Search

Objective: To compare the efficacy and safety of remimazolam besylate and propofol for deep sedation in critically ill patients. Methods: In this single-center, prospective, randomized, controlled pilot study, patients in the intensive care unit (ICU) requiring deep sedation were randomized to receive remimazolam besylate or propofol intravenously. Deep sedation was defined as a Richmond Agitation and Sedation Scale (RASS) score of − 4 or − 5. Sedation depth was monitored using RASS and Narcotrend Index (NI). The primary outcome was the percentage of time within the target sedation range without rescue sedation. The secondary outcomes included ventilator-free hours within 7 days, successful extubation, length of ICU stay, and 28-day mortality. Adverse events during the interventional period were also recorded. Results: Thirty patients were assigned to each group. The median (IQR) RASS score was − 5.0 (− 5.0, − 4.0), and the median (IQR) NI value was 29.0 (21.0, 37.0) during the intervention period. Target RASS was reached a median of 100% of the sedation time in the two groups. No significant differences were observed in ventilator-free hours within 7 days, successful extubation, length of ICU stay, or 28-day mortality among groups. Hypotension occurred in 16 (53.3%) patients of remimazolam group and 18 (60.0%) patients of propofol group (p > 0.05). No patient experienced bradycardia. Conclusions: Remimazolam besylate appears to be an effective and safe agent for short-term deep sedation in critically ill patients. Our findings warrant large sample-sized randomized clinical trials. [ABSTRACT FROM AUTHOR]

OBJECTIVES We introduced an extubation strategy for emphysema patients after bilateral lung transplantation. Patients who met the extubation criteria were extubated in the operating room (OR) followed by non-invasive ventilation, and the other patients were extubated in the intensive care unit (ICU). The primary objective was to determine the extubation rate. The secondary outcomes were to determine the factors allowing for extubation in the OR and the postoperative course. METHODS This study is a single-centre retrospective database analysis of 96 patients. Anaesthesia was performed using automated titration of total intravenous anaesthesia combined with thoracic epidural analgesia. Extubation criteria included arterial partial pressure oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio, chest radiograph, oedema and haemodynamic stability. Data were compared using non-parametric tests and expressed as median (interquartile ranges) or number (%). RESULTS Fifty-three (55%) patients were extubated in the OR (the OR group) with 1 requiring reintubation and 43 (45%) patients were extubated in the ICU (the ICU group). Preoperative pulmonary hypertension, the requirement for intraoperative extracorporeal membrane oxygenation (ECMO), bleeding and ex vivo lung reconditioning donors were lower in the OR group. At the end of the procedure, the PaO2/FiO2ratio was better [352 (289–437) vs 206 (144–357), P = 0.004), and the need for postoperative ECMO, mechanical ventilation duration, length of stay in the ICU [5 (4–7) vs 12 (8–20) days, P < 0.0001], Grade 3 primary graft dysfunction at 72 h [1 (2%) vs 10 (24%), P = 0.002] and 1-year mortality [5 (9%) vs 11 (26%) patients, P = 0.014] were lower in the OR group than in the ICU group. CONCLUSIONS Half of patients were extubated in the OR, and this strategy does not require additional ICU resources. [ABSTRACT FROM AUTHOR]

Objective: This study was performed to evaluate how well states of deep sedation in ICU patients can be detected from the frontal electroencephalogram (EEG) using features based on the method of atomic decomposition (AD).Methods: We analyzed a clinical dataset of 20 min of EEG recordings per patient from 44 mechanically ventilated adult patients receiving sedatives in an intensive care unit (ICU) setting. Several features derived from AD of the EEG signal were used to discriminate between awake and sedated states. We trained support vector machine (SVM) classifiers using AD features and compared the classification performance with SVM classifiers trained using standard spectral and entropy features using leave-one-subject-out validation. The potential of each feature to discriminate between awake and sedated states was quantified using area under the receiver operating characteristic curve (AUC).Results: The sedation level classification system using AD was able to reliably discriminate between sedated and awake states achieving an average AUC of 0.90, which was significantly better ($p <0.05$) than performance achieved using spectral (AUC = 0.86) and entropy (AUC = 0.81) domain features. A combined feature set consisting of AD, entropy, and spectral features provided better discrimination (AUC = 0.91, $p <0.05$) than any individual feature set.Conclusions: Features derived from the atomic decomposition of EEG signals provide useful discriminative information about the depth of sedation in ICU patients.Significance: With further refinement and external validation, the proposed system may be able to assist clinical staff with continuous surveillance of sedation levels in mechanically ventilated critically ill ICU patients. [ABSTRACT FROM AUTHOR]

Objective: Inappropriate dosing of patients with antibiotics is a driver of antimicrobial resistance, toxicity, and poor outcomes of therapy. In this paper, we investigate, in silico, the hypothesis that the use of a closed-loop control system could improve the attainment of pharmacokinetic–pharmacodynamic targets for antimicrobial therapy, where wide variations in target attainment have been reported. This includes patients in critical care, patients with renal disease, and patients with obesity. Methods: The presented in silico study focuses on vancomycin delivery, a first line therapy for Methicillin-resistant Staphylococcus aureus (MRSA) that has serious side effects, including nephrotoxicity. For this purpose, an in silico platform for the simulation of pharmacokinetics of vancomycin agents was developed including 24 virtual noncritically ill-adult subjects obtained from routinely collected data from two prospective audits of vancomycin therapy. Intraday variability on renal clearance, sensor error, and infusion constraints were taken into account. Proportional integral derivative (PID) controller was chosen because of its simplicity of implementation and satisfactory performance. Results: Even though significant intraday variability and sensor error were considered in the simulations, by assuming a minimum inhibitory concentration of 1 mg/l for MRSA, the proposed controller was able to reach the well-established therapeutic target of 24-h area under curve to minimum inhibitory concentration ratio equal to 400 $\text{mg} \cdot \text{h}\text{/}\text{l}$ for all the studied subjects, while staying significantly below toxic levels. Conclusion: A PID controller has the potential to precisely deliver a vancomycin therapy in a noncritically ill-adult population. Significance: Closed-loop control for precision Vancomycin delivery can potentially reduce toxicity and poor therapeutic outcomes, as well as reduce antimicrobial resistance. [ABSTRACT FROM AUTHOR]

Background: Automated systems are available in various application areas all over the world for the purpose of reducing workload and increasing safety. However, such support systems that would aid caregivers are still lacking in the medical sector. With respect to workload and safety, especially, the intensive care unit appears to be an important and challenging application field. Whereas many closed-loop subsystems for single applications already exist, no comprehensive system covering multiple therapeutic aspects and interactions is available yet. This paper describes a fully closed-loop intensive care therapy and presents a feasibility analysis performed in three healthy pigs over a period of 72 h each to demonstrate the technical and practical implementation of automated intensive care therapy. Methods: The study was performed in three healthy, female German Landrace pigs under general anesthesia with endotracheal intubation. An arterial and a central venous line were implemented, and a suprapubic urinary catheter was inserted. Electrolytes, glucose levels, acid-base balance, and respiratory management were completely controlled by an automated fuzzy logic system based on individual targets. Fluid management by adaption of the respective infusion rates for the individual parameters was included. Results: During the study, no manual modification of the device settings was allowed or required. Homoeostasis in all animals was kept stable during the entire observation period. All remote-controlled parameters were maintained within physiological ranges for most of the time (free arterial calcium 73%, glucose 98%, arterial base excess 89%, and etCO 98%). Subsystem interaction was analyzed. Conclusions: In the presented study, we demonstrate the feasibility of a fully closed-loop system, for which we collected high-resolution data on the interaction and response of the different subsystems. Further studies should use big data approaches to analyze and investigate the interactions between the subsystems in more detail. [ABSTRACT FROM AUTHOR]