Clinical model for predicting prolonged mechanical ventilation.pdf
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1、Clinical model for predicting prolonged mechanical ventilation, Paul A. Clark DO a, Christopher J. Lettieri MDb,c aDepartment of Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA bPulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center,
2、 Bethesda, MD 20889, USA cDepartment of Medicine, Uniformed Services University, Bethesda, MD, USA Keywords: Mechanical ventilatory support; Prolonged mechanical ventilation; Tracheostomy; Predictive model; Medical intensive care unit Abstract Introduction: Mechanical ventilation (MV) predisposes pa
3、tients to numerous complications, which increases with longer durations of treatment. Identifying individuals more likely to require prolonged MV (PMV) may alter ventilation strategies or potentially minimize the duration of therapy and its associated complications. Our aim was to identify clinical
4、variables at the time of intubation that could identify individuals who will require PMV. Methods: One hundred thirty consecutive adult patients requiring MV support in a medical intensive care unit (ICU)were retrospectively assessed. Prolonged MV was defined as MV support more than 14 days. Results
5、: Mean age was 62.3 21.1 years, 64.6% were men, and mean duration of MV support was 11.4 11.9 days. Prolonged MV was required in 31.3%. Requiring intubation after admission to the ICU, heart rate greater than 110, blood urea nitrogen more than 25 mg/dL, serum pH less than 7.25, serum creatinine more
6、 than 2.0 mg/dL, and a HCO3less than 20 mEq/L were the only variables independently associated with PMV. Specificity for predicting PMV was 100% with 4 or more of these variables. Conclusion: The novel predictive model, using Intubation in the ICU, Tachycardia, Renal dysfunction, Acidemia, elevated
7、Creatinine, and a decreased HCO3, was highly specific in identifying patients who subsequently required PMV support and performed better than Acute Physiology Age Chronic Health Evaluation III. Published by Elsevier Inc. 1. Introduction The requirement for prolonged mechanical ventilation (PMV) supp
8、ort is common among intensive care unit (ICU) patients and is predicted to increase to 625298 patients per year by 2020 1. Prolonged mechanical ventilation increases the risk for complications and is often difficult to predict. Approximately 5% to 25% of all mixed ICU patients acutely requiring mech
9、anical ventilation (MV) will remain intubated for more than 5 days, and 3% to 14% will require PMV, typically described as more than 14 or more than 21 days of MV support 2-9. The prevalence of PMV among a pure medical ICU (MICU) population has not been well defined but is likely more common. Financ
10、ial support: None. Disclosure: None. Corresponding author. Tel.: +1 301 295 4630. E-mail address: Paul.albert.clarkus.army.mil (P.A. Clark). 0883-9441/$ see front matter. Published by Elsevier Inc. http:/dx.doi.org/10.1016/j.jcrc.2013.03.013 Journal of Critical Care (2013) 28, 880.e1880.e7 Although
11、lifesaving, MV predisposes patients to numer- ous complications, such as ventilator-induced lung injury, ventilator-associated pneumonia, and other nosocomial in- fections, venothrombotic events, pressure ulcerations, gastri- tis, and increased length of stay 10-12. The probability of developing the
12、se complications increases with longer durations of MV support in a near linear relationship 13. To help mitigate these risks, several strategies have been developed and implemented to reduce the duration of MV. These often encompass minimizing sedation and performing daily spontaneous breathing tri
13、als to facilitate liberation from MV support as soon as the reason for intubation resolves 14,15. However, not all conditions requiring MV will resolve quickly. In these instances, aggressive measures to minimize the number of ventilator days may actually be counterproductive; lead to more pain, dis
14、comfort, or anxiety; andmayincreaseintubationtime16,17.Earlyidentification of those individuals who will ultimately require PMV would likely alter traditional ventilator and sedation management or identify those who may benefit from early tracheostomy. Unfortunately, there are limited models that ca
15、n reliable predict PMV, especially on an individual patient basis. Although the Acute Physiology Score (APS) and Acute Physiology Age Chronic Health Evaluation III (APACHE III) score serve as a reliable index of disease severity and predictor of mortality, it is cumbersome to use in clinical practic
16、e. More importantly, Acute Physiology Age Chronic Health Evaluation and APS were not developed as predictors of PMV. Seneff et al 13 attempted to create an equation to predict the duration of MV support using clinical variables. In this study, the authors observed that 20% of patients receiving MV s
17、upport required PMV, which they defined as more than 7 days. Similar to other studies exploring the duration of MV support, the authors included a mixed population of medical, surgical, and cardiac ICU patients. The prevalence of PMV and identifying factors that could predict longer durations of sup
18、port among a pure MICU population remains unknown. A predictive model identifying those at risk for PMV could help clinicians better manage MV support. Our study had 2 objectives. First, we sought to determine the prevalence of PMV among a pure MICU population. Second, we attempted to develop an ass
19、essment tool using readily available clinical information at the time of intubation to predict patients who would subsequently require MV more than 14 days. 2. Materials and methods 2.1. Study design This retrospective review of all patients intubated in the MICU occurred at a single institution sta
20、rting in January 2009 extending over a period of 1.5 years. Our institution (Walter Reed Army Medical Center, Washington, DC) is an academic, tertiary care center, with a closed, 16-bed MICU. During the 1.5 years, 231 consecutive patients were intubated in the MICU. Of the entire cohort, 101 MV pati
21、ents (44%) were excluded for the following reasons: trauma patient, surgical patient boarding in MICU, and 31 patients (13%) who died before 14 days of MV, which resulted in 99 consecutive adult, nonsurgical, MICU patients (43%) requiring MV (Fig. 1). Those who died during the first 14 days on MV su
22、pport were not included, as we could not determine if they would have required PMV. Otherwise, no records were excluded from the final analysis. The protocol was approved by our institutions Department of Clinical Investigation (Institutional Review Board IRB, Scientific Review Committee, and Human
23、Use Committee, approval no. 364496). No external funding was used. 2.2. Measured variables All data were recorded using a closed electronic medical record system, and all measured variables were collected at the time of intubation. We recorded 27 commonly obtained clinical and laboratory variables i
24、n each patient. These included age, sex, weight, body mass index, core body temperature, heart rate (HR), mean arterial blood pressure, respiratory rate, saturation of peripheral oxygen, fraction of inspired oxygen (FIO2), and Glasgow Coma Scale score. Exclusion, N = 101 Trauma patients (N = 73) Sur
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