Psychological dependence to mechanical ventilation

In the last 50 years, medicine in intensive care units has focused in improving quality and safety processes involved in the attention of critically ill patients, and to reduce co-morbidities associated with these units. This goes beyond offering new treatments or drastic and innovating changes in the intervention of these conditions. (1)
Methods and ways in which these processes are carried out, have become crucial points of the assessment in patient care.
We are referring to psychiatric disorders frequently associated with critically ill patients, out of which delirium is the most studied one. However, depression and anxiety will also often be present, resulting in an extended hospital stay and/or complications.
Mechanical ventilation is an immediate synonym of anxiety, just like it’s also a necessary treatment for patients with respiratory distress, frequently used in intensive care units. When the critically ill patient’s basal condition that led them to need said support, has improved, its withdrawal, also necessary, turns into another problem to take into account, and a number of complications may arise in the process. (2)
One of the aspects, long evaluated, has been ventilator weaning, of which much has been talked about, and different approaches for its achievement have been proposed, as well as the measurement of pulmonary function tests, in order to ensure a successful extubation.
The main determinants of the outcome of weaning include the adequacy of pulmonary gas exchange, respiratory muscle function and psychological problems. (3)

Psychological dependence to mechanical ventilation


Painful skin lesions and bloody diarrhea

Pyoderma gangrenosum (PG) is a rare ulcerative lesion, commonly associated with an underlying systemic disease. The diagnosis of pyoderma gangrenosum can be challenging, and often requires a good history and exclusion of other ulcerative cutaneous disease. We present an impressive case of pyoderma gangrenosum in a young woman with bloody diarrhea.

Painful skin lesions and bloody diarrhea


A dermatologic presentation of pancreatitis

A 40-year-old adopted obese Caucasian male with a past medical history of type 2 diabetes, hypertension, and seizures presented to an Emergency Department with a one-day history of sharp epigastric pain accompanied by nausea and emesis. Dermatologic examination of his arms (Figure A) and legs (Figure B) was consistent with widespread cutaneous xanthomas secondary to hypertriglyceridemia. Venous and arterial (Figure C) blood samples appearing lipemic were obtained. His lipase level was 1,470 U/L and his triglyceride level was 13,563 mg/dL. CT imaging (Figures D and E) was consistent with necrotizing pancreatitis. He required admission to the Intensive Care Unit (ICU) for resuscitation, bowel rest, and supportive care. He underwent emergent plasmaphoresis with the goal of triglyceride reduction. (1) Hypertriglyceridemia is the third most common cause of pancreatitis (after alcohol abuse and gallstones) and is usually seen with triglyceride levels greater than 1000 mg/dL. (2) Patients may have a genetic predisposition such as type V hyperlipidemia and/or may have coexisting secondary causes of hypertriglyceridemia such as alcohol abuse, poorly controlled diabetes, obesity or rapid weight gain, hypothyroidism, uremia, nephritic syndrome, or third trimester pregnancy. (2) Management strategies include supportive care, early initiation of lipid lowering agents, tight glycemic control, plasma exchange, plasmaphoresis, and the use of heparin and insulin to stimulate lipoprotein lipase and chylomicron degradation (although data is limited for all of these strategies). (3) The patient’s prolonged ICU course was complicated by abdominal compartment syndrome, respiratory failure requiring tracheostomy, renal failure requiring renal replacement therapy (limiting the ability to use fibrates), and a partial pancreatic necrosectomy.

A dermatologic presentation of pancreatitis


Airway pressure release ventilation: translating clinical research to the bedside in acute respiratory distress syndrome

Abstract
Since its birth in the mid eighties of the last century, airway pressure release ventilation (APRV) has been a victim of much debate about its clinical use, benefits, and possible harms. With growing body of literature and evidence, APRV is gaining more acceptance and enthusiasm. Interesting research has been conducted in regards to its benefits in prevention of acute respiratory distress syndrome (ARDS), reduction of extra vascular lung water (EVLW), reduction in ventilator-induced lung injury (VILI), reduction of dead space, weaning off mechanical ventilation, improvement of hemodynamics, improvement in oxygenation, impact on mortality, its use as a non-invasive mode of ventilation, and its role in improving lung procurement for transplantation. The research and clinical application has expanded beyond the adult patients to include critically ill pediatric patients and critically ill animals. This article will review some of the plethora of research done in an attempt to promote its implementation to the bedside.

Airway pressure release ventilation- translating clinical research to the bedside in acute respiratory distress syndrome


The impact of illness severity evolution measured with LOD, SOFA, APACHE II and SAPS II scores on the development of ICU acquired infections

Abstract
Several studies were intended to evaluate ICU risk factors, but only few integrated the impact of illness severity variation in their study.
The aim of the present study is to explore the illness severity variation for patients having contracted an ICU-acquired infection and to check if this variation correlates to the nosocomial episode. The study is mono-centric, retrospective and non interventional. It is a case control type with matching approach 1 case vs. 1 control. It is based on a total of 250 patients, at least of 16-year-old, who spent a minimum of 72 hours in the ICU of Timone University Hospital.
The severity of the illness was measured according to the following scores: Logistic Organ Dysfunction (LOD), Simplified Acute Physiology Score (SAPS), Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE).
These scores were calculated retrospectively each day, from the day of admission in ICU to the day of discharge or death, except for APACHE score, which is interesting only for the first 24h of admission. The ability of the models for predicting ICU mortality was determined by examining their discrimination. Forty-six patients developed one or more nosocomial episodes, and 65 died. The matching of cases was successful for 71.73% of them. All SOFA scores values are higher in the case's group: IS (6.652±2.946 cases vs. 5.795±2.494 controls), H48 (6.652±2.767 cases vs. 5.077±2.082 controls), H72 (6.957±2.944 cases vs. 4.538±2.258 controls).
It is quite similar for the LOD score IS (6.087±2.889 cases vs. 5.821±2.72 controls), H48 (5.870±2.864 cases vs. 5.154±1.94 controls), H72 (5.761±2.677 cases vs. 5.256±2.074 controls). As far as APACHE II score is concerned, it counts: 20.478±7.938 cases vs. 24.23±7.938 controls. Among the four documented scores, only SOFA H48 has foreseen a nosocomial risk.


Psychological ventilator dependence: A case report

Abstract
Weaning a patient off mechanical ventilation, especially when they have been dependent on it for a long time, can be a difficult task. Many physical and psychological factors contribute towards dependence on the ventilator. We report a case of a 28-year-old female patient that developed anxiety and a psychological dependence on the ventilator thereby making weaning off difficult. Timely psychiatric intervention resulted in successful weaning off the ventilator.

Psychological ventilator dependence: A case report