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INTRODUCTION The number of patients depending on long-term invasive mechanical ventilation (IMV) has increased in last years ( Simonds, 2016 ; Ambrosino & Vitacca, 2018 ). International reports indicate that prevalence rates continue to rise due to demographic and epidemiological changes, advances in diagnostic and supportive technology, improved healthcare delivery and a better understanding of the beneficial effects of IMV on quality of life in some conditions ( Rose et al., 2015 ). Many IMV patients are seriously ill, have complex medical needs and require

Abstract

Introduction: In the light of constant pressure for minimizing healthcare costs we made a cost-minimization analysis comparing invasive mechanical ventilation (IMV) and non-invasive ventilation (NIV) as treatment for hypoxemic acute respiratory failure (ARF).

Aim: The primary objective was to estimate the direct medical costs generated by a patient on IMV and NIV. A secondary objective was to identify which aspect of the treatment was most expensive.

Material and Methods: This is a single center retrospective study including 36 patients on mechanical ventilation due to hypoxemic ARF, separated in two groups – NIV (n = 18) and IMV (n = 18). We calculated all direct medical costs in Euro and compared them statistically.

Results: On admission the PaO2/FiO2 and SAPS II score were comparable in both groups. We observed a significant difference in the costs per patient for drug treatment (NIV: 616.07; IQR: 236.68, IMV:1456.18; IQR:1741.95, p = 0.005), consumables (NIV: 16.47; IQR: 21.44, IMV: 98.79; IQR: 81.52, p < 0.001) and diagnostic tests (NIV: 351; IQR: 183.88, IMV: 765.69; IQR: 851.43, p < 0.001). We also computed the costs per patient per day and there was a significant difference in the costs in all above listed categories. In both groups the highest costs were for drug treatment – around 61%.

Conclusions: In the setting of hypoxemic ARF NIV reduces significantly the direct medical costs of treatment in comparison to IMV. The decreased costs in NIV are not associated with severity of disease according to the respiratory quotient and SAPS II score.

Abstract

Introduction: Cupriavidus pauculus is a rarely isolated non-fermentative, aerobic bacillus, which occasionally causes severe human infections, especially in immunocompromised patients. Strains have been isolated from various clinical and environmental sources.

Case presentation: A 67-year-old man was admitted to the Intensive Care Unit with acute respiratory failure. The patient was diagnosed with bilateral pneumonia, pulmonary sepsis and underwent invasive mechanical ventilation. Examination revealed diminished bilateral vesicular breath sounds, fever, intense yellow tracheal secretions, a respiratory rate of 24/minute, a heart rate of 123/minute, and blood pressure of 75/55 mmHg. Vasoactive treatment was initiated. Investigations revealed elevated lactate and C-reactive protein levels. A chest X-ray showed bilateral infiltration. Parenteral ciprofloxacin and ceftriaxone were administered. Tracheal aspirate culture and blood culture showed bacterial growth of Cupriavidus pauculus. Colistin was added to the treatment. There was a poor clinical response despite repeated blood culture showing negative results. The diagnosis of multiple organ dysfunction syndrome (MODS) caused by C. pauculus was made. The patient died eleven days after admission.

Conclusions: Clinical improvement cannot always be expected in spite of targeted antibiotic therapy. This pathogen should be considered responsible for infections that usually develop in immunocompromised patients.

Abstract

A male patient, 54 years old, was initially admitted to the hospital because of fatigue he felt during the last month and swelling of the lower legs. Upon hospital admittance, gas exchange analysis showed global respiratory failure: pO2=6.1 kPa, pCO2=10.9 kPa, pH=7.35, A-a gradient = 1.0. Due to the existence of hypercapnia and decompensated respiratory acidosis, the patient was connected to a device for non-invasive mechanical ventilation. Reduced chest mobility was noticed, and the respiratory index value was decreased. Radiographs of the chest and thoracic and lumbo-sacral spine showed marked changes on the spine attributable to ankylosing spondylitis (AS). Radiographs of the sacroiliac joints showed reduced sacroiliac joint intraarticular space with signs of subchondral sclerosis. The diagnosis of AS was set on the basis of New York Criteria (bilateral sacroiliitis, grade 3) and clinical criteria (back pain, lumbar spine limitation and chest expansion limitation). HLA typing (HLA B27 +) confirmed the diagnosis of AS. Pulmonary function test proved severe restrictive syndrome. Polysomnography verified the existence of severe obstructive sleep apnoea (AHI =73). This was a patient with newly diagnosed AS, with consequent severe restrictive syndrome and global respiratory failure with severe obstructive sleep apnoea. Thee patient was discharged from the hospital with a NIV (global respiratory failure) device for home use during the night.

“this was the beginning of a beautiful friendship between man and machine”. Nowadays, we cannot imagine a modern ICU without performant, user-friendly ventilators with advanced monitoring functions, which are able to provide mechanical support as close as possible to respiratory physiology. An epidemiological study reveals that in the United States approximately 310 persons out of 100,000 undergo invasive mechanical ventilation for nonsurgical indications, meanwhile in Israel 8,4% of the population in Jerusalem area received respiratory support [ 3 ]. The most common

severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation, Obesity ( Silver Spring ) 2020 April 9. 34. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet 2020;395:1054–1062. 35. Kerkhove MDV, Vandemaele KAH, Shinde V, et al. Risk Factors for Severe Outcomes following 2009 Influenza A (H1N1) Infection: A Global Pooled Analysis. PLOS Medicine 2011;8:e1001053 36. Handbook of COVID-19 Prevention and Treatment

prescribed early in the disease process and might lead to delayed viral clearance. Recently, an inspiring RCT showed that dexamethasone at a dose of 6 mg once daily for up to 10 days resulted in one-third lower 28-day mortality than usual care in COVID-19 patients who were receiving invasive mechanical ventilation or oxygen; but no benefit and possible harm were found in mild patients who were not receiving respiratory support. This study may have profound effects on the recommendations of corticosteroids in COVID-19 patients. [ 27 ] Cons A systematic review of

+ Tertiary 2.9 1.8–4.6 <0.001  Primary 0.6 0.4–1.0  Private 1 Region  Central 1.94  Northern 1.27 1.5–2.6 <0.001  Northeast 0.80 0.9–1.7 >0.05  Southern 1 0.6–1.1 >0.05 Insurance Group  Universal Coverage 3.1 1.9–4.8 <0.001  Government Welfare Medical Expense 2.6 1.6–4.2  Social Security Fund 1 Sex, male 1.6 1.4–1.9 <0.001 Age on admission >60 years old 1.8 1.52.2 <0.001 Length of stay >3 days 0.8 0.7–1.02 >0.05 Complications  Congestive heart failure 2.7 1.6–4.5 <0.001  Septicemia 20.2 16.5–24.9 <0.001  Respiratory failure requiring continuous invasive mechanical

ventilation; HLH, hemophagocytic lymphohistiocytosis; IBW, ideal body weight; I/O, intake/output; LOS, length of stay; NIV, noninvasive ventilation; PaO 2 /FiO 2 , the ratio of partial pressure arterial oxygen and fraction of inspired oxygen; PCV, pressure-controlled ventilation; PEEP, positive end-expiratory pressure; PIP, peak inspiratory pressure; PSV, pressure support ventilation; SIMV, simultaneous invasive mechanical ventilation; VCV, volume-controlled ventilation; TV, tidal volume The majority of the ARDS patients had pneumonia and were assisted with pressure

value of ˃0.05). The five critical attending nursing factors that were related to the implementation of EM are as follows: nurses’ age less than 25 years, male gender, technical secondary education, 5–10 years of nursing experience, and critical attending experience less than 5 years, which reported higher EM rates in ICUs (each with a P value of ˂0.05). We identified six patient-specific treatments as follows: non-invasive mechanical ventilation (NIPPV), intubation, tracheotomy, CRRT-jugular vein catheter, CRRT-femoral vein catheter, and ECMO, which were associated