Acute and Critical Care

Original Articles

Nursing
Characteristics and associated risk factors of exposure keratopathy among ventilated patients in intensive care units in Jordan: Sajeda Al-Tamimi, Mohammad Y.N. Saleh, Al-Mutez Gharaibeh, Farah Al-A’mar, Rasmieh Al-Amer; Acute Crit Care. 2025;40(2):330-338. Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.003648

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Background
Exposure keratopathy is the most common ocular surface disorder in ventilated patients due to poor eyelid closure, decreased blink reflex, and the inability to produce tears. Healthcare providers in intensive care units (ICUs) play a significant role in preventing exposure keratopathy through appropriate eyelid taping and eye ointments.
Methods
This is a cross-sectional study to describe the characteristics and factors associated with exposure keratopathy in all mechanically ventilated patients admitted to an adult ICU between February and June 2023. Patients were examined for corneal changes using a corneal fluorescein staining test with a cobalt blue filter indirect ophthalmoscope.
Results
Of 156 ventilated patients included in this study, 42.3% had exposure keratopathy, 13.5% had lagophthalmos, and 26.9% of patients had chemosis. For patients with a Glasgow Coma Scale (GCS) score of 3, the odds ratio of exposure keratopathy was 21.47 (95% confidence interval [CI], 2.82–163.05). The use of inotropes increased the odds ratio to 35.55 (95% CI, 3.41–369.90), whereas a hospital stay >7.23 days increased the odds ratio to 43.59 (95% CI, 15.66–1,316.32).
Conclusions
The frequency of exposure keratopathy is high and is underestimated in ventilated patients, with lower GCS and increased hospital length of stay as the main risk factors. Prioritizing eye care in ventilated patients with low GCS scores or prolonged ICU stays is essential to reduce exposure keratopathy.

Citations

Citations to this article as recorded by

Effect of video-based educational program on ICU nurses’ awareness and practices regarding the prevention and care of exposure keratopathy among unconscious and mechanical ventilated patients: a quasi experimental study
Murad Jkhlab, Ismail A. Elhaty, Imad Fashafsheh, Ahmad I. Miqdadi, Nawras Fashafsheh
BMC Nursing.2025;[Epub] CrossRef

Pediatrics
A deep learning model for estimating sedation levels using heart rate variability and vital signs: a retrospective cross-sectional study at a center in South Korea: You Sun Kim, Bongjin Lee, Wonjin Jang, Yonghyuk Jeon, June Dong Park; Acute Crit Care. 2024;39(4):621-629. Published online November 25, 2024; DOI: https://doi.org/10.4266/acc.2024.01200; Retraction in: Acute Crit Care 2025;40(3):512

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Case Reports

Sedation with Dexmedetomidine during Tracheostomy in Severe Tracheal Stenotic Patients: Injung Jun, Kye Min Kim, Sang Seok Lee, Byung Hoon Yoo, Yoo Yong Lee, Yun Hee Lim, Se Jin Song, Mun Cheol Kim; Korean J Crit Care Med. 2013;28(4):314-317.; DOI: https://doi.org/10.4266/kjccm.2013.28.4.314

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Abstract PDF

In patients with severely compromised airways, a tracheostomy is usually performed under local anesthesia. Dexmedetomidine can be a better choice of sedative for such patients because it causes minimal respiratory depression. We report two cases of patients with severe stenosis of the airways who underwent sedation with dexmedetomidine during tracheostomy under local anesthesia. In the first case, recurrent laryngeal cancer caused laryngeal stenosis, and the narrowest laryngeal width was less than 3 mm. In the second case, the tracheostomy opening site was narrowed to a diameter of 3.4 mm in a patient with a history of total laryngectomy. For both patients, sedation was induced by dexmedetomidine infusion and the tracheostomy was performed successfully under local anesthesia without any events. Dexmedetomidine seems to be an effective and safe sedative for tracheostomies in patients with critical airways. The management and implications of sedation with dexmedetomidine in the patients with severe stenotic airways are discussed.

Citations

Citations to this article as recorded by

Dexmedetomidine and Emergency Front of Neck Access for Acute Stridor in Advanced Laryngeal Carcinoma
Neelakshi Koul, Uma Hariharan, Amit Kumar, Nidhi Yadav, Vijay Kumar Nagpal
Journal of Indian College of Anaesthesiologists.2022; 1(1): 30. CrossRef
Comment contrôler les voies aériennes en présence de masses cervicomédiastinales ?
Fabien Espitalier, Marc Laffon
Le Praticien en Anesthésie Réanimation.2015; 19(4): 172. CrossRef

Continuous Infusion of Ketamine in Mechanically Ventilated Patient in Septic Shock with Status Asthmaticus: Bon Nyeo Koo, Shin Ok Koh, Sung Yong Park, Jae Kwang Shim, Sung Sik Chon; Korean J Crit Care Med. 2000;15(2):108-112.

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Abstract PDF: Ketamine is well known for its analgesic, bronchodilating and sympathetic stimulating effect. Hence, it has been widely used for induction of patients with hypotension or asthma and also for analgesic and sedating purposes in the ICU. We presented a 62 year old female patient with ventilator support in septic shock with refractory asthma whom we managed successfully with continuous intravenous infusion of ketamine postoperatively in the ICU. The patient had a history of asthma but had been asymptomatic recently and was scheduled for an emergent explo-laparotomy under the diagnosis of acute panperitonitis. Before the induction of anesthesia, the patient was in septic shock but no wheezing could be auscultated. After the induction of general anesthesia and endotracheal intubation, wheezing was apparent in both lung fields with a high peak inspiratory pressure. Inotropics, vasopressors and bronchodilators were promptly instituted without any improvement of asthma and the patient had to be transferred to the ICU with intubated after the operation. Clinical symptoms of asthma continued throughout the first day despite using bronchodilators under mechanical ventilation but, after starting the IV infusion of ketamine, there were decrease in the peak inspiratory pressure and wheezing with a subsequent improvement in the arterial blood gas analysis findings. We could also achieve considerable analgesic and sedating effect without any decrease in the blood pressure. The patient's general physical status improved and weaning with extubation was successfully done on the 21st day and was transferred to the general ward on the 28th day.

Randomized Controlled Trial

Comparison of the Efficacy between Ketamine and Morphine on Sedation and Analgesia in Patients with Mechanical Ventilation: Tae Hyung Kim, Chae Man Lim, Tae Sun Shim, Sang Do Lee, Woo Sung Kim, Dong Soon Kim, Won Dong Kim, Younsuck Koh; Korean J Crit Care Med. 2000;15(2):82-87.

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Abstract PDF: BACKGROUND
While the combination therapy of morphine and benzodiazepine has been recommended as a standard therapy for sedation and analgesia in patients with mechanical ventilation, morphine can suppress respiratory center, and also decrease blood pressure and bowel movement. Because ketamine has analgesic and sedative effects compatible to morphine without depression of the cardiovascular and respiratory systems in addition to the preservation of bowel activity, ketamine may substitute morphine. However, it has not well known such potential advantages of ketamine in patients with mechanical ventilation.
METHODS
Thirty eight patients (male:female=30:8, age=62.6 +/- 11.7 years) with mechanical ventilation were randomized as ketamine and morphine group (n=21 vs. n=17). There was no significant differences in sex, age and APACHE III score at the initiation of mechanical ventilation (ketamine group, morphine group: 79.4 +/- 2.0, 82.0 +/- 20.6). The study duration was 24 h after drug administration and minimum dose, which maintains ventilator-patient synchrony or the status of Ramsay score 3, was used. Ramsay sedation score, hemodynamic variables, respiratory and arterial blood gas variables, and bowel sound were measured at every 4 h. Arterial blood gas analysis was checked at 0, 4, and 24 h.
RESULTS
1) There were no significant differences in Ramsay sedation score and other hemodynamic, respiratory, and arterial blood gas variables in each group. The dose of combined midazolam was not different between two groups (ketamine vs. morphine; 52.1 +/- 11.9 vs. 46.7 +/- 15.1 mg/d; p=0.23). 2) The cases with decreased mean arterial pressure over 25% of the baseline shortly after the drug administration less frequently observed in ketamine group, although the difference did not reach statistical significance (n=2, 9.5% vs. n=5, 29.4%; p=0.12). 3) Bowel movement reduction at 4 h after the drug administration was less in ketamine group (n=1, 4.8% vs. n=6, 35.3%, p=0.03). The difference was not observed at 8 h. 4) Cost of the drug for 24 h was more expensive in ketamine group (dose & cost; 688 506 mg/d & 25,891 7,743 won vs. 40 +/- 18 mg/d, 15,814 +/- 4,853 won; p<0.001).
CONCLUSIONS
Considering the advantages in the hemodynamics and bowel movement, ketamine may substitute morphine for the sedation of patients with mechanical ventilation, if indicated.

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