Critical Care Practice Research Articles

Editor's Choice Articles for February.

Editor's Choice Articles for February.

Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Argument for CKRT.

Continuous kidney replacement therapy (CKRT) is well entrenched as one of the dominant KRT modalities in modern critical care practice. Since its introduction four decades ago, there have been considerable innovations in CKRT machines that have improved precision, safety, and simplicity. CKRT is the preferred KRT modality for critically ill patients with hemodynamic instability. Early physical therapy and rehabilitation can be feasibly and safely provided to patients connected to CKRT, thus obviating concerns about immobility. Although randomized clinical trials have not shown a mortality difference when comparing CKRT and intermittent hemodialysis, CKRT allows precision delivery of solute and fluid removal that can be readily adjusted in the face of dynamic circumstances. Accumulated evidence from observational studies, although susceptible to bias, has shown that CKRT, when compared with intermittent hemodialysis, is associated with better short- and long-term kidney recovery and KRT independence. Critical care medicine encompasses a wide range of sick patients, and no single KRT modality is likely to ideally suit every patient in every context and for every condition. The provision of KRT represents a spectrum of modalities to which patients can flexibly transition in response to their evolving condition. As a vital tool for organ support in the intensive care unit, CKRT enables the personalization of KRT to meet the clinical demands of patients during the most severe phases of their illness.

Survey of critical care pharmacists on sedation and analgesia practices in adult and pediatric patients receiving continuous neuromuscular blocking agents

AbstractIntroductionThere is a lack of recommendations regarding sedation/analgesia practices for patients receiving continuous or frequent boluses of neuromuscular blocking agents (NMBAs), which may cause variation among different clinical practice sites.ObjectivesThe primary objective of this study was to determine critical care pharmacist's perceptions and practices regarding sedation/analgesia for patients receiving NMBAs and to compare sedation/analgesia regimens among adult and pediatric populations.MethodsA 10‐question survey was provided to critical care pharmacists regarding practice site, comfort using NMBAs, and monitoring practices. Respondents could select all sedation/analgesia regimens they commonly see, would recommend, and would consider inappropriate. Responses from adult and pediatric pharmacists were compared.ResultsOf the 2435 pharmacists who received the survey, 192 (7.9%) completed the survey. Most respondents practiced in the United States (97.9%), cared for adult patients (60.7%), and worked in a medical intensive care unit (ICU) (81.3%). Most respondents reported monitoring sedation depth (82.6%) with vitals (49%) and bispectral index (30.3%) being the most common methods. The most commonly observed regimens were continuous infusion (CI) benzodiazepine and CI opioid (n = 114, 66.7%), followed by propofol and CI opioid (n = 104, 60.8%). These were also the most commonly recommended regimens (n = 102, 59.6%; n = 108, 63.2%), respectively. Most respondents would not recommend monotherapy regimens. Dexmedatomidine was utilized and recommended significantly more by pediatric pharmacists while propofol was utilzied and recommended more by adult pharmaicsts. Regimens deemed inappropriate were similar between adult and pediatric pharmacists except for dexmedetomidine‐containing regimens which significantly more adult pharmacists deemed inappropriate.ConclusionDespite a lack of guideline recommendations, use of combination therapy with sedation/analgesia was frequently reported; however, the choice of sedation agent was variable. Given concern with the inability to achieve deep sedation with dexmedetomidine and a high response rate recommending/utilizing dexmedetomidine, further research is needed to guide recommendations for providing appropriate sedation/analgesia to patients receiving NMBAs.

A multisite exploration of the association between critical care implementation factors and clinical outcomes during the COVID-19 pandemic.

Little is known about strategies to implement new critical care practices in response to COVID-19. Moreover, the association between differing implementation climates and COVID-19 clinical outcomes has not been examined. The purpose of this study was to evaluate the relationship between implementation determinants and COVID-19 mortality rates. We used mixed methods guided by the Consolidated Framework for Implementation Research (CFIR). Semi-structured qualitative interviews were conducted with critical care leaders and analyzed to rate the influence of CFIR constructs on the implementation of new care practices. Qualitative and quantitative comparisons of CFIR construct ratings were performed between hospital groups with low- versus high-mortality rates. We found associations between various implementation factors and clinical outcomes of critically ill COVID-19 patients. Three CFIR constructs (implementation climate, leadership engagement, and engaging staff) had both qualitative and statistically significant quantitative correlations with mortality outcomes. An implementation climate governed by a trial-and-error approach was correlated with high COVID-19 mortality, while leadership engagement and engaging staff were correlated with low mortality. Another three constructs (needs of patient; organizational incentives and rewards; and engaging implementation leaders) were qualitatively different across mortality outcome groups, but these differences were not statistically significant. Improving clinical outcomes during future public health emergencies will require reducing identified barriers associated with high mortality and harnessing salient facilitators associated with low mortality. Our findings suggest that collaborative and engaged leadership styles that promote the integration of new yet evidence-based critical care practices best support COVID-19 patients and contribute to lower mortality.

Attitudes, beliefs, and practices toward end-of-life care among physicians in sub-Saharan Africa.

as the opportunity to receive life-sustaining treatments expands in sub-Saharan Africa (SSA), so do potential ethical dilemmas. Little is known regarding the attitudes, beliefs, and practices of physicians in SSA regarding end-of-life care ethics. we used validated survey items addressing physician end-of-life care views and added SSA-context specific items. We identified a convenience sample using the authors' existing African professional contacts and snowball recruitment. Participants were invited via email to an anonymous online survey. we contacted 78 physicians who practice critical care in Africa, and 68% (n=53) completed the survey. Of those, 66% were male, 55% were aged 36-45, 75% were Christian. They were from Kenya (30%), Zambia (28%), Rwanda (25%), Botswana (11%), and other countries (6%). Most (75%) agreed that competent patients can refuse even life-saving care. Only 32% agreed that their hospital had clear policies regarding withdrawing and withholding care, 11% agreed that their country had legal precedent for end-of-life care, and 43% believed that doctors could face legal or financial consequences for allowing patients to die by forgoing treatment. Pain control at the end of life, even if it may hasten death, was supported by 83%. However, 75% felt that clinicians undertreat pain due to fear of hastening death. participants strongly supported patient autonomy and end-of-life pain control but expressed concern that inadequate policy and legal frameworks exist to guide care and that pain is undertreated. Humane and actionable end-of-life care frameworks are needed to guide decisions in SSA.

Application of Evidence-based Practice in Intensive and Critical Care Nursing

Background: Evidence-based solutions are the main point of high-quality and patient-centered care. Studies analyzing the implementation of evidence-based nursing are an integral part of quality improvement. The study aims to analyze the application of evidence-based practice in intensive and critical care nursing. Methods: This research was performed in the Hospital of Lithuanian University of Health Sciences Kaunas Clinics in intensive care units (ICU) departments in 2019. 202 critical care nurses participated in this survey (response rate 94.3%)—method of research – anonymous questionnaire. Research object – implementing evidence-based nursing practice among nurses working in intensive care units. Research instrument – questionnaire composed by McEvoy et al. (2010) [1]. Statistical analysis was performed with SPSS 24.0 and MS Excel 2016 software. Descriptive statistics were used to analyse our sample and presented in percentages. Quantitive data are presented as mean with standard deviation (m±SD). Among exploratory groups, a p-value <0.05 was considered statistically significant. Results: Nurses with higher university education claim to know evidence-based nursing terminology better with a statistical significance (p= 0.001) and to have higher self-confidence in evidence application (p= 0.001) compared to nurses with professional or higher non-university education. It has been determined that age directly correlates with the implementation of evidence-based nursing: compared to their older colleagues, younger nurses have statistically significantly more knowledge (p= 0.001), skills (p= 0.012) and self-confidence when applying evidence (p= 0.001) as well as a more positive approach to evidence-based nursing (p= 0.041). Nurses whose total work experience exceeds 20 years have statistically significantly less knowledge of evidence-based practice terminology than nurses whose work experience is 10 years or less (p= 0.001). It has been determined that Intensive and Critical Care Nurses (ICU Nurses) with 10 years or less experience under their belt know the terms related to evidence-based nursing statistically significantly better (p= 0.001) and applies evidence-based knowledge in clinical practice more often, compared to nurses who have worked in the ICU for longer, e.g., 11-20 years or more than 20 years (p= 0.006). Compared to the nurses working in the ICU for 11-20 years, 10 years or less, those working for more than 20 years encounter statistically significantly more problems when applying an evidence-based approach in clinical practice (p=0.017). Conclusion: Younger nurses with higher education and less general work experience tend to have more knowledge and a more positive approach to evidence-based nursing. Problems with an evidence-based approach in clinical practice more often occur in nurses who have worked in the ICU for more than 20 years. Most of the nurses who participated in the study claimed that the lack of time was one of the key problems when practicing evidence-based nursing.

Framework of humanistic care for patients in the ICU: A preliminary study.

Humanistic care involves caring, concern, paying attention to people's individuality, meeting their needs and respecting their rights, which is the core concept and central task of nursing. Effective care can enhance patients' ability to deal with stress and promote patient recovery. Implementing humanistic care in the intensive care unit (ICU) is particularly important for health care providers. This study aims to develop a framework of the humanistic care in the ICU. The qualitative research followed Strauss' procedural grounded theory approach. Purposive sampling and theoretical sampling were used to select 12 nurses in the Department of Critical Medicine, 16 patients, and eight family members for semi-structured interviews from October 2020 to April 2021. Results were summarized and analysed through three-level coding based on grounded principles. Sixteen subcategories and six main categories were extracted after three-level coding, and the final ICU humanistic care framework was formed with home, activity, visit, environment, nursing and safety ("HAVENS") as the core. This study provides an explanatory theory of humanistic care in the ICU that can guide nurses' practice in ICU clinical work. This theory provides guidance for nurses to implement humanistic care in critical care practice to improve the ICU stay experience of critically ill patients.

568: HUMANIZING THE INTENSIVE CARE UNIT: PERSPECTIVES OF PATIENTS AND FAMILIES ON GET-TO-KNOW-ME BOARD

Introduction: The common practice in critical care of referring to patients by their chief complaint or room number combined with high workload, burnout, prioritization of the medical aspect of illness, limited family presence and even the new normal of masking one’s face may inadvertently result in patient dehumanization. Can something as simple as taking a few minutes to fill out the Get to Know Me (GTKM) board help remind the providers of the actual person they are treating? Methods: This is a single center mixed methods study of the critically ill patients and their families conducted between March 2021 to February 2022. A survey and structured interview were administered to explore key perspectives on the potential value of the GTKM board during their care in the intensive care unit (ICU). Results: There were 29 patients who recovered from critical illness and 53 family members agreed to participate. Key themes included importance of knowing the patient, potential value in building relationship with providers, and possible disadvantages of using this tool. Most patients (26, 89%) and family members (52, 99%) expressed that GTKM board was important in recognizing patient’s humanity. Majority patients (20, 68%) and families (39, 74%) said that it helped to build a better relationship with the provider team. 60% of patients and families commented that the GTKM board was used as a platform by providers to interact with them. Up to 85% (N=45) of the family members supported specific contents of the GTKM board such as names patients preferer to be addressed by, their hobbies, favorite food, books, movies, and achievements. Concern for intrusion on patient privacy was minor. In structured interviews, families further commented on ways providers used the GTKM board to communicate and on how much this meant to them. Conclusions: The GTKM board can be a helpful tool in fostering a more humane ICU environment. Furthermore, it may aid to build a better therapeutic relationship between patient, their family and providers, resulting in a more holistic approach to patient care.

Fifty Years of Critical Care Medicine: The Editors' Perspective.

Fifty Years of Critical Care Medicine: The Editors' Perspective.

Artificial Intelligence in Intensive Care Medicine: Bibliometric Analysis.

Interest in critical care-related artificial intelligence (AI) research is growing rapidly. However, the literature is still lacking in comprehensive bibliometric studies that measure and analyze scientific publications globally. The objective of this study was to assess the global research trends in AI in intensive care medicine based on publication outputs, citations, coauthorships between nations, and co-occurrences of author keywords. A total of 3619 documents published until March 2022 were retrieved from the Scopus database. After selecting the document type as articles, the titles and abstracts were checked for eligibility. In the final bibliometric study using VOSviewer, 1198 papers were included. The growth rate of publications, preferred journals, leading research countries, international collaborations, and top institutions were computed. The number of publications increased steeply between 2018 and 2022, accounting for 72.53% (869/1198) of all the included papers. The United States and China contributed to approximately 55.17% (661/1198) of the total publications. Of the 15 most productive institutions, 9 were among the top 100 universities worldwide. Detecting clinical deterioration, monitoring, predicting disease progression, mortality, prognosis, and classifying disease phenotypes or subtypes were some of the research hot spots for AI in patients who are critically ill. Neural networks, decision support systems, machine learning, and deep learning were all commonly used AI technologies. This study highlights popular areas in AI research aimed at improving health care in intensive care units, offers a comprehensive look at the research trend in AI application in the intensive care unit, and provides an insight into potential collaboration and prospects for future research. The 30 articles that received the most citations were listed in detail. For AI-based clinical research to be sufficiently convincing for routine critical care practice, collaborative research efforts are needed to increase the maturity and robustness of AI-driven models.

Collaborative Artificial Intelligence in Practice: The Next Steps.

Collaborative Artificial Intelligence in Practice: The Next Steps.

On Low-Value Nursing Care: Part 2, De-implementing Practices in Your Unit.

On Low-Value Nursing Care: Part 2, De-implementing Practices in Your Unit.

Renal Replacement Therapy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendation.

Mishra RC, Sinha S, Govil D, Chatterjee R, Gupta V, Singhal V, et al. Renal Replacement Therapy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendation. Indian J Crit Care Med 2022;26(S2):S3-S6.

Clinician preference instrumental variable analysis of the effectiveness of magnesium supplementation for atrial fibrillation prophylaxis in critical care

Atrial fibrillation is a frequently encountered condition in critical illness and causes adverse effects including haemodynamic decompensation, stroke and prolonged hospital stay. It is a common practice in critical care to supplement serum magnesium for the purpose of preventing episodes of atrial fibrillation. However, no randomised studies support this practice in the non-cardiac surgery critical care population, and the effectiveness of magnesium supplementation is unclear. We sought to investigate the effectiveness of magnesium supplementation in preventing the onset of atrial fibrillation in a mixed critical care population. We conducted a single centre retrospective observational study of adult critical care patients. We utilised a natural experiment design, using the supplementation preference of the bedside critical care nurse as an instrumental variable. Using routinely collected electronic patient data, magnesium supplementation opportunities were defined and linked to the bedside nurse. Nurse preference for administering magnesium was obtained using multilevel modelling. The results were used to define "liberal" and "restrictive" supplementation groups, which were inputted into an instrumental variable regression to obtain an estimate of the effect of magnesium supplementation. 9114 magnesium supplementation opportunities were analysed, representing 2137 critical care admissions for 1914 patients. There was significant variation in magnesium supplementation practices attributable to the individual nurse, after accounting for covariates. The instrumental variable analysis showed magnesium supplementation was associated with a 3% decreased relative risk of experiencing an atrial fibrillation event (95% CI − 0.06 to − 0.004, p = 0.03). This study supports the strategy of routine supplementation, but further work is required to identify optimal serum magnesium targets for atrial fibrillation prophylaxis.

CALCIFIED CAVITARY CONUNDRUM: DELAYED DIAGNOSIS OF HISTOPLASMOSIS

CALCIFIED CAVITARY CONUNDRUM: DELAYED DIAGNOSIS OF HISTOPLASMOSIS

Intravenous fluid therapy in perioperative and critical care setting-Knowledge test and practice: An international cross-sectional survey.

In the absence of recent international recommendations supported by scientific societies like Anesthesiology or Intensive Care Medicine, healthcare professionals (HCP) knowledge on IV fluid is expected to vary. We undertook a cross-sectional survey, aiming to assess prescription patterns and test the knowledge of HCP for IV fluid use in the operating room (OR) and intensive care unit (ICU). An online international cross-sectional survey was conducted between October 20, 2019, and November 27, 2021. The survey included multiple-choice questions on demographics, practice patterns and knowledge of IV fluids, and a hemodynamically unstable patient assessment. 1045 HCP, from 97 countries responded to the survey. Nearly three-quarters reported the non-existence of internal hospital or ICU-based guidelines on IV fluids. The respondents' mean score on the knowledge assessment questions was 46.4 ± 14.4. The cumulative mean scores were significantly higher among those supervising trainees (p = 0.02), specialists (p < 0.001) and those working in high-income (p < 0.001) countries. Overall performance of respondents on the knowledge testing for IV fluid was unsatisfactory with only 6.5% respondents performed above average. There is a wide difference in the knowledge and prescription of IV fluids among the HCP surveyed. These findings reflect the urgent need for education on IV fluids.

Personalized Critical Care Medicine (Review)

Personalized medicine (PM) is a major trend in health care development in the 21st century. This area includes studying risk factors for disease development (prediction), interventions for preventing diseases (prophylaxis), individualization of diagnosis and treatment (personalization), informing the patient on disease prevention and treatment (participation). In the recent years, an intense research to introduce the personalized medicine principles into the management of critically ill patients, has been under way. This includes identification of patient groups based on genomic research, development of diagnostic tests using molecular markers, creation of novel classes of drugs based on individual patient characteristics.The aim of the review is to summarize the available data on the implementation of the principles of PM in the routine practice of critical care institutions.We analyzed more than 300 sources of literature from the Pubmed and Scopus databases, as well as the RSCI database. Eighty five most relevant sources were selected for the review. The paper reports data on the organization and results of implementation of PM principles and advanced technologies, such as Emergency Medicine Sample Bank (EMSB), in the daily activity of clinics providing emergency critical care. The formation of the novel PM concept focused on the treatment of critically ill patients has been discussed. The review contains detailed data on the patterns of development of specific critical illnesses such as acute cerebrovascular events, acute respiratory distress syndrome, traumatic brain injury, shock, myocardial infarction, cardiac rhythm and conduction disturbances. Medication efficacy in view of individual genetic patient characteristics has also been highlighted. No research limitations on the subject were identified.Conclusion. The analysis of literature has demonstrated positive results of implementing PM principles in prevention, diagnosis and treatment of critically ill patients. Creation of Biobanks, development of training programs and regulatory documentation, advancing the scientific research, introduction of new methods of diagnosis and treatment will contribute to the implementation of PM principles in practical healthcare.

Assessing Discomfort in Critically Ill Patients: A Narrative Review of the Literature.

The intensive care unit environment exposes patients to stressful conditions contributing to distressing symptoms. Discomfort is an infrequently and inconsistently described symptom experienced by intensive care unit patients. To complete a narrative literature review to summarize the currently available literature on discomfort assessment in critical care practice and identify knowledge gaps to direct future intervention research. A review of the currently available literature was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. No parameters were set for publication years or specific study designs. Inclusion criteria were patients aged at least 18 years, description of patient reports of discomfort in the intensive care unit, and English language. This narrative review includes 10 studies that used 4 distinct self-reported, discomfort-related symptom assessment instruments. Two studies assessed overall discomfort. Only 1 assessment instrument, Inconforts des Patients de Reanimation, is validated for use in the intensive care unit. The reviewed literature highlights the current gap in discomfort symptom assessment during the intensive care unit stay. An assessment instrument specific for intensive care unit-related discomfort, such as the Inconforts des Patients de Reanimation, would allow for prompt recognition and mitigation of intensive care unit-related patient discomfort.

50 Years of SNACC: Pushing the Needle Forward

Subspecialty News| August 2022 50 Years of SNACC: Pushing the Needle Forward Abhijit V. Lele, MBBS, MD, MSCR, FNCS; Abhijit V. Lele, MBBS, MD, MSCR, FNCS Search for other works by this author on: This Site PubMed Google Scholar John F. Bebawy, MD John F. Bebawy, MD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor August 2022, Vol. 86, 34–35. https://doi.org/10.1097/01.ASM.0000855700.19482.d1 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Abhijit V. Lele, John F. Bebawy; 50 Years of SNACC: Pushing the Needle Forward. ASA Monitor 2022; 86:34–35 doi: https://doi.org/10.1097/01.ASM.0000855700.19482.d1 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: needles The Society for Neuroscience in Anesthesiology and Critical Care (SNACC), an international society with a proud history of scientific contribution and inclusivity, is celebrating its 50th anniversary this year (www.snacc.org). The mission of SNACC is to advance the art and science of the care of the neurologically impaired patient through education, training, and research in perioperative neuroscience. While the history of SNACC abounds with stories of groundbreaking discoveries and paradigm-shifting advancements in modern perioperative and critical care practice, it has always equally been a place of camaraderie, collegiality, and true friendships that last a lifetime. SNACC, as a society, is even more keen on the future, with a sincere and profound desire within its membership and leadership to bring more “friends into the fold” from all spaces, fostering the next generation of skilled and compassionate perioperative neuroscience experts. The SNACC 50th Anniversary Annual Meeting, which will take place... You do not currently have access to this content.

Survey of critical care practices for alcohol withdrawal syndrome in the intensive care unit

AbstractIntroductionAlcohol use disorder affects up to 60% of intensive care unit (ICU) patients. Alcohol withdrawal syndrome (AWS) is associated with increased length of stay, mechanical ventilation, and mortality. The lack of clinical practice guidelines specific to ICU patients leads to ambiguity about the standard management of AWS in this population.ObjectivesThe aim of this study was to describe current practice patterns employed for AWS management in ICU settings across the United States.MethodsThis was a cross‐sectional survey of practicing critical care pharmacists identified via a pharmacy professional organization critical care listserv. Emails were sent four times to the recipient list from May 14, 2021 to June 25, 2021. Retired pharmacists and trainees on the listserv were excluded. The survey was conducted by REDCap and descriptive statistics were performed.ResultsThere were a total of 144/1534 (9.4%) responses. Predominant characteristics included university hospital settings (n = 71/143, 49.7%) with greater than 75 ICU beds (n = 54/144, 37.5%), and medical (n = 53/144, 36.8%) or mixed (n = 52/144, 36.1%) ICU populations. The majority reported having an institutional AWS guideline (n = 96/140, 68.6%). A total of 139/143 (97.2%) preferred benzodiazepines, with lorazepam (n = 136/143, 97.8%) as the primary benzodiazepine agent. Most preferred lorazepam as needed, rather than preemptively (n = 137/138, 99.3%). Phenobarbital use was reported by 82.6% (n = 119/144) of respondents, primarily for treatment of benzodiazepine‐refractory withdrawal (n = 96/117, 82.1%). Similarly, dexmedetomidine use was reported by 86.1% (n = 124/144) of respondents, primarily for refractory withdrawal (n = 48/121, 39.7%). Propofol was primarily preferred for patients on mechanical ventilation (n = 56/98, 57.1%) or refractory withdrawal (n = 51/98, 52.0%). Clonidine was preferred by 45.8% (n = 66/144) and atypical antipsychotics by 33.6% (n = 48/143) of respondents.ConclusionsMost ICU pharmacists prefer symptom‐triggered benzodiazepines first line, followed by propofol in intubated patients and dexmedetomidine and/or phenobarbital for refractory cases. Clinical practice guidelines may help provide guidance for the management of these patients.