phenylephrine-hydrochloride and Critical-Illness

High-flow nasal cannula (HFNC) oxygen therapy is carried out using an air/oxygen blender, active humidifier, single heated tube, and nasal cannula. Able to deliver adequately heated and humidified medical gas at flows up to 60 L/min, it is considered to have a number of physiological advantages compared with other standard oxygen therapies, including reduced anatomical dead space, PEEP, constant F(IO2), and good humidification. Although few large randomized clinical trials have been performed, HFNC has been gaining attention as an alternative respiratory support for critically ill patients. Published data are mostly available for neonates. For critically ill adults, however, evidence is uneven because the reports cover various subjects with diverse underlying conditions, such as hypoxemic respiratory failure, exacerbation of COPD, postextubation, preintubation oxygenation, sleep apnea, acute heart failure, and conditions entailing do-not-intubate orders. Even so, across the diversity, many published reports suggest that HFNC decreases breathing frequency and work of breathing and reduces the need for respiratory support escalation. Some important issues remain to be resolved, such as definitive indications for HFNC and criteria for timing the starting and stopping of HFNC and for escalating treatment. Despite these issues, HFNC has emerged as an innovative and effective modality for early treatment of adults with respiratory failure with diverse underlying diseases.

Topics: Adult; Cannula; Critical Illness; Female; Humans; Humidity; Male; Nose; Oxygen; Oxygen Inhalation Therapy; Respiratory Insufficiency; Work of Breathing

High flow nasal cannula (HFNC) systems utilize higher gas flow rates than standard nasal cannulae. The use of HFNC as a respiratory support modality is increasing in the infant, pediatric, and adult populations as an alternative to non-invasive positive pressure ventilation.. This critical review aims to: (1) appraise available evidence with regard to the utility of HFNC in neonatal, pediatric, and adult patients; (2) review the physiology of HFNC; (3) describe available HFNC systems (online supplement); and (4) review ongoing and planned trials studying the utility of HFNC in various clinical settings.. Clinical neonatal studies are limited to premature infants. Only a few pediatric studies have examined the use of HFNC, with most focusing on this modality for viral bronchiolitis. In critically ill adults, most studies have focused on acute respiratory parameters and short-term physiologic outcomes with limited investigations focusing on clinical outcomes such as duration of therapy and need for escalation of ventilatory support. Current evidence demonstrates that HFNC generates positive airway pressure in most circumstances; however, the predominant mechanism of action in relieving respiratory distress is not well established.. Current evidence suggests that HFNC is well tolerated and may be feasible in a subset of patients who require ventilatory support with non-invasive ventilation. However, HFNC has not been demonstrated to be equivalent or superior to non-invasive positive pressure ventilation, and further studies are needed to identify clinical indications for HFNC in patients with moderate to severe respiratory distress.

Topics: Adult; Catheters; Child; Critical Illness; Humans; Infant; Noninvasive Ventilation; Nose

Commensal microbiota are immunomodulatory, and their pathological perturbation can affect the risk and outcomes of infectious and inflammatory diseases. Consequently, the human microbiota is an emerging diagnostic and therapeutic target in critical illness. In this study, we compared four sample types-rectal, naris, and antecubital swabs and stool samples-for 16S rRNA gene microbiota sequencing in intensive care unit (ICU) patients. Stool samples were obtained in only 31% of daily attempts, while swabs were reliably obtained (≥97% of attempts). Swabs were compositionally distinct by anatomical site, and rectal swabs identified within-patient temporal trends in microbiota composition. Rectal swabs from ICU patients demonstrated differences from healthy stool similar to those observed in comparing stool samples from ICU patients to those from the same healthy controls. Rectal swabs are a useful complement to other sample types for analysis of the intestinal microbiota in critical illness, particularly when obtaining stool may not be feasible or practical.

Topics: Cluster Analysis; Critical Illness; DNA, Ribosomal; Feces; Humans; Intensive Care Units; Microbiota; Nose; Phylogeny; Rectum; RNA, Ribosomal, 16S; Sequence Analysis, DNA; Skin

The objective of the study is to investigate the feasibility of noninvasive nasal positive pressure ventilation (NINPPV) for optimizing oxygenation during the rapid sequence intubation in critically ill patients.. A prospective, observational study was performed in an emergency department. Noninvasive nasal positive pressure ventilation was applied in the preoxygenation step and maintained until successful intubation. A pulse oximetry (Spo2) was continuously monitored throughout the procedure and recorded 5 times. The degree of interfering was surveyed with 10-point Likert scale.. Thirty patients were enrolled. The most of enrolled patients were diagnosed as pneumonia, acute heart failure, and traumatic brain injury. The Spo2 was increased to 100% (98%-100%) at the time of starting endotracheal intubation with NINPPV and maintained as 97% (95%-100%) until successful intubation (P< .001). Total apnea duration was 195 seconds (190-196). The degree of interfering intubation was 1 (0-1).. Noninvasive nasal positive pressure ventilation would be useful for optimizing oxygenation during rapid sequence intubation.

Topics: Aged; Critical Illness; Emergency Service, Hospital; Female; Humans; Hypoxia; Intubation, Intratracheal; Male; Middle Aged; Noninvasive Ventilation; Nose; Oximetry; Oxygen; Prospective Studies

High-flow nasal cannula (HFNC) creates positive oropharyngeal airway pressure and improves oxygenation. It remains unclear, however, whether HFNC improves thoraco-abdominal synchrony in patients with mild to moderate respiratory failure. Using respiratory inductive plethysmography, we investigated the effects of HFNC on thoraco-abdominal synchrony.. We studied 40 adult subjects requiring oxygen therapy in the ICU. Low-flow oxygen (up to 8 L/min) was administered via oronasal mask for 30 min, followed by HFNC at 30-50 L/min. Respiratory inductive plethysmography transducer bands were circumferentially placed: one around the rib cage, and one around the abdomen. We measured the movement of the rib-cage and abdomen, and used the sum signal to represent tidal volume (V(T)) during mask breathing, and at 30 min during HFNC. We calculated the ratio of maximum compartmental amplitude (MCA) to V(T), and the phase angle. We assessed arterial blood gas and vital signs at each period, and mouth status during HFNC. We used multiple regression analysis to identify factors associated with improvement in thoraco-abdominal synchrony.. During HFNC, breathing frequency significantly decreased from 25 breaths/min (IQR 22-27 breaths/min) to 21 breaths/min (IQR 18-24 breaths/min) (P < .001), and MCA/VT (P < .001) and phase angle (P = .047) significantly improved.. HFNC improved thoraco-abdominal synchrony in adult subjects with mild to moderate respiratory failure.

Topics: Abdomen; Aged; Catheters; Critical Illness; Female; Humans; Male; Middle Aged; Movement; Noninvasive Ventilation; Nose; Oxygen Inhalation Therapy; Prospective Studies; Respiratory Insufficiency; Respiratory Mechanics; Thorax

Nasoenteral intubation is among the most common procedures performed by clinicians across all medical specialties. The most common technique for nasoenteral intubation is blind passage, as it does not require the use of sophisticated or expensive medical equipment. Unfortunately, blind placement too frequently results in trauma and is a source of significant morbidity and mortality. It is apparent that altered mental status, a preexisting endotracheal tube, and critical illness put a patient in a higher risk group for malposition and complications. Nasoenteral intubation should be attempted only with an understanding of the possibility for difficult placement and the potential complications that can arise from trauma or malposition.

Topics: Critical Illness; Enteral Nutrition; Humans; Intraoperative Complications; Intubation; Nose; Research Design

Methicillin-resistant Staphylococcus aureus (MRSA) colonization is a predictor of subsequent infection in hospitalized adults. The risk of subsequent MRSA infections in hospitalized children colonized with MRSA is unknown.. Children admitted to an academic medical center's pediatric intensive care unit between March 2007 and March 2010 were included in the study. Anterior naris swabs were cultured to identify children with MRSA colonization at admission. Laboratory databases were queried and National Healthcare Safety Network definitions applied to identify patients with MRSA infections during their hospitalization or after discharge.. The MRSA admission prevalence among 3140 children was 4.9%. Overall, 56 children (1.8%) developed an MRSA infection, including 13 (8.5%) colonized on admission and 43 (1.4%) not colonized on admission (relative risk [RR], 5.9; 95% confidence interval [CI], 3.4-10.1). Of those, 10 children (0.3%) developed an MRSA infection during their hospitalization, including 3 of 153 children (1.9%) colonized on admission and 7 of 2987 children (0.2%) not colonized on admission (RR, 8.4; 95% CI, 2.7-25.8). African-Americans and those with public health insurance were more likely to get a subsequent infection (P < .01 and P = .03, respectively). We found that 15 children acquired MRSA colonization in the pediatric intensive care unit, and 7 (47%) developed a subsequent MRSA infection.. MRSA colonization is a risk factor for subsequent MRSA infection in children. Although MRSA colonized children may have lower risks of subsequent infection than adults, children who acquire MRSA in the hospital have similarly high rates of infection. Preventing transmission of MRSA in hospitalized children should remain a priority.

Topics: Academic Medical Centers; Carrier State; Child; Child, Preschool; Critical Illness; Female; Humans; Infant; Intensive Care Units, Pediatric; Male; Methicillin-Resistant Staphylococcus aureus; Nose; Risk Factors; Staphylococcal Infections

To determine the rate of Staphylococcus aureus nasal colonization at admission to intensive care units (ICU) and assess its effect on the development of an ICU-acquired S aureus infection.. We screened all ICU admissions for nasal colonization within the Calgary Health Region from October 2005 to September 2006 and followed up patients to hospital discharge or death or S aureus infection to 30 days.. One thousand three hundred eight patients were admitted to ICU for more than 48 hours and screened for nasal colonization. Fifty (4%) were methicillin-resistant S aureus (MRSA)-positive, 311 (24%) were methicillin-sensitive S aureus (MSSA)-positive, and 947 (72%) were nasal screen-negative. Overall, 5% (63/1239) of patients uninfected at ICU admission developed an ICU-acquired S aureus infection. The rate of ICU-acquired infection was 5% in MRSA colonized patients, 12% in MSSA colonized patients, and 3% in noncolonized patients. A positive nasal screen (odds ratio [OR], 4.7; 95% confidence interval [CI] 2.7-7.9), neuro/trauma patients (OR, 3.1; 95% CI, 1.8-5.2), and higher first Therapeutic Intervention Scoring System score (OR, 1.03 per point; 95% CI, 1.01-1.05) were independent predictors for developing an ICU-acquired S aureus infection.. Nasal colonization with S aureus is a significant risk factor for ICU-acquired S aureus infections, and strategies to control these infections should target both MSSA and MRSA colonization.

Topics: Aged; Critical Illness; Female; Humans; Intensive Care Units; Male; Methicillin-Resistant Staphylococcus aureus; Middle Aged; Nose; Staphylococcal Infections; Staphylococcus aureus

The relationship between nasal Staphylococcus aureus carriage and lower respiratory tract infections was studied in 16 critically ill patients. S. aureus strains from nasal and bronchial samples were characterized by pulsed-field gel electrophoresis. In all but one case, nasal and bronchial strains were genetically identical in the same patients.

Topics: Adult; Aged; Bronchitis; Carrier State; Critical Illness; Electrophoresis, Gel, Pulsed-Field; Female; Humans; Male; Middle Aged; Nose; Pneumonia, Staphylococcal; Staphylococcal Infections; Staphylococcus aureus

The role of rectal carriage of Staphylococcus aureus as a risk factor for nosocomial S. aureus infections in critically ill patients has not been fully discerned.. Nasal and rectal swabs for S. aureus were obtained on admission and weekly thereafter until discharge or death from 204 consecutive patients admitted to the surgical intensive care unit and liver transplant unit. Overall, 49.5% (101 of 204) of the patients never harbored S. aureus, 21.6% (44 of 204) were nasal carriers only, 3.4% (7 of 204) were rectal carriers only, and 25.5% (52 of 204) were both nasal and rectal carriers. Infections due to S. aureus developed in 15.7% (32 of 204) of the patients; these included 3% (3 of 101) of the non-carriers, 18.2% (8 of 44) of the nasal carriers only, 0% (0 of 7) of the rectal carriers only, and 40.4% (21 of 52) of the patients who were both nasal and rectal carriers (P - .001). Patients with both rectal and nasal carriage were significantly more likely to develop S. aureus infection than were those with nasal carriage only (odds ratio, 3.9; 95% confidence interval, 1.18 to 7.85; P= .025). By pulsed-field gel electrophoresis, the infecting rectal and nasal isolates were clonally identical in 82% (14 of 17) of the patients with S. aureus infections.. Rectal carriage represents an underappreciated reservoir for S. aureus in patients in the intensive care unit and liver transplant recipients. Rectal plus nasal carriage may portend a greater risk for S. aureus infections in these patients than currently realized.

Topics: Adult; Aged; Aged, 80 and over; Carrier State; Critical Illness; Cross Infection; Female; Hospitals, Veterans; Humans; Infection Control; Intensive Care Units; Liver Transplantation; Male; Methicillin Resistance; Middle Aged; Nose; Pennsylvania; Prevalence; Rectum; Risk Factors; Serotyping; Staphylococcal Infections; Staphylococcus aureus