Bedside In Intensive Care Unit Research Articles

The Safety of Pediatric Bedside Tracheostomy.

Traditionally, pediatric tracheostomy has been viewed as a technically demanding procedure with a high complication rate, requiring the routine use of a formal operating room. Pediatric bedside tracheostomy in an intensive care unit (ICU) setting has not been widely reported, in contrast to the widespread adult bedside ICU tracheostomy. Transport of these critically ill, multiple life support systems dependent patients can be technically difficult, labor intensive, and potentially risky for these patients. Our study aimed to demonstrate the safety and efficacy of bedside tracheostomy in the pediatric ICU. A retrospective analysis of all pediatric patients undergoing tracheostomy at a tertiary care center, between 1st of January 2013 and 31st of December 2019. During the study period, 117 pediatric patients underwent tracheostomy, 57 (48.7%) were performed bedside while 60 (51.3%) were performed in the operating room. Patients' ages ranged from 2 weeks to 17 years of age, with a median age of 16 months. No case of bedside tracheostomy necessitated a shift to the operating room. There was no difference in 30-day morbidity and mortality between the 2 groups. Our results suggest that pediatric open bedside tracheostomy in an ICU setting is a safe procedure, with similar complications and outcomes compared to tracheostomy performed in the operating room.

Clinical Decision Support System to Detect the Occurrence of Ventilator-Associated Pneumonia in Pediatric Intensive Care.

Ventilator-associated pneumonia (VAP) is a severe care-related disease. The Centers for Disease Control defined the diagnosis criteria; however, the pediatric criteria are mainly subjective and retrospective. Clinical decision support systems have recently been developed in healthcare to help the physician to be more accurate for the early detection of severe pathology. We aimed at developing a predictive model to provide early diagnosis of VAP at the bedside in a pediatric intensive care unit (PICU). We performed a retrospective single-center study at a tertiary-care pediatric teaching hospital. All patients treated by invasive mechanical ventilation between September 2013 and October 2019 were included. Data were collected in the PICU electronic medical record and high-resolution research database. Development of the clinical decision support was then performed using open-access R software (Version 3.6.1®). In total, 2077 children were mechanically ventilated. We identified 827 episodes with almost 48 h of mechanical invasive ventilation and 77 patients who suffered from at least one VAP event. We split our database at the patient level in a training set of 461 patients free of VAP and 45 patients with VAP and in a testing set of 199 patients free of VAP and 20 patients with VAP. The Imbalanced Random Forest model was considered as the best fit with an area under the ROC curve from fitting the Imbalanced Random Forest model on the testing set being 0.82 (95% CI: (0.71, 0.93)). An optimal threshold of 0.41 gave a sensitivity of 79.7% and a specificity of 72.7%, with a positive predictive value (PPV) of 9% and a negative predictive value of 99%, and with an accuracy of 79.5% (95% CI: (0.77, 0.82)). Using machine learning, we developed a clinical predictive algorithm based on clinical data stored prospectively in a database. The next step will be to implement the algorithm in PICUs to provide early, automatic detection of ventilator-associated pneumonia.

Effects of participation in interdisciplinary rounds in the intensive care unit on family satisfaction: A cross-sectional study.

To investigate whether family participation in intensive care unit interdisciplinary bedside rounds affects family satisfaction. A cross-sectional study was conducted at a 56-bed, adult, mixed intensive care unit of a tertiary hospital in Southern Brazil. From May to June 2019, family members of patients who stayed in the intensive care unit for at least 48 hours were invited to participate in the study at the time of patient discharge. The main exposure variable was participation in intensive care unit bedside rounds during the intensive care unit stay. Family satisfaction was assessed by using the Brazilian version of the Family Satisfaction in the Intensive Care Unit questionnaire. Of the 234 screened individuals, 118 were included. Eleven participants withdrew consent. A total of 107 individuals were assessed; 58 (54%) reported being present during bedside rounds, and 49 (46%) reported never being present. General satisfaction and satisfaction with the decision-making process were higher among families who were present during rounds than among families who were not (p = 0.01 and p = 0.007, respectively). The presence during interdisciplinary rounds was associated with improved general satisfaction and satisfaction with the decision-making aspect. This outcome indicates that efforts must be directed to conduct studies with more robust methodologies to confirm this association.

Safety of Rigid Bronchoscopy for Therapeutic Intervention at the Intensive Care Unit Bedside.

Background and Objective: Although rigid bronchoscopy is generally performed in the operating room (OR), the intervention is sometimes emergently required at the intensive care unit (ICU) bedside. The aim of this study is to evaluate the safety of rigid bronchoscopy at the ICU bedside. Materials and Methods: We retrospectively analyzed medical records of patients who underwent rigid bronchoscopy while in the ICU from January 2014 to December 2020. According to the location of rigid bronchoscopic intervention, patients were classified into the ICU group (n = 171, cases emergently performed at the ICU bedside without anesthesiologists) and the OR group (n = 165, cases electively performed in the OR with anesthesiologists). The risk of intra- and post-procedural complications in the ICU group was analyzed using multivariable logistic regression, with the OR group as the reference category. Results: Of 336 patients, 175 (52.1%) were moribund and survival was not expected without intervention, and 170 (50.6%) received invasive respiratory support before the intervention. The most common reasons for intervention were post-intubation tracheal stenosis (39.3%) and malignant airway obstruction (34.5%). Although the overall rate of intra-procedural complications did not differ between the two groups (86.0% vs. 80.6%, p = 0.188), post-procedural complications were more frequent in the ICU group than in the OR group (24.0% vs. 12.1%, p = 0.005). Severe complications requiring unexpected invasive management occurred only post-procedurally and were more common in the ICU group (10.5% vs. 4.8%, p = 0.052). In the fully adjusted model, the ICU group had increased odds for severe post-procedural complications, but statistical significance was not observed (odds ratio, 2.54; 95% confidence interval, 0.73-8.88; p = 0.144). Conclusions: Although general anesthesia is generally considered the gold standard for rigid bronchoscopy, our findings indicate that rigid bronchoscopy may be safely performed at the ICU bedside in selective cases of emergency. Moreover, adequate patient selection and close post-procedural monitoring are required to prevent severe complications.

Up to the Challenge: Adapting Pediatric Intensive Care During a Global Pandemic.

BackgroundThe COVID-19 pandemic has strained health systems world wide. In our region, surging numbers of critically ill adult patients demanded urgent system-wide responses. During the peak of the pandemic, our Pediatric Intensive Care Unit (PICU) team redesigned the existing educational resources and processes of care to ensure for adult patients for the first time in the hospital’s history.AimDescribe the experiences and impacts of the rapidly initiated Adult COVID-19 Program on health care providers (HCP) and family members. Havelock’s Theory of Change framed the examination of Adult COVID-19 Program participant experiences and surfaced lessons learned.Materials and MethodsA quality improvement review was employed to collect feedback about the program experience from the health care team and patient’s family members. HCP completed a questionnaire 10 months following the implementation of the program and feedback from family members was provided during the program was obtained. Havelock’s Theory of Change was used to explore trends and frame participants’ experiences.ResultsPediatric Intensive Care Unit bedside team members and clinical leaders (n = 17), adult hospital partners (n = 3), and family members (n = 8) participated. HCP describe; motivation and readiness; concern for personal safety and uncertainty experienced in the early program phases; the importance of supports and resources; use of relationships and collaboration to facilitate change; the emotional impacts of this unique experience; and opportunities for individual and team growth. An overarching theme of ‘doing our part to help’ emerged. Family members described the positive impacts of family-centered interventions offered, individualized care, and shock at their family member’s illness.ConclusionThe PICU team rapidly adapted to provide care for adults at the peak of the pandemic. Family members expressed feeling grateful for the care their loved ones received in the pediatric setting. The experience of caring for adult patients with COVID-19 was a source of tension, personal growth, and meaning for the pediatric intensive care team.

Feasibility of and experience using a portable MRI scanner in the neonatal intensive care unit

ObjectiveA portable, low-field MRI system is now Food and Drug Administration cleared and has been shown to be safe and useful in adult intensive care unit settings. No neonatal studies...

Efficacy Of Bedside Cannulation For Percutaneous Ventricular Assist Devices

AbstractPercutaneous ventricular assist devices (pVAD) have become a mainstay in the treatment of cardiogenic shock, but their use is limited by the need for specialized staff, equipment, and facilities which may not be readily available. Moreover, the COVID-19 pandemic has further limited such interventions due to possible staff exposure, need for additional protective personal equipment, and efforts to limit patient transport. We have implemented a bedside intensive care unit pVAD cannulation strategy using a mobile fluoroscopy arm with transesophageal echocardiogram to guide placement. Table 1 shows characteristics and outcomes of 6 patients cannulated with a percutaneous right or left ventricular assist device (pRVAD or pLVAD). All patients were previously supported with Veno-Arterial or Veno-Venous Extracorporeal Membrane Oxygenation (VA or VV ECMO). 3 patients had pLVAD placed for worsening LV distention after VA-ECMO initiation. 3 patients had pRVAD placed for severe RV failure in the setting of severe COVID infection and hypoxia. In all cases pVADs were successfully placed and patients anticoagulated with IV heparin afterwards. Although one patient with pLVAD placement had an access site compartment syndrome that required fasciotomy, we were able to maintain pLVAD support. Hemodynamic data showed that each patient was supported by their pVAD; unfortunately, 4 of the 6 passed away due to their underlying condition. ConclusionsBedside placement of pVAD can be performed safely and effectively. Mortality remains high, though this was unrelated to device function in our patients. Our approach limits the need for specialized staff and facilities and may allow for more rapid initiation of mechanical circulatory support while decreasing healthcare costs.

The Monitoring with Advanced Sensors, Transmission and E-Resuscitation in Traumatic Brain Injury (MASTER-TBI) collaborative: bringing data science to the ICU bedside

Background: With the adoption of multimodal neuromonitoring techniques, a large amount of high resolution neurophysiological data is generated during the treatment of patients with moderate to severe traumatic brain injury (m-sTBI) that is available for further analysis. The Monitoring with Advanced Sensors, Transmission and E-Resuscitation in Traumatic Brain Injury (MASTER-TBI) collaborative was formed in 2020 to facilitate analysis of these data. Objective: The MASTER-TBI collaborative curates m-sTBI patient data for the purposes of comparative effectiveness research, machine learning algorithm development, and neuropathophysiological phenomena analysis. Design, setting and participants: The MASTER-TBI collaborative is a multicentre longitudinal cohort study which utilises a novel hybrid cloud platform and other data science-informed techniques to collect and analyse data from patients with m-sTBI in whom both intracranial pressure monitoring and ICM+ (Cambridge Enterprise, Cambridge, UK) neuromonitoring software are utilised. MASTER-TBI enrols patients with m-sTBI from three participating Australian trauma intensive care units (ICUs). Main outcome measures: Captured outcome measures available for analysis include pathophysiological events (intracranial hypertension, cerebral perfusion pressure variations etc), surgical interventions, ICU and hospital length of stay, patient discharge status, and, where available, Glasgow Outcome Score-Extended (GOS-E) at 6 months. Results and conclusion: MASTER-TBI continues to develop data science-informed systems and techniques to maximise the use of captured high resolution m-sTBI patient neuromonitoring data. The highly innovative systems provide a world-class platform which aims to enhance the search for improved m-sTBI care and outcomes. This article provides an overview of the MASTER-TBI project's developed systems and techniques as well as a rationale for the approaches taken.

Emergency Dynamic Central Venous Cannulation in Preterm Neonates- A Case Series

Neonatal venous cannulation is one of the challenges faced by Anaesthesiologists in routine practice. Neonatal cannulation is extremely difficult and time consuming and it has become an inevitable procedure in neonatal intensive care unit, because of the small vessel diameter and sometimes it is impossible to differentiate between artery and vein. Routinely umbilical vein, scalp vein and peripherally inserted central catheters cannulation are done during initial neonatal period. Central vein cannulation is needed in sick neonates for nutrition, antibiotics, venous sampling, and inotropic support and enables haemodynamics monitoring. Even with the point of care ultrasound, neonatal cannulation is technically challenging in well-experienced hands. Cannulation in a preterm neonate is highly demanding and nightmarish for all intensivists. The present case series aimed to show the successful placement of ultrasound guided supraclavicular subclavian cannulation in a very low birth preterm (less than 1500 gm) in three septic neonates. All three cannulations were done bedside in Neonatal Intensive Care Unit (NICU) with close monitoring of heart rate, pulse oximeter and electrocardiogram. Venipuncture was done under ultrasound guidance. After identifying the anatomic landmarks, subclavian cannulation was done using Seldinger technique. Subclavian cannulation was preferred because of easy accessibility, comfortable fixation and low infection rate

Using Telehealth to Improve the Accuracy of Delirium Screening by Bedside Critical Care Nurses.

Delirium affects up to 80% of patients in the intensive care unit (ICU) but is missed in up to 75% of cases. Telehealth in the ICU (tele-ICU) has become the standard for providing timely, expert care to remotely located ICUs. This pilot study assessed the feasibility and acceptability of using tele-ICU to increase the accuracy of delirium screening and recognition by ICU nurses. The pilot sites included 4 ICUs across 3 hospitals. A geriatrician with delirium expertise remotely observed 13 bedside ICU nurses administering the Confusion Assessment Method for the ICU (CAM-ICU) to patients in real time via the tele-ICU platform and subsequently provided training on CAM-ICU performance and delirium management. Training evaluation consisted of a validated spot check form, a 2-item satisfaction/change-of-practice survey, and a qualitative question on acceptability. Thirteen ICU nurses were observed performing 26 bedside delirium assessments. The top observed barriers to accurate delirium screening were CAM-ICU knowledge deficits, establishment of baseline cognition, and inappropriate use of the "unable to assess" designation. The mean percentage of correct observations improved from 40% (first observation) to 90% (second observation) (P < .001). All 13 nurses strongly agreed that the training was beneficial and practice changing. The use of tele-ICU to improve the accuracy of delirium screening by ICU nurses appears to be feasible and efficient for leveraging delirium expertise across multiple ICUs. Future studies should evaluate the effects of tele-ICU delirium training on patient-centered outcomes.

Real-Time Arrhythmia Detection Using Hybrid Convolutional Neural Networks.

BackgroundAccurate detection of arrhythmic events in the intensive care units (ICU) is of paramount significance in providing timely care. However, traditional ICU monitors generate a high rate of false alarms causing alarm fatigue. In this work, we develop an algorithm to improve life threatening arrhythmia detection in the ICUs using a deep learning approach.Methods and ResultsThis study involves a total of 953 independent life‐threatening arrhythmia alarms generated from the ICU bedside monitors of 410 patients. Specifically, we used the ECG (4 channels), arterial blood pressure, and photoplethysmograph signals to accurately detect the onset and offset of various arrhythmias, without prior knowledge of the alarm type. We used a hybrid convolutional neural network based classifier that fuses traditional handcrafted features with features automatically learned using convolutional neural networks. Further, the proposed architecture remains flexible to be adapted to various arrhythmic conditions as well as multiple physiological signals. Our hybrid‐ convolutional neural network approach achieved superior performance compared with methods which only used convolutional neural network. We evaluated our algorithm using 5‐fold cross‐validation for 5 times and obtained an accuracy of 87.5%±0.5%, and a score of 81%±0.9%. Independent evaluation of our algorithm on the publicly available PhysioNet 2015 Challenge database resulted in overall classification accuracy and score of 93.9% and 84.3%, respectively, indicating its efficacy and generalizability.ConclusionsOur method accurately detects multiple arrhythmic conditions. Suitable translation of our algorithm may significantly improve the quality of care in ICUs by reducing the burden of false alarms.

Ultrasound Assessment in Cardiogenic Shock Weaning: A Review of the State of the Art.

Cardiogenic shock (CS) is associated with a high in-hospital mortality despite the achieved advances in diagnosis and management. Invasive mechanical ventilation and circulatory support constitute the highest step in cardiogenic shock therapy. Once established, taking the decision of weaning from such support is challenging. Intensive care unit (ICU) bedside echocardiography provides noninvasive, immediate, and low-cost monitoring of hemodynamic parameters such as cardiac output, filling pressure, structural disease, congestion status, and device functioning. Supplemented by an ultrasound of the lung and diaphragm, it is able to provide valuable information about signs suggesting a weaning failure. The aim of this article was to review the state of the art taking into account current evidence and knowledge on ICU bedside ultrasound for the evaluation of weaning from mechanical ventilation and circulatory support in cardiogenic shock.

Feasibility of the Ultrasound-Guided Insertion of the Peripherally Inserted Central Catheter (PICC) by the Vascular Surgeon at the Bedside in the Trauma Intensive Care Unit

This study analyzed the outcomes of the ultrasound-guided insertion of the peripherally inserted central venous catheter (PICC) by experienced vascular surgeons at the bedside of the trauma intensive care unit (ICU) and compared the outcomes with those of fluoroscopy-guided PICC performed by radiologists in the interventional suite. Between May 1, 2016, and April 30, 2021, 97 patients who were hospitalized in the trauma ICU and underwent PICC insertion were enrolled in the study. Forty-two out of the 97 patients underwent PICC insertion by interventional radiologists in the interventional radiology suite under fluoroscopy guidance, while the remaining 55 cases underwent ultrasound-guided PICC insertion by the vascular surgeon at the trauma ICU bedside. The technical failure (P=0.504) and malposition (P=0.127) rates were not significantly different between the 2 groups. However, it took significantly less time for the vascular surgeon to complete the PICC insertion procedure (P < 0.001). Significantly more patients of the ultrasound-guided group required inotropes (P=0.012) and mechanical ventilation (P=0.003) at the time of the procedure. In addition, the ultrasound-guided group appeared to be in critical condition in terms of kidney function according to laboratory data (P=0.014). Meanwhile, the ultrasound-guided group maintained the central line catheter for a shorter time (P < 0.001). In trauma patients, ultrasound-guided PICC insertion at the bedside by experienced vascular surgeons at the trauma ICU was feasible compared to fluoroscopy-guided insertion performed by interventional radiologists.

Comparison of PLANE Technique versus Standard Echocardiography Guidance for Pediatric Pericardiocentesis

AbstractPercutaneous pericardiocentesis remains a challenging and potentially dangerous procedure, particularly in small, critically ill patients. We present outcomes of the PLANE (pericardiocentesis using long-axis in-plane real-time echocardiography) technique for pediatric pericardiocentesis compared with a standard echocardiography (ECHO) guidance cohort. This was a retrospective chart review of all children undergoing percutaneous pericardiocentesis from March 2013 to February 2021 at a single center. A total of 78 procedures were performed, 52 utilizing PLANE technique and 26 utilizing standard ECHO-guidance technique. There was 100% technical success rate with only one minor complication for the entire cohort. Procedures were evenly split between the bedside intensive care unit and cardiac catheterization laboratory. PLANE technique was utilized in significantly younger (1.4 vs. 8.4 years, p = 0.008) and smaller (11.1 vs. 31.8 kg, p = 0.007) patients, as well as in most patients deemed high risk (postoperative &lt; 7 days, extracorporeal membrane oxygenation (ECMO) support, and/or weight less than 5 kg; 19/22, p = 0.021). Other patient characteristics were similar between the two groups. There was a trend toward PLANE technique utilization by noncardiology trained operators. The PLANE technique for pediatric pericardiocentesis is safe and effective and can be effectively utilized in small and high-risk patient populations. The technical similarity to other long-axis ultrasound-guided procedures may facilitate adoption and mastery by critical care trained operators.

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

Delirium in critical illness: clinical manifestations, outcomes, and management.

Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose–response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.

Anesthesia protocols for "bedside" preterm patent ductus arteriosus ligation: A single-institutional experience.

Background :Hemodynamically significant patent ductus arteriosus (PDA) is frequently encountered in preterm infants sometimes requiring surgical attention. Although PDA ligation is regularly performed in the operating room, conducting it at the bedside in a neonatal intensive care unit (NICU) and its anesthetic management remains challenging.Aim :We aim to discuss the anesthetic considerations in patients undergoing bedside PDA ligation and describe our experience highlighting the feasibility and safety of this procedure.Setting and Design :The study was conducted in the NICU in a tertiary care hospital; This was a retrospective, observational study.Methods :Preterm infants scheduled for bedside PDA ligation using a predefined anesthesia protocol between August 2005 and October 2020 were included.Statistical Analysis Used:Quantitative data were presented as median with interquartile range and categorical data were presented as numbers and percentage thereof.Results :Sixty-six premature infants underwent bedside PDA ligation. Thirty-day mortality was 4.5% (3 infants), but there were no procedural deaths. One (1.5%) patient had intraoperative endotracheal tube dislodgement. Three (4.5%) infants had postoperative pneumothorax requiring an additional chest tube insertion. Twenty-one (32%) patients required initiation of postoperative inotrope/vasodilator therapy within 6 h. Three postligation cardiac syndromes (≥ Grade-III mitral regurgitation with left ventricular dysfunction and hypotension) occurred.Conclusions :Although anesthesia for preterm neonates undergoing bedside PDA ligation poses unique challenges, it can be safely conducted by following a predetermined standardized anesthesia protocol. Its successful conduct requires utmost vigilance and pristine understanding of the principles of neonatal and cardiac care.

Bedside Right Atrium to Left Atrium ECMO Cannulation: A Novel Approach in Patients With Severe ARDS Due to Covid-19

Background: Extracorporeal membrane oxygenation (ECMO) can provide life-saving treatment of adult respiratory distress syndrome (ARDS) complicating COVID-19 infection. We hypothesized that a modified ECMO (right to left atrium [RA-LA] cannulation with TandemHeart cannula and an oxygenator;TandemHeart ECMO) might be superior to conventional veno-venous (VV)-ECMO. Methods: A total of 19 patients with COVID-19 underwent ECMO at Princeton Hospital. We compared in-hospital complications and short-term outcomes between patients with VV ECMO vs. RA-LA ECMO. VV-ECMO was initiated in the cath lab, while RA-LA ECMO was initiated bedside using intracardiac echo guidance. We used Fisher’s exact test for mortality and Student’s t-test for other variables. Results: Between March and September 2020, 19 patients underwent ECMO cannulation. Out of 19 patients, 5 patients had beside TandemHeart ECMO (we performed bedside ICU ECMO procedure in 5 patients, 3 males and 2 females). We placed a 21F LA cannula (TandemHeart, TandemHeart, Pittsburgh, PA) via the right common femoral vein (CFV) and a 25F RA cannula (Edwards, Irvine, CA) through the left CFV. Both the oxygenator and pump were also a TandemHeart system. The median duration of ECMO was 16 days (range 7 to 19 days) for RA-LA ECMO compared to 26 days (range 12-81 days) for conventional VV-ECMO (p<0.02). The mean number of blood transfusions was 10.4±1.6 vs. 21.8±7.1 units, p<0.0001. One patient in the TandemHeart ECMO arm required dialysis, while 8/14 patients on VV-ECMO required dialysis, p=0.1. Intensive care unit (ICU) length of stay was shorter in the RA-LA ECMO group compared to VV ECMO (25.8±7.4 vs. 3.67±14.1 days, p<0.05). A total of 6/14 (42.8%) patients in the VV-ECMO vs. 0/5 (0%) in the RA-LA ECMO died in the hospital. However, this was not statistically significant (p=0.2). No major procedural complications, including tamponade occurred in the RA-LA arm despite using bedside ICE without fluoroscopy. Conclusion: Bedside percutaneous RA-LA cannulation was feasible and safe and was associated with significantly shorter ECMO and ICU days among COVID-19 patients presenting with ARDS. This strategy has the potential benefit of providing complete cardiopulmonary support in patients with ARDS. However, larger studies are needed to confirm its role in COVID-19 infections and potentially other ARDS scenarios.

The use of transbronchial cryobiopsy for diffuse parenchymal lung disease in critically ill patients with acute hypoxemic respiratory failure—A case series

Accurate diagnosis and management of undifferentiated diffuse parenchymal lung disease (DPLD) in critically ill patients is challenging. Transbronchial forceps biopsies have limited utility and surgical lung biopsies can be detrimental for critically ill patients. Transbronchial cryobiopsy (TBC) has shown increased diagnostic yield compared to conventional forceps biopsy in DPLD. However, TBC has not been studied in intensive care unit (ICU) patients. In this case series, we describe our experience with TBC for diagnosis of DPLD in ICU patients with acute hypoxemic respiratory failure. This case series includes critically ill patients who underwent TBC at two different tertiary care hospitals. Procedures were performed by the same interventional pulmonologist using the two therapeutic bronchoscopes with a 2.8-mm working channel, and a 1.9- or 2.4-mm cryoprobe. We performed TBC in 17 patients of which 12 (70.1%) were performed at bedside in ICU without fluoroscopic guidance. Pathological diagnosis was made in 15 (88%) patients which resulted in changes in management in most of these patients. Six patients (35.3%) developed pneumothorax post-procedure with 5 (29.4%) requiring a chest tube. Moderate bleeding was noted in one (6%) patient and no severe or fatal bleeding occurred. Our 30-day ICU mortality was 47% (n=8); however, no deaths were directly attributable to the procedure. TBC is a feasible technique with an acceptable complication rate and a fairly high histopathological yield in ICU patients with DPLD and acute hypoxemic respiratory failure. Appropriate diagnosis can be crucial in making management decisions for these patients.

Implementation of the Family HELP Protocol: A Feasibility Project for a West Texas ICU.

The purpose of this project was to determine if bedside intensive care unit (ICU) nurse buy-in to the Family Hospital Elder Life Program (HELP) protocol was sufficient to make implementation feasible at one county hospital in West Texas. Surveys were anonymous with ballot box collection being available to the bedside ICU nurses for one week each. Questions were based on literature findings of expected outcomes, identified barriers and facilitators, Calgary Family Intervention Method framework domains, and the Centers for Disease Control and Prevention Framework for program evaluation. Outcome measures were taken from the stated aims of the project and evaluated from paired baseline and summative survey questions. Survey participation was approximately half of nurses employed in the studied ICU. Analysis of the surveys showed a positive perception of family presence decreasing patient delirium symptoms, and a positive perception of the Family HELP protocol. The results described a high perception of family members as partners in care and high intention to implement the Family HELP protocol, indicating strong support of a full implementation of the protocol. The high level of bedside nurse buy-in present in this study has large implications for successful implementation of the Family HELP protocol in the near future, with sustainability and continued use supported by potential inclusion of the task in the electronic health record charting.