Acute Deterioration Research Articles

Critical Points of Risk in Registered Nurses' Use of a National Early Warning Score-Perceptions and Challenges.

To explore Registered Nurses' experiences and perceptions of using the National Early Warning Score in the U.K. as part of the recognition and management of acute adult patient deterioration. Hermeneutic Phenomenological design. Sixteen Registered Nurses from a U.K. NHS hospital were interviewed using an interpretative phenomenological approach (2019-2020). Registered Nurses' use of NEWS highlighted 3 risk areas: delegation of vital sign monitoring to unregistered staff leading to uncertainty and delayed escalation, junior nurses' over-reliance on NEWS and deference to expertise, and senior nurses' self-management of deteriorating patients. The workplace culture revealed frequent compromises and limited learning opportunities. When using NEWS, failure to recognise associated risks threatens patient safety. Wrong decisions at the three 'pinch points' may lead to missed chances in preventing deterioration. Incorrect judgements may lead to unrecognised patient deterioration or inappropriate management leading to preventable adverse events. The way in which NEWS is used by healthcare professionals brings inherent patient safety risks. Addressing education gaps and fostering a supportive culture in nursing, valuing and enhancing nurses' clinical judgement, is crucial for mitigating these risks and ensuring patient safety. The study deepens understanding of nurses' use of NEWS and identifies components affecting the recognition of patient deterioration. Adherence to the EQUATOR guidelines SRQR confirmed. Service user involvement was included within the design of the study and ethical approval.

Dichotomous horizontal representation of acute deterioration risk on illnesses

The possibility that risks interact with spatial information (such as the SNARC effect) has been explored but studies did not demonstrate a consistent left-to-right representation of risks. This is probably due to the perception of risk being different in each individual experience. The present study aimed to clarify the spatial characteristics of acute deterioration risks perceived from illnesses. Registered nurses and general students participated in the present experiment. They were instructed to judge, by pressing one of the left/right response buttons, whether the risk of a given target (illness name) presented on a computer screen was higher or lower compared to that of a standard stimulus. Reaction times to the target were measured. No spatial-risk association was observed in the comprehensive analysis, but further inspection revealed that approximately half of the participants have a left-to-right representation and the other half have a right-to-left representation. Moreover, participants’ responses appeared to be faster when the target was representationally farther away from the standard stimulus (i.e., distance effect). These findings therefore suggest a spatially aligned magnitude representation of acute deterioration risk (i.e., mental risk line) but this horizontal risk orientation is likely to be dichotomous depending on the individuals and/or given situations.

Acute Traumatic Epidural Hematoma in Geriatri, case report

Acute epidural haematomas (AEDH) are rare cases in geriatric age group as the dura adheres firmly to the inner table of the cranial bone. Trauma Brain Injuries are attributed to several mechanisms of injury, including falls, motor vehicle or other types of road injuries, sports-related injuries, and interpersonal physical violence or violence by other means (e.g., blast injury). Presentation may range widely from normal mental status to severe intracerebral injury in the elderly although acute deterioration may occur in previously conscious patients. There are only a few studies in the literature concerning acute epidural haematomas in geriatric age group. In our case, a 66-year-old male patient with cranial Computerized Tomography (CT) showed AEDH at the right parietotemporooccipital region.

Development of continuous warning system for timely prediction of septic shock.

As delayed treatment of septic shock can lead to an irreversible health state, timely identification of septic shock holds immense value. While numerous approaches have been proposed to build early warning systems, these approaches primarily focus on predicting the future risk of septic shock, irrespective of its precise onset timing. Such early prediction systems without consideration of timeliness fall short in assisting clinicians in taking proactive measures. To address this limitation, we establish a timely warning system for septic shock with data-task engineering, a novel technique regarding the control of data samples and prediction targets. Leveraging machine learning techniques and the real-world electronic medical records from the MIMIC-IV (Medical Information Mart for Intensive Care) database, our system, TEW3S (Timely Early Warning System for Septic Shock), successfully predicted 94% of all shock events with one true alarm for every four false alarms and a maximum lead time of 8 hours. This approach emphasizes the often-overlooked importance of prediction timeliness and may provide a practical avenue to develop a timely warning system for acute deterioration in hospital settings, ultimately improving patient outcomes.

A rare case of infiltrative optic neuropathy caused by vitreoretinal lymphoma with hyperreflective deposits in the intraretinal and subretinal pigment epithelial layers prior to the disease onset

BackgroundTo describe a rare case of infiltrative optic neuropathy (ION) caused by vitreoretinal lymphoma (VRL) with hyperreflective deposits in the intraretinal and subretinal pigment epithelial (RPE) layers before the disease onset.Case presentationAn 87-year-old Japanese female, previously treated for unexplained uveitis in the right eye, was referred for further evaluation. Despite the absence of intraocular inflammation or vitreous opacification (VO), yellowish-white deposits were noted in the macula, and OCT revealed hyperreflective deposits in the intraretinal and sub-RPE layers. One month later, she returned with acute visual deterioration. Optic disc swelling and disc hemorrhage were observed without VO or intraocular inflammation. Magnetic resonance imaging (MRI) showed no abnormalities. One week later, VO developed and we performed a 25-gauge vitrectomy. Cytology, flow cytometry, and gene rearrangement confirmed malignant B-cell lymphoma. The diagnosis of ION secondary to VRL was made, and intravitreal methotrexate injections were administered a total of 6 times. Six months postoperatively, VO and optic disc swelling resolved, and visual acuity improved to 20/50, with no recurrence on MRI.ConclusionsAlthough there were reports on VRL advanced from hyperreflective deposits in the intraretinal or sub-RPE layers, there have been no studies that these OCT findings has progressed to ION with VRL. When differentiating optic neuropathy, OCT may assist in the diagnosis by evaluating intraretinal and sub-RPE findings.

Abstract 4117397: SGLT2i And Cardio-Renal Outcomes In Type 2 Diabetes Mellitus: A Systematic Review And Meta Analysis.

Background: Diabetes Mellitus (DM) significantly impacts global health through cardiovascular and renal complications. SGLT2 inhibitors (SGLT2i) have emerged as beneficial for cardiovascular outcomes in Type 2 Diabetes Mellitus (T2DM). However, only few studies report outcomes related to renal function. Aim: This study aims to analyse the efficacy of SGLT2i on cardiorenal outcomes in adults with T2DM. Methods: A systematic review and meta-analysis, following PRISMA-2020 guidelines was conducted. We evaluated the efficacy of SGLT2i on cardiorenal outcomes in adults with T2DM. We included randomized controlled trials(RCT) and post hoc analyses that compared SGLT2i with placebo, focusing on cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, heart failure hospitalizations, and renal outcomes such as the progression of albuminuria and the decline of eGFR. Dichotomous outcomes were calculated using relative risk (RR) with 95% confidence interval (CI). Results: We identified 2753 studies, registered in PubMed(=788), Embase(n=538), WoS(n=369), Scopus(n=908), and Cochrane(n=150). We included 11 studies 6 RCT and 7 Post Hoc Analysis, sample size of 50.653 patients. Meta-analysis showed that SGLT2i improve cardiovascular outcomes such as reduced cardiovascular mortality (RR 0.84 [95% CI 0.73–0.97] p=0.02), heart failure hospitalizations (RR 0.65 [95%CI 0.54–0.77]p<0.00001), and their composites outcomes. Furthermore, renal outcomes with SGLT2i significantly improve Urinary Albumin-to-Creatinine Ratio (RR1.10 [95%CI 1.03–1.18]p=0.004), Improvement of the decline of the eGFR (RR1.08 [95%CI 1.04–1.11] p<0.00001) and progression of albuminuria (RR 0.69[95%CI 0.66–0.72]p<0.00001). Slower Doubling of serum creatinine (RR 0.71 [95% CI 0.61–0.82] p<0.00001), end-stage kidney disease (RR 0.66 [95% CI 0.53–0.83] p=0.0003). Reduced Acute Kidney Injury (RR 0.72 [95% CI 0.58–0.89] p=0.002) and renal impairment (RR 0.57 [95% CI 0.34–0.95] p=0.03). Regarding death from renal causes, we identified a 46% relative reduction in the risk in SGLT2i group, although was not statistically significant (RR 0.54 [95% CI: 0.23, 1.27] p=0.16). The observed heterogeneity across studies calls for careful application of these results to individual patients. Conclusion: SGLT2i confers notable advantages in managing cardiorenal complications in T2DM, demonstrating a reduction in cardiovascular mortality and heart failure hospitalizations and offering a nephroprotective effect.

Abstract 4129273: Severe Mitral Regurgitation from Impella-associated Mitral Chordae Rupture with Successful Transcatheter Edge-to-edge Repair

Background: Limited data exists describing Impella-related mechanical mitral valve complications. Diagnosis and management can be challenging due to potential underestimation of mitral regurgitation severity from Impella and acute clinical deterioration upon removal. We present a case of successful mitral transcatheter edge-to-edge repair (TEER) for acute severe MR secondary to Impella-related mitral chordae rupture resulting in acute pulmonary edema post-Impella removal. Case Summary: A 37-year-old male smoker presented with chest pain complicated by cardiac arrest due to ventricular fibrillation. Spontaneous circulation could not be restored, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Coronary angiography revealed total occlusion of the proximal left anterior descending artery, which was successfully stented. Transfemoral Impella CP was placed for left ventricular venting under fluoroscopy (Panel A) with TTE showing no complications. In the intensive care unit, the Impella was advanced under TTE guidance; its tip was found to be positioned deep at the base of the posteromedial pupillary muscle without suction alarms or ventricular arrhythmias on the following day (Panel B). Several days later, TTE revealed new eccentric MR with hyperdynamic left ventricular motion (Panel C). The patient remained hemodynamically stable after VA-ECMO decannulation with Impella at P4. Following Impella removal, he developed repeated flash pulmonary edema despite aggressive fluid removal attributed to acute severe MR secondary to a flail P3 leaflet with ruptured chordae tendineae confirmed by transesophageal echocardiography (Panel D). Given the patient's poor surgical candidacy with a STS score of 13.2%, the team proceeded with mitral TEER, successfully reducing MR severity from severe to mild with a single NT Mitraclip ® across the medial commissure (Panel E). His post-operative cardiac course was uneventful without recurrence of pulmonary edema. Discussion: Irreversible mechanical damage to the mitral valve apparatus caused by Impella placement and repositioning is a rare, potentially fatal complication requiring emergent intervention. Mitral TEER can be a viable salvage option for poor surgical candidates.

Empirical Testing of a Middle-Range Theory for Ineffective Breathing Pattern in Children With Congenital Heart Disease.

To test a middle-range theory (MRT) for the nursing diagnosis of ineffective breathing pattern in children with congenital heart disease (CHD) based on analysis of two general propositions. This cross-sectional study is guided by STROBE. The propositions represent hypotheses about the relationships between the concepts of this MRT to be tested empirically, and thus, log-linear models were used to verify the structure of the proposition related to the stimuli. Diagnostic accuracy measures, univariate logistic regressions and the Mann-Whitney test were used to analyse the structure of the propositions related to behaviours. The analysis of the propositions related to the stimuli (eight concepts, four of which were classified as focal stimuli and four as contextual stimuli) suggested a reclassification of the stimulus "deformities in the thoracic wall" which became too focal. In the analysis of the propositions related to behaviours (17 concepts, five of which were classified as acute confirmatory, nine as acute clinical deterioration and three classified as chronic), guided changes in the operationalisation of concepts were suggested after comparing clinical findings; thus, acute confirmatory behaviours now have 10 concepts, while acute clinical deterioration behaviours and chronic behaviours continued with nine and three concepts, respectively, but with reclassifications between them. Changes in the operationalisation of the classification of the elements of the two propositions occurred after comparing the clinical findings with the theoretical model. By establishing precise causal relationships and describing how IBP manifests itself over time in children with CHD, empirical testing of this MRT helps nurses understand clinical reasoning based on temporal logic and spectral interaction between diagnostic components, which in turn will improve the use and accuracy of nursing diagnoses. Children and adolescents with CHD were recruited for this study sharing their clinical history and physical lung examination.

Diagnostic performance of assays for urgent MPO, PR3 and GBM autoantibodies in suspected vasculitis

Rapid testing for anti-neutrophil cytoplasmic antibodies (ANCA) and glomerular basement membrane (GBM) antibodies may assist in the early diagnosis of small vessel vasculitis. Clinical utility of urgent testing of these antibodies in an Australian context is not known. Our retrospective study examined the urgent test requests for ANCA and/or GBM antibodies performed over a 2-year period. Overall, urgent testing was positive in 28.6% of all requests. When cases of known ANCA associated vasculitis or GBM disease were excluded, the urgent test positive rate remained high at 23%. The highest rates of new positivity were seen in patients with acute renal impairment and haemoptysis (71%), isolated acute renal impairment (21%) and isolated haemoptysis (18%). Dual positivity with both ANCA and anti-GBM antibodies occurred in 4 patients. Our study confirms that clinicians requesting urgent testing are able to identify patients with a high pre-test probability for small vessel vasculitis, thus allowing for rapid serological diagnosis.

PP454 Topic: AS16–Medical, Nursing and AHP Workforce & Education: Staff Education and Development/Equity, Diversity, Inclusion/Other: RECOGNITION OF ACUTE DETERIORATION IN SURGICAL CHILDREN (RADISCH): A NOVEL SIMULATION-BASED TEACHING PROGRAMME TO SUPPORT THE CARE OF SURGICAL PAEDIATRIC PATIENTS.

PP454 Topic: AS16–Medical, Nursing and AHP Workforce & Education: Staff Education and Development/Equity, Diversity, Inclusion/Other: RECOGNITION OF ACUTE DETERIORATION IN SURGICAL CHILDREN (RADISCH): A NOVEL SIMULATION-BASED TEACHING PROGRAMME TO SUPPORT THE CARE OF SURGICAL PAEDIATRIC PATIENTS.

Survival benefit of guideline-directed medical therapy in elderly patients with heart failure with reduced ejection fraction: a systematic review and meta-analysis

Abstract Background Heart failure is a major cause of mortality in the elderly and heart failure-related mortality in elderly patients has increased since 2012. The evidence of guideline-directed medical therapy (GDMT), the four pillars of treatment of heart failure with reduced ejection fraction (HFrEF), remains insufficient in this population. Aim The objective of this study was to assess the survival benefit of the four pillars of GDMT in elderly patients aged ≥ 65-years-old with HFrEF. Methods MEDLINE, EMBASE and the Cochrane Library were searched from inception to 21 July 2023. The inclusion criteria were studies comparing survival between patients ≥ 65-years-old with left ventricular systolic dysfunction receiving and not receiving GDMT. Pooled prevalence, hazard ratio (HR) and risk ratio (RR) were calculated with 95% confidence interval (CI). Heterogeneity was explored through subgroup analyses based on the number of GDMT, age cut-off, sample size, ejection fraction cut-off, study type and study publication date. Results Thirty studies with 86,941 patients from 1994 to 2019 were included. The GDMT group received three drug classes in three studies, two drug classes in four studies, and at least one class in the remaining studies. There were no reported studies on elderly patients receiving four classes of GDMT. Over 5% of the elderly HFrEF patients were frail (Pooled prevelance 7%, 95%CI 2.0–14.0, I2 98%). Frail elderly patients were less likely to receive GDMT (RR 0.63, 95%CI 0.45–0.89, I2 50%, p = 0.009). There was a survival benefit of GDMT in elderly patients with HFrEF (HR 0.70, 95%CI 0.65-0.76, I2 75%, p < 0.001). Elderly patients receiving BB were more likely to develop bradycardia (RR 3.96, 95%CI 2.71-5.80, p < 0.001, I2 0%). There was no difference in the incidence of hypotension, acute renal impairment, and hypoglycemia between the GDMT and control group. The funnel plot appeared asymmetrical which suggests possible publication bias. Conclusion The use of GDMT in elderly HFrEF patients was associated with a survival benefit. Frailty may interfere with the implementation of GDMT. High quality studies are needed to guide the safety and efficacy of GDMT, and the development of guidelines on HFrEF management the in elderly according to frailty status.Forrest plot of overall survival

Self-management app usage and expectations by patients with heart failure: results of a qualitative study

Abstract Background Effective self-care in heart failure (HF) is essential to prevent acute deterioration and improve treatment adherence and quality of life. The supportive role of eHealth is becoming increasingly important to alert HF patients to changes in symptoms and take greater responsibility for maintaining or improving their state of health. Integrating the expectations, perceptions, and impression of HF patients into the design, customization, and utilization of self-care apps is crucial to ensure sustainable and beneficial implementation of such solutions. Purpose To explore patients' with HF expectations, their usage, and first impressions towards a self-care app. Methods The self-care app developed could monitor HF symptoms, provide education via e-learning modules, and telemedical services including regular checkups, recommendations, and feedback from healthcare professionals (HCP). Patients from four clinical sites in Europe, Germany (DE), United Kingdom (UK), Ireland (IRL), Netherlands (NL), who had used this app were invited to participate in a semi-structured interview. These were recorded, transcribed, and analysed by two researchers based on qualitative content analysis according to Mayring. Results In total 32 male and 6 female HF patients aged between 32 and 84 years (66±13) were interviewed (see figure 1). Average duration was 34 minutes. Most patients had used the app for 1-2 weeks at time of the interview. Most patients planned to use the app 2-3 times a week and integrate it into their daily routines. Patients expressed a preference for sessions (regular checkups, e-learnings) not to exceed 10 minutes. Patients believed features like reminders, gamification, and direct feedback from the app could positively influence their behaviour. Conversely, technical issues, too frequent data entry or repetitive questioning were perceived as negative. In case the app could give medical advice, some patients (n=12) indicated that they would only follow the app's recommendations after consulting an HCP. Overall, patients expected the app to provide continuous monitoring and an early warning system to detect and counteract deterioration at an early stage. They deemed the combination of telemedical services and patient records to be particularly valuable. Moreover, patients expected the app to serve as an information source on HF and believed it could increase their motivation and self-discipline for better self-care and therapy adherence (see figure 2). Conclusion The results show that HF patients consider eHealth apps to be valuable tools for autonomously monitoring and improving their health. However, behaviour and acceptance can be encouraged or inhibited depending on the functionalities and design of the app. The findings underline the increasing relevance of eHealth solutions, such as a self-care app in healthcare and emphasize the necessity of considering patients' needs and preferences during the development.Functions with the greatest benefit

INCIDENCE OF CONTRAST-INDUCED NEPHROPATHY FOLLOWING CHRONIC TOTAL OCCLUSION PERCUTANEOUS CORONARY INTERVENTION

Contrast-induced nephropathy (CIN) is a potentially serious complication following percutaneous coronary intervention (PCI), particularly in patients with chronic total occlusion (CTO). It is characterized by an acute deterioration in renal function after exposure to contrast media. CIN is associated with increased morbidity, hospital stays, and long-term renal outcomes, making it crucial to identify and mitigate its incidence. This study aimed to evaluate the incidence of CIN in patients undergoing CTO-PCI and its associated complications. Objective: To assess the incidence of contrast-induced nephropathy (CIN) following percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) and evaluate in-hospital complications, hospital stay duration, and short-term mortality. Methods: This cross-sectional study was conducted with ethical approval at a tertiary care hospital, including 118 patients who underwent PCI for CTO at the Department of Cardiology, Lady Reading Hospital Peshawar, Pakistan from 10th June 2023 to 09th June 2024. Standardized pre- and post-procedural hydration protocols were implemented to reduce the risk of CIN, and non-ionic, iso-osmolar contrast agents were used. CIN was defined as a 25% increase in serum creatinine or an absolute increase of ≥0.5 mg/dL within 48–72 hours post-procedure. Data on demographic characteristics, complications, and mortality were collected and analyzed using SPSS Version 25, with categorical variables expressed as percentages and continuous variables as means. Chi-square tests were used to assess statistical significance, with P-values < 0.05 considered significant. Results: Of the 118 patients included, the mean age was 56.34 years, and 52.5% were male. Age distribution showed that 43.2% were between 51-60 years, while 33.1% were between 61-70 years. CIN was observed in 6.8% of patients, with 9.7% of males and 3.6% of females affected (P=0.188). In-hospital complications included arrhythmias in 4.2% of patients, heart failure in 0.8%, and mortality in 0.8%. Hospital stay averaged 5.94 days, with no significant differences in CIN incidence across age groups (P=0.186). Conclusion: The incidence of contrast-induced nephropathy following PCI for chronic total occlusion is a clinically significant issue, affecting 6.8% of patients despite preventative measures. This emphasizes the need for ongoing risk assessment, monitoring, and the implementation of effective prevention strategies. Further research is warranted to refine risk stratification tools and develop targeted interventions to minimize CIN incidence, particularly in high-risk patient populations.

19 How are paediatric tertiary care hospitals structured to respond to the needs of children with medical complexity during acute deteriorations? A landscape study in Canada

Abstract Background Children with medical complexity (CMC) are at risk of unplanned healthcare visits especially due to acute clinical deteriorations. Complex care (CC) programs help facilitate the needs of CMC. Objectives To identify the organizational and administrative resources available for the care of CMC in Canadian tertiary care paediatric hospitals and to assess how physicians believe these resources are adapted to the specific urgent needs of CMC. Design/Methods In this observational study, key informants representing complex care (CC) and paediatric emergency medicine (PEM) services from 15 paediatric tertiary care hospitals in Canada completed cross-sectional structured questionnaires. Participants were identified through national research networks (Pediatric Emergency Research Canada (PERC), Pediatric Inpatient Research Network (PIRN) and by snowball sampling. Utilizing the Lime Survey web application, two questionnaires (one for PEM, one for CC) were develop based on a literature review and following Burns methodology. Verbal questionnaires were administered via a secured teleconference application or completed digitally. Descriptive data were generated using Excel and SPSS v.29. Results From 09/2022 to 09/2023, 93% (28/30) key informants completed questionnaires (15 PEM, 13 CC, Table 1). Across the 15 sites, 12 had a CC program or clinic. Information about established CC programs was available for 10 sites (Table 2), from participating CC informants: 4/10 offered outpatient services; 6/10 offered inpatient and outpatient services; 8/10 offered last minute appointments for CMC. CC programs had variable staffing: mostly physicians (median 3 FTE, range: 0.2-6) and nurse practitioners (0.75 FTE, range: 0-9) or registered nurses (0.9 FTE, 0-8). CC informants reported offering an ED consultation service at 8/10 sites, while 6/12 PEM participants reported access to such a service. CC informants reported that their program rarely offered consultations during weekends (2/10) or nights (1/10). Across all sites, PEM informants reported good access to documents to help with continuity of care including emergency care plans (13/15), medical history (14/15), goals of care (13/15). Using an 11-point scale, CC informants rated their hospital’s median ability to meet the outpatient needs of CMC as 6.5 (range: 0-10), and their ED’s median ability to meet the needs of CMC as 7 (range 5-10). PEM informants reported their median ability to meet the needs of CMC as 8 (range 6-9). Informants made suggestions to improve the ED care of CMC (Table 3). Conclusion There exists wide variation in the structures caring for CMC and their availability in case of acute needs. National collaboration between CC and PEM teams may facilitate the design of programs to improve the acute outpatient care of CMC.

Cardiac Failure and Cardiogenic Shock: Insights Into Pathophysiology, Classification, and Hemodynamic Assessment.

Heart failure is defined as increased intracardiac pressures, either alone or combined with reduced cardiac output. Clinically, it is presented with signs and symptoms of congestion and compensated perfusion. Cardiogenic shock, on the other hand, is the spectrum of hemodynamic disturbances that lead to hypoperfusion or need for circulatory support, due to cardiac disease. Both entities affect millions of people worldwide, have a dismal prognosis, and constitute a severe socioeconomic burden. Heart failure can be the aftermath of ischemic heart disease, hypertension, arrhythmias, or cardiomyopathies. It undergoes multiple classifications, facilitating its investigation and treatment. The pathogenetic mechanisms differ in various types of heart failure, regarding the affected ventricles, the duration of symptoms, and their primary/secondary onset. These mechanisms reflect the complex interactions between cardiopulmonary, vascular, and hepatorenal systems. Acute deterioration of cardiac function can lead to cardiogenic shock. Myocardial infarction accounts for 81% of such cases. Healthy lifestyle and timely management of coronary artery disease are paramount, as they can prevent this life-threatening situation and reduce mortality and the economic burden for healthcare systems. Irrespective of the etiology, cardiogenic shock is interpreted using the pressure-volume loop. This can be modified for each ventricle, the underlying pathophysiology, and the time since symptoms' onset. It therefore provides valuable information about the native circulation and the expected alterations under mechanical or pharmacological support, facilitating the decision-making progress. In 2019, given the phenotypical heterogeneity of cardiogenic shock, the Society for Cardiovascular Angiography and Interventions introduced a classification system. According to this, patients are stratified in five stages proportionally to the severity of their condition. Aside from this classification, various biochemical, imaging, and hemodynamic monitoring indices are used to assess coagulation pathway and cardiac, hepatorenal, and pulmonary function, enabling the heart team to tailor therapy. Additionally, the prognostication progress is facilitated by scores, such as the Observatoire Regional Breton sur l'Infarctus (ORBI) score, the intra-aortic balloon pump (IABP) SHOCK-II score, and the CardShock score, indicating suitable escalation or de-escalation strategies. Despite the current progress, there are several areas of advancement regarding the role of vasoactive drugs in cardiogenic shock, revascularization options, mechanical ventilation patterns, hypothermia treatment, and mechanical circulatory support protocols.

Efficacy of Early Warning Scores as the Prediction Tool for Detecting Patients With Acute Deterioration in a High Dependent Unit.

Background Early detection and response to patient deterioration are essential to prevent serious outcomes such as unplanned intensive care unit (ICU) transfers and cardiac arrests. Rapid response systems (RRS) have been implemented globally, leading to a reduction in in-hospital mortality. In high-dependency units (HDUs), where patient monitoring is more frequent than in general wards, but staffing levels are lower than in intensive care units (ICUs), the challenge of identifying deteriorating patients persists. The Early Warning Score System (EWSS), including the National EWS (NEWS) and the artificial intelligence (AI)-based Visensia Safety Index (VSI), offer tools for early detection of patients' exacerbations. This study evaluates the effectiveness of NEWS and VSI in predicting patient deterioration in an HDU in Japan. Methods This single-center retrospective cohort study was conducted at a 344-bed acute care hospital. The study population included patients admitted to the HDU between September 27, 2019, and December 31, 2019. Study outcomes were unexpected ICU admission, endotracheal intubation, de novo use of vasopressors, de novo use of non-invasive positive pressure ventilation (NPPV), cardiac arrest, and the composite outcome (any of these outcomes). The predictive accuracy of the National Early Warning Score (NEWS) and the Visensia Safety Index (VSI) for detecting outcomes within 24 hours from each time point was analyzed. Results A total of 356 patients were included, with a median age of 76 years old (interquartile range (IQR): 64-84) and a median HDU stay of 2.0 days (IQR: 2.0-3.0). Among the 2648 analyzed vital sign sets, the median NEWS score was 5.0 (IQR: 3.0-7.0) and the median VSI score was 1.1 (IQR: 0.7-1.9). Twenty-six patients (7.3%) experienced outcomes. Among these, 13 (3.7%) required unexpected ICU transfers, 6 (1.7%) required endotracheal intubation, 15 (4.2%) required de novo vasopressor use, and 7 (2.0%) required de novo NPPV. NEWS could predict unexpected ICU admissions with good accuracy (the area under the curve (AUC) 0.834), as well as de novo vasopressor use (AUC 0.765) and the composite outcome (AUC 0.701). VSI also demonstrated modest predictive efficacy for unexpected ICU transfers (AUC 0.767), endotracheal intubation (AUC 0.712), and de novo vasopressor use (AUC 0.733). Based on ROC analysis, the appropriate threshold for NEWS ranged between 6.0 and 8.0, and the optimal threshold for VSI was found to be 1.5. Chronologically, NEWS remained stable before the occurrence of outcomes, whereas VSI showed a significant upward trend, suggesting that VSI may be more sensitive to detecting early deterioration. Conclusions In this study, both NEWS and VSI demonstrated modest accuracy in predicting unexpected ICU admission and vasopressor use in an HDU. While NEWS high risk (7≥) is an appropriate cutoff value for detecting adverse outcomes, particularly lowering the VSI cutoff to 1.5, may enhance the identification of high-risk patients.

Use of neonatal lung ultrasound in European neonatal units: a survey by the European Society of Paediatric Research

ObjectiveRegarding the use of lung ultrasound (LU) in neonatal intensive care units (NICUs) across Europe, to assess how widely it is used, for what indications and how its implementation might...

Clinician and Visitor Activity Patterns in an Intensive Care Unit Room: A Study to Examine How Ambient Monitoring Can Inform the Measurement of Delirium Severity and Escalation of Care.

The early detection of the acute deterioration of escalating illness severity is crucial for effective patient management and can significantly impact patient outcomes. Ambient sensing technology, such as computer vision, may provide real-time information that could impact early recognition and response. This study aimed to develop a computer vision model to quantify the number and type (clinician vs. visitor) of people in an intensive care unit (ICU) room, study the trajectory of their movement, and preliminarily explore its relationship with delirium as a marker of illness severity. To quantify the number of people present, we implemented a counting-by-detection supervised strategy using images from ICU rooms. This was accomplished through developing three methods: single-frame, multi-frame, and tracking-to-count. We then explored how the type of person and distribution in the room corresponded to the presence of delirium. Our designed pipeline was tested with a different set of detection models. We report model performance statistics and preliminary insights into the relationship between the number and type of persons in the ICU room and delirium. We evaluated our method and compared it with other approaches, including density estimation, counting by detection, regression methods, and their adaptability to ICU environments.

Endothelin Inhibitors in Chronic Kidney Disease: New Treatment Prospects.

The endothelin system is reported to play a significant role in glomerular and tubulointerstitial kidney disease. In the kidney, endothelins are produced in mesangial cells and the glomerular basement membrane by the endothelium and podocytes. The endothelin system regulates glomerular function by inducing proliferation, increasing permeability and in effect proteinuria, and stimulating inflammation, tubular fibrosis, and glomerular scarring. Endothelin A receptor antagonists have been proven to delay the progression of chronic kidney disease and play a protective role in immunoglobulin A nephropathy, focal segmental glomerulosclerosis, and diabetic nephropathy. There are several ongoing research studies with ETAR antagonists in nondiabetic nephropathy, Alport disease, vasculitis and scleroderma nephropathy, which results are promising. Some reports suggest that the endothelin system might contribute to ischemia-reperfusion injury, acute graft rejection and deterioration of graft function. Endothelin inhibition in renal transplantation and its influence on graft survival is the future direction needing further research. The most frequent side effects associated with ETAR antagonists is fluid retention. Additionally, it should be considered if selective ETAR antagonists therapy needs to be co-administered with sodium-glucose co-transporter 2 inhibitors, renin-angiotensin-aldosterone inhibitors or diuretics and which patients should be recruited to such treatment to minimize the risk of adverse outcomes.

Metabolic emergencies in the NICU

Metabolic emergencies in neonates can present with nonspecific signs and symptoms. Sudden acute deterioration in a neonate should prompt consideration of metabolic disease. Common metabolic emergencies in the Neonatal Intensive Care Unit (NICU) include hypoglycemia, hyperammonemia, hyperbilirubinemia, metabolic acidosis, adrenal insufficiency, and electrolyte imbalances. These emergencies often require prompt recognition and intervention to prevent serious complications. Appropriate management depends on the diagnosis. However, initial resuscitation and stabilization can be started without a definitive diagnosis. Confirmatory testing and long-term management vary by condition and should be guided by symptoms and endocrinologist input.