Non-pharmacological interventions to reduce physical restraints in critical care units

Physical restraint use in critical care units is a frequent low-value care practice influenced by numerous factors creating a local culture. The translation of evidence-based recommendations into clinical practice is scarce so, the analysis of interventions to de-adopt this practice is needed. This update aims to describe and identify nonpharmacological interventions that contribute to minimising the use of physical restraints in adult critically ill patients. Interventions are classified into two groups: those that include education alone and those that combine training with one or more components (multicomponent interventions). These components include less restrictive restraint alternatives, use of physical and cognitive stimulation, decision support tools, institutional multidisciplinary committees, and team involvement. The heterogeneity in the design of the programmes and the low quality of the evidence of the interventions do not allow us to establish recommendations on their effectiveness. However, multicomponent interventions including training, physical and cognitive stimulation of the patient and a culture change of professionals and the organisations towards making restraints visible might be the most effective. The implementation of these programmes should underpin on a prior analysis of each local context to design the most effective-tailored combination of interventions to help reduce or eliminate them from clinical practice.

Clinical description and outcome of overall varicella-zoster virus-related organ dysfunctions admitted in intensive care units: the VAZOREA cohort study

BACKGROUND

Due to aging population and increasing part of immunocompromised patients, a raise in life-threatening organ damage related to VZV can be expected. Two retrospective studies were already conducted on VZV in ICU but focused on specific organ injury. Patients with high-risk of VZV disease still must be identified. The objective of this study was to report the clinical features and outcome of all life-threatening VZV manifestations requiring intensive care unit (ICU) admission. This retrospective cohort study was conducted in 26 French ICUs and included all adult patients with any life-threatening VZV-related event requiring ICU admission or occurring in ICU between 2010 and 2019.

RESULTS

One-hundred nineteen patients were included with a median SOFA score of 6. One hundred eight patients (90.8%) were admitted in ICU for VZV disease, leaving 11 (9.2%) with VZV disease occurring in ICU. Sixty-one patients (51.3%) were immunocompromised. Encephalitis was the most prominent organ involvement (55.5%), followed by pneumonia (44.5%) and hepatitis (9.2%). Fifty-four patients (45.4%) received norepinephrine, 72 (60.5% of the total cohort) needed invasive mechanical ventilation, and 31 (26.3%) received renal-replacement therapy. In-hospital mortality was 36.1% and was significantly associated with three independent risk factors by multivariable logistic regression: immunosuppression, VZV disease occurring in ICU and alcohol abuse. Hierarchical clustering on principal components revealed five phenotypically distinct clusters of patients: VZV-related pneumonia, mild encephalitis, severe encephalitis in solid organ transplant recipients, encephalitis in other immunocompromised hosts and VZV disease occurring in ICU. In-hospital mortality was highly different across phenotypes, ranging from zero to 75% (p < 0.001).

CONCLUSION

Overall, severe VZV manifestations are associated with high mortality in the ICU, which appears to be driven by immunosuppression status rather than any specific organ involvement. Deciphering the clinical phenotypes may help clinicians identify high-risk patients and assess prognosis.

Gender perspective in the implementation of hygiene in cardiology intensive care

INTRODUCTION

Hygiene in critical patients is an essential daily care, provided under safe conditions, to promote comfort and maintain the integrity of skin and mucous membranes, however, it can generate feelings of dependence and vulnerability in patients. The aim of this post hoc study is to know the differences in satisfaction and lived experience regarding bed hygiene in an intensive care unit according to biological sex and gender perspective.

METHODS

Observational, descriptive and prospective study in which an ad hoc questionnaire was administered to 148 conscious and oriented patients of legal age. The questionnaire was completed 24-48 hours after admission to the unit, once the initial bed hygiene had been performed.

RESULTS

Males experienced conformism (51%), embarrassment (31%) and relief (9%); Women felt conformism (35.4%), embarrassment (18.8%) and relief (29.2%) (p < 0.05). Women experienced a feeling of cleanliness in 89.1% compared to 56.1% of men (p < 0.05). Men were offered to wash their genitals in 72.9% compared to 35.7% of women (p < 0.05). 34.3% of men would prefer a family member to assist them during hygiene (62.9% by their wives), compared to 27.1% of women who would prefer a family member (84.6% by their daughters).

CONCLUSION

Women tolerate bed hygiene better than men and appreciate more the feeling of cleanliness. Women are identified as caregivers, both professionally and in the family, and patients prefer them to collaborate in the performance of hygiene, being wives preferred by men and daughters preferred by women.

Real-time machine learning model to predict short-term mortality in critically ill patients: development and international validation

BACKGROUND

A real-time model for predicting short-term mortality in critically ill patients is needed to identify patients at imminent risk. However, the performance of the model needs to be validated in various clinical settings and ethnicities before its clinical application. In this study, we aim to develop an ensemble machine learning model using routinely measured clinical variables at a single academic institution in South Korea.

METHODS

We developed an ensemble model using deep learning and light gradient boosting machine models. Internal validation was performed using the last two years of the internal cohort dataset, collected from a single academic hospital in South Korea between 2007 and 2021. External validation was performed using the full Medical Information Mart for Intensive Care (MIMIC), eICU-Collaborative Research Database (eICU-CRD), and Amsterdam University Medical Center database (AmsterdamUMCdb) data. The area under the receiver operating characteristic curve (AUROC) was calculated and compared to that for the National Early Warning Score (NEWS).

RESULTS

The developed model (iMORS) demonstrated high predictive performance with an internal AUROC of 0.964 (95% confidence interval [CI] 0.963-0.965) and external AUROCs of 0.890 (95% CI 0.889-0.891) for MIMIC, 0.886 (95% CI 0.885-0.887) for eICU-CRD, and 0.870 (95% CI 0.868-0.873) for AmsterdamUMCdb. The model outperformed the NEWS with higher AUROCs in the internal and external validation (0.866 for the internal, 0.746 for MIMIC, 0.798 for eICU-CRD, and 0.819 for AmsterdamUMCdb; p < 0.001).

CONCLUSIONS

Our real-time machine learning model to predict short-term mortality in critically ill patients showed excellent performance in both internal and external validations. This model could be a useful decision-support tool in the intensive care units to assist clinicians.

Study of Colistin Resistant Gram Negative Organism in Hospitalized Patients: A Retrospective Study

Background

Intensive care units have become hotspots for antimicrobial resistance, particularly concerning colistin resistance, posing a threat of untreatable infections.

Aim

This study aims to analyze the epidemiological and clinical aspects of patients carrying colistin-resistant organisms. It focuses on identifying risk factors, the microbiological profile, susceptibility patterns, and treatment outcomes.

Materials and methods

Isolates with colistin MIC >2 µg/mL, identified via BD PHOENIX, were subjected to colistin broth disc elution testing (as per CLSI guidelines) in our Microbiology Department between January and December 2022.

Results

Among the 30 patients, colistin-resistant gram-negative isolates were found predominantly in blood cultures (50%), followed by ET/TT cultures (23.3%), urine cultures (10%), and other sites (16.7%). Klebsiella pneumoniae was the most common organism (80%), showing the highest sensitivity to Ceftazidime-avibactam + Aztreonam (CAZ-AVI + ATM) (76.7%). Of these patients, 66.7% recovered and were discharged, while 33.3% succumbed during hospitalization despite treatment.

Conclusion

The study underscores a notable presence of colistin-resistant gram-negative isolates, predominantly in blood cultures, with K. pneumoniae being predominant. The combination of CAZ-AVI + ATM exhibited the highest sensitivity. However, the mortality rate of 33.3% despite sensitive antibiotic treatment highlights the urgency for ongoing vigilance and research to combat colistin-resistant infections and improve patient outcomes.

How to cite this article

Diwane D, Rajhans PA, Jog SA, Dalvi M. Study of Colistin Resistant Gram Negative Organism in Hospitalized Patients: A Retrospective Study. Indian J Crit Care Med 2024;28(3):286-289.

Intensive care unit nurses' perceptions of debriefing after critical incidents: A qualitative descriptive study

BACKGROUND

Intensive care unit (ICU) nurses are exposed to critical incidents daily at their workplace, which may have long-term physical and psychological impacts. Despite the growing evidence supporting clinical debriefing in health care to prevent these impacts, a scarcity of literature exists to support its use in the adult intensive care setting.

OBJECTIVES

The objective of this study was to explore nurses' perceptions of clinical debriefing after critical incidents in an adult ICU.

METHODS

A qualitative descriptive design was utilised. Thematic analysis of data from individual semistructured interviews with six ICU nurses was undertaken.

FINDINGS

In this study, two themes were identified. Firstly, participants valued hot debriefing after critical incidents for the key reasons of having an opportunity to reflect on and learn from a critical incident and reduce normalisation of stressful situations. Secondly, when logistical factors such as communication, timing, and location were not considered, the attendance at debriefings was negatively influenced. Participants identified that ICU nurses commonly prioritised patient tasks over attending a debrief; therefore, teamwork and flexibility with logistics was crucial.

CONCLUSIONS

Hot debriefing, of a short duration and close to the time of the event, was valued and played an important role in staff wellbeing and self-care, contributing to preventing self-blame and normalisation of stressful situations. A clearer definition of the term along with greater recognition of types of events that could be considered critical incidents is required for staff support after critical incidents in the complex intensive care setting.

Critical care bed capacity in Asian countries and regions before and during the COVID-19 pandemic: an observational study

Background

The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of critical care. The aim of the current study was to compare the number of adult critical care beds in relation to population size in Asian countries and regions before (2017) and during (2022) the pandemic.

Methods

This observational study collected data closest to 2022 on critical care beds (intensive care units and intermediate care units) in 12 middle-income and 7 high-income economies (using the 2022-2023 World Bank classification), through a mix of methods including government sources, national critical care societies, personal contacts, and data extrapolation. Data were compared with a prior study from 2017 of the same countries and regions.

Findings

The cumulative number of critical care beds per 100,000 population increased from 3.0 in 2017 to 9.4 in 2022 (p = 0.003). The median figure for middle-income economies increased from 2.6 (interquartile range [IQR] 1.7-7.8) to 6.6 (IQR 2.2-13.3), and that for high-income economies increased from 11.4 (IQR 7.3-22.8) to 13.9 (IQR 10.7-21.7). Only 3 countries did not see a rise in bed capacity. Where data were available in 2022, 10.9% of critical care beds were in single rooms (median 5.0% in middle-income and 20.3% in high-income economies), and 5.3% had negative pressure (median 0.7% in middle-income and 18.5% in high-income economies).

Interpretation

Critical care bed capacity in the studied Asian countries and regions increased close to three-fold from 2017 to 2022. Much of this increase was attributed to middle-income economies, but substantial heterogeneity exists.

Funding

None.

Adolescents with Rett syndrome at critical care pathway junctures: Examining clinicians' decision to initiate invasive long-term ventilation

BACKGROUND

The initiation of invasive long-term ventilation (I-LTV) for an adolescent with Rett Syndrome (RTT) involves many serious bioethical considerations. In moving towards a more inclusive model of patient participation, transparency surrounding the main influencing factors around this decision is important.

OBJECTIVE

We aimed to identify the main drivers influencing a clinician's decision to support initiation of I-LTV for an adolescent with RTT.

METHOD

We used an anonymous online vignette-based factorial survey. The survey was distributed internationally through eight professional multi-disciplinary organisations to reach clinicians working in paediatrics.

RESULTS

We analysed 504 RTT vignettes completed by 246 clinicians using mixed effect regression modelling. The main three significant influencing factors identified were: parental agreement with the decision to support initiation, the family's support network, and proximity to a tertiary care centre. Additional comments from participants focused on family support, and the importance of on-going communication with the family.

CONCLUSION

As the rights of those with disabilities improve and participation of adolescents in decision-making becomes more established, effective communications with the family around goals of care and particular sensitivity and reflective practice around methods of consensus building will likely contribute to a positive decision-making process at this difficult time.

Prognostic prediction of sepsis patient using transformer with skip connected token for tabular data

Sepsis is known as a common syndrome in intensive care units (ICU), and severe sepsis and septic shock are among the leading causes of death worldwide. The purpose of this study is to develop a deep learning model that supports clinicians in efficiently managing sepsis patients in the ICU by predicting mortality, ICU length of stay (>14 days), and hospital length of stay (>30 days). The proposed model was developed using 591 retrospective data with 16 tabular data related to a sequential organ failure assessment (SOFA) score. To analyze tabular data, we designed the modified architecture of the transformer that has achieved extraordinary success in the field of languages and computer vision tasks in recent years. The main idea of the proposed model is to use a skip-connected token, which combines both local (feature-wise token) and global (classification token) information as the output of a transformer encoder. The proposed model was compared with four machine learning models (ElasticNet, Extreme Gradient Boosting [XGBoost]), and Random Forest) and three deep learning models (Multi-Layer Perceptron [MLP], transformer, and Feature-Tokenizer transformer [FT-Transformer]) and achieved the best performance (mortality, area under the receiver operating characteristic (AUROC) 0.8047; ICU length of stay, AUROC 0.8314; hospital length of stay, AUROC 0.7342). We anticipate that the proposed model architecture will provide a promising approach to predict the various clinical endpoints using tabular data such as electronic health and medical records.

Efficacy of preventive interventions against ventilator-associated pneumonia in critically ill patients: an umbrella review of meta-analyses

Many meta-analyses have assessed the efficacy of preventive interventions against ventilator-associated pneumonia (VAP) in critically ill patients. However, there has been no comprehensive analysis of the strength and quality of evidence to date. Systematic reviews of randomized and quasi-randomized controlled trials, which evaluated the effect of preventive strategies on the incidence of VAP in critically ill patients receiving mechanical ventilation for at least 48 h, were included in this article. We identified a total of 34 interventions derived from 31 studies. Among these interventions, 19 resulted in a significantly reduced incidence of VAP. Among numerous strategies, only selective decontamination of the digestive tract (SDD) was supported by highly suggestive (Class II) evidence (risk ratio (RR)=0.439, 95% CI: 0.362-0.532). Based on data from the sensitivity analysis, the evidence for the efficacy of non-invasive ventilation in weaning from mechanical ventilation (NIV) was upgraded from weak (Class IV) to highly suggestive (Class II) (RR=0.32, 95% CI: 0.22-0.46). All preventive interventions were not supported by robust evidence for reducing mortality. Early mobilization exhibited suggestive (Class III) evidence in shortening both intensive length of stay (LOS) in the intensive care unit (ICU) (mean difference (MD)=-0.85, 95% CI: -1.21 to -0.49) and duration of mechanical ventilation (MD=-1.02, 95% CI: -1.41 to -0.63). In conclusion, SDD and NIV are supported by robust evidence for prevention against VAP, while early mobilization has been shown to significantly shorten the LOS in the ICU and the duration of mechanical ventilation. These three strategies are recommendable for inclusion in the ventilator bundle to lower the risk of VAP and improve the prognosis of critically ill patients.

Incidence and risk factors for subsequent infections among rectal carriers with carbapenem-resistant Klebsiella pneumoniae: a systematic review and meta-analysis

BACKGROUND

Carbapenem-resistant Klebsiella pneumoniae (CRKp) is a major pathogen causing nosocomial infections with a high mortality and poor prognosis. Gastrointestinal carriage has been acknowledged as the primary reservoir of CRKp infections.

AIM

To explore the incidence and risk factors associated with CRKp infection following colonization.

METHODS

The PubMed, Web of Science, and Cochrane Library databases were searched for relevant articles published between December 1998 and June 2023. Pooled estimates with a 95% confidence interval (CI) were calculated for the incidence rate, whereas pooled odds ratios (ORs) were calculated for the risk factors for which the OR was reported in three or more studies.

FINDINGS

Fourteen studies were included in the review with 5483 patients for the assessment of incidence, whereas seven of these studies with 2170 patients were included for the analysis of risk factors. In the meta-analysis, the incidence of CRKp infections after colonization was 23.2% (17.9-28.5). Additionally, three independent risk factors for subsequent CRKp infections were identified as admission to the intensive care unit (ICU) (2.59; 95% CI: 1.64-4.11), invasive procedures (2.53; 95% CI: 1.59-4.03), and multi-site colonization (6.24; 95% CI: 2.38-16.33).

CONCLUSION

This review reveals the incidence of CRKp infections in rectal carriers in different countries, emphasizing the role of rectal colonization with CRKp as an important source of nosocomial infections. Significantly, the risk factors indicated in this review can assist clinicians in identifying CRKp carriers with an elevated risk of subsequent infections, thereby enabling further measures to be taken to prevent nosocomial infections.

Identifying the barriers and facilitators to implementation of ventilator bundle in the nepalese intensive care unit: A descriptive qualitative study

BACKGROUND

A ventilator bundle is an effective preventive strategy against the development of ventilator-associated pneumonia (VAP). However, in clinical practice ventilator bundle implementation is poor. Understanding the barriers to ventilator bundle implementation in low- and middle-income countries can inform the development of effective implementation strategies to reduce the burden of VAP.

OBJECTIVES

The primary objective of this study was to explore the barriers and facilitators of ventilator bundle implementation perceived by healthcare professionals (HCPs) working in intensive care units (ICU) in Nepal. The secondary objective was to prioritise the barriers when developing implementation strategies.

METHODS

This study used a pragmatic approach comprising a series of methods to identify the implementation strategies: (i) Barriers and facilitators were explored using a qualitative study design. Twenty-one HCPs selected using the maximum variation sampling technique from a large tertiary hospital, completed semistructured interviews. All the interviews were recorded, transcribed word-by-word, and uploaded into NVivo for analysis using the thematic analysis approach. (ii) After analysis, nine participants were selecteded to determine the priority order of the barriers using a barrier identification and mitigation tool.

RESULTS

The data analysis revealed five main themes and 19 subthemes that affected ventilator bundle implementation. The main themes were provider-related factors, organisational and practice-related factors, performances of work, environmental conditions, and patient-related factors. The common barriers were job insecurity, poor knowledge, negative attitude, insufficient equipment, and severity of patient disease. Common facilitators were educational training, equipment functioning, adequate staff, strong leadership, and organisational support. Finally, eight main barriers were prioritised to target the change.

CONCLUSION

The barriers to implementing ventilator bundles in ICUs were identified. Focussing on addressing the prioritised barriers may aid in improving patient care and safety in ICUs. Results may guide HCPs in the development of implementation strategies to reduce the burden of VAP.

ICU-acquired infections in immunocompromised patients

Immunocompromised patients account for an increasing proportion of the typical intensive care unit (ICU) case-mix. Because of the increased availability of new drugs for cancer and auto-immune diseases, and improvement in the care of the most severely immunocompromised ICU patients (including those with hematologic malignancies), critically ill immunocompromised patients form a highly heterogeneous patient population. Furthermore, a large number of ICU patients with no apparent immunosuppression also harbor underlying conditions altering their immune response, or develop ICU-acquired immune deficiencies as a result of sepsis, trauma or major surgery. While infections are associated with significant morbidity and mortality in immunocompromised critically ill patients, little specific data are available on the incidence, microbiology, management and outcomes of ICU-acquired infections in this population. As a result, immunocompromised patients are usually excluded from trials and guidelines on the management of ICU-acquired infections. The most common ICU-acquired infections in immunocompromised patients are ventilator-associated lower respiratory tract infections (which include ventilator-associated pneumonia and tracheobronchitis) and bloodstream infections. Recently, several large observational studies have shed light on some of the epidemiological specificities of these infections-as well as on the dynamics of colonization and infection with multidrug-resistant bacteria-in these patients, and these will be discussed in this review. Immunocompromised patients are also at higher risk than non-immunocompromised hosts of fungal and viral infections, and the diagnostic and therapeutic management of these infections will be covered. Finally, we will suggest some important areas of future investigation.

The application of two drainage angles in neurocritical care patients with complicated pneumonia: a randomized controlled trial

Background

Although head elevation is an early first-line treatment for elevated intracranial pressure (ICP), the use of the head-down or prone position in managing neurocritical patients is controversial because a change in a position directly affects the intracranial and cerebral perfusion pressure, which may cause secondary brain injury and affect patient outcomes. This study compared the effects of two postural drainage positions (30° head-up tilt and 0° head flat) on the prognosis of neurocritical care patients with complicated pneumonia and a clinical pulmonary infection score (CPIS) ≥5 points to provide a reference for selecting appropriate postural drainage positions for patients with pneumonia in neurocritical care units.

Methods

A prospective randomized controlled study was conducted with 62 neurocritical care patients with complicated pneumonia. The patients were categorized into control (=31) and experimental (=31) groups in a 1:1 ratio using a simple randomized non-homologous pairing method. Emphasis was placed on matching the baseline characteristics of the two groups, including patient age, sex, height, weight, Glasgow Coma Scale score, heart rate, mean arterial pressure, cough reflex, and mechanical ventilation usage to ensure comparability. Both groups received bundled care for artificial airway management. The control group maintained a standard postural drainage position of 0° head-flat, whereas the experimental group maintained a 30° head-up tilt. The efficacy of the nursing intervention was evaluated by comparing the CPIS and other therapeutic indicators between the two groups after postural drainage.

Results

After the intervention, the within-group comparison showed a significant decrease in the CPIS (P < 0.001); procalcitonin levels showed a significant decreasing trend (P < 0.05); the arterial oxygen pressure significantly increased (P < 0.05); the oxygenation index significantly increased (P < 0.001); and the aspiration risk score showed a significant decreasing trend (P < 0.001). A between-group comparison showed no significant differences in any of the indicators before and after the intervention (P < 0.05).

Conclusion

Postural drainage positions of 30° head-up tilt and 0° head-flat can improve the CPIS and oxygenation in patients without adverse effects. Therefore, we recommend that patients under neurological intensive care and having pneumonia be drained in a 30° head-up tilt position with good centralized care of the lung infection.

Trial registration

The study, "Study of Angles of Postural Drainage in Neurocritical Patients with Pneumonia," was registered in the Protocol Registration Data Element Definitions for Interventional Study database (# ChiCTR2100042155); date of registration: 2021-01-14.

Violence against healthcare professionals in intensive care units: a systematic review and meta-analysis of frequency, risk factors, interventions, and preventive measures

BACKGROUND

To assess the frequency, risk factors, consequences, and prevention of violence against healthcare workers in intensive care units.

METHODS

PubMed, Scopus, Google Scholar, EMBASE, Cochrane, and Web of Science were searched for studies on violence against healthcare workers in adult intensive care units. Risk factors, patient characteristics, and implications for healthcare workers were collected. Study quality, bias, and level of evidence were assessed using established tools.

RESULTS

Seventy-five studies with 139,533 healthcare workers from 32 countries were included. The overall median frequency of violence was 51% (IQR 37-75%). Up to 97% of healthcare workers experienced verbal violence, and up to 82% were victims of physical violence. Meta-analysis of frequency revealed an average frequency of 31% (95% CI 22-41%) for physical violence, 57% for verbal violence (95% CI 48-66%), and 12% for sexual violence (95% CI 4-23%). Heterogeneity was high according to the I2 statistics. Patients were the most common perpetrators (median 56%), followed by visitors (median 22%). Twenty-two studies reported increased risk ratios of up to 2.3 or odds ratios of up to 22.9 for healthcare workers in the ICU compared to other healthcare workers. Risk factors for experiencing violence included young age, less work experience, and being a nurse. Patients who exhibited violent behavior were often male, older, and physically impaired by drugs. Violence was underreported in up to 80% of cases and associated with higher burnout rates, increased anxiety, and higher turnover intentions. Overall the level of evidence was low.

CONCLUSIONS

Workplace violence is frequent and underreported in intensive care units, with potential serious consequences for healthcare workers, calling for heightened awareness, screening, and preventive measures. The potential risk factors for violence should be further investigated.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this review was registered with Prospero on January 15, 2023 (ID CRD42023388449).

Exploring the therapeutic role of early heparin administration in ARDS management: a MIMIC-IV database analysis

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a severe respiratory condition characterized by a high mortality rate, the management of which relies on supportive care and a profound understanding of its pathophysiology. Heparin, with its anticoagulant and potential anti-inflammatory properties, offers a new therapeutic opportunity for the treatment of ARDS.

METHODS

In this retrospective cohort study, we examined the MIMIC-IV database for ARDS patients who received prophylactic heparin within the first 72 h of ICU admission. Employing propensity score matching and inverse probability weighting (IPW) analysis, we evaluated the impact of early heparin use on patient outcomes, focusing on mortality rates.

RESULTS

Patients who received prophylactic heparin had a significantly lower in-hospital mortality rate compared to those who did not (13.55% vs 17.93%, HR = 0.71, 95% CI: 0.54-0.93, P = 0.012). This result remained significant after propensity score matching (12.75% vs 17.93%, HR = 0.65, 95% CI 0.47-0.90, P = 0.010). Analysis using five different statistical models indicated that early use of heparin significantly reduced the in-hospital mortality rate, with HR = 0.669 (95% CI 0.487-0.919, P = 0.013) in the doubly robust model without balanced covariates; HR = 0.705 (95% CI 0.515-0.965, P = 0.029) with all covariates considered; HR = 0.660 (95% CI 0.491-0.888, P = 0.006) in the propensity score (IPW) model; HR = 0.650 (95% CI 0.470-0.900, P = 0.010) in the propensity score matching model; and HR = 0.706 (95% CI 0.536-0.930, P = 0.013) in the multivariate Cox regression model. Secondary outcomes indicated that heparin use was also associated with reduced mortality rates at 60 days, and 90 days.

CONCLUSION

This research highlights that early prophylactic administration of heparin may substantially lower mortality in ARDS patients. These findings underscore the potential of heparin as a key component in the management of ARDS, offering a new perspective and novel strategies for clinical treatment.

A nationwide cohort study on the association between intensive care treatments and mental distress linked psychiatric disorders

Given the psychic strain patients experience in the intensive care unit (ICU), a potential risk of mental disorders has been suggested. However, the effects of intensive care treatment per se are unknown. We investigated whether the level of intensive care treatments is an independent risk factor for developing long-term mental disorders after intensive care. In a national cohort of adult ICU patients we combined data on diagnoses, treatment, and causes of death. We defined extensive ICU treatment as being treated with invasive ventilation for > 24 h, continuous renal replacement therapy, or both. The primary outcome was incident mental disorder 1 year after ICU admission. Extensive ICU treatment was found to be associated with a decreased risk of developing a mental disorder ≥ 1 year after ICU admission (HR 0.90, 95% CI 0.82-0.99, p = 0.04), and increasing severity of acute illness (HR 1.18, 95% CI 1.06-1.32, p < 0.001) were associated with an increased risk of mental disorders. Because death acted as a competing risk for mental illness, mortality might help explain the apparent protective effect of extensive ICU care.Trial registration Clinical Trials Registry (Identification number NCT05137977). Registered 16 November 2021. As a registry trial the patients were already included at the trial registration i.e. it was retrospectively registered.

The effect of nurse-initiated diary intervention on posttraumatic stress disorder and recall of memories in ICU survivors: a randomized controlled trial

BACKGROUND

Patients' recall of memories from the ICU plays an important role in the occurrence of post-traumatic stress disorder. This study aimed to determine the effect of nurse-initiated diary intervention on post-traumatic stress disorder and recall of memories in ICU survivors.

METHODS

This RCT study included all patients admitted to two trauma ICUs in Southeast of Iran. Thirty patients considered in control and intervention groups. Data collection tools included the Impact of Events Scale-Revised (IES-R), and the ICU Memory Tool (ICU-MT). The researcher wrote daily diaries of the intervention and control groups during the first 72 h of their admissions. SPSS25 was used to analyze the data.

RESULTS

The total mean PTSD score in the intervention group was significantly lower than that in the control group (p > 0.0001, z = -3.75). The number of those in the intervention group who clearly recalled their admission to hospital, their hospital stay before being admitted to the ICU and all memories from the ICU stay, was more than those in the control group; this difference was statistically significant (p > 0.0001).

CONCLUSION

The results showed that the nurse-initiated diary was effective on the PTSD and recall clear memories of patients admitted to the ICU. We suggest medical and educational centers to use this intervention in order to reduce the posttraumatic stress disorder in these patients. As nurse-initiated diary intervention had no significant difference in the recall of different types of memories from the ICU, we require further studies in this field.

Intradialytic hypotension and worse outcomes in patients with acute kidney injury requiring intermittent hemodialysis

Background

Intradialytic hypotension (IDH) is a critical complication related to worse outcomes in patients undergoing maintenance hemodialysis. Herein, we addressed the impact of IDH on mortality and other outcomes in patients with severe acute kidney injury (AKI) requiring intermittent hemodialysis.

Methods

We retrospectively reviewed 1,009 patients who underwent intermittent hemodialysis due to severe AKI. IDH was defined as either dialysis discontinuation due to hemodynamic instability or a decrease in systolic blood pressure (BP) of ≥30 mmHg, with or without a nadir systolic BP of <90 mmHg during the first session. The primary outcome was all-cause mortality, and transfer to the intensive care unit (ICU) due to unstable status was additionally analyzed. Hazard ratios (HRs) of outcomes were calculated using a Cox regression model after adjusting for multiple variables. Risk factors for IDH were evaluated using a logistic regression model.

Results

IDH occurred in 449 patients (44.5%) during the first hemodialysis session. Patients with IDH had a higher mortality rate than those without IDH (40% vs. 23%; HR, 1.30; 95% confidence interval [CI], 1.02-1.65). The rate of ICU transfer was higher in patients experiencing IDH than in those without IDH (17% vs. 11%; HR, 1.43; 95% CI, 1.02-2.02). Factors such as old age, high BP and pulse rate, active malignancy, cirrhosis, and hypoalbuminemia were associated with an increased risk of IDH episodes.

Conclusion

The occurrence of IDH is associated with worse outcomes in patients with AKI requiring intermittent hemodialysis. Therefore, careful monitoring and early intervention of IDH may be necessary in this patient subset.

Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis

BACKGROUND

Tracheal intubation is a high-risk intervention commonly performed in critically ill patients. Due to its favorable cardiovascular profile, ketamine is considered less likely to compromise clinical outcomes. This meta-analysis aimed to assess whether ketamine, compared with other agents, reduces mortality in critically ill patients undergoing intubation.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library from inception until April 27, 2023, for randomized controlled trials and matched observational studies comparing ketamine with any control in critically ill patients as an induction agent. The primary outcome was mortality at the longest follow-up available, and the secondary outcomes included Sequential Organ Failure Assessment score, ventilator-free days at day 28, vasopressor-free days at day 28, post-induction mean arterial pressure, and successful intubation on the first attempt. For the primary outcome, we used a Bayesian random-effects meta-analysis on the risk ratio (RR) scale with a weakly informative neutral prior corresponding to a mean estimate of no difference with 95% probability; the estimated effect size will fall between a relative risk of 0.25 and 4. The RR and 95% credible interval (CrI) were used to estimate the probability of mortality reduction (RR < 1). The secondary outcomes were assessed with a frequentist random-effects model. We registered this study in Open Science Framework ( https://osf.io/2vf79/ ).

RESULTS

We included seven randomized trials and one propensity-matched study totaling 2978 patients. Etomidate was the comparator in all the identified studies. The probability that ketamine reduced mortality was 83.2% (376/1475 [25%] vs. 411/1503 [27%]; RR, 0.93; 95% CrI, 0.79-1.08), which was confirmed by a subgroup analysis excluding studies with a high risk of bias. No significant difference was observed in any secondary outcomes.

CONCLUSIONS

All of the included studies evaluated ketamine versus etomidate among critically ill adults requiring tracheal intubation. This meta-analysis showed a moderate probability that induction with ketamine is associated with a reduced risk of mortality.

Psychosocial Predictors of Ventilator weaning Outcomes among patients in intensive care units

Background

Ventilator weaning is a process of discontinuing mechanical ventilation and transitioning patients to independent breathing after a period of mechanical support. Weaning outcomes among the critically ill in intensive care units (ICUs) vary significantly among individuals, leading to considerable variation in healthcare costs, length of hospital stay, morbidity and mortality. Addressing psychosocial aspects of care can improve weaning outcomes.

Objective

This study aimed to determine the effect of psychosocial factors (social support, family/significant other support, ability to communicate) on weaning outcome within intensive care patients. This research hypothesized that psychological and social factors play a role in determining ventilator weaning outcomes among ICU patients.

Methods

This study used a longitudinal, retrospective research design to analyze positive and negative psychosocial predictors of ventilator weaning outcomes. Data collection methods include interviews and questionnaires with patients and their families, as well as clinical data from the patient's medical records.

Results

presence of anxiety, depression, and hallucinations, have a negative relationship with weaning outcomes regarding a patient's psychological characteristics (rs = -0.207, -0.163, -0.158), while communication with a patient during mechanical ventilation have a positive relationship with weaning outcomes regarding a patient's psychological characteristics (rs = 0.152; p ≤ 0.05). Moreover patients who have fear during weaning trials, feeling neglected, and feeling insecurity have a negative relationship with weaning outcomes while gaining family support during mechanical ventilation have a positive relationship with weaning outcomes (rs = 0.144; p ≤ 0.05).Significance of results, the findings suggests that psychosocial factors, such as anxiety, depression, patient's perception of their illness, motivation to wean, and family involvement can influence the success of ventilator weaning among patients in ICUs.

Glucose management in critically ill adults: A qualitative study from the experiences of health care providers

Aims and objective

To explain the components and elements of glucose management in critically ill adult patients from the healthcare providers' experiences.

Background

Critically ill adults are highly susceptible to stress-induced hyperglycaemia due to glucose metabolic disorders. Healthcare workers play a key role in the glycaemic management of critically ill patients. However, there is a lack of qualitative studies on the content and elements of glycaemic management and healthcare workers' perceptions about glycaemic management in China.

Design

Qualitative study that followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Methods

Individual semi-structured interviews were conducted from January to April 2022. Fifteen physicians and nurses were recruited from ten hospitals in mainland China. Data were analysed using inductive thematic analysis.

Results

Glucose management in critically ill adult patients from their experiences included two parts: the inner ring (practice behaviours) and the external space (methods and drivers). The practice behaviours of glucose management include five elements, while the methods and drivers of glucose management focus on three elements. The content covered under each element was identified.

Conclusion

This study developed a glycaemic management model for critically ill adult patients, clarified its elements based on the perceptions of healthcare providers and elaborated on the methods and drivers covered under each element to provide a reference for physicians and nurses to develop a comprehensive glycaemic management guideline for critically ill adult patients.

Relevance to clinical practice

Our study proposed a glucose management practice model for critically ill adult patients, and the elements and components included in this model can provide a reference for physicians and nurses when performing glucose management in critically ill patients.

Validation of a low-cost continuous renal replacement therapy dialysate fluid controller for experimental purposes

BACKGROUND

Continuous renal replacement therapy (CRRT) support is crucial for critically ill patients and it is underexplored in specific situations. Experimental CRRT offers a means to gain insights into these scenarios, but the prohibitive cost of CRRT machines limits their accessibility. This study aimed to develop and validate a low-cost and precise dialysate controller for experimental CRRT.

RESULTS

Our results demonstrate a commendable level of precision in affluent flow control, with a robust correlation (R2 = 0.99) for continuous flow and a strong correlation (R2 = 0.95) for intermittent flow. Additionally, we observed acceptable agreement with a bias = 3.4 mL (upper limit 95% = 43.9 mL and lower limit 95% = - 37 mL) for continuous flow and bias = - 20.9 mL (upper limit 95% = 54 mL and lower limit 95% = - 95.7 mL) for intermittent flow, in this way, offering a precise CRRT dose for the subjects. Furthermore, we achieved excellent precision in the cumulative ultrafiltration net (UFnet), with a bias = - 2.8 mL (upper limit 95% = 6.5 mL and lower limit 95% = - 12 mL). These results remained consistent even at low affluent flow rates of 8, 12, and 20 mL/min, which are compatible with CRRT doses of 25-30 mL/kg for medium-sized animals. Moreover, the acceptable precision of our findings persisted when the dialysate controller was subjected to high filter dialysate chamber pressure for an extended duration, up to 797 min.

CONCLUSIONS

The low-cost dialysate controller developed and tested in this study offers a precise means of regulating CRRT in experimental settings. Its affordability and accuracy render it a valuable instrument for studying CRRT support in unconventional clinical scenarios, particularly in middle-income countries' experimental ICU laboratories.

Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH.

METHODS

This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used.

RESULTS

A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome.

CONCLUSIONS

The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.

Consensus-based indicators for evaluating and improving the quality of regional collaborative networks of intensive care units: Results of a nationwide Delphi study

PURPOSE

To select a consensus-based set of relevant and feasible indicators for monitoring and improving the quality of regional ICU network collaboratives.

METHODS

A three-round Delphi study was conducted in the Netherlands between April and July 2022. A multidisciplinary expert panel prioritized potentially relevant and feasible indicators in two questionnaire rounds with two consensus meetings between both rounds. The RAND/UCLA appropriateness method was used to categorize indicators and synthesize results. A core set of highest ranked indicators with consensus-based levels of relevance and feasibility were finally tested in two ICU networks to assess their measurability.

RESULTS

Twenty-four indicators were deemed as relevant and feasible. Seven indicators were selected for the core set measuring the standardized mortality rate in the region (n = 1) and evaluating the presence, content and/or follow-up of a formal plan describing network structures and policy agreements (n = 3), a long-term network vision statement (n = 1), and network meetings to reflect on and learn from outcome data (n = 2). The practice tests led to minor reformulations.

CONCLUSIONS

This study generated relevant and feasible indicators for monitoring and improving the quality of ICU network collaboratives based on the collective opinion of various experts. The indicators may help to effectively govern such networks.