Dexanabinol was safe and well tolerated in severe head injury. The treated patients achieved significantly better intracranial pressure/cerebral perfusion pressure control without jeopardizing blood pressure. A trend toward faster and better neurologic outcome was also observed.