Adult Intensive Care Patients Research Articles

A Review of the Tolerance and Adequacy of Enteral Nutrition Administered in the Prone Position in Critically Ill Patients Receiving Mechanical Ventilation

ObjectivesDuring the coronavirus 2019 (COVID-19) pandemic, more patients require enteral nutrition (EN) while mechanically ventilated in the prone position (PP). Prone positioning may improve oxygenation in patients receiving mechanical ventilation; however, it is unclear how it affects EN adequacy and tolerance. This review explored how EN delivered in the PP impacts EN tolerance (vomiting, diarrhea, abdominal distention, or aspiration pneumonia) and adequacy (meeting estimated energy and protein requirements) in critically ill adults receiving mechanical ventilation.MethodsA literature search was conducted in PubMed, CINAHL, Academic Search Premier, and Cochrane Library for English-language studies exploring EN administered in the PP published between 2000–2020. Studies that met inclusion criteria enrolled adult patients inintensive care units with acute respiratory distress syndrome or other respiratory conditions requiring mechanical ventilation, were cohort studies with ≥5 patients per study group, and had a dropout rate <20%. Studies were excluded if patients received only parenteral nutrition.ResultsOf 45 studies, 4 met inclusion criteria. Three were prospective cohorts and 1 was a before-after study. When comparing EN tolerance in the PP and supine positions, 1 study found no difference in diarrhea occurrence, 2 studies found no difference in the rate of vomiting, and 1 study found significantly higher rates of vomiting while in the PP. For feeding adequacy, 2 studies found no difference in the % of calories received when administered in prone or supine positions, while 1 study found patients in the PP received significantly less EN volume than patients in the supine position. One study concluded that prophylactic prokinetic agent use and head elevation while prone resulted in larger EN volumes delivered with reduced vomiting risk.ConclusionsThese results suggest the adequacy of EN delivered in the PP is comparable to the supine position and PP does not substantially increase vomiting or diarrhea risk. Prone positioning should not be considered an immediate contraindication to EN for adults receiving mechanical ventilation. These findings may apply to the nutritional management of critically ill mechanically ventilated adults with COVID-19.Funding SourcesNone

Delirium in adult patients in intensive care: nursing interventions.

Delirium is a neuropsychiatric syndrome of high incidence in the critically ill patient. It is characterised by changes in acute attention and cognition, has a multifactorial aetiology and has a negative impact on the patient's clinical situation and future quality of life. Prevention of delirium and early identification can reduce associated morbidity and mortality. Consequently, it is vital that intensive care unit (ICU) nurses perform targeted patient monitoring to identify acute cognitive changes. To identify nursing interventions directed at the prevention and management of delirium in adult patients in ICU. A scoping review was undertaken based on the principles recommended by the Joanna Briggs Institute. Seven studies were selected for inclusion. Non-pharmacological and pharmacological nursing interventions were identified. The interventions identified were predominantly aimed at the prevention of delirium. The training of nurses and wider clinical team in preventing and identifying this syndrome is crucial.

Cardiac biomarkers in acute respiratory distress syndrome: a systematic review and meta-analysis

BackgroundAcute respiratory distress syndrome (ARDS) is a leading cause of morbidity and mortality in the intensive care unit. Biochemical markers of cardiac dysfunction are associated with high mortality in many respiratory conditions. The aim of this systematic review is to examine the link between elevated biomarkers of cardiac dysfunction in ARDS and mortality.MethodsA systematic review of MEDLINE, EMBASE, Web of Science and CENTRAL databases was performed. We included studies of adult intensive care patients with ARDS that reported the risk of death in relation to a measured biomarker of cardiac dysfunction. The primary outcome of interest was mortality up to 60 days. A random-effects model was used for pooled estimates. Funnel-plot inspection was done to evaluate publication bias; Cochrane chi-square tests and I2 tests were used to assess heterogeneity.ResultsTwenty-two studies were included in the systematic review and 18 in the meta-analysis. Biomarkers of cardiac stretch included NT-ProBNP (nine studies) and BNP (six studies). Biomarkers of cardiac injury included Troponin-T (two studies), Troponin-I (one study) and High-Sensitivity-Troponin-I (three studies). Three studies assessed multiple cardiac biomarkers. High levels of NT-proBNP and BNP were associated with a higher risk of death up to 60 days (unadjusted OR 8.98; CI 4.15-19.43; p<0.00001). This association persisted after adjustment for age and illness severity. Biomarkers of cardiac injury were also associated with higher mortality, but this association was not statistically significant (unadjusted OR 2.21; CI 0.94-5.16; p= 0.07).ConclusionBiomarkers of cardiac stretch are associated with increased mortality in ARDS.

Sedation in the Intensive Care Unit.

Purpose of ReviewThis narrative review illustrates literature over the last 5 years relating to sedation delivery to mechanically ventilated adult patients in intensive care units.Recent FindingsThere has been an increase in dexmedetomidine-related publications but although systematic reviews suggest dexmedetomidine reduces delirium, agitation, and length of stay, clinical trials have not supported these findings. It is likely to be useful for the managing patients with persisting agitation. Guidelines continue to recommend lightly sedating patients but considerable variation remains in clinical practice and in research trials. Protocols with no sedative infusions and morphine boluses as needed are feasible and safe, while educational interventions can decrease sedation-related adverse events.SummaryResearch trials have mainly focused on individual drugs rather than practice. Given evidence is slow to translate into practice; work is needed to understand and respond to the concerns of clinicians regarding deep sedation and agitation.

A systematic review and meta-analysis of propofol versus midazolam sedation in adult intensive care (ICU) patients.

Compare outcomes of adult patients admitted to ICU- length of ICU stay, length of mechanical ventilation (MV), and time until extubation- according to the use of propofol versus midazolam. We searched MEDLINE, EMBASE, LILACS, and Cochrane databases to retrieve RCTs that compared propofol and midazolam used as sedatives in adult ICU patients. We applied a random-effects, meta-analytic model in all calculations. We applied the Cochrane collaboration tool and GRADE. We separated patients into two groups: acute surgical patients (hospitalization up to 24 h) and critically-ill patients (hospitalization over 24 h and whose articles mostly mix surgical, medical and trauma patients). Globally, propofol was associated with a reduced MV time of 4.46 h (MD: -4.46 [95% CI -7.51 to -1.42] p = 0.004, I2 = 63%, 6 studies) and extubation time of 7.95 h (MD: -7.95 [95% CI -9.86 to -6.03] p < 0.00001, I2 = 98%, 16 studies). Acute surgical patients sedation with propofol compared to midazolam was associated with a reduced ICU stay of 5.07 h (MD: -5.07 [95% CI -8.68 to -1.45] p = 0.006, I2 = 41%, 5 studies), MV time of 4.28 h (MD: -4.28; [95% CI -4.62 to -3.94] p < 0.0001, I2 = 0%, 3 studies), extubation time of 1.92 h (MD: -1.92; [95% CI -2.71 to -1.13] p = 0.00001, I2 = 89%, 9 studies). In critically-ill patients sedation with propofol compared to midazolam was associated with a reduced extubation time of 32.68 h (MD: -32.68 [95% CI -48.37 to -16.98] p = 0.0001, I2 = 97%, 9 studies). GRADE was very low for all outcomes. Sedation with propofol compared to midazolam is associated with improved clinical outcomes in ICU, with reduced ICU stay MV time and extubation time in acute surgical patients and reduced extubation time in critically-ill patients.

Patient blood management – recommendations from the International Consensus Conference, Frankfurt/Main, Germany

An International Consensus Conference (ICC) on PBM was held in 2018 to develop evidence‐based clinical and research recommendations for preoperative anaemia, red blood cell (RBC) transfusion thresholds for adults and implementation of PBM programmes. An international scientific committee (SC) defined 17 Population‐Intervention‐Comparison‐Outcome (PICO) questions for the three topics preoperative anaemia, red blood cell (RBC) transfusion thresholds for adults and PBM implementation. Based on these questions, an extensive literature search was conducted in four biomedical databases. The GRADE framework (= grading of recommendations, assessment, development and evaluation) was used to develop a systematic approach to the presentation of evidence summaries and for making clinical recommendations. Three expert panels (EP) consisting of clinicians, scientists, nurses, patient representatives and methodologists were established and used these methods to develop recommendations driven by published evidence. Out of more than 17 500 literature citations, data from 145 studies were incorporated. The expert panel for preoperative anaemia developed 4 clinical and 3 research recommendations. A strong recommendation advices early detection and management of preoperative anaemia before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations have been formulated. Two strong clinical recommendations for RBC transfusion thresholds comprise a haemoglobin concentration of &lt;7 g/dl for critically ill, but clinical stable adult intensive care patients independent of septic shock and &lt;7·5 g/dl for adults undergoing cardiac surgery. For the implementation of PBM programmes, 2 clinical and 3 research recommendations were developed. Research recommendations were formulated as encouragement of new studies to answer open questions. Due to the relative paucity of strong evidence‐based answers in current publications to the 17 PICO questions, additional research, an international consensus for accepted definitions and Hb thresholds as well as clinically meaningful end‐points for clinical studies are necessary. The 2018 PBM ICC defined the current status of PBM evidence and established 10 clinical and 12 research recommendations for preoperative anaemia, RBC transfusion thresholds for adults and implementation of PBM programmes.

High-flow nasal cannulae for respiratory support in adult intensive care patients.

High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review. To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU. We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches. We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU. We used standard methodological procedures as expected by Cochrane. We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evidence). We are very uncertain about the effect of using HFNC on incidence of pneumonia (RR 0.51, 95% CI 0.17 to 1.52; 3 studies, 1750 participants; very low-certainty evidence), and HFNC may result in little or no difference to barotrauma (RR 1.15, 95% CI 0.42 to 3.14; 1 study, 830 participants; low-certainty evidence). HFNC may make little or no difference to the length of ICU stay (MD -0.72 days, 95% CI -2.85 to 1.42; 2 studies, 246 participants; low-certainty evidence). The ratio of PaO2/FiO2 may be lower up to 24 hours with HFNC use (MD -58.10 mmHg, 95% CI -71.68 to -44.51; 3 studies, 1086 participants; low-certainty evidence). We are uncertain whether HFNC improved short-term comfort when measured using comfort scores (MD 1.33, 95% CI 0.74 to 1.92; 2 studies, 258 participants) and responses to questionnaires (RR 1.30, 95% CI 1.10 to 1.53; 1 study, 168 participants); evidence for short-term comfort was very low certainty. No studies reported on nasal mucosa or skin trauma. HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects.

Nebulised heparin for patients with or at risk of acute respiratory distress syndrome: a multicentre, randomised, double-blind, placebo-controlled phase 3 trial

BackgroundMechanical ventilation in intensive care for 48 h or longer is associated with the acute respiratory distress syndrome (ARDS), which might be present at the time ventilatory support is instituted or develop afterwards, predominantly during the first 5 days. Survivors of prolonged mechanical ventilation and ARDS are at risk of considerably impaired physical function that can persist for years. An early pathogenic mechanism of lung injury in mechanically ventilated, critically ill patients is inflammation-induced pulmonary fibrin deposition, leading to thrombosis of the microvasculature and hyaline membrane formation in the air sacs. The main aim of this study was to determine if nebulised heparin, which targets fibrin deposition, would limit lung injury and thereby accelerate recovery of physical function in patients with or at risk of ARDS.MethodsThe Can Heparin Administration Reduce Lung Injury (CHARLI) study was an investigator-initiated, multicentre, double-blind, randomised phase 3 trial across nine hospitals in Australia. Adult intensive care patients on invasive ventilation, with impaired oxygenation defined by a PaO2/FiO2 ratio of less than 300, and with the expectation of invasive ventilation beyond the next calendar day were recruited. Key exclusion criteria were heparin allergy, pulmonary bleeding, and platelet count less than 50 X 109/L. Patients were randomly assigned 1:1, with stratification by site and using blocks of variable size and random seed, via a web-based system, to either unfractionated heparin sodium 25 000 IU in 5 mL or identical placebo (sodium chloride 0·9% 5 mL), administered using a vibrating mesh membrane nebuliser every 6 h to day 10 while invasively ventilated. Patients, clinicians, and investigators were masked to treatment allocation. The primary outcome was the Short Form 36 Health Survey Physical Function Score (out of 100) of survivors at day 60. Prespecified secondary outcomes, which are exploratory, included development of ARDS to day 5 among at-risk patients, deterioration of the Murray Lung Injury Score (MLIS) to day 5, mortality at day 60, residence of survivors at day 60, and serious adverse events. Analyses followed the intention-to-treat principle. There was no imputation of missing data. The trial is registered with the Australian and New Zealand Clinical Trials Register, number ACTRN12612000418875 .FindingsBetween Sept 4, 2012, and Aug 23, 2018, 256 patients were randomised. Final follow-up was on Feb 25, 2019. We excluded three patients who revoked consent and one ineligible participant who received no intervention. Of 252 patients included in data analysis, the mean age was 58 years (SD 15), 157 (62%) were men, and 118 (47%) had ARDS. 128 (51%) patients were assigned to the heparin group and 124 (49%) to the placebo group, all of whom received their assigned intervention. Survivors in the heparin group (n=97) had similar SF-36 Physical Function Scores at day 60 compared to the placebo group (n=94; mean 53·6 [SD 31·6] vs 48·7 [35·7]; difference 4·9 [95% CI −4·8 to 14·5]; p=0·32). Compared with the placebo group, the heparin group had fewer cases of ARDS develop to day 5 among the at-risk patients (nine [15%] of 62 patients vs 21 [30%] of 71 patients; hazard ratio 0·46 [95% CI 0·22 to 0·98]; p=0·0431), less deterioration of the MLIS to day 5 (difference −0·14 [–0·26 to −0·02]; p=0·0215), similar day 60 mortality (23 [18%] of 127 patients vs 18 [15%] of 123 patients; odds ratio [OR] 1·29 [95% CI 0·66 to 2·53]; p=0·46), and more day 60 survivors at home (86 [87%] of 99 patients vs 73 [73%] of 100 patients; OR 2·45 [1·18 to 5·08]; p=0·0165). A similar number of serious adverse events occurred in each group (seven [5%] of 128 patients in the heparin group vs three [2%] of 124 patients in the placebo group; OR 2·33 [0·59 to 9·24]; p=0·23), which were a transient increase in airway pressure during nebulisation (n=3 in the heparin group), major non-pulmonary bleeding (n=2 in each group), haemoptysis (n=1 in the heparin group), tracheotomy site bleeding (n=1 in the heparin group), and hypoxaemia during nebulisation (n=1 in the placebo group).InterpretationIn patients with or at risk of ARDS, nebulised heparin did not improve self-reported performance of daily physical activities, but was well tolerated and exploratory outcomes suggest less progression of lung injury and earlier return home. Further research is justified to establish if nebulised heparin accelerates recovery in those who have or are at risk of ARDS.FundingRowe Family Foundation, TR and RB Ditchfield Medical Research Endowment Fund, Patricia Madigan Charitable Trust, and The J and R McGauran Trust Fund.

Indications for transfusion of blood components

Indications for transfusion of blood components

Alignment in Surrogate Decision Maker Research Opinions: Adult vs Pediatric Intensive Care Patients

Ann Sealey, Leslie MBBS; Raddatz, Julia; Shah, Nirav R. PhD; Cunningham, Kyle MD, MPH, FACS; Morey, Jacqueline BA; Laverick, Paige MS; Thiet Huynh, Toan MD, FACS Author Information

The psychological burden of restricted parental visiting in paediatric intensive care.

A recently published study in this journal found that more flexible visiting arrangements reduced the heart rate and blood pressure of adult intensive care patients, in addition to improving patient satisfaction. 1 Although this article does not discuss visiting arrangements in relation to the Coronavirus (COVID-19) pandemic, it does acknowledge the positive effects that visiting has on physiological parameters. There have been some recent publications observing the collateral damage this pandemic has caused on children's education, social care, and health services. 2, 3 This commentary refers to collateral damage in terms of visiting restrictions on children in paediatric intensive care units (PICUs). A pertinent consideration is the psychological burden of separation on children, young people, and their families during this time.

Associations of 4 Nurse Staffing Practices With Hospital Mortality.

Cross-sectional studies of hospital-level administrative data have suggested that 4 nurse staffing practices-using adequate staffing levels, higher proportions of registered nurses (RNs) (skill mix), and more educated and experienced RNs-are each associated with reduced hospital mortality. To increase the validity of this evidence, patient-level longitudinal studies assessing the simultaneous associations of these staffing practices with mortality are required. A dynamic cohort of 146,349 adult medical, surgical, and intensive care patients admitted to a Canadian University Health Center was followed for 7 years (2010-2017). We used a multivariable Cox proportional hazards model to estimate the associations between patients' time-varying cumulative exposure to measures of RN understaffing, skill mix, education, and experience, each relative to nursing unit and shift means, and the hazard of in-hospital mortality, while adjusting for patient and nursing unit characteristics, and modeling the current nursing unit of hospitalization as a random effect. Overall, 4854 in-hospital deaths occurred during 3,478,603 patient-shifts of follow-up (13.95 deaths/10,000 patient-shifts). In multivariable analyses, every 5% increase in the cumulative proportion of understaffed shifts was associated with a 1.0% increase in mortality (hazard ratio: 1.010; 95% confidence interval: 1.002-1.017; P=0.009). Moreover, every 5% increase in the cumulative proportion of worked hours by baccalaureate-prepared RNs was associated with a 2.0% reduction of mortality (hazard ratio: 0.980; 95% confidence interval: 0.965-0.995, P=0.008). RN experience and skill mix were not significantly associated with mortality. Reducing the frequency of understaffed shifts and increasing the proportion of baccalaureate-prepared RNs are associated with reduced hospital mortality.

Association of nucleated red blood cell count with mortality among neonatal intensive care unit patients

Nucleated red blood cells (nRBCs) are associated with adverse outcomes for pediatric and adult intensive care patients. The association between nRBC count and mortality was examined in an observational cohort of patients admitted to the neonatal intensive care unit from December 2015-December 2018. Among the 1059 patients with at least one nRBC count obtained, 45 infants (4.2%) experienced in-hospital mortality prior to NICU discharge, the primary outcome measured in this study. Infants with any nRBC count >0 had a significantly higher risk of mortality (5.3% [45/849] vs. 0% [0/351], p<0.001 by Fisher exact), and time to mortality decreased with higher nRBC counts (Spearman correlation -0.59, p<0.001). The association between nRBC count and mortality remained significant even when restricting only to infants who were older than 7 days at time of nRBC count. Among neonatal intensive care unit patients, including those >7 days old, nRBCs are associated with significantly elevated mortality risk. A prospective study to better characterize clinical co-variants is necessary to better establish the use of nRBCs as a predictor of mortality.

Loop diuretics in adult intensive care patients with fluid overload: A protocol for a systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis.

In the intensive care unit, fluid overload is frequent and a risk factor for organ dysfunction and increased mortality. Primarily, lung and kidney functions may be impaired by fluid overload resulting in acute respiratory failure and acute kidney injury. No clinical guidelines exist for treatment of fluid overload in intensive care patients. Loop diuretics, most often furosemide, appear to be the most frequently used pharmacological intervention. The aim of this protocol is to describe the methods of a systematic review assessing the evidence of treatment with loop diuretics in adult intensive care patients with fluid overload. We will conduct a systematic review with meta-analysis and report it according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statements, use the recommendations of the Cochrane Handbook and assess the quality of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. We will include randomised clinical trials identified through searches of major international databases and trial registers. Two authors will independently screen and select trials for inclusion, extract data and assess the methodological quality using the Cochrane risk of bias tool. Extracted data will be analysed using Review Manager and Trial Sequential Analysis. The protocol is registered at PROSPERO. We aim to provide reliable evidence on the use of loop diuretics in adult intensive care patients with fluid overload to guide clinicians, decision makers and trialists on clinical practice.

PMU1 PROPOFOL VERSUS MIDAZOLAM FOR SEDATION IN ADULT PATIENTS IN INTENSIVE CARE UNIT (ICU): A META-ANALYSIS

To compare propofol and midazolam in adult intensive care patients in relation to length of ICU stay, length of mechanical ventilation (MV) and time until extubation. MEDLINE, EMBASE, LILACS and Cochrane databases were searched from inception until July 2019 to retrieve RCTs that compared propofol and midazolam use as sedatives in adult ICU patients. There was no language restriction. We extracted and combined data from studies that reported to length of ICU stay, length of MV and time until extubation. A random-effects, meta-analytic model was applied in all calculations. Cochrane collaboration tool and GRADE were used to assess bias and certainty of the outcomes of the included studies, respectively. Two groups of patients were analyzed: elective surgical patients and critically ill patients. Elective surgical patients receiving propofol reduced ICU stay by 5.07 hours (MD -5.07; 95% CI -8.68 to -1.45; p <0.006, I2 = 41 %, 5 studies), MV time by 4.28 hours (MD -4.28; 95% CI -4.62 to -3.94 (p <0.00001, I2 = 0, 3 studies), extubation time by 1.92 hours (MD -1.92; 95% CI -2.71 to -1.13; p <0.00001, I2 = 89%, 9 studies) compared to patients receiving midazolam. Critically ill patients receiving propofol reduced extubation time by 32.68 hours (MD -32.68; 95% CI -48.37 to -16.98; p <0.0001, I2 = 97%, 7 studies) compared to patients receiving midazolam. GRADE was very low for all outcomes. We conclude that propofol is a safe sedation strategy for general and elective surgery patients in the ICU. It is associated with improved outcomes when compared to the use of midazolam. Our data is in accordance with the recent sedation guideline (PADIS) recommendations where propofol can be used as the first-line sedative in adult ICU patients.

The Neuropsychiatric Iceberg Under Withdrawal Syndrome.

We have read with a great interest the article “Validation of the Withdrawal Assessment Tool-1 in Adult Intensive Care Patients,”1 by Capilnean and colleagues. The study emphasizes the importance of a validated tool to detect opioid withdrawal syndrome in adult intensive care units (ICUs), and yet we wonder if one possible explanation for the low accuracy of the Withdrawal Assessment Tool (WAT-1) in their study was that they included all patients with brain injury and a score of 9 or greater on the Glasgow Coma Scale (GCS) if the patient’s intracranial pressure was not increased. Although the number of patients in the study with nervous system disorders as the cause of admission to the ICU was low, we note that such patients made up nearly 15% of the patients in the study who had iatrogenic withdrawal syndrome.Although we suspect that using such broad inclusion criteria is a logical and reasonable way to improve the generalizability of such a small prospective study, this approach may have decreased the accuracy of the WAT-1 in their cohort. For instance, consider a patient with traumatic brain injury being evaluated in the ICU who has a right-sided patchy subarachnoid hemorrhage with a GCS score of 12. Such a patient’s WAT-1 score of 3 or greater could be due to probable autonomic dysfunction,2 increased tonus,3 and acute confusional state,4,5 all of which could be attributed to the organic involvement of subarachnoid hemorrhage. In this situation, if one uses the criteria in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), unlike WAT-1, such patients would not be placed in the “withdrawal-positive” group because of the presence of another medical condition that better explains the symptoms.In an ongoing cohort study being conducted in our tertiary care university hospital, we have so far found the accuracy of WAT-1 to be nearly 85% in our preliminary analysis using more rigid criteria that excluded all patients with other neurologic and/or psychiatric disorders. We think an algorithm that separates patients with organic cerebral involvement from those without will shed much more light on this ambiguous issue of “opioid withdrawal syndrome.”

Prevalence of pressure injuries and the management of support surfaces (mattresses) in adult intensive care patients: A multicentre point prevalence study in Australia and New Zealand

BackgroundPressure injuries (PIs) are a patient safety issue that impact patient outcomes. Intensive care unit (ICU) patients are at high risk of PIs. ObjectivesTo report the prevalence and classification of documented PIs in adult ICU patients, the use of pressure injury risk assessment tools, and support surface management as a part of the prevention of PIs. MethodsThis was a prospective, single-day, multicentre, cross-sectional study of patients aged ≥ 16 years admitted to adult ICUs in Australia and New Zealand (ANZ), August 2016 as part of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) Point Prevalence Program. FindingsData were collected on 671 patients (58% male) in 47 ICUs. The mean [standard deviation] age and weight were 60.2 years [17.2 years] and 82.1 kg [29.7 kg], respectively, with a severity of illness score (Acute Physiology and Chronic Health Evaluation [APACHE] II) of 18.2 [8.4]. PIs were reported in 10% (70/671) of patients. Patients with a PI had a mean APACHE II score of 22.5 [standard deviation; 7.7], and 57.1% (40/70) met the criteria for sepsis on the study day. There were 107 PIs documented on the study day (N = 107) in the 70 patients with nearly half of PIs present on ICU admission (46.7%; 50/107). The sacrum was the most common location for PIs (28.9%; 31/107) and then the heels (15.9%; 17/107). All units routinely use a risk of PI assessment tool and were cared for on an active or reactive support surface. Patients with a PI were more often moved to an active support surface. ConclusionsThe prevalence rate was reported at 10% for PIs for adult intensive care patients on the study day. More than half of the patients with a PI had signs of sepsis on the study day and a higher severity of illness, and more were cared for on active support surfaces. Most PIs were located at the sacrum and then the heels. All clinical sites routinely used a PI risk assessment tool.

Clinical Recommendations for Managing the Impact of Insulin Adsorptive Loss in Hospital and Diabetes Care.

Adsorption of insulin to infusion sets impacts patient therapeutic outcomes and, unaccounted for, may exacerbate persistent hyperglycemia or result in therapy-induced hypoglycemia. This article aims to provide recommendations for clinicians involved in intensive care and/or outpatient pump therapy contexts. A dynamic adsorption model is used to evaluate time-varying insulin concentration in the infusion set outflow. Hourly and daily percentage insulin loss to adsorption is examined for neonatal, pediatric, and adult intensive care patients, as well as outpatient children and adults weighing 30, 50, and 80 kg. A short review of preconditioning methods is included. Insulin adsorption in outpatient pump therapy is most pronounced in the first hour, where as much as 80% of the intended insulin dose may be lost to adsorption. Subsequently, insulin adsorptive loss is typically negligible. Overall, extra care should be taken in the first 1-6 h of a new infusion set, particularly in children or teenagers. Typically, insulin adsorption in the adult intensive care unit is negligible unless infused at low flow rates (<2 mL/h). Insulin adsorption is significant in pediatric and neonatal intensive care, resulting in delivery concentrations as low as 5%-50% of that intended. Thus, it is recommended that preconditioning of insulin delivery lines be carried out prior to infusion initiation in this context. However, no preconditioning method completely removes adsorption, and care should still be taken in the first 1-6 h of insulin dosing. Recommendations made in this article are dependent on the insulin concentration and flow rate used in each clinical context.

Different applications of the KDIGO criteria for AKI lead to different incidences in critically ill patients: a post hoc analysis from the prospective observational SICS-II study

BackgroundAcute kidney injury (AKI) is a frequent and clinically relevant problem in critically ill patients. Various randomized controlled trials (RCT) have attempted to assess potentially beneficial treatments for AKI. Different approaches to applying the Kidney Disease Improving Global Outcomes (KDIGO) criteria for AKI make a comparison of studies difficult. The objective of this study was to assess how different approaches may impact estimates of AKI incidence and whether the association between AKI and 90-day mortality varied by the approach used.MethodsConsecutive acutely admitted adult intensive care patients were included in a prospective observational study. AKI was determined following the KDIGO criteria during the first 7 days of ICU admission. In this post hoc analysis, we assessed whether AKI incidence differed when applying the KDIGO criteria in 30 different possible methods, varying in (A) serum creatinine (sCr), (B) urine output (UO), and (C) the method of combining these two into an outcome, e.g., severe AKI. We assessed point estimates and 95% confidence intervals for each incidence. Univariable regression was used to assess the associations between AKI and 90-day mortality.ResultsA total of 1010 patients were included. Baseline creatinine was available in 449 (44%) patients. The incidence of any AKI ranged from 28% (95%CI 25–31%) to 75% (95%CI 72–77%) depending on the approach used. Methods to estimate missing baseline sCr caused a variation in AKI incidence up to 15%. Different methods of handling UO caused a variation of up to 35%. At 90 days, 263 patients (26%) had died, and all 30 variations were associated with 90-day mortality.ConclusionsIn this cohort of critically ill patients, AKI incidence varied from 28 to 75%, depending on the method used of applying the KDIGO criteria. A tighter adherence to KDIGO definitions is warranted to decrease the heterogeneity of AKI and increase the comparability of future studies.

Acute Skin Failure in the Critically Ill Adult Population: A Systematic Review.

To present a systematic review of the literature conducted to define and extend knowledge of the risk factors, causes, and antecedent conditions of acute skin failure (ASF) in adult intensive care patients. This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. After participating in this educational activity, the participant should be better able to:1. Outline the background information helpful for understanding the authors' systematic review of ASF in adult intensive care patients.2. Summarize the results of the authors' review of the risk factors, causes, and antecedent conditions of ASF in adult intensive care patients. To define and extend knowledge of the risk factors, causes, and antecedent conditions of acute skin failure (ASF) in the adult intensive care patient cohort.The Cochrane Library, Joanna Briggs Institute Evidence-Based Practice Database, PubMed, Medical Literature Analysis and Retrieval System, Cumulative Index of Nursing and Allied Health Literature, and Google Scholar.Studies were selected if they were qualitative or quantitative research that reported ASF in adult human patients in an ICU setting. The preliminary search yielded 991 records and 22 full texts were assessed for eligibility. A total of three records were included. Studies were appraised using the Mixed Methods Appraisal Tool.Data from the included studies were extracted by one reviewer and summarized in data collection tables that were checked and verified by a second reviewer.Study authors identified five independent predictors of ASF: peripheral vascular disease, mechanical ventilation longer than 72 hours, respiratory failure, liver failure, and sepsis. However, the term ASF was applied to retrospective cohorts of patients who developed severe pressure injuries. This, combined with the absence of evidence surrounding the assessment, clinical criteria, and diagnosis of ASF, could impact these variables' predictability relative to the condition.These results highlight a substantial evidence gap regarding the etiology, diagnostic biomarkers, and predictors of ASF. Further research focused on these gaps may contribute to an accurate and agreed-upon definition for ASF, as well as improved skin integrity outcomes.