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Introduction Measurement of energy expenditure (EE) is recommended to guide nutrition in critically ill patients. Availability of a gold standard indirect calorimetry is limited, and continuous measurement is unfeasible. Equations used to predict EE are inaccurate. The purpose of this study was to provide proof of concept that EE can be accurately assessed on the basis of ventilator-derived carbon dioxide production (VCO 2 ) and to determine whether this method is more accurate than frequently used predictive equations. Methods In 84 mechanically ventilated critically ill patients, we performed 24-h indirect calorimetry to obtain a gold standard EE. Simultaneously, we collected 24-h ventilator-derived VCO 2 , extracted the respiratory quotient of the administered nutrition, and calculated EE with a rewritten Weir formula. Bias, precision, and accuracy and inaccuracy rates were determined and compared with four predictive equations: the Harris–Benedict, Faisy, and Penn State University equations and the European Society for Clinical Nutrition and Metabolism (ESPEN) guideline equation of 25 kcal/kg/day. Results Mean 24-h indirect calorimetry EE was 1823 ± 408 kcal. EE from ventilator-derived VCO 2 was accurate (bias +141 ± 153 kcal/24 h; 7.7 % of gold standard) and more precise than the predictive equations (limits of agreement −166 to +447 kcal/24 h). The 10 % and 15 % accuracy rates were 61 % and 76 %, respectively, which were significantly higher than those of the Harris–Benedict, Faisy, and ESPEN guideline equations. Large errors of more than 30 % inaccuracy did not occur with EE derived from ventilator-derived VCO 2 . This 30 % inaccuracy rate was significantly lower than that of the predictive equations. Conclusions In critically ill mechanically ventilated patients, assessment of EE based on ventilator-derived VCO 2 is accurate and more precise than frequently used predictive equations. It allows for continuous monitoring and is the best alternative to indirect calorimetry.

Background: Neurally adjusted ventilator assist (NAVA) uses electrical activity of the diaphragm (Edi) to provide patient-directed ventilatory support. The NAVA level determines the proportional amount of ventilatory support. Systematically increasing NAVA level initially increases peak inspiratory pressure (PIP) while maintaining a constant Edi until a breakpoint (BrP) is reached. Further increases in NAVA level reduce the Edi, while the PIP plateaus. This study was performed to establish whether premature neonates have intact neural feedback systems allowing them to have a BrP. Method: NAVA level was increased by 0.5 cm H 2 O μV −1 every 3 min from 0.5 to 4.0 cm H 2 O μV −1 . PIP, Edi, mean blood pressure, heart rate, respiratory rate, oxygen saturation and F I O 2 were recorded. Statistics: Non-linear regression was done for PIP and Edi. Linear regression was done for the other variables. The data from the trials were combined by normalizing to NAVA levels above and below the BrP. Result: Nine neonates were studied on NAVA and 12 on non-invasive NAVA. PIP increased until the BrP was reached and then remained unchanged. Edi decreased after the BrP was reached. All other variables remained unchanged. Conclusion: Neonates demonstrated a BrP suggesting intact neural feedback mechanisms that may protect lungs from over distention with NAVA ventilation.

Background There are substantial differences between the costs of medical masks and N95 respirators. Cost-effectiveness analysis is required to assist decision-makers evaluating alternative healthcare worker (HCW) mask/respirator strategies. This study aims to compare the cost-effectiveness of N95 respirators and medical masks for protecting HCWs in Beijing, China. Methods We developed a cost-effectiveness analysis model utilising efficacy and resource use data from two cluster randomised clinical trials assessing various mask/respirator strategies conducted in HCWs in Level 2 and 3 Beijing hospitals for the 2008–09 and 2009–10 influenza seasons. The main outcome measure was the incremental cost-effectiveness ratio (ICER) per clinical respiratory illness (CRI) case prevented. We used a societal perspective which included intervention costs, the healthcare costs of CRI in HCWs and absenteeism costs. Results The incremental cost to prevent a CRI case with continuous use of N95 respirators when compared to medical masks ranged from US $490–$1230 (approx. 3000-7600 RMB). One-way sensitivity analysis indicated that the CRI attack rate and intervention effectiveness had the greatest impact on cost-effectiveness. Conclusions The determination of cost-effectiveness for mask/respirator strategies will depend on the willingness to pay to prevent a CRI case in a HCW, which will vary between countries. In the case of a highly pathogenic pandemic, respirator use in HCWs would likely be a cost-effective intervention.

Objectives. Conservative management of patients with flail chest is the treatment of choice. Rib fracture repair is technically challenging; however, with the advent of specially designed molding titanium clips, surgical management has been simplified. Surgical stabilization has been used with good outcomes. We are reporting on our institutional matched-case-control study. Methods. Between April 2010 and April 2011, ten polytraumatized patients undergoing rib stabilization for flail chest were matched 1 : 1 to 10 control patients by age ±10 years, sex, neurological or vertebral trauma, abdominal injury, and arm and leg fractures. Surgery was realized in the first 48 hours. Results. There were no significant differences between groups for matched data and prognostic scores: injury severity score, revised trauma score, and trauma injury severity score. Ventilator time (142 ± 224 versus 74 ± 125 hours, P=0.026) and overall hospital stay (142 ± 224 versus 74 ± 125 hours, P=0.026) were significantly lower for the surgical group after adjustment on prognostic scores. There was a trend towards shorter ICU stay for operative patients (12.3 ± 8.5 versus 9.0 ± 4.3 days, P=0.076). Conclusions. Rib fixation with Stracos is feasible and decreases the length of ventilation and hospital stay. A multicenter randomized study is warranted so as to confirm these results and to evaluate impact on pulmonary function status, pain, and quality of life.

Introduction Acute respiratory distress syndrome (ARDS) with concomitant impairment of oxygenation and decarboxylation represents a complex problem in patients with increased intracranial pressure (ICP). Permissive hypercapnia is not an option to obtain and maintain lung-protective ventilation in the presence of elevated ICP. Pumpless extracorporeal lung assist (pECLA) devices (iLA Membrane Ventilator; Novalung, Heilbronn, Germany) can improve decarboxylation without aggravation associated with invasive ventilation. In this pilot series, we analyzed the safety and efficacy of pECLA in patients with ARDS and elevated ICP after severe traumatic brain injury (TBI). Methods The medical records of ten patients (eight male, two female) with severe ARDS and severe TBI concurrently managed with external ventricular drainage in the neurointensive care unit (NICU) were retrospectively analyzed. The effect of pECLA on enabling lung-protective ventilation was evaluated using the difference between plateau pressure and positive end-expiratory pressure, defined as driving pressure (ΔP), during the 3 days preceding the implant of pECLA devices until 3 days afterward. The ICP threshold was set at 20 mmHg. To evaluate effects on ICP, the volume of daily cerebrospinal fluid (CSF) drainage needed to maintain the set ICP threshold was compared pre- and postimplant. Results The ΔP values after pECLA implantation decreased from a mean 17.1 ± 0.7 cm/H 2 O to 11.9±0.5 cm/H 2 O ( p  = 0.011). In spite of this improved lung-protective ventilation, carbon dioxide pressure decreased from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg ( p  = 0.005). The volume of daily CSF drainage needed to maintain ICP at 20 mmHg decreased significantly from 141.5 ± 103.5 ml to 62.2 ± 68.1 ml ( p  = 0.037). Conclusions For selected patients with concomitant severe TBI and ARDS, the application of pECLA is safe and effective. pECLA devices improve decarboxylation, thus enabling lung-protective ventilation. At the same time, potentially detrimental hypercapnia that may increase ICP is avoided. Larger prospective trials are warranted to further elucidate application of pECLA devices in NICU patients.

Background There has been increasing debate surrounding mask and respirator interventions to control respiratory infection transmission in both healthcare and community settings. As decision makers are considering the recommendations they should evaluate how to provide the most efficient protection strategies with minimum costs. The aim of this review is to identify and evaluate the existing economic evaluation literature in this area and to offer advice on how future evaluations on this topic should be conducted. Methods We searched the Scopus database for all literature on economic evaluation of mask or respirator use to control respiratory infection transmission. Reference lists from the identified studies were also manually searched. Seven studies met our inclusion criteria from the initial 806 studies identified by the search strategy and our manual search. Results Five studies considered interventions for seasonal and/or pandemic influenza, with one also considering SARS (Severe Acute Respiratory Syndrome). The other two studies focussed on tuberculosis transmission control interventions. The settings and methodologies of the studies varied greatly. No low-middle income settings were identified. Only one of the reviewed studies cited clinical evidence to inform their mask/respirator intervention effectiveness parameters. Mask and respirator interventions were generally reported by the study authors to be cost saving or cost-effective when compared to no intervention or other control measures, however the evaluations had important limitations. Conclusions Given the large cost differential between masks and respirators, there is a need for more comprehensive economic evaluations to compare the relative costs and benefits of these interventions in situations and settings where alternative options are potentially applicable. There are at present insufficient well conducted cost-effectiveness studies to inform decision-makers on the value for money of alternative mask/respirator options.

“Bundles” strategies improve health care–associated infection (HCAI) rates in medical intensive care units (MICUs). However, few studies have analyzed HCAI rates adjusted for the device removal component of the bundles. An observational study of adult MICU patients while using bundles to prevent HCAIs associated with endovascular catheters, mechanical ventilation, and urinary tract catheters was conducted. The HCAI rates, unadjusted and adjusted for device use, were calculated using incidence rate ratios (unadjusted IRRs [uIRR] and adjusted IRRs [aIRR], respectively). Among 4550 study patients, HCAIs declined from 47 in 2004 to 10 in 2005, 8 in 2006, and 3 in 2007. Catheter-related blood stream infection (CRBSI) rates decreased from 10.77 to 1.67 per 1000 central line days (uIRR, 0.155; 95% confidence interval [CI], 0.13-0.18; P < .0001). Foley-related urinary tract infections (CA-UTI) decreased from 6.23 to 0.63 per 1000 device days (uIRR, 0.1; 95% CI, 0.08-0.19; P < .0001). Ventilator-associated pneumonia (VAP) per 1000 ventilator days diminished from 2.17 to 0.62 (uIRR, 0.29; 95% CI, 0.21-0.38; P < .0001). After adjustment for device use, aIRRs of CRBSI (0.14; 95% CI, 0.11-0.18), UTI (0.09; 95% CI, 0.06-0.12), and VAP (0.33; 95% CI, 0.22-0.47) declined significantly ( P < .00001). Implementing comprehensive bundle strategies reduces HCAI beyond the impact of device removal.

Introduction The ability of standard operating procedures to improve pre-hospital critical care by changing pre-hospital physician behaviour is uncertain. We report data from a prospective quality control study of the effect on pre-hospital critical care anaesthesiologists’ behaviour of implementing a standard operating procedure for pre-hospital controlled ventilation. Materials and methods Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region prospectively registered pre-hospital advanced airway-management data according to the Utstein-style template. We collected pre-intervention data from February 1 st 2011 to January 31 st 2012, implemented the standard operating procedure on February 1 st 2012 and collected post intervention data from February 1 st 2012 until October 31 st 2012. We included transported patients of all ages in need of controlled ventilation treated with pre-hospital endotracheal intubation or the insertion of a supraglottic airways device. The objective was to evaluate whether the development and implementation of a standard operating procedure for controlled ventilation during transport could change pre-hospital critical care anaesthesiologists’ behaviour and thereby increase the use of automated ventilators in these patients. Results The implementation of a standard operating procedure increased the overall prevalence of automated ventilator use in transported patients in need of controlled ventilation from 0.40 (0.34-0.47) to 0.74 (0.69-0.80) with a prevalence ratio of 1.85 (1.57-2.19) (p = 0.00). The prevalence of automated ventilator use in transported traumatic brain injury patients in need of controlled ventilation increased from 0.44 (0.26-0.62) to 0.85 (0.62-0.97) with a prevalence ratio of 1.94 (1.26-3.0) (p = 0.0039). The prevalence of automated ventilator use in patients transported after return of spontaneous circulation following pre-hospital cardiac arrest increased from 0.39 (0.26-0.48) to 0.69 (0.58-0.78) with a prevalence ratio of 1.79 (1.36-2.35) (p = 0.00). Conclusion We have shown that the implementation of a standard operating procedure for pre-hospital controlled ventilation can significantly change pre-hospital critical care anaesthesiologists’ behaviour.

Purpose. To determine the factors that are associated with Mexican Americans’ preference for ventilator support, given a supposed terminal diagnosis. Methods. 100 Mexican Americans, aged 60–89, were recruited and screened for MMSE scores above 18. Eligible subjects answered a questionnaire in their preferred language (English/Spanish) concerning ventilator use during terminal illness. Mediator variables examined included demographics, generation, religiosity, occupation, self-reported depression, self-reported health, and activities of daily living. Results. Being first or second generation American (OR = 0.18, CI = 0.05–0.66) with no IADL disability (OR = 0.11, CI = 0.02–0.59) and having depressive symptoms (OR = 1.43, CI = 1.08–1.89) were associated with preference for ventilator support. Implications. First and second generation older Mexican Americans and those functionally independent are more likely to prefer end-of-life ventilation support. Although depressive symptoms were inversely associated with ventilator use at the end of life, scores may more accurately reflect psychological stress associated with enduring the scenario. Further studies are needed to determine these factors’ generalizability to the larger Mexican American community.