Search

Background: Gastrointestinal dysfunction is a common complication of medical nutrition therapy in critically ill patients. Whether prone positioning leads to a deterioration in gastrointestinal function has not been fully clarified. Thus, we aimed to analyze the influence of prone positioning on the tolerance of medical nutrition therapy. Methods: We conducted a retrospective analysis of 102 SARS-CoV-2 infected patients with venovenous extracorporeal membrane oxygenation support (VV ECMO). Gastric residual volume (GRV) was used to assess the tolerance of enteral nutrition. Results: Nutritional data were collected for 2344 days. Undernutrition was observed in 40.8%, with a significantly higher incidence on days in prone position (48.4% versus 38.6%, p < 0.001). On days in supine position, significantly more calories were administered enterally than on days in prone position (p < 0.001). The mean GRV/24 h was 111.1 mL on days in supine position and 187.3 mL on days in prone position (p < 0.001). Prone positioning was associated with higher rates of GRV of ≥500 mL/24 h independent of age, disease severity at ECMO start, ECMO runtime and ICU length of stay (adjusted hazard ratio: 4.06; 95%CI: 3.0–5.5; p < 0.001). Conclusions: Prone position was associated with lower tolerance of enteral nutrition, as indicated by an increased GRV. As a result, reduced enteral nutritional support was administered. [ABSTRACT FROM AUTHOR]

Although extracorporeal membrane ventilation offers the possibility for low-frequency ventilation, protocols commonly used in patients with acute respiratory distress syndrome (ARDS) and treated with extracorporeal membrane oxygenation (ECMO) vary largely. Whether strict adherence to low-frequency ventilation offers benefit on important outcome measures is poorly understood. Background/Objectives: This pilot clinical study investigated the efficacy of low-frequency ventilation on ventilator-free days (VFDs) in patients suffering from ARDS who were treated with ECMO therapy. Methods: In this single-center randomized controlled trial, 44 (70% male) successive ARDS patients treated with ECMO (aged 56 ± 12 years, SAPS III 64 (SD ± 14)) were randomly assigned 1:1 to the control group (conventional ventilation) or the treatment group (low-frequency ventilation during first 72 h on ECMO: respiratory rate 4–5/min; PEEP 14–16 cm H2O; plateau pressure 23–25 cm H2O, tidal volume: <4 mL/kg). The primary endpoint was VFDs at day 28 after starting ECMO treatment. The major secondary endpoint was ICU mortality, 28-day mortality and 90-day mortality. Results: Twenty-three (52%) patients were successfully weaned from ECMO and were discharged from the intensive care unit (ICU). Twelve patients in the treatment group and five patients in the control group showed more than one VFD at day 28 of ECMO treatment. VFDs were 3.0 (SD ± 5.5) days in the control group and 5.4 (SD ± 6) days in the treatment group (p = 0.117). Until day 28 of ECMO initiation, patients in the treatment group could be successfully weaned off of the ventilator more often (OR of 0.164 of 0 VFDs at day 28 after ECMO start; 95% CI 0.036–0.758; p = 0.021). ICU mortality did not differ significantly (36% in treatment group and 59% in control group; p = 0.227). Conclusions: Low-frequency ventilation is comparable to conventional protective ventilation in patients with ARDS who have been treated with ECMO. However, low-frequency ventilation may support weaning from invasive mechanical ventilation in patients suffering from ARDS and treated with ECMO therapy. [ABSTRACT FROM AUTHOR]

Background/Objectives: Septic shock is a severe condition with high mortality necessitating precise prognostic tools for improved patient outcomes. This study aimed to evaluate the collective predictive value of the Simplified Acute Physiology Score 3 (SAPS-3) and lactate measurements (initial, peak, last, and clearance rates within the first 24 h) in patients with septic shock. Specifically, it sought to determine how these markers enhance predictive accuracy for 28-day mortality beyond SAPS-3 alone. Methods: This retrospective cohort study analyzed data from 66 septic shock patients at two ICUs of Vienna General Hospital (2017–2019). SAPS-3 and lactate levels (initial, peak, last measurement within 24 h, and 24 h clearance) were obtained from electronic health records. Logistic regression models were constructed to identify predictors of 28-day mortality, and receiver operating characteristic (ROC) curves assessed predictive accuracy. Results: Among 66 patients, 36 (55%) died within 28 days. SAPS-3 scores significantly differed between survivors and non-survivors (76 vs. 85 points; p = 0.016). First, last, and peak lactate were significantly higher in non-survivors compared to survivors (all p < 0.001). The combination of SAPS-3 and first lactate produced the highest predictive accuracy (AUC = 80.6%). However, 24 h lactate clearance was not predictive of mortality. Conclusions: Integrating SAPS-3 with lactate measurements, particularly first lactate, improves predictive accuracy for 28-day mortality in septic shock patients. First lactate serves as an early, robust prognostic marker, providing crucial information for clinical decision-making and care prioritization. Further large-scale studies are needed to refine these predictive tools and validate their efficacy in guiding treatment strategies. [ABSTRACT FROM AUTHOR]

Purpose: A systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO2R) on gas exchange and respiratory settings in critically ill adults with respiratory failure. Methods: We conducted a comprehensive database search, including observational studies and randomized controlled trials (RCTs) from January 2000 to March 2022, targeting adult ICU patients undergoing ECCO2R. Primary outcomes were changes in gas exchange and ventilator settings 24 h after ECCO2R initiation, estimated as mean of differences, or proportions for adverse events (AEs); with subgroup analyses for disease indication and technology. Across RCTs, we assessed mortality, length of stay, ventilation days, and AEs as mean differences or odds ratios. Results: A total of 49 studies encompassing 1672 patients were included. ECCO2R was associated with a significant decrease in PaCO2, plateau pressure, and tidal volume and an increase in pH across all patient groups, at an overall 19% adverse event rate. In ARDS and lung transplant patients, the PaO2/FiO2 ratio increased significantly while ventilator settings were variable. "Higher extraction" systems reduced PaCO2 and respiratory rate more efficiently. The three available RCTs did not demonstrate an effect on mortality, but a significantly longer ICU and hospital stay associated with ECCO2R. Conclusions: ECCO2R effectively reduces PaCO2 and acidosis allowing for less invasive ventilation. "Higher extraction" systems may be more efficient to achieve this goal. However, as RCTs have not shown a mortality benefit but increase AEs, ECCO2R's effects on clinical outcome remain unclear. Future studies should target patient groups that may benefit from ECCO2R. PROSPERO Registration No: CRD 42020154110 (on January 24, 2021). [ABSTRACT FROM AUTHOR]

The United States is in a housing affordability crisis, with nearly half of all renter households spending more than 30% of their incomes on rent and utilities each month. This traditional measure of housing affordability may understate the hardships renter households face because it does not consider the array of expenses households have. Whereas housing policy has relied on percentage-of-income measures to indicate whether housing is affordable, researchers over the last three decades have called for a residual income approach that uses spending estimates to calculate what a household can actually afford. This article examines the extent of the affordability crisis by comparing standard cost burden rates for working-age renter households with residual-income cost burdens. Using the Economic Policy Institute's Family Budget Calculator and the 2018 American Community Survey, we estimate the number of renter households that do not have enough income to afford a comfortable standard of living after paying rent and utilities. We investigate several policy levers, finding that a combined policy that addresses both housing and transportation affordability would have the largest impact on reducing residual-income cost burdens. [ABSTRACT FROM AUTHOR]

Drawing on the nationally representative Census Bureau Household Pulse Survey (N = 443,375), this study examined how pre-pandemic and pandemic-induced vulnerabilities shaped racial inequalities in housing insecurity from August to December 2020. Theorizing the pandemic as a “systemic shock,” this article helps explain how racial inequalities are reproduced both as legacies of long-standing disparities and through widespread, societal moments of disruption. Our results indicated that Black, Hispanic, and Asian households were all significantly more likely to fall behind on housing payments than white households. We found that preexisting racial inequities, including in educational attainment, household income, and homeownership rates, largely explained racial disparities in housing insecurity during COVID-19. However, the pandemic also induced new pathways to racial inequalities. Black and Hispanic households were more likely to lose income and when they lost income, they faced a greater likelihood of experiencing housing insecurity. We conclude by highlighting the importance of theorizing disruptive systemic shocks to understand racial inequalities and discuss findings of both disparities faced by Black and Hispanic households, as well as underrecognized housing insecurity among Asian Americans. [ABSTRACT FROM AUTHOR]

Purpose Pump-driven veno-venous extracorporeal CO.sub.2-removal (ECCO.sub.2-R) increasingly takes root in hypercapnic lung failure to minimize ventilation invasiveness or to avoid intubation. A recently developed device (iLA activve.sup.®, Novalung, Germany) allows effective decarboxylation via a 22 French double lumen cannula. To assess determinants of gas exchange, we prospectively evaluated the performance of ECCO.sub.2-R in ten patients receiving iLA activve.sup.® due to hypercapnic respiratory failure. Methods Sweep gas flow was increased in steps from 1 to 14 L/min at constant blood flow (phase 1). Similarly, blood flow was gradually increased at constant sweep gas flow (phase 2). At each step gas transfer via the membrane as well as arterial blood gas samples were analyzed. Results During phase 1, we observed a significant increase in CO.sub.2 transfer together with a decrease in PaCO.sub.2 levels from a median of 66 mmHg (range 46-85) to 49 (31-65) mmHg from 1 to 14 L/min sweep gas flow (p < 0.0001), while arterial oxygenation deteriorated with high sweep gas flow rates. During phase 2, oxygen transfer significantly increased leading to an increase in PaO.sub.2 from 67 (49-87) at 0.5 L/min to 117 (66-305) mmHg at 2.0 L/min (p < 0.0001). Higher blood flows also significantly enhanced decarboxylation (p < 0.0001). Conclusions Increasing sweep gas flow results in effective CO.sub.2-removal, which can be further reinforced by raising blood flow. The clinically relevant oxygenation effect in this setting could broaden the range of indications of the system and help to set up an individually tailored configuration., Author(s): Alexander Hermann [sup.1], Katharina Riss [sup.1], Peter Schellongowski [sup.1], Andja Bojic [sup.1], Philipp Wohlfarth [sup.1], Oliver Robak [sup.1], Wolfgang R. Sperr [sup.1], Thomas Staudinger [sup.1] Author Affiliations: (1) grid.22937.3d, [...]