Baseline immune status and the effectiveness of response to enteral nutrition among ICU patients with COVID-19: An observational, retrospective study

OBJECTIVES

This study aimed to compare how immunocompromised and immunocompetent patients responded differently to enteral nutrition (EN) support in intensive care units (ICUs) during the COVID-19 pandemic, including serum nutritional biomarkers, inflammatory biomarkers, gastrointestinal (GI) intolerance symptoms, and clinical outcomes.

METHODS

An observational, retrospective study was conducted in the ICUs of a teaching hospital in southwest China. We recruited a convenience sample of 154 patients between December 2022 and February 2023. We defined immunocompromise as primary immunodeficiency diseases, active malignancy, receiving cancer chemotherapy, HIV infection, solid organ transplantation, hematopoietic stem cell transplantation, receiving corticosteroid therapy with a target dose, receiving biological immune modulators, or receiving disease-modifying antirheumatic drugs or other immunosuppressive drugs. We conducted a Mann-Whitney U test, χ2 test, or generalized estimation equation model to explore the differences between immunocompromised and immunocompetent patients.

RESULTS

Among the 154 study participants, 41 (27%) were defined as immunocompromised. The immunocompromised patients were younger than the immunocompetent patients. There were no statistically significant differences between the two groups with respect to serum nutritional biomarkers, inflammatory biomarkers, incidence of GI intolerance symptoms, and in-hospital mortality. However, the immunocompromised patients exhibited a longer hospitalization duration than the immunocompetent patients.

CONCLUSION

We found that the immunocompromised patients spent more time in the hospital. These findings may help us to standardize the participants before EN interventional studies better and better individualize EN supports based on patients' immunity status.

Implementing an ICU registry in Ethiopia-Implications for critical care quality improvement

PURPOSE

Intensive care units (ICUs) in low- and middle-income countries have high mortality rates, and clinical data are needed to guide quality improvement (QI) efforts. This study utilizes data from a validated ICU registry specially developed for resource-limited settings to identify evidence-based QI priorities for ICUs in Ethiopia.

MATERIALS AND METHODS

A retrospective cohort analysis of data from two tertiary referral hospital ICUs in Addis Ababa, Ethiopia from July 2021-June 2022 was conducted to describe casemix, complications and outcomes and identify features associated with ICU mortality.

RESULTS

Among 496 patients, ICU mortality was 35.3%. The most common reasons for ICU admission were respiratory failure (24.0%), major head injury (17.5%) and sepsis/septic shock (13.3%). Complications occurred in 41.0% of patients. ICU mortality was higher among patients with respiratory failure (46.2%), sepsis (66.7%) and vasopressor requirements (70.5%), those admitted from the hospital ward (64.7%), and those experiencing major complications in the ICU (62.3%).

CONCLUSIONS

In this study, ICU mortality was high, and complications were common and associated with increased mortality. ICU registries are invaluable tools to understand local casemix and clinical outcomes, especially in resource-limited settings. These findings provide a foundation for QI efforts and a baseline to evaluate their impact.

What every Intensivist should know about ... Ammonia in liver failure

PURPOSE

Acute liver failure (ALF) or acute-on-chronic liver failure (ACLF) patients have high short-term mortality and morbidity. In the context of liver failure, increased serum ammonia is associated with worse neurological outcomes, including high-grade hepatic encephalopathy (HE), cerebral edema, and intracranial hypertension. Besides its neurotoxicity, hyperammonemia may contribute to immune dysfunction and the risk of infection, a frequent trigger for multi-organ failure in these patients.

MATERIAL AND METHODS

We performed a literature-based narrative review. Publications available in PubMed® up to June 2023 were considered.

RESULTS

In the ICU management of liver failure patients, serum ammonia may play an important role. Accordingly, in this review, we focus on recent insights about ammonia metabolism, serum ammonia measurement strategies, hyperammonemia prognostic value, and ammonia-targeted therapeutic strategies.

CONCLUSIONS

Serum ammonia may have prognostic value in liver failure. Effective ammonia targeted therapeutic strategies are available, such as laxatives, rifaximin, L-ornithine-l-aspartate, and continuous renal replacement therapy.

Plasma sodium during the recovery of renal function in critically ill adult patients: Multicenter prospective cohort study

BACKGROUND

Sodium increases during acute kidney injury (AKI) recovery. Both hypernatremia and positive fluid balances are associated with increased mortality. We aimed to evaluate the association between daily fluid balance and daily plasma sodium during the recovery from AKI among critical patients.

METHODS

Adult patients with AKI were enrolled in four ICUs and followed up for four days or until ICU discharge or hemodialysis initiation. Day zero was the peak day of creatinine. The primary outcome was daily plasma sodium; the main exposure was daily fluid balance.

RESULTS

93 patients were included. The median age was 66 years; 68% were male. Plasma sodium increased in 79 patients (85%), and 52% presented hypernatremia. We found no effect of daily fluid balance on plasma sodium (β -0.26, IC95%: -0.63-0.13; p = 0.19). A higher total sodium variation was observed in patients with lower initial plasma sodium (β -0.40, IC95%: -0.53 to -0.27; p < 0.01), higher initial urea (β 0.07, IC95%: 0.04-0.01; p < 0.01), and higher net sodium balance (β 0.002, IC95%: 0.0001-0.01; p = 0.05).

CONCLUSIONS

The increase in plasma sodium is common during AKI recovery and can only partially be attributed to the water and electrolyte balances. The incidence of hypernatremia in this population of patients is higher than in the general critically ill patient population.

Continuous renal replacement therapy and survival in acute liver failure: A systematic review and meta-analysis

OBJECTIVE

Acute liver failure (ALF) is a rare syndrome leading to significant morbidity and mortality. An important cause of mortality is cerebral edema due to hyperammonemia. Different therapies for hyperammonemia have been assessed including continuous renal replacement therapy (CRRT). We conducted a systematic review and meta-analysis to determine the efficacy of CRRT in ALF patients.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE, Cochrane Library, and Web of Science. Inclusion criteria included adult patients admitted to an ICU with ALF. Intervention was the use of CRRT for one or more indications with the comparator being standard care without the use of CRRT. Outcomes of interest were overall survival, transplant-free survival (TFS), mortality and changes in serum ammonia levels.

RESULTS

In total, 305 patients underwent CRRT while 1137 patients did not receive CRRT. CRRT was associated with improved overall survival [risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70-0.99, p-value 0.04, I2 = 50%] and improved TFS (RR 0.65, 95% CI 0.49-0.85, p-value 0.002, I2 = 25%). There was a trend towards higher mortality with no CRRT (RR 1.24, 95% CI 0.84-1.81, p-value 0.28, I2 = 37%). Ammonia clearance data was unable to be pooled and was not analyzable.

CONCLUSION

Use of CRRT in ALF patients is associated with improved overall and transplant-free survival compared to no CRRT.

Different ventilation intensities among various categories of patients ventilated for reasons other than ARDS--A pooled analysis of 4 observational studies

PURPOSE

We investigated driving pressure (ΔP) and mechanical power (MP) and associations with clinical outcomes in critically ill patients ventilated for reasons other than ARDS.

MATERIALS AND METHODS

Individual patient data analysis of a pooled database that included patients from four observational studies of ventilation. ΔP and MP were compared among invasively ventilated non-ARDS patients with sepsis, with pneumonia, and not having sepsis or pneumonia. The primary endpoint was ΔP; secondary endpoints included MP, ICU mortality and length of stay, and duration of ventilation.

RESULTS

This analysis included 372 (11%) sepsis patients, 944 (28%) pneumonia patients, and 2040 (61%) patients ventilated for any other reason. On day 1, median ΔP was higher in sepsis (14 [11-18] cmH2O) and pneumonia patients (14 [11-18]cmH2O), as compared to patients not having sepsis or pneumonia (13 [10-16] cmH2O) (P < 0.001). Median MP was also higher in sepsis and pneumonia patients. ΔP, as opposed to MP, was associated with ICU mortality in sepsis and pneumonia patients.

CONCLUSIONS

The intensity of ventilation differed between patients with sepsis or pneumonia and patients receiving ventilation for any other reason; ΔP was associated with higher mortality in sepsis and pneumonia patients.

REGISTRATION

This post hoc analysis was not registered; the individual studies that were merged into the used database were registered at clinicaltrials.gov: NCT01268410 (ERICC), NCT02010073 (LUNG SAFE), NCT01868321 (PRoVENT), and NCT03188770 (PRoVENT-iMiC).

Diagnostic accuracy of the pediatric CAM-ICU, pre-school CAM-ICU, Pediatric Anesthesia Emergence Delirium and Cornell Assessment of Pediatric Delirium for detecting delirium in the pediatric intensive care unit: A systematic review and meta-analysis

OBJECTIVES

Delirium is a frequent complication of critical illness, affecting 34% of children admitted to pediatric intensive care units. The commonly used tools for detecting delirium in the pediatric intensive care unit include the Pediatric Confusion Assessment Method for the intensive care unit (ICU, pCAM-ICU), Preschool Confusion Assessment Method for the ICU (psCAM-ICU), Pediatric Anesthesia Emergence Delirium and the Cornell Assessment of Pediatric Delirium.

DATA SOURCES

We searched four electronic databases for relevant articles from inception to March 1, 2023.

STUDY SELECTION

All full-text observational studies examining the sensitivity and specificity of the four tools for screening delirium in the pediatric intensive care units were included.

DATA EXTRACTION

Two researchers independently identified articles, extracted data, and retrieved the diagnostic accuracy parameters of the pediatric CAM-ICU, pre-school CAM-ICU, Pediatric Anesthesia Emergence Delirium, and Cornell Assessment of Pediatric Delirium relative to standard references. A bivariate diagnostic statistical analysis with a random-effects model was performed.

DATA SYNTHESIS

Four, five, three and seven studies on the pediatric CAM-ICU, pre-school CAM-ICU, Pediatric Anesthesia Emergence Delirium, and Cornell Assessment of Pediatric Delirium, respectively, were identified. Due to the limited number of Pediatric Anesthesia Emergence Delirium articles included, no pooled diagnostic accuracy was produced. The pooled sensitivity was 0.73, 0.84, and 0.95 for the pediatric CAM-ICU, pre-school CAM-ICU, and Cornell Assessment of Pediatric Delirium, respectively, whereas the pooled specificity was 0.98, 0.90, and 0.81, respectively. The Cornell Assessment of Pediatric Delirium had greater sensitivity compared to both the pediatric CAM-ICU and pre-school CAM-ICU (both p = 0.04) and lower specificity than the pediatric CAM-ICU did (p < 0.001). Age, sample size, and mechanical ventilation use were significant moderators of the specificity of the pediatric CAM-ICU (p < 0.001, <0.001, and = 0.001, respectively).

CONCLUSIONS

Our data indicate that the Cornell Assessment of Pediatric Delirium is a more dependable instrument than the pediatric CAM-ICU and pre-school CAM-ICU for detecting pediatric intensive care delirium occurrence. More studies on the Pediatric Anesthesia Emergence Delirium are warranted.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare providers are suggested adopting the Cornell Assessment of Pediatric Delirium into daily routine for the early detection of delirium in pediatric intensive care units.

Part III: Temporal patterns, relative potencies, and hospital mortality

INTRODUCTION

The relationship between critical care mortality and combined impact of malglycemia remains undefined.

METHODS

We assessed the risk-adjusted relationship (n = 4790) between hospital mortality with malglycemia, defined as hypergycemia (hours Glycemic Ratio ≥ 1.1, where GR is quotient of mean ICU blood glucose (BG) and estimated average BG), absolute hypoglycemia (hours BG < 70 mg/dL) and relative hypoglycemia (excursions GR < 0.7 in those with HbA1c ≥ 8%).

RESULTS

Each malglycemia was independently associated with mortality - hyperglycemia (OR 1.0020/h, 95%CI 1.0009-1.0031, p = 0.0004), absolute hypoglycemia (OR 1.0616/h, 95%CI 1.0190-1.1061, p = 0.0043), and relative hypoglycemia (OR 1.2813/excursion, 95%CI 1.0704-1.5338, p = 0.0069). Absolute (7.4%) and relative hypoglycemia (6.7%) exposure dominated the first 24 h, decreasing thereafter. While hyperglycemia had lower risk association with mortality, it was persistently present across the length-of-stay (68-76% incidence daily), making it the dominant form of malglycemia. Relative contributions in the first five days from hyperglycemia, absolute hypoglycemia and relative hypoglycemia were 60%, 21% and 19% respectively.

CONCLUSIONS

Absolute and relative hypoglycemia occurred largely in the first 24 h. Relative to all hypoglycemia, the associated mortality from the seemingly less potent but consistently more prevalent hyperglycemia steadily accumulated with increasing length-of-stay. This has important implications for interpretation of study results.

Patient-important upper gastrointestinal bleeding in the ICU: A mixed-methods study of patient and family perspectives

INTRODUCTION

The objective of this study was to create a definition of patient-important upper gastrointestinal bleeding during critical illness as an outcome for a randomized trial.

DESIGN

This was a sequential mixed-methods qualitative-dominant multi-center study with an instrument-building aim. In semi-structured individual interviews or focus groups we elicited views from survivors of critical illness and family members of patients in the intensive care unit (ICU) regarding which features indicate important gastrointestinal bleeding. Quantitative demographic characteristics were collected. We analyzed qualitative data using inductive content analysis to develop a definition for patient-important upper gastrointestinal bleeding.

SETTING

Canada and the United States.

PARTICIPANTS

51 ICU survivors and family members of ICU patients.

RESULTS

Participants considered gastrointestinal bleeding to be important if it resulted in death, disability, or prolonged hospitalization. The following also signaled patient-important upper gastrointestinal bleeding: blood transfusion, vasopressors, endoscopy, CT-angiography, or surgery. Whether an intervention evinced concern depended on its effectiveness, side-effects, invasiveness and accessibility; contextual influences included participant familiarity and knowledge of interventions and trust in the clinical team.

CONCLUSIONS

Survivors of critical illness and family members described patient-important upper gastrointestinal bleeding differently than current definitions of clinically-important upper gastrointestinal bleeding.

Caregiver burden and impact on COVID-19 patient participation and quality of life one year after ICU discharge - A prospective cohort study

OBJECTIVES

to investigate changes in caregiver strain, mental health complaints and QoL in caregivers of COVID-19 ICU survivors in the first year after discharge, and their associations with patients' participation and quality of life.

METHODS

Post-ICU COVID-19 survivors, needing inpatient rehabilitation and their informal caregivers were included. Caregiver self-administered questionnaires included quality of life, self-rated health, caregiver strain, anxiety and depression symptoms, post-traumatic stress and coping style. Patients' participation in society was assessed and quality of life.

RESULTS

67 patients (78% male) and 57 caregivers (23.6% male) were included. Three months post-ICU, caregivers experienced caregiver strain (32%), anxiety (41%), depressive symptoms (16%) and PTSD (24%). One year post-ICU, rates decreased, still being 11%, 26%, 10% and 5%, respectively. Caregiver anxiety symptoms and self-rated health at three months were associated with worse patient levels of participation and quality of life one year after ICU discharge (p < 0.05).

CONCLUSIONS

COVID-19 caregivers experience high levels of mental health complaints one year after a patient's ICU discharge. Furthermore, our results indicate that patient participation levels and quality of life one year after ICU discharge may be negatively associated by caregiver complaints.

PRACTICAL IMPLICATIONS

Counselling and routine assessment of emotional complaints and unmet needs of the informal caregiver should be incorporated and addressed in the rehabilitation treatment of (COVID-19) post-ICU patients.

Gut microbiota disturbances in hospitalized older adults with malnutrition and clinical outcomes

OBJECTIVE

Malnutrition is one of the most threatening conditions in geriatric populations. The gut microbiota has an important role in the host's metabolic and muscular health: however, its interplay with disease-related malnutrition is not well understood. We aimed to identify the association of malnutrition with the gut microbiota and predict clinical outcomes in hospitalized acutely ill older adults.

METHODS

We performed a secondary longitudinal analysis in 108 geriatric patients from a prospective cohort evaluated at admission and 72 h of hospitalization. We collected clinical, demographic, nutritional, and 16S rRNA gene-sequenced gut microbiota data. Microbiota diversity, overall composition, and differential abundance were calculated and compared between patients with and without malnutrition. Microbiota features associated with malnutrition were used to predict clinical outcomes.

RESULTS

Patients with malnutrition (51%) had a different microbiota composition compared to those who were well-nourished during hospitalization (ANOSIM R = 0.079, P = 0.003). Patients with severe malnutrition showed poorer α-diversity at admission (Shannon P = 0.012, Simpson P = 0.018) and follow-up (Shannon P = 0.023, Chao1 P = 0.008). Differential abundance of Lachnospiraceae NK4A136 group, Subdoligranulum, and Faecalibacterium prausnitzii were significantly lower and inversely associated with malnutrition, while Corynebacterium, Ruminococcaceae Incertae Sedis, and Fusobacterium were significantly increased and positively associated with malnutrition. Corynebacterium, Ruminococcaceae Incertae Sedis, and the overall composition were important predictors of critical care in patients with malnutrition during hospitalization.

CONCLUSION

Older adults with malnutrition, especially in a severe stage, may be subject to substantial gut microbial disturbances during hospitalization. The gut microbiota profile of patients with malnutrition might help us to predict worse clinical outcomes.

Adjudication of a primary trial outcome: Results of a calibration exercise and protocol for a large international trial

Background

Ascertainment of the severity of the primary outcome of upper gastrointestinal (GI) bleeding is integral to stress ulcer prophylaxis trials. This protocol outlines the adjudication process for GI bleeding events in an international trial comparing pantoprazole to placebo in critically ill patients (REVISE: Re-Evaluating the Inhibition of Stress Erosions). The primary objective of the adjudication process is to assess episodes submitted by participating sites to determine which fulfil the definition of the primary efficacy outcome of clinically important upper GI bleeding. Secondary objectives are to categorize the bleeding severity if deemed not clinically important, and adjudicate the bleeding site, timing, investigations, and treatments.

Methods

Research coordinators follow patients daily for any suspected clinically important upper GI bleeding, and submit case report forms, doctors' and nurses' notes, laboratory, imaging, and procedural reports to the methods center. An international central adjudication committee reflecting diverse specialty backgrounds conducted an initial calibration exercise to delineate the scope of the adjudication process, review components of the definition, and agree on how each criterion will be considered fulfilled. Henceforth, bleeding events will be stratified by study drug, and randomly assigned to adjudicator pairs (blinded to treatment allocation, and study center).

Results

Crude agreement, chance-corrected agreement, or chance-independent agreement if data have a skewed distribution will be calculated.

Conclusions

Focusing on consistency and accuracy, central independent blinded duplicate adjudication of suspected clinically important upper GI bleeding events will determine which events fulfil the definition of the primary efficacy outcome for this stress ulcer prophylaxis trial.

Registration

NCT03374800 (REVISE: Re-Evaluating the Inhibition of Stress Erosions).

Exploring patients' and families' preferences for auditory stimulation in ICU delirium prevention: A qualitative study

OBJECTIVES

To explore the preferences of patients and families for delirium prevention by auditory stimulation in intensive care units.

RESEARCH METHODOLOGY

One-on-one, face-to-face, semistructured interviews with 17 participants (6 patients and 11 family members) were conducted at a step-down unit in a tertiary general hospital using a descriptive qualitative design. The data were analyzed via inductive thematic analysis.

RESULTS

Four major themes and ten subthemes emerged from the interviews: (1) reality orientation; (2) emotional support; (3) links to the outside; and (4) promising future.

CONCLUSIONS

The results in this qualitative study shed light on patients' and families' preferences for auditory stimulation in preventing ICU delirium. The participation of family members plays a crucial role in preventing ICU delirium. Family members can assist patients in reducing confusion about the situation by providing accurate and clear reality orientation. The emotional support and promising future provided by family members can help patients regain confidence and courage, which are often lacking in ICU patients. Linking patients to the outside world helps them stay connected, understand what is happening outside and reduce feelings of isolation.

IMPLICATIONS FOR CLINICAL PRACTICE

These findings can help health care staff gain insight into patients' and families' preferences and needs for auditory stimulation. Furthermore, these findings pave the way for crafting effective auditory interventions.

Clinical pharmacist interventions in an intensive care unit reduces ICU mortality at a tertiary hospital in Dubai, United Arab Emirates

Background

Drug-related problems (DRPs) are prevalent in critical care settings and can be life-threatening. Involving clinical pharmacists (CP) within the critical care team is recommended to optimize therapy and improve patient survival.

Objective

To classify DRPs identified by a CP in the Intensive Care Unit (ICU) and to assess the impact of CP interventions accepted by physicians on the length of ICU stay and in-hospital survival.

Methods

This study was conducted prospectively at the Medical ICU of Rashid Hospital, a tertiary hospital in Dubai, over a 16-month period from September 2021 to December 2022. The study included patients admitted to ICU during the study period. CP interventions were documented, and DRPs were classified using the modified Pharmaceutical Care Network Europe V.9.1.

Results

During the study period, 1004 interventions were recommended for 200 patients. The majority of these interventions, 92% (n = 922), received physician acceptance, and 82% (n = 820) were fully implemented by the physician. In total, 1033 drug-related problems (DRPs) were identified, with a median of 3 DRPs per patient. The most common DRPs was drug selection (61%), followed by dose selection (22%). There were 337 DRPs related to antimicrobial agents. Interestingly, we noted that when we adjusted for patients' demographic data and the Glasgow Coma Scale severity score, patients who received >4 implemented interventions exhibited lower cumulative hazard of death within 90 days of their ICU stay in comparison to their counterparts (adjusted Hazard Ratio: 0.10, 95% CI of 0.02-0.41; P = 0.027).

Conclusion

The study emphasizes the critical role of CP in the ICU, addressing DRPs, and enhancing overall patient care. Furthermore, it highlights the potential impact of pharmacist interventions in improving patient survival outcomes. This underscores the importance of implementing CP services in ICUs across the UAE.

Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis

PURPOSE

The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada.

MATERIAL AND METHODS

We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record.

RESULTS

44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events.

CONCLUSIONS

An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.

Dietitian and nutrition-related practices and resources in Australian and New Zealand PICUs: A clinician survey

BACKGROUND

Recommendations to facilitate evidence-based nutrition provision for critically ill children exist and indicate the importance of nutrition in this population. Despite these recommendations, it is currently unknown how well Australian and New Zealand (ANZ) paediatric intensive care units (PICUs) are equipped to provide nutrition care.

OBJECTIVES

The objectives of this project were to describe the dietitian and nutrition-related practices and resources in ANZ PICUs.

METHODS

A clinician survey was completed as a component of an observational study across nine ANZ PICUs in June 2021. The online survey comprised 31 questions. Data points included reporting on dietetics resourcing, local feeding-related guidelines and algorithms, nutrition screening and assessment practices, anthropometry practices, and indirect calorimetry (IC) device availability and local technical expertise. Data are presented as frequency (%), mean (standard deviation), or median (interquartile range).

RESULTS

Survey responses were received from all nine participating sites. Dietetics staffing per available PICU bed ranged from 0.01 to 0.07 full-time equivalent (median: 0.03 [interquartile range: 0.02-0.04]). Nutrition screening was established in three (33%) units, all of which used the Paediatric Nutrition Screening Tool. Dietitians consulted all appropriate patients (or where capacity allowed) in six (66%) units and on a request or referral basis only in three (33%) units. All units possessed a local feeding guideline or algorithm. An IC device was available in two (22%) PICUs and was used in one of these units.

CONCLUSIONS

This is the first study to describe the dietitian and nutrition-related practices and resources of ANZ PICUs. Areas for potential improvement include dietetics full-time equivalent, routine nutrition assessment, and access to IC.

Caffeine consumption and withdrawal among patients in the intensive care unit

BACKGROUND

There is a lack of data surrounding the use of therapeutic caffeine among adults admitted to intensive care units (ICUs).

OBJECTIVES

The objective of this study was to determine reported caffeine use and withdrawal symptoms among patients admitted to the ICU to inform future prospective interventional trials.

METHODS

This study used a cross-sectional survey design, where a survey was conducted by a registered dietitian among 100 adult patients admitted to an ICU in Brisbane, Australia.

RESULTS

The median age of patients was 59.8 y (interquartile range: 44.0-70.0), and 68% were male. Ninety-nine percent of patients had daily consumption of caffeine with a median 338 mg (interquartile range: 162-504). Caffeine consumption was self-reported in 89% of patients and was uncovered by detailed identification in 10%. Almost one-third (29%) reported caffeine withdrawal symptoms while admitted to intensive care. Common withdrawal symptoms reported were headaches, irritability, fatigue, anxiety, and constipation. Eighty-eight percent of patients reported willingness to participate in future studies of therapeutic caffeine if they were admitted to the ICU. Preferred methods of parenteral and enteral routes of administration varied by patient and illness characteristics.

CONCLUSIONS

Patients admitted to this ICU were ubiquitous consumers of caffeine before admission, and one-tenth were unaware. Patients viewed trials of therapeutic caffeine as highly acceptable. The results provide important baseline information for future prospective studies.

Feasibility, safety, and patient acceptability of electronic inspiratory muscle training in patients who require prolonged mechanical ventilation in the intensive care unit: A dual-centre observational study

BACKGROUND

Inspiratory muscle training (IMT) is an intervention that can be used to rehabilitate the respiratory muscle deconditioning experienced by patients with critical illness, requiring prolonged mechanical ventilation. Clinicians are currently using mechanical threshold IMT devices that have limited resistance ranges.

OBJECTIVES

The objective of this study was to evaluate the safety, feasibility, and acceptability of using an electronic device to facilitate IMT with participants requiring prolonged mechanical ventilation.

METHOD

A dual-centre observational cohort study, with convenience sampling, was conducted at two tertiary intensive care units. Daily training supervised by intensive care unit physiotherapists was completed with the electronic IMT device. A priori definitions for feasibility, safety, and acceptability were determined. Feasibility was defined as more than 80% of planned sessions completed. Safety was defined as no major adverse events and less than 3% minor adverse event rate, and acceptability was evaluated following the acceptability of intervention framework principles.

RESULTS

Forty participants completed 197 electronic IMT treatment sessions. Electronic IMT was feasible, with 81% of planned sessions completed. There were 10% minor adverse events and no major adverse events. All the minor adverse events were transient without clinical consequences. All the participants who recalled completing electronic IMT sessions reported that the training was acceptable. Acceptability was demonstrated; over 85% of participants reported that electronic IMT was either helpful or beneficial and that electronic IMT assisted their recovery.

CONCLUSION

Electronic IMT is feasible and acceptable to complete with critically ill participants who require prolonged mechanical ventilation. As all minor adverse events were transient without clinical consequences, electronic IMT can be considered a relatively safe intervention with patients who require prolonged mechanical ventilation.

The COVIDTW2 study: Role of COVID-19 vaccination in intubated patients with COVID-19-related acute respiratory distress syndrome in Taiwan

BACKGROUND

COVID-19 vaccines have reduced the risk of disease progression to respiratory failure or death. However, in patients with breakthrough infections requiring invasive mechanical ventilation, the effect of prior COVID-19 vaccination on mortality remains inconclusive.

METHOD

We retrospectively analyzed data on patients intubated due to COVID-19 pneumonia between May 1, 2022 and October 31, 2022. Receipt of two or more doses of vaccine were considered as fully vaccinated. The primary outcome was the time from intubation to all-cause intensive care unit (ICU) mortality.

RESULT

A total of 84 patients were included (40 fully vaccinated versus 44 controls). The baseline characteristics, including age, comorbidities, and Sequential Organ Failure Assessment (SOFA) score on the day of intubation were similar between the two groups. The difference in ICU mortality rate between the fully vaccinated and control groups was not significant (35 % vs. 25 %, P = 0.317; hazard ratio with 95 % confidence interval = 1.246 (0.575-2.666), P = 0.571). The SOFA score (hazard ratio: 1.319, P = 0.001) and body mass index (BMI) (hazard ratio: 0.883, P = 0.022) were significantly associated with ICU mortality.

CONCLUSION

Being fully vaccinated was not associated with a mortality benefit in intubated patients with COVID-19. A higher SOFA score on the day of intubation and lower BMI were poor prognostic factors.

Factors associated with intubation in patients with acute hypoxaemic respiratory failure treated with high-flow nasal cannula oxygen therapy: A prospective, observational study

BACKGROUND

High-flow nasal cannula (HFNC) oxygen is an alternative to conventional oxygen in acute hypoxaemic respiratory failure. Some patients require intubation, with a risk of delay; thus, early predictors may identify those requiring earlier intubation. The "ROX" index (ratio of pulse oximetry/fraction of inspired oxygen to respiratory rate) predicts intubation in patients with pneumonia treated with HFNC therapy, but this index has not been validated in non-pneumonia causes of acute hypoxaemic respiratory failure.

AIM/OBJECTIVE

The aim of this study was to identify factors associated with intubation in a heterogeneous group of patients with acute hypoxaemic respiratory failure treated with HFNC oxygen.

METHODS

This prospective observational study was undertaken in an Australian tertiary intensive care unit and included patients over 18 y of age with acute hypoxaemic respiratory failure who were treated with oxygen via HFNC. Vital signs and arterial blood gases were recorded prospectively at baseline and regular prespecified intervals for 48 h after HFNC initiation. Multivariate logistic regression was used to identify the factors associated with intubation.

RESULTS

Forty-three patients were included (N = 43). The multivariate factors associated with intubation were admission Sequential Organ Failure Assessment score (odds ratio [OR]: 1.94 [95% confidence interval {CI}: 1.06-3.57]; p = 0.032) and Pneumonia Severity Index (OR: 0.95 [95% CI: 0.90-0.99]; p = 0.034). The ROX index was not independently associated with intubation when adjusted for Sequential Organ Failure Assessment score (OR: 0.71 [95% CI: 0.47-1.06]; p = 0.09). There was no difference in mortality between patients intubated early (<24 h) compared to those intubated late.

CONCLUSIONS

Intubation was associated with admission Sequential Organ Failure Assessment score and Pneumonia Severity Index. The ROX index was not associated with intubation when adjusted for admission Sequential Organ Failure Assessment score. Outcomes were similar irrespective of whether patients were intubated late rather than early.

Gender differences in professional social networks use among critical care researchers

BACKGROUND

Recent studies highlight that female anaesthesiology researchers have lower visibility on professional social networks (PSNs) than male researchers.

OBJECTIVE

The objective of this work was to compare the use of PSNs between women and men in critical care research.

METHODS

We included the first/last authors (FAs/LAs) among the most frequently cited articles in 2018 and 2019 in three critical care journals (Intensive Care Medicine, Critical Care Medicine, and Critical Care). We compared the use of three PSNs-Twitter, ResearchGate, and LinkedIn-between women and men in the FA/LA positions.

RESULTS

We analysed 494 articles, which allowed us to include 426 FAs and 383 LAs. The use of a PSN was similar between women and men (Twitter: 35 vs. 31% FA p = 0.76, 38 vs. 31% LA p = 0.24; ResearchGate: 60 vs. 70% FA p = 0.06, 67 vs. 66% LA p = 0.95; LinkedIn: 54 vs. 56% FA p = 0.25, 68 vs. 64% LA p = 0.58; respectively). On ResearchGate, women had a lower reputation score (FA group 26.4 [19.5-31.5] vs. 34.8 [27.4-41.6], p < 0.01; LA group 38.5 [30.9-43.7] vs. 42.3 [37.6-46.4], p < 0.01) and fewer followers (FA group 28.5 [19-45] vs. 68.5 [72,5-657] p < 0.01; LA group 96.5 [43,8-258] vs. 178 [76.3-313.5] p = 0.02). Female researchers were FAs in 30% of the articles and LAs in 16%.

CONCLUSION

In the field of critical care, the visibility of female researchers on the social networks dedicated to scientific research is lower than that of male researchers.

Emergencies in Pulmonary Hypertension

Pulmonary hypertension is a challenging disease entity with various underlying etiologies. The management of patients with pulmonary arterial hypertension (WHO Group 1) remains challenging especially in the critical care setting. With risk of high morbidity and mortality, these patients require a multidisciplinary team approach at a speciality care facility for pulmonary hypertension for comprehensive evaluation and rapid initiation of treatment. For acute decompensated right heart failure, management should concentrate on optimizing preload and after load with use of pulmonary vasodilator therapy. A careful evaluation of specialized situations is required for appropriate treatment response.

Models of intensive care unit follow-up care and feasibility of intervention delivery: A systematic review

BACKGROUND

The optimal model of outpatient intensive care unit (ICU) follow-up care remains uncertain, and there is limited evidence of benefit.

RESEARCH QUESTION

The objective of this research is to describe existing models of outpatient ICU follow-up care, quantify participant recruitment and retention, and describe facilitators of patient engagement.

STUDY DESIGN & METHODS

A systematic search of the MEDLINE and EMBASE databases was undertaken in June 2021. Two independent reviewers screened titles, abstracts, and full texts against eligibility criteria. Studies of adults with any outpatient ICU follow-up were included. Studies were excluded if published before 1990, not published in English, or of paediatric patients. Quantitative data were extracted using predefined data fields. Key themes were extracted from qualitative studies. Risk of bias was assessed.

RESULTS

A total of 531 studies were screened. Forty-seven studies (32 quantitative and 15 qualitative studies) with a total of 5998 participants were included. Of 33 quantitative study interventions, the most frequently reported model of care was in-person hospital-based interventions (n = 27), with 10 hybrid (part in-hospital, part remote) interventions. Literature was limited for interventions without hospital attendance (n = 6), including telehealth and diaries. The median ranges of rates of recruitment, rates of intervention delivery, and retention to outcome assessment for hospital-based interventions were 51.5% [24-94%], 61.9% [8-100%], and 52% [8.1-82%], respectively. Rates were higher for interventions without hospital attendance: 82.6% [60-100%], 68.5% [59-89%], and 75% [54-100%]. Facilitators of engagement included patient-perceived value of follow-up, continuity of care, intervention accessibility and flexibility, and follow-up design. Studies had a moderate risk of bias.

INTERPRETATION

Models of post-ICU care without in-person attendance at the index hospital potentially have higher rates of recruitment, intervention delivery success, and increased participant retention when compared to hospital-based interventions.

PROSPERO REGISTRATION

CRD42021260279.

Development and validation of a risk score to predict unplanned hospital readmissions in ICU survivors: A data linkage study

BACKGROUND

Intensive Care Unit (ICU) follow-up clinics are growing in popularity internationally; however, there is limited evidence as to which patients would benefit most from a referral to this service.

OBJECTIVES

The objective of this study was to develop and validate a model to predict which ICU survivors are most likely to experience an unplanned hospital readmission or death in the year after hospital discharge and derive a risk score capable of identifying high-risk patients who may benefit from referral to follow-up services.

METHODS

A multicentre, retrospective observational cohort study using linked administrative data from eight ICUs was conducted in the state of New South Wales, Australia. A logistic regression model was developed for the composite outcome of death or unplanned readmission in the 12 months after discharge from the index hospitalisation.

RESULTS

12,862 ICU survivors were included in the study, of which 5940 (46.2%) patients experienced unplanned readmission or death. Strong predictors of readmission or death included the presence of a pre-existing mental health disorder (odds ratio [OR]: 1.52, 95% confidence interval [CI]: 1.40-1.65), severity of critical illness (OR: 1.57, 95% CI: 1.39-1.76), and two or more physical comorbidities (OR: 2.39, 95% CI: 2.14-2.68). The prediction model demonstrated reasonable discrimination (area under the receiver operating characteristic curve: 0.68, 95% CI: 0.67-0.69) and overall performance (scaled Brier score: 0.10). The risk score was capable of stratifying patients into three distinct risk groups-high (64.05% readmitted or died), medium (45.77% readmitted or died), and low (29.30% readmitted or died).

CONCLUSIONS

Unplanned readmission or death is common amongst survivors of critical illness. The risk score presented here allows patients to be stratified by risk level, enabling targeted referral to preventative follow-up services.

The impact of tubular dysfunction and its relationship with acute kidney injury in children

BACKGROUND

Tubular dysfunction can cause electrolyte disturbances with potentially serious consequences. We studied the epidemiology and outcomes of electrolyte disturbances and tubular dysfunction among critically ill children and evaluated their relationships with acute kidney injury (AKI).

METHODS

We conducted a prospective cohort study recruiting children aged 1 month to ≤ 18 years old admitted to the pediatric intensive care unit (PICU) from 6/2020 to 6/2021. The serum levels of sodium, potassium, calcium, phosphate, and magnesium were reviewed and simultaneous urinary investigations for tubular function were performed among children with electrolyte disturbances.

RESULTS

Altogether there were 253 episodes of admission. The median (interquartile) age was 4.9 (1.3-11.0) years and 58.1% were male. The median number of electrolyte disorders was 3 (2-4) types. Hypophosphatemia (74.2%), hypocalcemia (70.3%) and hypermagnesemia (52.9%) were the three commonest types of disturbances. Urinary electrolyte wasting was commonly observed among children with hypomagnesemia (70.6%), hypophosphatemia (67.4%) and hypokalemia (28.6%). Tubular dysfunction was detected in 82.6% of patients and urinary β2-microglobulin level significantly correlated with the severity of tubular dysfunction (p < 0.001). The development of tubular dysfunction was independent of AKI status. Tubular dysfunction was associated with mortality (p < 0.001) and was an independent predictor of PICU length of stay (LOS) (p < 0.001). The incorporation of the tubular dysfunction severity into the AKI staging system improved the prediction of PICU LOS.

CONCLUSIONS

Tubular dysfunction was associated with both morbidity and mortality in critically ill children and its assessment may help to capture a more comprehensive picture of acute kidney insult.

Understanding an epidemiological view of a retrospective audit of medication errors in an intensive care unit

BACKGROUND

Medication errors in the intensive care setting continue to occur at significant rates and are often associated with adverse events and potentially life-threatening repercussions.

AIM/OBJECTIVE

The aim of this study was to (i) determine the frequency and severity of medication errors reported in the incident management reporting system; (ii) examine the antecedent events, their nature, the circumstances, risk factors, and contributing factors leading to medication errors; and (iii) identify strategies to improve medication safety in the intensive care unit (ICU).

METHOD

A retrospective, exploratory, descriptive design was selected. Retrospective data were collected from the incident report management system and electronic medical records over a 13-month period from a major metropolitan teaching hospital ICU.

RESULTS

A total of 162 medication errors were reported during a 13-month period, of which, 150 were eligible for inclusion. Most medication errors occurred during the administration (89.4%) and dispensing phases (23.3%). The highest reported errors included incorrect doses (25.3%), incorrect medications (12.7%), omissions (10.7%), and documentation errors (9.3%). Narcotic analgesics (20%), anaesthetics (13.3%), and immunomodifiers (10.7%) were the most frequently reported medication classes associated with medication errors. Prevention strategies were found to be focussed on active errors (67.7%) as opposed to latent errors (32.3%) and included various and infrequent levels of education and follow-up. Active antecedent events included action-based errors (39%) and rule-based errors (29.5%), whereas latent antecedent events were most associated with a breakdown in system safety (39.3%) and education (25%).

CONCLUSION

This study presents an epidemiological view and understanding of medication errors in an Australian ICU. This study highlighted the preventable nature of most medication errors in this study. Improving administration-checking procedures would prevent the occurrence of many medication errors. Approaches aimed at both individual- and organisational-level improvements are recommended to address administration errors and inconsistent medication-checking procedures. Areas for further research include determining the most effective system developments for improving administration-checking procedures and verifying the risk and prevalence of immunomodifier administration errors in the ICU as this is an area not reported previously in the literature. In addition, the impact of single- versus two-person checking procedures on medication errors in the ICU should be prioritised to address current evidence gaps.

Multidrug-resistant pathogens and ventilator-associated pneumonia in critically ill COVID-19 and non-COVID-19 patients: a prospective observational monocentric comparative study

BACKGROUND

The COVID-19 pandemic has increased the incidence of ventilator-associated pneumonia (VAP) among critically ill patients. However, a comparison of VAP incidence in COVID-19 and non-COVID-19 cohorts, particularly in a context with a high prevalence of multidrug-resistant (MDR) organisms, is lacking.

MATERIAL AND METHODS

We conducted a single-center, mixed prospective and retrospective cohort study comparing COVID-19 patients admitted to the intensive care unit (ICU) of the "Città della Salute e della Scienza" University Hospital in Turin, Italy, between March 2020 and December 2021 (COVID-19 group), with a historical cohort of ICU patients admitted between June 2016 and March 2018 (NON-COVID-19 group). The primary objective was to define the incidence of VAP in both cohorts. Secondary objectives were to evaluate the microbial cause, resistance patters, risk factors and impact on 28 days, ICU and in-hospital mortality, duration of ICU stay, and duration of hospitalization).

RESULTS

We found a significantly higher incidence of VAP (51.9% - n = 125) among the 241 COVID-19 patients compared to that observed (31.2% - n = 78) among the 252 NON-COVID-19 patients. The median SOFA score was significantly lower in the COVID-19 group (9, Interquartile range, IQR: 7-11 vs. 10, IQR: 8-13, p < 0.001). The COVID-19 group had a higher prevalence of Gram-positive bacteria-related VAP (30% vs. 9%, p < 0.001), but no significant difference was observed in the prevalence of difficult-to-treat (DTR) or MDR bacteria. ICU and in-hospital mortality in the COVID-19 and NON-COVID-19 groups were 71% and 74%, vs. 33% and 43%, respectively. The presence of COVID-19 was significantly associated with an increased risk of 28-day all-cause hospital mortality (Hazard ratio, HR: 7.95, 95% Confidence Intervals, 95% CI: 3.10-20.36, p < 0.001). Tracheostomy and a shorter duration of mechanical ventilation were protective against 28-day mortality, while dialysis and a high SOFA score were associated with a higher risk of 28-day mortality.

CONCLUSION

COVID-19 patients with VAP appear to have a significantly higher ICU and in-hospital mortality risk regardless of the presence of MDR and DTR pathogens. Tracheostomy and a shorter duration of mechanical ventilation appear to be associated with better outcomes.

A Direct Assessment of Noninvasive Continuous Blood Pressure Monitoring in the Emergency Department and Intensive Care Unit

INTRODUCTION

Noninvasive continuous blood pressure monitoring has the potential to improve patient treatment in the hospital setting. Such noninvasive devices can be applied earlier in the treatment process to empower nurses and clinicians to react more quickly to patient deterioration with the added benefit of eliminating the risks associated with invasive monitoring. However, emerging technologies must be capable of reproducing current clinical measures for medical decision making.

METHODS

This study aimed to determine the usability and willingness of nurses to implement a noninvasive continuous blood pressure monitoring device. The secondary aim directly compared the systolic blood pressure, diastolic blood pressure, and mean arterial pressure values recorded by the device (VitalStream; CareTaker Medical LLC, Charlottesville, VA) with the "gold standard" brachial cuff and arterial line measures recorded in the emergency department and intensive care unit settings.

RESULTS

VitalStream was similarly received by nurses in the emergency department and intensive care setting, but ultimately had greater promotion from emergency nurses. Despite some statistical similarity between measurement methodologies, all direct comparisons were found to not meet the Association for the Advancement of Medical Instrumentation 2008 and Association for the Advancement of Medical Instrumentation / European Society of Hypertension / International Organization for Standardization 2019 consensus statement criteria for acceptable blood pressure measure differences between the VitalStream and "gold standard" clinical measures. In all instances, the standard deviation of the Bland-Altman bias exceeded 8 mm Hg with less than 85% of paired differences falling within 10 mm Hg of the "gold standard."

DISCUSSION

Taken together, the tested device requires additional postprocessing for medical decision making in trauma or emergent care.

Polymorphic ventricular tachycardia and cardiac arrest from abiraterone-induced hypokalemia: a case report

BACKGROUND

Polymorphic ventricular tachycardia (PMVT) is an unstable and often fatal cardiac tachyarrhythmia. While there are many causes of this rhythm, including electrolyte imbalances, ischemia, and genetic disorders, iatrogenic etiologies are important to recognize. Abiraterone is an androgen synthesis antagonist effective in treating prostate cancer, but here we describe a case of severe hypokalemia secondary to abiraterone resulting in polymorphic ventricular tachycardia and cardiac arrest. While this is a potential adverse effect of the medication, severe hypokalemia causing polymorphic ventricular tachycardia and cardiac arrest, as seen in our patient's case, has not been described.

CASE PRESENTATION

A 78-year-old African-American man with history of prostate cancer presents with polymorphic ventricular tachycardia and cardiac arrest. After resuscitation, he was found to be severely hypokalemic and refractory to large doses of repletion. Evaluation of secondary causes of hypokalemia identified the likely culprit to be adverse effects from prostate cancer treatment.

CONCLUSION

A broad differential diagnosis for polymorphic ventricular tachycardia is essential in identifying and treating patients presenting in this rhythm. Here we present a case of iatrogenic polymorphic ventricular tachycardia secondary to oncologic treatment.

Survivorship After Neurocritical Care: A Scoping Review of Outcomes Beyond Physical Status

Following intensive care unit hospitalization, survivors of acute neurological injury often experience debilitating short-term and long-term impairments. Although the physical/motor impairments experienced by survivors of acute neurological injury have been described extensively, fewer studies have examined cognitive, mental health, health-related quality of life (HRQoL), and employment outcomes. This scoping review describes the publication landscape beyond physical and/or motor sequelae in neurocritical care survivors. Databases were searched for terms related to critical illness, intensive care, and outcomes from January 1970 to March 2022. English-language studies of critically ill adults with a primary neurological diagnosis were included if they reported on at least one outcome of interest: cognition, mental health, HRQoL or employment. Data extraction was performed in duplicate for prespecified variables related to study outcomes. Of 16,036 abstracts screened, 74 citations were identified for inclusion. The studies encompassed seven worldwide regions and eight neurocritical diagnosis categories. Publications reporting outcomes of interest increased from 3 before the year 2000 to 71 after. Follow-up time points included ≤ 1 (n = 15 [20%] citations), 3 (n = 28 [38%]), 6 (n = 28 [38%]), and 12 (n = 21 [28%]) months and 1 to 5 (n = 19 [26%]) and > 5 years (n = 8 [11%]), with 28 (38%) citations evaluating outcomes at multiple time points. Sixty-six assessment tools were used to evaluate the four outcomes of interest: 22 evaluating HRQoL (56 [76%] citations), 21 evaluating cognition (20 [27%] citations), 21 evaluating mental health (18 [24%] citations), and 2 evaluating employment (9 [12%] citations). This scoping review aimed to better understand the literature landscape regarding nonphysical outcomes in survivors of neurocritical care. Although a rising number of publications highlight growing awareness, future efforts are needed to improve study consistency and comparability and characterize outcomes in a disease-specific manner, including outlining of a minimum core outcomes set and associated assessment tools.

Evaluation of prognostic scores for status epilepticus in the neurology ICU: A retrospective study

OBJECTIVE

Status epilepticus (SE) in the neurology intensive care unit (ICU) is associated with significant morbidity. We aimed to evaluate the utility of existing prognostic scores, namely the Status Epilepticus Severity Score (STESS), Epidemiology Based Mortality Score in Status Epilepticus (EMSE)-EACE and Encephalitis-Nonconvulsive Status Epilepticus-Diazepam Resistance-Image Abnormalities-Tracheal Intubation (END-IT), among SE patients in the neurology ICU.

METHODS

Neurology ICU patients with SE requiring continuous electroencephalography (cEEG) monitoring over a 10 year period were included. The STESS, EMSE-EACE and END-IT scores were applied retrospectively. Receiver operating characteristic (ROC) analysis was performed to assess the discriminatory value of the scores for inpatient mortality and functional decline, as measured by increase in the modified Rankin Scale (mRS) on discharge.

RESULTS

Eighty-five patients were included in the study, of which 71 (83.5%) had refractory SE. Inpatient mortality was 36.5%. Sixty - seven (78.8%) of patients suffered functional decline, with a median mRS of 5 upon hospital discharge. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with inpatient mortality were 0.723 (95% CI 0.613-0.833), 0.722 (95% CI 0.609-0.834) and 0.560 (95% CI 0.436-0.684) respectively. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with functional decline were 0.604 (95% CI 0.468-0.741), 0.596 (95% CI 0.439-0.754) and 0.477 (95% CI 0.331-0.623).

SIGNIFICANCE

SE was associated with high mortality and morbidity in this cohort of neurology ICU patients requiring cEEG monitoring. The STESS and EMSE-EACE scores had acceptable AUCs for prediction of inpatient mortality. However, the STESS, EMSE-EACE and END-IT were poorly-correlated with discharge functional outcomes. Further refinements of the scores may be necessary among neurology ICU patients for predicting discharge functional outcomes.

The optimal glycemic target in critically ill patients: an updated network meta-analysis

Acute glycemic control significantly affects the clinical outcomes of critically ill patients. This updated network meta-analysis examines the benefits and harms of four target blood glucose levels (< 110, 110-144, 144-180, and > 180 mg/dL). Analyzing data of 27,541 patients from 37 trials, the surface under the cumulative ranking curve for mortality and hypoglycemia was highest at a target blood glucose level of 144-180 mg/dL, while for infection and acute kidney injury at 110-144 mg/dL. Further evidence is needed to determine whether 110-144 or 144-180 mg/dL is superior as an optimal glucose target, considering prioritized outcomes.

Supporting rural families during interhospital patient transfers for critical illness events: An exploration of an acceptable communication process

Critically ill patients in rural areas at times require an interhospital transfer from their local hospital to an urban tertiary care centre for advanced critical care services not available locally. Family members have described this transfer window as a communication blackout and one of the most stressful times of their relative's critical illness event.

OBJECTIVE

To explore what communication process would be most acceptable between family members and transfer team members (consisting of critical care nurses, paramedics, and physicians) during interhospital transfers of critically ill patients.

RESEARCH METHODOLOGY

Using a qualitative descriptive approach of critical thematic analysis, data were collected in September and November 2022, from focus groups of five family members and four transfer team members who experienced this phenomenon.

SETTING

Rural Canada where speciality services such as interventional cardiology and neurosurgery are unavailable, and a tertiary care hospital is more than 160 km away.

FINDINGS

Within themes of unequal power relations and status-based hierarchies, family members described how communication during interhospital transfers supports connection and coping, challenges experienced in accessing information, an overwhelming unknown, and practical challenges of the transfer. Transfer team members described a context of power relations and status-based hierarchies in which themes of transfer team burden, role confusion or connection, protection and management of family members, and complexities of information sharing during interhospital transfers were identified.

CONCLUSION

In critical illness, communication linkages are created between healthcare providers and family members but are broken during an interhospital transfer resulting in increased stress for family members. Acceptable communication elements described by transfer team members and family members may maintain these linkages during the transfer window.

IMPLICATIONS FOR CLINICAL PRACTICE

These findings provide the foundation for critical care nurses and their professional colleagues to take family care to the next level with an explicit communication strategy during interhospital transfers.

Retrospective Analysis of Burn Injuries in Children with Autism Spectrum Disorder

Children with neurodevelopmental disorders are at risk for burn injury, but the clinical outcomes, particularly mortality, are unknown in this patient population in the United States (U.S.). The main objectives of this study are to evaluate (1) subject characteristics; (2) burn injury type; (3) clinical care provided; and (4) mortality in children with autism spectrum disorder (ASD), hypothesizing that this patient population has similar mortality and critical care management requirements when compared to children without ASD. This is a retrospective observational cohort study utilizing the TriNetX ® electronic health record database of subjects aged 0 to 18 years with burn injury associated diagnostic codes. Data were analyzed for demographics, diagnostic, medication, procedural codes, and mortality. We analyzed 99,323 subjects (n, %) coded for a burn injury [3083 (3.1%) with ASD and 96,240 (96.9%) without ASD]. Children with ASD had a higher odds of 1-year all-cause mortality [1.9 (1.06, 3.40), p = 0.004], need for critical care services [1.88 (1.40, 2.52), p < 0.001], and mechanical ventilation [2.69 (1.74, 4.17), p < 0.001] compared to those without. Our study found that U.S. children with ASD who had a burn injury had a higher odds of mortality and critical care needs when compared to children without ASD. Future studies are needed to understand the impact of burn injuries and factors associated with mortality in this patient population.

The effects of a novel, continuous disinfectant technology on methicillin resistant Staphylococcus aureus (MRSA), fungi and aerobic bacteria in two separate Intensive Care Units in two different states: an experimental design with observed impact on Healthcare Associated Infections (HAIs)

BACKGROUND

Hospitals are exposed to abundant contamination sources with limited remediation strategies. Without new countermeasures or treatments, the risk of hospital-associated infections will remain high. This study explored the impact of advanced photohydrolysis (AP) continuous disinfection technology on hospital environmental bioburden.

METHODS

Two acute care Intensive Care Units in different locations (i.e., Kentucky, Louisiana) during different time periods. Locations were sampled every 4 weeks for 4 months for colony forming units (CFUs) of methicillin resistant Staphylococcus aureus (MRSA) and fungi on surfaces and floors and fungi and aerobic bacteria in air.

RESULTS

At both sites, surface testing showed greater than 98% reduction in mean fungi and MRSA CFUs. Floor results had reductions by more than 96% for fungi and MRSA at both sites. Aerobic bacterial air and fungal CFUs had reductions up to 72% and 89%, respectively. HAIs declined 70% when post activation data was compared to pre-activation data.

DISCUSSION

The continuous nature of the AP decontamination, its ability to be used in occupied rooms, and its independence of human resources, provides an innovative intervention for complex healthcare environments.

CONCLUSIONS

This study is on the pioneering edge of demonstrating that continuous decontamination can reduce surface, floor, and air contamination and thereby reduce acquisition of HAIs.

Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review

BACKGROUND

Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them.

AIM

The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies.

DESIGN

Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies.

METHODS

Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions.

RESULTS

Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity.

CONCLUSION

Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.

[Discharge of infants with complex care needs from the neonatal intensive care unit : Ensuring continued inpatient care via the Bunter Kreis aftercare model]

After discharge of premature infants with complex care needs from the neonatal intensive care unit, a care gap arises due to the transition from inpatient to outpatient care. Consequences can be rehospitalization, revolving door effects, and high costs. Therefore, following hospitalization or inpatient rehabilitation, the patient is intended to transition to sociomedical aftercare. The legal basis for this is formed by § 43 paragraph 2 of the Fifth Book of the German Social Code (SGB V). Over 80 aftercare institutions in Germany work according to the model of the Bunter Kreis. The comprehensive concept describes possibilities for networking which exceed the services provided by sociomedical aftercare. Simultaneously, depending on their stage of development, young adults can receive aftercare according to this model up to their 27th year of life. The interdisciplinary team at the Bunter Kreis comprises nurses, social workers, social education workers, psychologists, and specialist physicians. The largest group of supported persons, with 6000-8000 children per year, is comprised of premature and at-risk babies as well as multiple births, followed by 3000-5000 children with neurologic and syndromic diseases. Other common diseases are metabolic diseases, epilepsy, and diabetes, as well as children after trauma and with rare diseases. Overall, the various diseases sum up to around 20 clinical pictures. The current article presents the Bunter Kreis aftercare process based on case examples.

The burden of anxiety, depression, and stress, along with the prevalence of symptoms of PTSD, and perceptions of the drivers of psychological harms, as perceived by doctors and nurses working in ICUs in Nepal during the COVID-19 pandemic; a mixed method evaluation

BACKGROUND

The COVID-19 pandemic resulted in significant physical and psychological impacts for survivors, and for the healthcare professionals caring for patients. Nurses and doctors in critical care faced longer working hours, increased burden of patients, and limited resources, all in the context of personal social isolation and uncertainties regarding cross-infection. We evaluated the burden of anxiety, depression, stress, post-traumatic stress disorder (PTSD), and alcohol dependence among doctors and nurses working in intensive care units (ICUs) in Nepal and explored the individual and social drivers for these impacts.

METHODS

We conducted a mixed-methods study in Nepal, using an online survey to assess psychological well-being and semi-structured interviews to explore perceptions as to the drivers of anxiety, stress, and depression. Participants were recruited from existing national critical care professional organisations in Nepal and using a snowball technique. The online survey comprised of validated assessment tools for anxiety, depression, stress, PTSD, and alcohol dependence; all tools were analysed using published guidelines. Interviews were analysed using rapid appraisal techniques, and themes regarding the drivers for psychological distress were explored.

RESULTS

134 respondents (113 nurses, 21 doctors) completed the online survey. Twenty-eight (21%) participants experienced moderate to severe symptoms of depression; 67 (50%) experienced moderate or severe symptoms of anxiety; 114 (85%) had scores indicative of moderate to high levels of stress; 46 out of 100 reported symptoms of PTSD. Compared to doctors, nurses experienced more severe symptoms of depression, anxiety, and PTSD, whereas doctors experienced higher levels of stress than nurses. Most (95%) participants had scores indicative of low risk of alcohol dependence. Twenty participants were followed up in interviews. Social stigmatism, physical and emotional safety, enforced role change and the absence of organisational support were perceived drivers for poor psychological well-being.

CONCLUSION

Nurses and doctors working in ICU during the COVID-19 pandemic sustained psychological impacts, manifesting as stress, anxiety, and for some, symptoms of PTSD. Nurses were more vulnerable. Individual characteristics and professional inequalities in healthcare may be potential modifiable factors for policy makers seeking to mitigate risks for healthcare providers.

Understanding the provision of goal-concordant care in the intensive care unit: A sequential two-phase qualitative descriptive study

BACKGROUND

Goal-concordant care in intensive care is care that aligns with the patient's expressed goals, values, preferences and beliefs. Communication and shared decision-making are key to ensuring goal-concordant care.

AIMS

The aims of his study were to explore (i) critical care clinicians' perspectives on how patient goals of care were communicated between clinicians, patients, and family in the intensive care unit; (ii) critical care nurses' role in this process; and (iii) how goals of care were used to guide care.

METHOD

Sequential two-phase qualitative descriptive design. Data were collected from February to June 2022 in a level-3 intensive care unit in a private hospital in Melbourne, Australia. In Phase One, individual interviews were conducted with critical care nurse participants (n = 11). In Phase Two, the findings were presented to senior clinical leaders (n = 2) to build a more comprehensive understanding. Data were analysed using Braun and Clarke's six step reflexive thematic analysis.

FINDINGS

There was poor consensus on the term 'goals of care', with some participants referring to daily treatment goals or treatment limitations and others to patients' wishes and expectations beyond the ICU. Critical care nurses perceived themselves as information brokers and patient advocates responsible for ensuring patient goals of care were respected, but engaging in goals-of-care conversations was challenging. A lack of role clarity, poor team communication, and inadequate processes to communicate patient goals impeded goal-concordant care. Senior clinical leaders affirmed these views, emphasising the need to utilise critical care nurses' insight for practical solutions to improve patient care.

CONCLUSIONS

Clarity in both, the term 'goals of care' and the critical care nurses' role in these conversations, are the essential first steps to ensuring patients' values, preferences, and beliefs to guide shared-decision-making and goal-concordant care. Improved verbal and written communication that is inclusive of all members of the treating team is key to addressing these issues.

Mortality, Functional Status, and Quality of Life after 5 Years of Patients Admitted to Critical Care for Spontaneous Intracerebral Hemorrhage

BACKGROUND

The objective of this study was to assess long-term outcome in patients with spontaneous intracerebral hemorrhage admitted to the intensive care unit.

METHODS

Mortality and Glasgow Outcome Scale, Barthel Index, and 5-level EQ-5D version (EQ-5D-5L) scores were analyzed in a multicenter cohort study of three Spanish hospitals (336 patients). Mortality was also analyzed in the Medical Information Mart for Intensive Care III (MIMIC-III) database.

RESULTS

The median (25th percentile-75th percentile) age was 62 (50-70) years, the median Glasgow Coma Score was 7 (4-11) points, and the median Acute Physiology and Chronic Health disease Classification System II (APACHE-II) score was 21 (15-26) points. Hospital mortality was 54.17%, mortality at 90 days was 56%, mortality at 1 year was 59.2%, and mortality at 5 years was 66.4%. In the Glasgow Outcome Scale, a normal or disabled self-sufficient situation was recorded in 21.5% of patients at 6 months, in 25.5% of patients after 1 year, and in 22.1% of patients after 5 years of follow-up (4.5% missing). The Barthel Index score of survivors improved over time: 50 (25-80) points at 6 months, 70 (35-95) points at 1 year, and 90 (40-100) points at 5 years (p < 0.001). Quality of life evaluated with the EQ-5D-5L at 1 year and 5 years indicated that greater than 50% of patients had no problems or slight problems in all items (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). In the MIMIC-III study (N = 1354), hospital mortality was 31.83% and was 40.5% at 90 days and 56.2% after 5 years.

CONCLUSIONS

In patients admitted to the intensive care unit with a diagnosis of nontraumatic intracerebral hemorrhage, hospital mortality up to 90 days after admission is very high. Between 90 days and 5 years after admission, mortality is not high. A large percentage of survivors presented a significant deficit in quality of life and functional status, although with progressive improvement over time. Five years after the hemorrhagic stroke, a survival of 30% was observed, with a good functional status seen in 20% of patients who had been admitted to the hospital.

Caring to care: Nurturing ICU healthcare professionals' wellbeing for enhanced patient safety

Healthcare professionals working in the Intensive Care Unit (ICU) care for patients suffering from a critical illness and their relatives. Working within a team of people with different personalities, competencies, and specialties, with constraints and demands might contribute to a working environment that is prone to conflicts and disagreements. This highlights that the ICU is a stressful place that can threaten healthcare professionals' wellbeing. This article aims to address the concept of wellbeing by describing how the stressful ICU work-environment threatens the wellbeing of health professionals and discussing how this situation jeopardizes patient safety. To promote wellbeing, it is imperative to explore actionable interventions such as improve communication skills, educational sessions on stress management, or mindfulness. Promoting ICU healthcare professionals' wellbeing through evidence-based strategies will not only increase their personal resilience but might contribute to a safer and more efficient patient care.

Effects of robotic-assisted early mobilization versus conventional mobilization in intensive care unit patients: prospective interventional cohort study with retrospective control group analysis

BACKGROUND

Approximately one in three survivors of critical illness suffers from intensive-care-unit-acquired weakness, which increases mortality and impairs quality of life. By counteracting immobilization, a known risk factor, active mobilization may mitigate its negative effects on patients. In this single-center trial, the effect of robotic-assisted early mobilization in the intensive care unit (ICU) on patients' outcomes was investigated.

METHODS

We enrolled 16 adults scheduled for lung transplantation to receive 20 min of robotic-assisted mobilization and verticalization twice daily during their first week in the ICU (intervention group: IG). A control group (CG) of 13 conventionally mobilized patients after lung transplantation was recruited retrospectively. Outcome measures included the duration of mechanical ventilation, length of ICU stay, muscle parameters evaluated by ultrasound, and quality of life after three months.

RESULTS

During the first week in the ICU, the intervention group received a median of 6 (interquartile range 3-8) robotic-assisted sessions of early mobilization and verticalization. There were no statistically significant differences in the duration of mechanical ventilation (IG: median 126 vs. CG: 78 h), length of ICU stay, muscle parameters evaluated by ultrasound, and quality of life after three months between the IG and CG.

CONCLUSION

In this study, robotic-assisted mobilization was successfully implemented in the ICU setting. No significant differences in patients' outcomes were observed between conventional and robotic-assisted mobilization. However, randomized and larger studies are necessary to validate the adequacy of robotic mobilization in other cohorts.

TRIAL REGISTRATION

This single-center interventional trial was registered in clinicaltrials.gov as NCT05071248 on 27/08/2021.

The value of artificial intelligence for the treatment of mechanically ventilated intensive care unit patients: An early health technology assessment

PURPOSE

The health and economic consequences of artificial intelligence (AI) systems for mechanically ventilated intensive care unit patients often remain unstudied. Early health technology assessments (HTA) can examine the potential impact of AI systems by using available data and simulations. Therefore, we developed a generic health-economic model suitable for early HTA of AI systems for mechanically ventilated patients.

MATERIALS AND METHODS

Our generic health-economic model simulates mechanically ventilated patients from their hospitalisation until their death. The model simulates two scenarios, care as usual and care with the AI system, and compares these scenarios to estimate their cost-effectiveness.

RESULTS

The generic health-economic model we developed is suitable for estimating the cost-effectiveness of various AI systems. By varying input parameters and assumptions, the model can examine the cost-effectiveness of AI systems across a wide range of different clinical settings.

CONCLUSIONS

Using the proposed generic health-economic model, investors and innovators can easily assess whether implementing a certain AI system is likely to be cost-effective before an exact clinical impact is determined. The results of the early HTA can aid investors and innovators in deployment of AI systems by supporting development decisions, informing value-based pricing, clinical trial design, and selection of target patient groups.

Volatile versus propofol sedation after cardiac valve surgery: a single-center prospective randomized controlled trial

BACKGROUND

Optimal intensive care of patients undergoing valve surgery is a complex balancing act between sedation for monitoring and timely postoperative awakening. It remains unclear, if these requirements can be fulfilled by volatile sedations in intensive care medicine in an efficient manner. Therefore, this study aimed to assess the time to extubation and secondary the workload required.

METHODS

We conducted a prospective randomized single-center trial at a tertiary university hospital to evaluate the postoperative management of open valve surgery patients. The study was randomized with regard to the use of volatile sedation compared to propofol sedation. Sedation was discontinued 60 min after admission for critical postoperative monitoring.

RESULTS

We observed a significantly earlier extubation (91 ± 39 min vs. 167 ± 77 min; p < 0.001), eye-opening (86 ± 28 min vs. 151 ± 71 min; p < 0.001) and command compliance (93 ± 38 min vs. 164 ± 75 min; p < 0.001) using volatile sedation, which in turn was associated with a significantly increased workload of a median of 9:56 min (± 4:16 min) set-up time. We did not observe any differences in complications. Cardiopulmonary bypass time did not differ between the groups 101 (IQR 81; 113) versus 112 (IQR 79; 136) minutes p = 0.36.

CONCLUSIONS

Using volatile sedation is associated with few minutes additional workload in assembling and enables a significantly accelerated evaluation of vulnerable patient groups. Volatile sedation has considerable advantages and emerges as a safe sedation technique in our vulnerable study population.

TRIAL REGISTRATION

Clinical trials registration (NCT04958668) was completed on 1 July 2021.

Pharyngeal Electrical Stimulation prior to extubation - Reduction of extubation failure rate in acute stroke patients?

PURPOSE

The aim of our study was to assess if PES before extubation can minimize the extubation failure risk in orally intubated, mechanically ventilated stroke patients at high risk of severe dysphagia.

MATERIALS AND METHODS

Thirty-two ICU patients were prospectively enrolled in this study presenting with a high risk for dysphagia as defined by a DEFISS (Determine Extubation Failure In Severe Stroke) risk score and compared 1:1 to a retrospective matched patient control group. The prospective patient group received PES prior to extubation. Endpoints were need for reintubation, swallowing function as assessed with FEES, pneumonia incidence and length of stay after extubation.

RESULTS

Post-extubation, the Fiberoptic Endoscopic Dysphagia Severity Score (FEDSS, 4.31 ± 1.53vs.5.03 ± 1.28;p = 0.047) and reintubation rate within 72 h (9.4vs.34.4%;p = 0.032) were significantly lower in the PES group than in the historical control group. Pulmonary infections after extubation were less common in PES-treated patients although this difference was not significant (37.5vs.59.4%;p = 0.133). Time from extubation to discharge was significantly shorter after PES compared with the control group (14.09 ± 11.58vs.26.59 ± 20.49 days;p = 0.003).

CONCLUSIONS

In orally intubated and mechanically ventilated stroke patients at high risk of severe dysphagia, PES may improve swallowing function, reduce extubation failure risk and decrease time from extubation to discharge. Further research is required.

Multidisciplinary Consensus on Curricular Priorities for Pediatric Neurocritical Care Nursing Education: A Modified Delphi Study in the United States

BACKGROUND

Nurses are vital partners in the development of pediatric neurocritical care (PNCC) programs. Nursing expertise is acknowledged to be an integral component of high-quality specialty patient care in the field, but little guidance exists regarding educational requirements to build that expertise. We sought to obtain expert consensus from nursing professionals and physicians on curricular priorities for specialized PNCC nursing education in pediatric centers across the United States.

METHODS

We used a modified Delphi study technique surveying a multidisciplinary expert panel of nursing professionals and physicians. Online surveys were distributed to 44 panelists over three rounds to achieve consensus on curricular topics deemed essential for PNCC nursing education. During each round, panelists were asked to rate topics as essential or not essential, as well as given opportunities to provide feedback and suggest changes. Feedback was shared anonymously to the panelist group throughout the process.

RESULTS

From 70 initial individual topics, the consensus process yielded 19 refined topics that were confirmed to be essential for a PNCC nursing curriculum by the expert panel. Discrepancies existed regarding how universally to recommend topics of advanced neuromonitoring, such as brain tissue oxygenation; specialized neurological assessments, such as the serial neurological assessment in pediatrics or National Institutes of Health Stroke Scale; and some disease-based populations. Panelists remarked that not all centers see specific diseases, and not all centers currently employ advanced neuromonitoring technologies and skills.

CONCLUSIONS

We report 19 widely accepted curricular priorities that can serve as a standard educational base for PNCC nursing. Developing education for nurses in PNCC will complement PNCC programs with targeted nursing expertise that extends comprehensive specialty care to the bedside. Further work is necessary to effectively execute educational certification programs, implement nursing standards in the field, and evaluate the impact of nursing expertise on patient care and outcomes.

[Relatives after a stay on the intensive care unit: a care gap to be closed]

Structures for the care of relatives after a stay on the intensive care unit are present in principle, but no systematic interfaces between the different types of care and the care sectors exists. Therefore, in a first step, the needs of relatives during intensive care treatment should be continuously assessed and addressed as early as possible. Furthermore, proactive provision of information regarding aftercare services is necessary throughout the entire course of hospitalization and rehabilitation, but also in the phase of general practitioner care. The patient's hospital discharge letter with a detailed social history can serve information transfer at the interfaces.

[Post-resuscitation talk in the intensive care unit : Living interprofessionalism-a must have!]

BACKGROUND

In the context of medical care, healthcare professionals are confronted with cardiopulmonary resuscitation, which can have long-term effects on the participants.

OBJECTIVE

The aim was to develop, implement, and evaluate a protocol-supported post-resuscitation talk for practice in the intensive care unit of a university hospital.

MATERIALS AND METHODS

Within the evidence-based nursing working group, university-qualified nurses performed a systematic literature search in CareLit (hpsmedia, Hungen, Germany), the Cochrane Library (Cochrane, London, England), LIVIVO (Deutsche Zentralbibliothek für Medizin, Cologne, Germany), and PubMed/MEDLINE (U.S. National Library of Medicine, Bethesda, MD, USA) as well as using the snowball principle. Based on the results, the post-resuscitation talk and a debriefing protocol were developed and consented in a multiprofessional team. Additionally, a questionnaire to analyze the current situation (t0) and evaluate the implementation (t1) was developed.

RESULTS

Implementation of the post-resuscitation talk was conducted from August 2021. The t0 survey took place from June to July 2021 and for t1 from February to March 2022. In t0, fewer interprofessional reflections were carried out after resuscitations in the category always or frequently (17.5%, n = 7) than in t1 (50.0%, n = 13). The rate of initiated improvement interventions was increased (t0: 24.3%, n = 9 vs. t1: 59.1%, n = 13). The results show promotion of multiprofessional collaboration in t0 and t1, and potential for optimization in the debriefing protocol in t1.

CONCLUSION

Implementation of a post-resuscitation talk in hospitals is a useful tool for the structured interprofessional follow-up of resuscitation events. The results demonstrated initial positive effects and potential for optimization.

Facial appearance associates with longitudinal multi-organ failure: an ICU cohort study

BACKGROUND

Facial appearance, whether consciously or subconsciously assessed, may affect clinical assessment and treatment strategies in the Intensive Care Unit (ICU). Nevertheless, the association between objective clinical measurement of facial appearance and multi-organ failure is currently unknown. The objective of this study was to examine whether facial appearance at admission is associated with longitudinal evaluation of multi-organ failure.

METHODS

This was a sub-study of the Simple Intensive Care Studies-II, a prospective observational cohort study. All adult patients acutely admitted to the ICU between March 26, 2019, and July 10, 2019, were included. Facial appearance was assessed within three hours of ICU admission using predefined pictograms. The SOFA score was serially measured each day for the first seven days after ICU admission. The association between the extent of eye-opening and facial skin colour with longitudinal Sequential Organ Failure Assessment (SOFA) scores was investigated using generalized estimation equations.

RESULTS

SOFA scores were measured in 228 patients. Facial appearance scored by the extent of eye-opening was associated with a higher SOFA score at admission and follow-up (unadjusted 0.7 points per step (95%CI 0.5 to 0.9)). There was no association between facial skin colour and a worse SOFA score over time. However, patients with half-open or closed eyes along with flushed skin had a lower SOFA score than patients with a pale or normal facial skin colour (P-interaction < 0.1).

CONCLUSIONS

The scoring of patients' facial cues, primarily the extent of eye-opening and facial colour, provided valuable insights into the disease state and progression of the disease of critically ill patients. The utilization of advanced monitoring techniques that incorporate facial appearance holds promise for enhancing future intensive care support.