BackgroundAtrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all‐cause mortality may guide interventions.Methods and ResultsIn the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose‐adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all‐cause mortality in the 14 171 participants in the intention‐to‐treat population. The median age was 73 years, and the mean CHADS 2 score was 3.5. Over 1.9 years of median follow‐up, 1214 (8.6%) patients died. Kaplan–Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all‐cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33–1.70, P<0.0001) and age ≥75 years (hazard ratio 1.69, 95% CI 1.51–1.90, P<0.0001) were associated with higher all‐cause mortality. Multiple additional characteristics were independently associated with higher mortality, with decreasing creatinine clearance, chronic obstructive pulmonary disease, male sex, peripheral vascular disease, and diabetes being among the most strongly associated (model C‐index 0.677).ConclusionsIn a large population of patients anticoagulated for nonvalvular atrial fibrillation, ≈7 in 10 deaths were cardiovascular, whereas <1 in 10 deaths were caused by nonhemorrhagic stroke or systemic embolism. Optimal prevention and treatment of heart failure, renal impairment, chronic obstructive pulmonary disease, and diabetes may improve survival.Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00403767.
Background Leaving against medical advice (LAMA) is a common health concern seen worldwide. It has variable incidence and reasons depending upon disease, geographical region and type of health care system. Materials and methods We approached anesthesiologists and intensivists for their opinion through ISA and ISCCM contact database using Monkey Survey of 22 questions covering geographical area, type of healthcare system, incidence, reasons, type of disease, expected outcome of LAMA patients etc. Results We received only 1154 responses. Only 584 answered all questions. Out of 1154, only 313 respondents were from government medical colleges or hospitals while remaining responses were from private and corporate sector. Most hospitals had >100 beds. ICUs were semi-closed and supervised by critical-care physicians. LAMA incidence was maximum from ICU (45%) followed by ward (32%) and emergency (25%). Most patients of LAMA had ICU stay for >1 week (60%). Eighty percent of the respondents opined that financial constraints are the most common reason of LAMA. Unsatisfactory care was rarely considered as a factor for LAMA. Approximately 40% patients had advanced malignancy or disease. Nearly 2/3rd strongly believed that insurance cover may reduce the LAMA rate. Conclusion Most patients get LAMA from the ICU after a stay of week. Financial constraints, terminal medical illness, malignancy and sepsis are major causes of LAMA. Remedial methods suggested to decrease the incidence include a good national health policy by the state; improved communication between the patient, caregivers and heathcare team; practice of palliative and end-of-life care support; and lastly, awareness among the people about advance directives. How to cite this article Paul G, Gautam PL et al . Patients Leaving Against Medical Advice-A National Survey. Indian J Crit Care Med 2019;23(3):143-148.
Background Mortality in ARDS was reduced significantly after the introduction of the low tidal volume ventilation strategy. It has been recently shown that lung-protective ventilation strategies should primarily target driving pressure rather than Vt and that ventilator induced lung injury is not just dependent on tidal volume but also other factors like respiratory rate and driving pressure. Ventilator induced lung injury is also thought to be dependent on the amount of energy transferred by the ventilator to the patient which in turn is dependent on tidal volume size (VT), plateau pressure (Pplat), respiratory rate (RR). Mechanical power can be calculated accurately through power equations which can increase their applicability in clinical practice. One simple composite equation (driving pressure multiplied by four plus respiratory rate [4DPRR]) has been recently suggested as a simple surrogate for the power equation. This equation also doesn’t include PEEP as it has been theorized that it is the only elastic dynamic component of driving energy which affects the outcome and not the elastic static component (i.e., PEEP) and the resistive power (related to flow and airway resistance). Objectives To assess the mechanical power as measured by 4DPRR in mechanically ventilated patients who have moderate to severe COVID-19 ARDS. Methods: We obtained data on ventilatory variables and mechanical power from the patients who were admitted with moderate to severe COVID ARDS in our hospital from March 2021 to June 2021. Results We included 34 patients (28% women; mean age, 57 ± 17 yrs.). The average ΔP was 21.44 ± 3.98 cmH2O, the RR was 23.8 ± 3.84 breaths/min, and the mean driving pressure was 21.4 cmH2O. 28% (n = 10) of patients expired. There was no significant association of 4DPRR (P 0.72), Pplat (P 0.79).and RR (P 0.21) with mortality as predicted by area under ROC curves. Conclusions Driving power and plateau pressure were associated with mortality during controlled mechanical ventilation in COVID ARDS, but a simpler model of mechanical power using only the driving pressure and respiratory rate was found to be a poor predictor of mortality. Keywords: COVID-19, ARDS, Mechanical power, Driving pressure, Plateau pressure
Enteral feeding (EF) is considered the preferred method of nutritional support for the critically ill and has reduced septic morbidity in high risk surgical patients, decreasing catabolic response to injury, maintaining bowel mucosal integrity, decreasing translocation of gut bacteria, improving wound healing and reducing septic complications. GI dysmotility implies feeding via a NGT is often associated with large gastric residual volumes, which may lead to increase in the potential for regurgitation and vomiting as used as delay in the achievement of nutritional goals and this can be managed by closely observing gastric residual volume (GRV). 5,6,7 GRV is the amount aspirated from stomach; it indicates that the GIT is functioning normally. 7 The practice of measuring GRV has become a routine part of enteral feeding protocols in the critical care setting, to assess the feeding tolerance, prevent gastric emptying delay and intolerance which may lead to increase in the potential for regurgitation, vomiting and a delay in the achievement of nutritional goals; however if the GRV is more than feed is often withheld unnecessarily. US guidelines state that GRVs of less than 500 ml should not result in termination of enteral feeding. 5,7 Disturbed GE occurs commonly in critically ill patients feed intolerance is an indirect marker of disturbed gastric motility and gastric emptying delay (GED). 2 Metheney et al. also conducted a study and concluded that no consistent relationship was found between aspiration and gastric residual volumes. Although aspiration occurs without high gastric residual volumes, it occurs significantly more often when volumes are high. 8 Juvé-Udina ME et al. showed that GED was almost 50% fewer if the aspirated contents are reintroduced than when the contents are discarded. 2 Some author concluded that High gastric residual volumes are not always indicative of gastric stasis, a low GRV does not protect against aspiration pneumonia. 5
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