Adult Intensive Care Unit Research Articles

Self-confidence as a mediator in the relationship between executive functioning and depression among ICU survivors: a latent variable analysis

BackgroundExecutive dysfunction and depression are common among ICU survivors, yet the mechanisms linking these two factors remain poorly understood. Self-confidence has been implicated as a key mediator in the relationship between cognitive impairments and mental health outcomes. This study aimed to explore the mediating role of self-confidence in the association between executive functioning and depression in ICU survivors.MethodA provisional questionnaire was used in a cross-sectional study to assess quality of life in 395 adult ICU survivors, each with a minimum 72-h stay at one of three ICUs at a Swedish university hospital, six months to three years post-discharge. Responses to questions on executive function, self-confidence, and depression were analysed. Structural equation modelling and confirmatory factor analysis were employed to examine the mediating effect of self-confidence on the relationship between executive function and depression. Model fit was evaluated using established indicators. Reliability of the measures was assessed using McDonald’s Omega and Cronbach’s Alpha.ResultsA significant positive correlation was found between depressive symptoms and both diminished self-confidence (r = 0.80, p < 0.001) and poorer executive function (r = 0.55, p < 0.001). Additionally, a correlation was observed between reduced self-confidence and compromised executive function (r = 0.62, p < 0.001). Age was negatively associated with depression, self-confidence, and executive function, while male gender was positively correlated with higher self-confidence.Mediation analysis revealed that the effect of impaired executive function on depressive symptoms was fully mediated by diminished self-confidence (B = 0.45; 95% CI 0.34–0.59). The direct effect of executive function on depression became non-significant when self-confidence was included in the model (B = 0.07, p = 0.18), suggesting complete mediation. The overall model fit was satisfactory (CFI = 0.962; RMSEA = 0.075), highlighting the robustness of the mediation pathway.ConclusionsSelf-confidence mediates the relationship between executive function and depression among ICU survivors. Interventions aimed at enhancing self-confidence could mitigate depressive symptoms in the ICU survivor population. Longitudinal studies are needed to confirm these findings and further explore the causal pathways involved.Trial registration ClinicalTrials.gov Ref# NCT02767180; Registered 28 April 2016.

The association of early passive mobilization with intracranial pressure in the adult intensive care unit: A prospective, cohort study.

Early mobilization are key components of the ABCDEF Care Bundle and critical treatments to reduce acquired muscle weakness, delirium and prolonged intensive care unit (ICU) stay. This study aimed to determine whether routine early mobilization related to intracranial pressure in intensive care patients on mechanical ventilation, using optic nerve sheath diameter measurement (ONSD). This study was planned as a prospective, cohort study in the third-step adult ICU of a faculty hospital. The study included only patients who were intubated and followed up on a mechanical ventilator and were clinically stable. Passive range of motion (PROM) exercises were performed daily by the physiotherapists as part of routine care from the day of hospitalization. ONSD was assessed before, during and 10 min after PROM exercises. The study included 20 eligible patients out of the 142 who were evaluated upon admission to the ICU. The median age of the patients was 65 years, and nine (45%) of them were female. The analyses showed that there was no statistically significant change in ONSD during and at the end of the PROM (ONSD right eye p:.621, Partial η2: 0.025, ONSD left eye p:.935, Partial η2: 0.004). Similarly, there was no statistically significant change in haemodynamic parameters in during and at the end of the PROM (Heart beat p:.849, Partial η2: 0.009, Systolic Pressure p:.435, Partial η2: 0.043, Diastolic Pressure p:.128, Partial η2:0.103, Saturation p:.103, Partial η2: 0.113 and Respiratory rate p:.071, Partial η2:0.130). This study suggests that daily extremity physiotherapy exercises can be safely applied without causing increased intracranial pressure or haemodynamic instability in intensive care patients followed up on mechanical ventilation, including patients with vasopressor therapy. Early mobilization, including PROM, is considered safe in terms of intracranial pressure for intubated patients in the ICU.

Spontaneous breathing trials should be adapted for each patient according to the critical illness. A new individualised approach: the GLOBAL WEAN study.

Spontaneous breathing trials (SBT) evaluate the patient's capacity to maintain inspiratory effort after extubation. SBT practices are heterogeneous and not individualised. The objective of this study was to assess which SBT best reproduces inspiratory effort after extubation in five critical illnesses. In this multicentre randomized cross-over study, adult intensive care unit patients under invasive mechanical ventilation for at least 24-h and ready for extubation, underwent three 15-min SBTs in random order: pressure support ventilation level of 7-cmH2O with positive end-expiratory pressure (PEEP) level of 0-cmH2O (PSV7PEEP0), PSV 0-cmH2O with PEEP 0-cmH2O (PSV0PEEP0) and T-piece trial. Primary outcome was the variation of pressure-time-product per minute (PTPmin) between each SBT and 20-min after extubation. Five categories of critical illnesses were selected: abdominal surgery, brain injury, chest trauma, chronic obstructive pulmonary disease (COPD) and miscellaneous. Five hundred measures of effort from 100 patients were analysed. PTPmin (cmH2O s/min, median and interquartile range, IQR) was 256 (208-321) after extubation, 192 (127-281) at the end of PSV7PEEP0 (p < 0.001 in comparison to after extubation), 291 (235-347) at the end of PSV0PEEP0 and 262 (198-338) at the end of T-piece (both no different from after extubation). One method of SBT in patients with brain injury (PSV0PEEP0), two in abdominal surgery (PSV0PEEP0 and T-piece) and miscellaneous patients (PSV7PEEP0 and T-piece) and all three methods in chest trauma and COPD exacerbation patients replicated reasonably accurately the postextubation effort to breathe. Unassisted SBTs, namely PSV0PEEP0 and T-piece trial, are the most appropriate to replicate the postextubation effort to breathe.

Extubation Advisor: Implementation and Evaluation of A Novel Extubation Clinical Decision Support Tool.

Extubation Advisor (EA) is a novel software tool that generates a synoptic report for each Spontaneous Breathing Trial (SBT) conducted to inform extubation decision-making. To assess bedside EA implementation, perceptions of utility, and identify barriers and facilitators of use. We conducted a phase I mixed-methods interventional study in three mixed intensive care unit (ICUs) in two academic hospitals. We interviewed critical care physicians (MDs) and respiratory therapists (RTs) regarding user-centered design principles and usability. We evaluated our ability to consent participants (feasibility threshold 50%), capture complete data (threshold 90%), generate and review EA reports in real-time (thresholds 75% and 80%, respectively), and MD perception of tool usefulness (6-point Likert scale). We analyzed interview transcripts using inductive coding to identify facilitators and barriers to EA implementation and perceived benefit of tool use. We enrolled 31 patients who underwent 70 SBTs. Although consent rates [31/31 (100%], complete data capture [68/68 (100%)], and EA report generation [68/70 (97.1%)] exceeded feasibility thresholds, reports were reviewed by MDs for [55/70 (78.6%)] SBTs. Mean MD usefulness score was 4.0/6. Based on feedback obtained from 36 interviews (15 MDs, 21 RTs), we revised the EA report twice and identified facilitators (ability to track patient progress, enhance extubation decision-making, and provide support in resource-limited settings) and barriers (resource constraints, need for education) to tool implementation. Half of respondents (9 MDs, 9 RTs; combined 50%) perceived definite or potential benefit to EA tool use. This is the first study of a waveform-based variability-derived, predictive clinical decision support tool evaluated in adult ICUs. Our findings support the feasibility of integrating the EA tool into bedside workflow. Clinical trials are needed to assess the utility of the EA tool in practice and its impact on extubation decision-making and outcomes. NCT04708509.

A Retrospective Closed Cohort Study on Distribution of Multidrug-Resistant Bacteria in Ventilator-Associated Pneumonia and its Impact on Patient Outcome.

Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection affecting critically ill patients undergoing mechanical ventilation. This study investigated the prevalence of multidrug-resistant (MDR) organisms in VAP, the VAP rate, and the outcomes associated with MDR-VAP. This retrospective single-center study, conducted in 2022, included adult ICU cases from April 2021 to March 2022, receiving mechanical ventilation for more than 48 h. Patient data were analyzed for demographics, comorbidities, empirical antibiotic use, and outcomes. MDR organisms were identified in respiratory cultures. Among 447 patients, 133 developed VAP, with 96 cases being MDR-VAP. The mean age of the overall VAP population was 52 years, 70% of which were males. The incidence of VAP was 30.0% (95% CI: 25.7%-34.5%), while that of MDR-VAP was 21.6% (95% CI: 17.9%-25.8%). The most prevalent MDR organisms were Acinetobacter species (50%) and Klebsiella pneumoniae (46.9%). Empirical antibiotics were administered in 96% of VAP cases. The overall VAP rate was 38.03/1000 ventilator days. No single antimicrobial agent seemed to offer an empirical cover, as the susceptibility rate for most tested antimicrobials was less than 85%. Patients with MDR-VAP had a low survival rate (64.6%) and were less likely to be extubated at 13.5% compared to non-MDR-VAP (survival rate of 62.2%). COVID-19 patients had a high incidence of MDR VAP, especially with Acinetobacter. Overall, VAP mortality was 57.1%. The median ventilator days were 16 for VAP and only four for non-VAP. Gram-negative organisms, particularly Klebsiella and Acinetobacter, were the main MDR VAP culprits. MDR-VAP exhibited higher morbidity and mortality. A study focused on developing resistance by microorganisms is warranted for further understanding.

Health care providers' perceptions of family participation in essential care in the intensive care unit: A qualitative study.

Family participation in essential care may benefit patients and relatives. To examine the needs, perceptions and preferences of health care providers about family participation in essential care in the adult intensive care unit. A qualitative descriptive study using inductive thematic analysis. Three focus group interviews with a total of 30 intensive care unit health care providers, consisting of 20 critical care nurses, one nursing assistant, five physicians, three physical therapists and one speech therapist working in three Dutch intensive care units. One overarching theme, balancing interests, and four main themes emerged: looking after the patient's interests, taking the relatives' perspective into account, looking after interests of intensive care unit health care providers and conditions for family participation. The first theme, looking after the patient's interests, included three sub-themes: insecurity about patient's wishes and needs, patient safety concerns and potential benefits for the patient. The second theme, taking the relatives' perspective into account, was also characterized by three sub-themes: concerns about the relatives' possible burden, potential benefits for the relative and the relationship between patient and relative. The third theme, looking after interests of intensive care unit health care providers, included three sub-themes: attitude towards family participation in essential care, differing perceptions of essential care and concerns about intensive care unit health care provider's burden. The last theme, conditions for family participation, included two sub-themes: establishing a relationship and considering family participation in essential care as a process. Health care providers' perceptions and preferences regarding family participation in essential care in the intensive care unit are summarized in the overarching theme balancing interests. This overarching theme also reflects the needs and perceptions of patients and relatives. These findings may support critical care nurses and other health care providers when encouraging family participation in essential care.

Management of adult mechanically ventilated patients: A UK-wide survey

Background: Mechanical ventilation is a common and often lifesaving intervention that is utilised in intensive care. However, the practices can vary between centres. Through this national survey we aim to gain more information about different strategies adopted across the UK. Methods: All adult intensive care units in the UK were approached to participate. The questionnaire was developed with an electronic survey engine and conducted between 09/11/2023 and 01/04/2024 (Survey Monkey®). The survey included questions on ventilator modes, settings, protocols/pathways, rescue strategies, immediate post-extubation period and follow-up. Results: There were 196 responses from 104 hospitals. The most widely adopted start-up ventilation mode was pressure-regulated volume-controlled mode. For acute hypoxaemic respiratory failure (AHRF), most of respondents reported full (39.8%) or partial compliance (58.1%) with the ARDSnet protocol, with PEEP settings being the commonest deviation. Prone positioning (99.0%), followed by recruitment manoeuvres (91.3%) were commonly used rescue measures during AHRF. APRV (55.7%), inhaled (51.3%) and systemic pulmonary vasodilators (44.1%) were also commonly used. Conservative oxygen targets (SaO2 of 88%–92%) were commonly adopted (70.6%). As a care bundle, intermittent ETT cuff pressure monitoring was more common (65.5%) than continuous cuff pressure monitoring (20.0%). Propofol and alfentanil were the most common initial sedative and analgesia (99.5% and 56.9%) respectively. Routine volatile anaesthetic use was rare. Conclusions: Our survey has shown significant variation of practice in common but crucial elements of management of patients receiving mechanical ventilation. We hope the results in our survey highlight potential future areas of research. Collaborators South-coast Peri-operative Audit and Research Collaborative (SPARC) Severn Trainee Anaesthetic and Critical Care Research group (STAR) Collaborative research in Anaesthesia in the Northeast (CRANE)

Validity and reliability of the Endotracheal Suction Assessment Tool© in adult ICU patients: A methodological study

BackgroundNovice nurses often find endotracheal suctioning signs unfamiliar. The Endotracheal Suction Assessment Tool© (ESAT©) aids pediatric nurses in suctioning but lacks an adult equivalent. A valid and reliable ESAT© for assessing intensive care unit patients’ suction needs across different populations is necessary. AimTo test the validity and reliability of the ESAT© in adult ICU patients. MethodsThis methodological study assessed suction needs in patients at a tertiary adult ICU of a university hospital. Two independent observers used the ESAT© to determine suction needs. Data from 106 suction procedures were collected using a patient characteristics form, the ESAT©, and a suction monitoring form. The ESAT© includes eight respiratory and ventilation parameters and seven clinical consideration parameters. Hemodynamic and respiratory parameters were measured before, and one and five minutes after suction. Linguistic validity, content validity, and pilot testing were conducted. Interobserver agreement was evaluated, and psychometric evaluation was done using content validity index (CVI) and intraclass correlation coefficient (ICC). Data were analyzed with paired samples t-test and ANOVA. ResultsItem CVI ranged from 0.80 to 1.00, and scale CVI was 0.96. Inter-item correlation and ICC for inter-rater reliability were both 0.933 (95 % CI = 0.903–0.954, p < 0.001 for ICC). Cohen’s Kappa coefficients ranged from 0.690 to 1.000 (p < 0.001), indicating high consistency between raters for all tool items. All scale items showed near-perfect agreement except SpO2, which showed substantial agreement. ConclusionThe S-CVI was good, indicating near-perfect agreement among raters. ESAT© is highly reliable and valid for determining suction needs in adult intensive care patients. Implications for PracticeThe ESAT© aids autonomous decision-making for suctioning needs. Originally for novice pediatric nurses, the ESAT© was adapted for adult intensive care nurses. The ESAT© is valid and reliable for adult intensive care patients.

Exploring Implementation Processes of a Multicomponent Family Support Intervention in Intensive Care Units (FICUS) Study: A Mixed-Methods Process Evaluation.

To investigate the experience with and progress of the implementation of a Family Support Intervention (FSI) into adult intensive care units (ICUs) as part of the cluster-randomised FICUS trial. A mixed-methods process evaluation using a multiple case study approach guided by the normalisation process theory. This study took place between June 2022 and July 2023 in eight Swiss ICUs randomised to the intervention arm. A tailored implementation strategy was used to introduce the multicomponent FSI, consisting of a new family nursing role and a family care pathway, into interprofessional ICU teams. Participants were 40 ICU key clinical partners. Qualitative data were collected twice, early (3-6 months) and mid-implementation (9-12 months), using small group interviews. A questionnaire with psychometric measures (Acceptability of Intervention Measure, Feasibility of Intervention Measure, Intervention Appropriateness Measure, Normalisation Measure Development Questionnaire) was administered at mid-implementation. RITA pragmatic rapid thematic analysis and descriptive statistics were used to analyse the data. Qualitative and quantitative results were then compared across ICUs (cases). Findings indicated the desired progress of the FSI integration overall and across cases, with high acceptability and appropriateness ratings but only moderate to high feasibility scores. Study-related barriers were noted in all ICUs (i.e., FSI delivery as part of a clinical trial). Implementation barriers included family nurses' limited capacity and clinician's attitudes towards the FSI. Leadership support and interprofessional collaboration were identified as facilitators. Case-based, integrated findings yielded two implementation pathways, namely early and protracted adopters. Implementation barriers were related to the feasibility of FSI delivery within the study context that required a high degree of standardisation and protocol adherence. Implementation progress was shaped by an interprofessional culture of family care, sufficient staff and time resources, and leadership support. The study's findings will inform future implementation of complex health interventions in ICUs. Good reporting of a Mixed-Methods Study (GRAMMS). Within the FICUS trial, a patient and family advisory board with a patient expert, three family members and a patient with own lived experience of critical care collaborate with the research team.

Acute amiodarone-induced pulmonary toxicity in adult ICU patients with new-onset atrial fibrillation-A systematic review.

New-onset atrial fibrillation or flutter (NOAF) is a common arrhythmia in adult intensive care unit (ICU) patients. Intravenous amiodarone is one of the most used anti-arrhythmic drugs, despite its risk of inducing acute amiodarone-induced pulmonary toxicity (APT). We aimed to outline the body of evidence on acute APT in ICU patients with NOAF. We performed a systematic search using the population, intervention, comparison, and outcome (PICO) approach. We included studies of adults admitted to the ICU, who developed NOAF during their ICU stay, were treated with amiodarone, and reported on acute APT, irrespective of research design. The CASE guidelines were applied to evaluate the quality of the included studies, and study results are reported in accordance with the preferred reporting items for systematic reviews and meta-analyses. No randomised controlled trials or observational studies were identified. Nine case reports and one retrospective case series of fatal outcomes in ICU patients treated with amiodarone for NOAF constituted the evidence base. The quality of the included studies was high with a mean of 10 (range 8-12) of the 13 CASE guideline criteria fulfilled. The studies included a total of 16 critically ill adults who was diagnosed with acute APT after a mean of 9 days (range 2-20 days) following initiation of amiodarone with a mean total dose of amiodarone of 4553 mg (range 1100-13,500 mg) predominantly administrated intravenously. Three out of nine patients in the case reports died in the ICU during the amiodarone treatment. No long-term follow-up was conducted for the survivors. Acute APT in adult ICU patients treated with amiodarone for NOAF is poorly described and is based on a total of 16 reported cases. Additional studies assessing the safety of amiodarone in critically ill adults with NOAF in the ICU is warranted.

Intensive care unit continuous kidney replacement therapy: time to change dosage recommendations?

Continuous kidney replacement therapy (CKRT) is the predominant form of acute kidney support used for hemodynamically unstable adult ICU patients with severe AKI (KDIGO stage 3). The success of CKRT depends on the achieved doses. Practice patterns worldwide are highly variable. A contemporary understanding of treatment adequacy is essential. The KDIGO AKI clinical guidelines recommend delivering effluent volumes of 20-25ml/kg/hour for CKRT in the ICU setting, with the caveat that higher prescribed doses (25-30ml(kg/h) may be necessary to achieve adequate delivered CKRT doses. The reference landmark trials provide definitive evidence that increases of delivered CKRT doses beyond the recommended dose are not beneficial for unselected ICU patients with severe AKI. However, the minimum delivered CKRT intensity at which underdosing becomes harmful remains unknown. The answer to this question has clinical relevance (dosing of critically ill patients with obesity or Covid-19 disease, minimizing adverse effects of CKRT) and a relevant impact on the costs of CKRT. The delivered dose of CKRT for Japanese ICU patients with severe AKI has been generally smaller (median 15ml/h/kg) than the recommended delivered KDIGO dose. The most recently published retrospective cohort study by Okamoto et al. demonstrated that low delivered CKRT doses were associated with a higher mortality among critically ill patients with severe AKI. These data challenge the nation-wide accepted hypothesis that a lower limit of delivered CKRT (< 20ml/ kg/h) may adequately control uremia/volume overload. Thus, there is an unmet clinical need for prospective randomized trials defining the minimal effective dose of CKRT. Given the dynamic nature of the precipitating critical illness and the natural course of most episodes of AKI, CKRT dose targets are likely to vary. Doses should be tailored to the needs of the individual patient within the limits of the KDIGO guideline recommendations. The Japanese experience with low-dose CKRT is not practice changing.

Towards an update on the antimicrobial use in Adult Care Units in Brazil: insights from multi-hospital prevalence study.

Introduction. Efforts to understand the burden of antibiotic use in low- and middle-income countries such as Brazil are essential for developing strategies that are effective and appropriate in the context of endemic multidrug-resistant organisms.Aim. This study aims to determine antimicrobial-prescribing practices among patients hospitalized in intensive care units (ICUs) for adults in Brazil.Methodology. A 1-day point prevalence multicentre survey was conducted in 58 adult ICUs across the five regions of Brazil. The institutions were categorized according to their type and size. Detailed antimicrobial prescription data were prospectively provided to all patients hospitalized on the day of data collection.Results. A total of 620 patients were included in the study, of whom 63.9% were receiving at least one antimicrobial. Of these, 34.6% were treated for an infection, but only 39.9% of the cases were based on microbiological criteria. Empirical treatment was applied to 72.3% of the patients. Significant differences in antibiotic usage were observed across the different hospitals included in the study. Overall, treatment was most commonly directed towards pneumonia (51.8%) and bloodstream infections (29.6%). Glycopeptides (19.4%) and carbapenems (18.5%) were the most prescribed in teaching hospitals, while in non-teaching hospitals, carbapenems (17.8%) and broad-spectrum cephalosporins (16.8%) were most frequently used.Conclusion. Our study reveals alarming data on antibiotic use in adult ICUs in Brazil, with high frequencies of severe healthcare-associated infections acquired in these units, where patients are frequently subjected to empirical treatment.

Benefits of Bedside Open Tracheostomy: A Safe and Cost-Effective Alternative to the Operating Room.

Tracheostomy is a commonly performed procedure in Otolaryngology and can be performed in different settings. We evaluate patient characteristics and cost efficacy of tracheostomy at the bedside versus operating room (OR). Retrospective chart review was performed for adult intensive care unit (ICU) patients who underwent tracheostomy from 2020 to 2023. Data and cost of procedures were analyzed using descriptive statistics. One hundred and sixty-five patients were included. One hundred and thirty-four (81.2%) patients underwent bedside tracheostomy. Age, sex, and BMI were not significantly different. Average time from consult to procedure and operative time was significantly shorter (p = 0.03; 0.008). There were no differences in postoperative complications, 30-day mortality, ICU length of stay (LOS), or overall LOS. Tracheostomy at the bedside offered a 73.1% cost reduction compared with performed in the OR. Advantages of bedside tracheostomy include decreased operative time, time from consult to procedure, and cost reduction for the hospital system. We advocate for consideration of bedside tracheostomy when appropriate.

Evaluation of Dexmedetomidine Withdrawal and Management After Prolonged Infusion

Dexmedetomidine is often used for longer than its labeled indication of 24 hours, raising concerns for potential withdrawal. Data are limited regarding this syndrome in adult patients. This study aimed to further characterize dexmedetomidine withdrawal in critically ill adult patients after prolonged use. This was an institutional review board-approved, single-center, retrospective chart review conducted at a tertiary academic medical center. Adult intensive care unit (ICU) patients on dexmedetomidine for ≥72 hours in 2019 were screened for inclusion. Exclusion criteria were interruption of dexmedetomidine for >6 hours, indications for dexmedetomidine other than sedation, or patients with neurological or burn injury. The major end point was the incidence of dexmedetomidine withdrawal, defined as meeting ≥2 of the following criteria within 24 hours of discontinuation: newly positive Confusion Assessment Method for ICU, Richmond Agitation Sedation Scale score of ≥+2, hypertension, and tachycardia. Minor end points were incidence of individual withdrawal signs as previously described, additional sedatives or antipsychotics required, dose and duration of dexmedetomidine infusion, length of ventilation, ICU and hospital length of stay, and new onset of the following: fever, vomiting, loose stools/diarrhea, diaphoresis, or seizure. Of the 152 patients included, dexmedetomidine withdrawal occurred in 54 patients (35.5%). Rebound hypertension was the most common withdrawal sign (47 patients [87.0%]). In the withdrawal group, significantly more patients required additional β-blockers (29 [53.7%] vs 10 [10.2%]; P < 0.01), were reinitiated on dexmedetomidine (16 [29.6%] vs 10 [10.2%]; P < 0.01), and required a start or increased dose of clonidine (6 [11.1%] vs 3 [3.1%]; P = 0.04). There was no significant difference in the cumulative dose or duration of dexmedetomidine between the groups. Length of ventilation was longer in the withdrawal group (171 hours [83.7-280.8 hours] vs 159 hours [149.0-335.7 hours]; P < 0.01), but there was no difference in ICU or hospital length of stay. Prolonged use of dexmedetomidine was associated with withdrawal syndrome in 35.5% of patients in our study. Larger trials are needed to confirm the risk factors for dexmedetomidine withdrawal and identify measures to prevent withdrawal.

Multicenter analysis of the main reasons for non-infusion of nutritional therapy in adult intensive care units

Multicenter analysis of the main reasons for non-infusion of nutritional therapy in adult intensive care units

Emerging Colistin Resistance: Experience from an Intensive Care Unit of a Tertiary Care Center in India.

Resistance to the currently available classes of antimicrobials has emerged as a major health concern, with a growing number of isolated organisms demonstrating resistance to available antimicrobials. With the escalation of carbapenem resistance, the use of polymyxin B/E (colistin) has increased over the years, which has, in turn, contributed to the worldwide emergence of colistin resistance. The available data on colistin resistance from Southeast Asian nations, including India, is limited, especially in intensive care unit (ICU) settings. The primary objective of our study was to analyze the clinical profile of patients with polymyxin B/E (colistin) resistant positive cultures and to study their outcome in terms of length of ICU stay and outcome at discharge. This observational, single-center, prospective study was conducted in a 20-bed adult ICU serving both medical and surgical patients at a 1,600-bed tertiary care institute in northern India between Jan 2020 and Dec 2021. In this study, all adult patients, defined as individuals older than 18 years of age, admitted to our ICU with cultures detecting polymyxin B/E (colistin) resistant organisms were included as cases, and all adult ICU patients (age >18 years) with polymyxin B/E (colistin) sensitive cultures were taken as controls. Clinical, laboratory, and demographic parameters, along with ICU variables like severity of illness, length of ICU stay, mechanical ventilation, days of shock, renal replacement therapy (RRT), etc., and outcome at discharge were collected. Identification of resistance to colistin and minimal inhibitory concentration (MIC) of colistin is based on Clinical and Laboratory Standards Institute (CLSI) guidelines. For statistical analysis, Mann-Whitney U test, Fisher's exact test, and binary logistic regression were used. Twenty-eight cases and 55 controls (n = 83) were included for analysis. Abdominal [gastrointestinal (GI)] sepsis was the most common diagnosis (41.8%) at admission to the ICU, and Klebsiella pneumoniae was the most common species isolated in both the cases (96.4%) and the controls (50.9%). The most common site of isolation of Gram-negative bacteria in both cases and controls was blood (71.4 vs 74.5%), followed by deep-seated pus (21.4 vs 23.64%). The most common class of drugs to which the cases were sensitive was tetracyclines in 60.7%, followed by ceftazidime-avibactam. Factors such as prior exposure to colistin, exposure to monobactams in the ICU, and ICU stay in days were identified as independent predictors for colistin resistance. Overall mortality was not statistically different between cases and controls (p -value 0.38). Factors like prolonged ICU stay, exposure to monobactams in the ICU, and a history of prior exposure to colistin in the previous 90 days are independent predictors of colistin resistance. The most common organism to develop colistin resistance identified was K. pneumoniae, and the most common site of isolation was blood. There was no difference in mortality between colistin-resistant and colistin-sensitive patients.

Early Rehabilitation Activity and Rehabilitation in ICU Wards in Central China: A Cross-Sectional Survey.

Patients in Intensive Care Units (ICUs) face high risks of physical, functional, cognitive, and mental impairments. Early rehabilitation activities are crucial for reducing mortality and complication rates. This survey investigates the characteristics, current implementation, and detailed status of early rehabilitation activities in ICUs across Central China. A cross-sectional survey was conducted involving 158hospitals, with 131 responding. Data on institutional characteristics and early rehabilitation activities were collected through questionnaires. Descriptive statistical analysis described the current status, and a univariate regression model identified factors associated with the implementation of early rehabilitation measures. A total of 131 ICUs completed the survey, with a response rate of 82.91% (131/158). Results indicated that 82.44% (108/131) of ICUs implemented early rehabilitation activities, but only 65 (49.62%) had explicit early rehabilitation exercise protocols or standards/procedures. Before implementing early rehabilitation activities, approximately 89.97% (110/131) of ICUs conducted assessments, and 46.56% (61/131) regularly held structured interdisciplinary rounds to discuss early activity measures and goals. More than half of the participating adult ICUs reported screening patients for swallowing function (64.89%; 85/131), and 55.73% (73/131) of adult ICUs reported having a nutrition therapy specialist conduct regular consultations/visits. Only 26.72% (35/131) of adult ICUs reported having a speech therapist conduct consultations/visits. A total of 81.68% (107/131) of ICUs believed that the current implementation of early rehabilitation activities was insufficient. In the analysis of influencing factors, the presence of rehabilitation therapists in the ICU was a significant factor for the implementation of early rehabilitation activities (P<0.05). The majority of ICUs in hospitals in central China have implemented early rehabilitation activities; however, less than half have explicit early rehabilitation exercise protocols or standards/procedures. The presence of professional rehabilitation therapists in the ICU is a key factor in the implementation of early rehabilitation activities in ICUs in hospitals in Central China.

Multidisciplinary care to optimise pregnancy outcomes among Jehovah’s Witness: Case series over fifteen years in a tertiary teaching hospital

ObjectiveTo assess the obstetric and neonatal outcomes of Jehovah’s Witness (JW) mothers and the willingness to accept blood products after multidisciplinary management. Study DesignA retrospective case-control study was conducted at Queen Mary Hospital from 2005 to 2020. Delivery records of pregnant women who identified themselves as JW were reviewed. The immediate next age-matched non-JW patient in the booking register was assigned as control. ResultsA total of 96 subjects were identified within the study period (48 JW and 48 non-JW age-matched patients). The haemoglobin levels of JW and non-JW were similar at booking, 28 weeks of gestation, pre-delivery and postnatal day 2. JW mothers were more likely to receive iron supplements in the antenatal period than the control group (27.1 % vs. 6.3 %, p = 0.01) despite the similar rate of antenatal anemia in both groups (4.2 % vs. 4.2 %, p = 1.00). There were no differences in mode of delivery, total blood loss at delivery, rate of primary postpartum haemorrhage, gestational age at delivery, birth weight, and Apgar score at 1 and 5 min between JW and non-JW. There were no maternal deaths, hysterectomy or admissions to the adult intensive care unit in either group. Six JW women accepted packed cell transfusion at the initial consultation and did not receive multidisciplinary care. The remaining 42 JW women had consultant obstetric and anesthesiologist review before delivery. After multidisciplinary consultation, two (4.8 %, 2/42) accepted blood transmission and 11 (26.2 %, 11/42) accepted some components of blood. The remaining 29 (69 %, 29/42) women refused all blood products. ConclusionJW patients who received multidisciplinary care achieved comparable pregnancy and neonatal outcomes to the normal population. Antenatal iron supplement was more common among pregnant JW despite the similar rate of antenatal anemia compared with the non-JW women. 12.5% of JW women agreed packed cell transfusion at the initial consultation and a further 27.1% of JW women agreed to some forms of blood products after multidisciplinary counseling.

Hospital-acquired pressure ulcers among adult ICU patients in tertiary hospitals in Oman: a one-year prevalence study.

Hospital-acquired pressure ulcer (HAPU) is a significant problem in healthcare settings and is associated with negative impacts on patient health. Although monitoring of pressure ulcers (PUs) among hospitalised patients was started more than a decade ago in Oman, no previous studies have been completed to estimate the prevalence and risk factors of HAPUs among patients in the intensive care unit (ICU). The aim of this study was to estimate the prevalence and identify risk factors for HAPUs among adult ICU patients in selected tertiary hospitals in Oman. A retrospective, cross-sectional, nested, case-control design was used to identify the prevalence rate of HAPUs and risk factors for a cohort of adult ICU patients over one calendar year (1 January-31 December 2019) in two tertiary hospitals in Oman. The prevalence rate for HAPU among ICU patients in Oman was 36.4%. However, when excluding cases of stage 1 ulcer, the rate was 30.37%. The most prevalent location was the sacrum (64.1%), and the most common stage was stage 2 (73.1%). The risk factors for HAPU included male sex (odds ratio (OR): 0.37; p=0.023), organ failure (OR: 3.2; p=0.033), cancer (OR: 3.41; p=0.049), cerebrovascular accident (OR: 12.33; p=0.001), mechanical ventilator (OR: 9.64; p=0.025) and ICU length of stay (OR: 1.24; p<0.001). HAPUs among ICU patients constitute a significant problem associated with severe clinical consequences and result in substantial adverse healthcare outcomes worldwide, including in Oman. Identifying the risk factors and the impact on the healthcare system is the foundation for preventing and managing HAPUs.

INhaled Sedation versus Propofol in REspiratory failure in the Intensive Care Unit (INSPiRE-ICU1): protocol for a randomised, controlled trial

IntroductionSedation in mechanically ventilated adults in the intensive care unit (ICU) is commonly achieved with intravenous infusions of propofol, dexmedetomidine or benzodiazepines. Significant limitations associated with each can impact their...