Contemporary Critical Care Research Articles

Maternal Sepsis.

Sepsis is the second leading cause of pregnancy-related mortality in the United States. Early recognition, treatment, and escalation of care for the obstetric patient affected by sepsis mitigate the risk of mortality and improve patient outcomes. In this article, we provide an overview of maternal sepsis and address topics of maternal pathophysiology, early warning signs, diagnostic criteria, early goal-directed therapy, and contemporary critical care practices. We also present an overview of common etiologies of maternal sepsis and suggested treatment approaches.

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

Characterization and Outcome of Two Pediatric Intensive Care Units with Different Resources.

Background The pediatric intensive care units (PICUs) in developing countries have a higher mortality outcome due to a wide variety of causes. Identifying differences in the structure, patient characteristics, and outcome between PICUs with different resources may add evidence to the need for incorporating more PICUs with limited resources in the contemporary critical care research to improve the care provided for severely ill children. Methods A retrospective study was conducted at Egyptian and Japanese PICUs as examples of resource-limited and resource-rich units, respectively. We collected and compared data of nonsurgical patients admitted between March 2018 and February 2019, including the patients' demographics, diagnosis, PICU length of stay, outcome, predicted risk of mortality using pediatric index of mortality-2 (PIM-2), and functional neurological status using the Pediatric Cerebral Performance Category (PCPC) scale. Results The Egyptian unit had a lower number of beds with a higher number of annual admission/bed than the Japanese unit. There was a shortage in the number of the skilled staff at the Egyptian unit. Nurse : patient ratios in both units were only similar at the nighttime (1 : 2). Most of the basic equipment and supplies were available at the Egyptian unit. Both actual and PIM-2 predicted mortalities were markedly higher for patients admitted to the Egyptian unit, and the mortality was significantly associated with age, severe sepsis, and PIM-2. The length of stay was shorter at the Egyptian unit. Conclusion The inadequate structure and the burden of more severely ill children at the Egyptian unit appear to be the most important causes behind the higher mortality at this unit. Increasing the number of qualified staff and providing cost-effective equipment may help in improving the mortality outcome and the quality of care.

Life-Threatening Infectious Complications in Sickle Cell Disease: A Concise Narrative Review.

Sickle cell disease (SCD) results in chronic hemolytic anemia, recurrent vascular occlusion, insidious vital organ deterioration, early mortality, and diminished quality of life. Life-threatening acute physiologic crises may occur on a background of progressive diminishing vital organ function. Sickle hemoglobin polymerizes in the deoxygenated state, resulting in erythrocyte membrane deformation, vascular occlusion, and hemolysis. Vascular occlusion and increased blood viscosity results in functional asplenia and immune deficiency in early childhood, resulting in life-long increased susceptibility to serious bacterial infections. Infection remains a main cause of overall mortality in patients with SCD in low- and middle-income countries due to increased exposure to pathogens, increased co-morbidities such as malnutrition, lower vaccination rates, and diminished access to definitive care, including antibiotics and blood. Thus, the greatest gains in preventing infection-associated mortality can be achieved by addressing these factors for SCD patients in austere environments. In contrast, in high-income countries, perinatal diagnosis of SCD, antimicrobial prophylaxis, vaccination, aggressive use of antibiotics for febrile episodes, and the availability of contemporary critical care resources have resulted in a significant reduction in deaths from infection; however, chronic organ injury is problematic. All clinicians, regardless of their discipline, who assume the care of SCD patients must understand the importance of infectious disease as a contributor to death and disability. In this concise narrative review, we summarize the data that describes the importance of infectious diseases as a contributor to death and disability in SCD and discuss pathophysiology, prevalent organisms, prevention, management of acute episodes of critical illness, and ongoing care.

What's in this Issue

What's in this Issue

A two phase study to revise the Australian Practice Standards for Specialist Critical Care Nurses

BackgroundObservational work to develop the ACCCN Competency Standards was undertaken more than 20 years ago. Since then the landscape of critical care nursing as a specialty has changed and it is not known if the Competency Standards reflected contemporary practice. ObjectivesTo revise the ACCCN Competency Standards for Specialist Critical Care Nurses to ensure they continue to meet the needs of critical care nurses and reflect current practice. MethodsA two-phased project was undertaken. In Phase I focus groups were held in all states. Thematic analysis was conducted using two techniques. The standards were revised based on the main themes. Phase II consisted of an eDelphi technique. A national panel of critical care nurses responded to three survey rounds using a 7 point likert-type scale to indicate their level of agreement with the revised standards. A 70% agreement level for each statement was determined a priori. ResultsPhase I: 12 focus groups (79 participants) were conducted. Phase II: A panel of specialist critical care nurses (research, management, clinical practice and education) responded to round 1 (n=64), round 2 (n=56), and round 3 (n=40). Fifteen practice standards with elements and performance criteria were grouped into four domains (professional practice, provision and coordination of care, critical thinking and analysis, collaboration and leadership). The revised Practice Standards for Specialist Critical Care Nurses build upon and are additional to the Nursing & Midwifery Board of Australia National Competency Standards for Registered Nurses. The standards reflect contemporary critical care nurse practices using an expanded range of technologies to care for complex critically ill patients across the lifespan in diverse settings. ConclusionThe national study has resulted in the 3rd edition of the Practice Standards for Specialist Critical Care Nurses. There was input from stakeholders and agreement that the revised standards capture contemporary Australian critical care nursing practice.

Caring for one and all – Exploring ethical challenges in an ICU

This discussion paper explores some of the complex ethical and moral issues confronting contemporary critical care nurses. In contemporary healthcare discussions, there is an increased appreciation of the complexity of ethical challenges, the multiplicity of stakeholders and that a broad range of possible and practical outcomes exist. Furthermore, many scholars also acknowledge the limitations of principle based ethical frameworks. In seeking to build critical care nurses’ capacity to negotiate the complex – and often conflicting – ethical challenges, the authors have adopted a person-centred, values-based approach in this case study. Furthermore, by exploring these complex issues, this paper supports and builds upon critical care nurses’ decision making capacities in the clinical area. This case study has been purposefully left open-ended with the aim of inviting the reader to consider the questions posed in a collegial, collaborative manner within the particular context in which she/he is embedded.

A survey on the resources and practices in pediatric critical care of resource-rich and resource-limited countries.

BackgroundContemporary critical care research necessitates involvement of multiple centers, preferably from many countries. Adult and pediatric research networks have produced outstanding data; however, their involvement is restricted to a small percentage of the industrialized nations. Implementation of their findings in low- and middle-income countries (LMICs) is fraught with challenges.MethodsWe conducted an online international survey to assess and compare disease burden and resources to participate in multicenter research studies through a listserv of the World Federation of Pediatric Intensive and Critical Care Societies. Respondents were grouped into high-income countries and LMICs on the basis of World Bank classification.ResultsSurvey was completed by 73 centers in 34 countries (34 from high-income countries and 39 from LMICs). Compared with high-income countries, the pediatric intensive care units in LMICs were characterized by a lower number of critical care specialists, more difficult access to hemodialysis, and a lower number of elective postoperative patients, but a similar overall disease burden. Training and resources for research were comparable in the two cohorts.ConclusionsAlthough differences exist in access to both trained providers and equipment, the survey results were more striking in their similarity. It is essential that centers from LMICs be included in multinational studies, to generate results applicable to all children worldwide.

Hyperoxemia--too much of a good thing?

While avoiding hypoxemia has long been a goal of critical care practitioners, less attention has been paid to the potential for excessive oxygenation. Interest has mounted recently in understanding the clinical effects of hyperoxemia during critical illness, in particular its impact following cardiac arrest. In this issue of Critical Care, Dell’Anna and colleagues review available animal and human data evaluating the impact of hyperoxemia after cardiac arrest. They conclude that while hyperoxemia during cardiopulmonary resuscitation is probably desirable, it should probably be avoided during post-resuscitation care. These conclusions are in line with two broader themes in contemporary critical care: that less may be more; and that it is time to look beyond simply preventing short-term mortality towards longer-term outcomes.

Therapeutic Range of Spontaneous Breathing during Mechanical Ventilation

In the 4th century before the common era, the Greek philosopher and physician Hippocrates expressed his wisdom on the value of activity to the sick and the healthy by stating that: “The sick will of course profit to a great extent from gymnastics with regard to the restoration of their health and the healthy will profit with regard to its maintenance” (On Regimen in Acute Diseases, 3, 400 BCE). In contemporary critical care medicine, driven by the goal of protecting our patients from self-inflicted injury, pain, and anxiety – and in contrast to Hippoctrates’ suggestions – we have built a culture of immobilizing our patients: we prescribe high doses of opioids, sedatives, anxiolytics, and anti-pychotics, and with the best intentions, place bed-rest and restraints orders. In patients with severe respiratory failure, we frequently use immobilizing ventilator settings such as volume control ventilation. Recent data have been increasingly challenging this tenet in relation to the fields of neuropsychiatry, rehabilitation, and respiratory medicine1–5. In this issue of Anesthesiology, two papers bring new information on why the concept of muscle activity is also relevant to lung biochemistry and regional function. Guldner et al.6 and Bruells et al.7 provide important experimental data on the relationship between the dose of diaphragmatic activity (spontaneous contribution to breathing during mechanical ventilation) and the resulting response in terms of lung mechanical stress, gas exchange, and markers of muscle deconditioning. As the main respiratory muscle, the diaphragm contributes 72% for tidal breathing8 and its role in respiratory mechanics and gas exchange goes well beyond this global number. One of the reasons is its curvature during spontaneous breathing in the supine position, which facilitates expansion of dependent lung regions9, optimizes the regional distribution of lung ventilation, and prevents loss of dependent lung aeration and increase in shunt observed when muscle paralysis is produced10. Accordingly, modes of ventilation proposed since the 1970s tried to explore those advantages in patients with acute respiratory failure. The beneficial effects of maintaining continuous spontaneous breathing during mechanical ventilation of patients with acute respiratory failure have been described by Putensen and coworkers in two well-designed studies11,12. However, in patients with severe respiratory failure, barriers to spontaneous breathing during mechanical ventilation including patient-ventilator asynchrony, high oxygen consumption of the respiratory pump muscles, and the risk of barotrauma, have hindered a clear determination of the value of spontaneous breathing during mechanical ventilation.

Leadership within contemporary critical care environments

Leadership within contemporary critical care environments

A revised method to assess intensive care unit clinical performance and resource utilization*

In 1994, Rapoport et al. published a two-dimensional graphical tool for benchmarking intensive care units (ICUs) using a Mortality Probability Model (MPM0-II) to assess clinical performance and a Weighted Hospital Days scale (WHD-94) to assess resource utilization. MPM0-II and WHD-94 do not calibrate on contemporary data, giving users of the graph an inflated assessment of their ICU's performance. MPM0-II was recently updated (MPM0-III) but not the model for predicting resource utilization. The objective was to develop a new WHD model and revised Rapoport-Teres graph. Multicenter cohort study. One hundred thirty-five ICUs in 98 hospitals participating in Project IMPACT. Patients were 124,855 MPM0-II eligible Project IMPACT patients treated between March 2001 and June 2004. None. WHD was redefined as 4 units for the first day of each ICU stay, 2.5 units for each additional ICU day, and 1 unit for each non-ICU day after the first ICU discharge. Stepwise linear regression was used to construct a model to predict ICU-specific log average WHD from 39 candidate variables available in Project IMPACT. The updated WHD model has four independent variables: percent of patients dying in the hospital, percent of unscheduled surgical patients, percent of patients on mechanical ventilation within 1 hr of ICU admission, and percent discharged from the ICU to an external post-acute care facility. The first three variables increase average WHD and the last decreases it. The new model has good performance (R = 0.47) and, when combined with MPM0-II, provides a well-calibrated Rapoport-Teres graph. A new WHD model has been derived from a large, contemporary critical care database and, when used with MPM0-III, updates a popular method for benchmarking ICUs. Project IMPACT participants will likely perceive a decline in their ICU performance coordinates due to the recalibrated graph and should instead focus on their unit's performance relative to their peers.

Use of technological equipment in critical care units: nurses’ perceptions in Greece

The aim of this study was to determine the perceptions of nurses who work in critical care units about positive and negative effects related to the use of technological equipment and identify relationships between these perceptions and demographic characteristics of participants. Previous researchers have investigated the perceptions of nursing personnel about the effects of technology on clinical practice. However, most of them focus on specific negative effects. Positive and negative effects have never been studied as a whole. Critical care nurses were surveyed to elicit their perceptions regarding the use of technological equipment. The instrument comprised a 14-item questionnaire and a series of demographic characteristics. A five-point Likert scale was used for each of these 14 questions. The questionnaire was administered to 122 nurses working at the four critical care units of a major academic hospital in Patras, Greece, from 1/10/2003 to 31/12/2003. The completion of the questionnaires was achieved by means of a personal interview. A total of 118 questionnaires were completed. The majority of nurses recognized the positive effects of equipment regarding patient care and clinical practice. At the same time, they agreed that use of equipment possibly leads to increased risk due to human errors or mechanical faults, increased stress and restricted autonomy of nursing personnel. The use of machines does not add to nursing prestige and this may be related to decreased autonomy. Human errors, mechanical faults and increased stress do not seem to come as a result of time constriction but rather of inadequate education. Undergraduate and continuing education should respond efficiently to the needs of contemporary critical care. Recognition of positive and negative effects of machines through the investigation of perceptions of nurses is the first step before looking for ways of maximizing advantages and facing disadvantages of equipment use.

Contemporary management of infected necrosis complicating severe acute pancreatitis

Pancreatic necrosis complicating severe acute pancreatitis is a challenging scenario in contemporary critical care practice; it requires multidisciplinary care in a setting where there is a relatively limited evidence base to support decision making. This commentary provides a concise overview of current management of patients with infected necrosis, focusing on detection, the role of pharmacologic intervention, and the timing and nature of surgical interventions. Fine-needle aspiration of necrosis remains the mainstay for establishment of infection. Pharmacological intervention includes antibiotic therapy as an adjunct to surgical debridement/drainage and, more recently, drotrecogin alfa. Specific concerns remain regarding the suitability of drotrecogin alfa in this setting. Early surgical intervention is unhelpful; surgery is indicated when there is strong evidence for infection of necrotic tissue, with the current trend being toward 'less drastic' surgical interventions.

Discussing life-sustaining treatments: an overview and communications guide for primary care physicians.

Physicians must be skilled communicators with patients, families, and multidisciplinary health care teams to meet ethical decision-making challenges arising in end-stage disease care. We offer practical suggestions for collaborative communication in the "perfect storm" of contemporary critical care settings.

Non-invasive positive pressure ventilation in patients with acute respiratory failure.

Non-invasive positive pressure ventilation is an emerging modality in contemporary critical care practice. Perhaps the most widely utilized and familiar form of non-invasive positive pressure ventilation is mask continuous positive airway pressure. Other common modes include mask Bi-level positive airway pressure and mask pressure support ventilation. All feature the delivery of positive airway pressure via a mask (full-face, naso-oral or nasal), and a patient-controlled respiratory cycle. The physiological benefits of non-invasive positive pressure ventilation suggested by a number of studies include improved oxygenation, decreased work of breathing, improved ventilation and perfusion matching, decreased fatigue, and increased minute ventilation. The utilization of non-invasive positive pressure ventilation has now been reported for a variety of clinical indications. In most, randomized trials are lacking, and the benefits and preferred mode of non-invasive positive pressure ventilation are still to be elucidated. In general, in patients that are candidates for endotracheal intubation, non-invasive positive pressure ventilation should be used as a way to possibly avoid endotracheal intubation rather than as an alternative to endotracheal intubation. Whilst the benefit of non-invasive positive pressure ventilation appears to be established in patients with chronic obstructive airways disease with hypercapnic acute respiratory failure, one of the major unresolved issues is whether one modality is significantly better than the others. Unfortunately, the question of whether Bi-level positive airway pressure is better than continuous positive airway pressure in this clinical scenario has not been satisfactorily addressed in any large randomized and controlled clinical trial. Further, there is no 'gold standard' for predicting success with non-invasive positive pressure ventilation, although several studies have looked at this aspect.

Is UpToDate ready for the ICU?

Owing to the complexity of modern medical care, providers are increasingly turning to a growing arsenal of computer-based references for quick and reliable clinical information. In recent years, UpToDate has emerged as one of the leading subscription-based software packages. The latest version (10.2) was released in June 2002 and includes an impressive 6259 topics from the fields of internal medicine and pediatrics. Thirteen medical subspecialties are also covered, including pulmonary and critical care, gastroenterology, and infectious diseases. In most cases, the authors are established experts in their respective field. Individual topics follow a review article format, including a brief introduction, subject explanation, some future predictions, graphics, tables, and references. The sidebar table of contents allows quick navigation to any section in the article. Whenever possible, links to other related topics are highlighted within the text. Click on a medication name and a pop-up window displays a concise monograph for the drug. Similarly, click on any reference and a pop-up window displays the citation's Medline abstract. Although UpToDate is well regarded by general internists and pediatricians, I decided to challenge the software with a variety of contemporary critical care topics. These included ventilator management in acute respiratory distress syndrome, glycemic control in the intensive care unit (ICU), recombinant activated protein C for sepsis, blood product transfusions in the ICU, corticosteroid administration for refractory shock, and nosocomial infections in the ICU. Overall, UpToDate performed well, and consistently returned the type of results I desired. Rarely did I need to refine my search strategy. Most topics were well written and emphasized the current scientific evidence. Graphics and tables were always printer-friendly. Needless to say, the references were up to date (all topics had been revised in the past six months). Although I recommend it, be prepared to pay. All these features come with a price tag.