Intensive Care Unit Management Research Articles

The Roles of Vitamin D Levels, Gla-Rich Protein (GRP) and Matrix Gla Protein (MGP), and Inflammatory Markers in Predicting Mortality in Intensive Care Patients: A New Biomarker Link?

Objectives: Identifying reliable biomarkers to predict mortality in critically ill patients is crucial for optimizing management in intensive care units (ICUs). Inflammatory and metabolic markers are increasingly recognized for their prognostic value. This study aims to evaluate the association of various inflammatory and metabolic markers with ICU mortality. Methods: This prospective observational study was conducted from January 2023 to January 2024 in the City Hospital’s ICU. A total of 160 critically ill patients were enrolled. Laboratory parameters, including white blood cell (WBC) count, red cell distribution width (RDW), platelet count, neutrophil count, mean platelet volume (MPV), monocyte count, lymphocyte count, procalcitonin (PCT), C-reactive protein (CRP), calcium (Ca++), and vitamin D levels, were analyzed. Additionally, ratios such as the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), systemic inflammatory index (SII), and pan-immune-inflammation value (PIV) were calculated. Plasma levels of Gla-rich protein (GRP) and dephosphorylated uncarboxylated matrix Gla protein (dp-ucMGP) were measured using ELISA. Results: The mean age of the patients included in the study was 60.5 ± 15.8 years. Cardiovascular disease was present in 72 patients (45%), respiratory system disease in 58 (36%), and chronic kidney disease (CKD) in 38 (24%). Additionally, 61 patients (38%) had diabetes, and 68 (42%) had hypertension. Inflammatory markers, including PLR, NLR, and PIV, were all significantly higher in non-survivors, while calcium and vitamin D levels were lower (p < 0.05). Higher WBC, RDW, neutrophil count, PLR, NLR, PIV, CRP, procalcitonin, GRP, and dp-ucMGP levels were positively correlated with longer hospital stays and increased mortality. In contrast, platelet and lymphocyte counts were negatively correlated with both outcomes (p < 0.05). Vitamin D levels showed an inverse relationship with both hospital stay and mortality, indicating that lower levels were associated with worse outcomes (p < 0.05). In multiple logistic regression analysis, elevated WBC count (OR = 1.20, p = 0.02), RDW (OR = 1.35, p = 0.01), neutrophil count (OR = 1.25, p = 0.01), MPV (OR = 1.20, p = 0.02), PLR (OR = 1.30, p = 0.01), NLR (OR = 1.40, p = 0.001), PIV (OR = 1.50, p = 0.001), CRP (OR = 1.32, p = 0.01), procalcitonin (OR = 1.45, p = 0.001), GRP (OR = 1.40, p = 0.001), and dp-ucMGP (OR = 1.30, p = 0.001) levels were significantly associated with increased mortality. Conclusions: Inflammatory and metabolic markers, particularly NLR, PLR, PIV, GRP, and dp-ucMGP, are strong predictors of mortality in ICU patients. These markers provide valuable insights for risk stratification and early identification of high-risk patients, potentially guiding more targeted interventions to improve outcomes.

Clinical characteristics and functional outcomes of pediatric Guillain-Barré syndrome admitted to the Neuro-intensive care unit: a decade-long retrospective observational study.

Guillain-Barré Syndrome (GBS) remains a significant contributor to acute flaccid paralysis in pediatric patients worldwide. Despite its impact, studies focusing on pediatric GBS requiring intensive care unit (ICU) management are limited. This study aimed to address this gap by exploring the clinical and outcome characteristics of pediatric GBS necessitating ICU care. This retrospective observational study, spanning a decade, analyzed the records of 75 pediatric GBS patients admitted to the Neuro-ICU of a tertiary care center in South India. Data included demographics, prodromal symptoms, clinical features, investigations, treatment modalities, and outcomes. The majority (55/75) of patients were male, with a median age of 12 years. The highest incidence of GBS requiring ICU admission was in the monsoon season. Prodromal symptoms were observed in 56%. Most patients (93.33%) presented with typical GBS symptoms, and 40% had respiratory distress on ICU admission. Acute motor axonal neuropathy (AMAN) was the most common subtype. Approximately 80% required mechanical ventilation, with a median duration of 22.5 days. No in-hospital mortality was recorded. At discharge, most patients had a GBS disability score of 4, improving to 2 at a median follow -up of 228 days. Pediatric GBS patients requiring ICU care exhibit distinctive characteristics, including a higher prevalence of AMAN subtype, seasonal clustering, and favorable outcomes with intensive treatment. The absence of in-hospital mortality underscores the effectiveness of prompt ICU admission and dedicated Neuro-intensive care.

Favorable Impact of Azithromycin on Patients in the Intensive Care Unit with Coronavirus Disease 2019: Insights from the First Wave Using a Japanese Database

BackgroundAzithromycin has favorable effects on critical respiratory diseases owing to its antimicrobial and anti-inflammatory properties. During the early stages of the coronavirus disease 2019 (COVID-19) pandemic, azithromycin was frequently administered before specific treatments were developed. However, the efficacy of this treatment has not been verified. We retrospectively investigated the effects of its intravenous (IV) administration in patients with severe/critical COVID-19 using the National Administrative Database of Japan during the first wave (February–April 2020). MethodsPatients were categorized based on whether they received IV azithromycin within three days of hospitalization. An overlap weighting method with estimated propensity scores was used to reduce bias. ResultsAmong the 830 patients with severe/critical COVID-19, 148 (17.8%) received azithromycin, and 682 (82.2%) did not. After adjustment, the use of azithromycin was associated with a shorter duration of intensive care unit (ICU) management (-3.48 days, 95% confidence interval [CI]: -4.59 to -2.38). However, other endpoints, including mortality rate, duration of mechanical ventilation, and duration of hospital stay, did not suggest any associations. Furthermore, of the 115 ICU patients, 27 (23.5%) were treated with IV azithromycin and 88 (76.5%) were not. After adjustment, azithromycin was associated with favorable outcomes, including reduced in-hospital mortality (odds ratio [OR], 0.45, 95% CI: 0.22 to 0.92), 30-day mortality (OR, 0.46, 95% CI: 0.22 to 0.94), and a shorter duration of ICU management (-2.94 days, 95% CI: -5.15 to -0.73). ConclusionWe verified that IV azithromycin was associated with favorable impact in patients with COVID-19 requiring ICU management.

Acute Kidney Injury in Children: Classification, Recognition and Treatment Principles

Acute kidney injury (AKI) in children is a critical medical condition characterized by a sudden decline in kidney function. This article provides a comprehensive overview of AKI in pediatric populations, exploring its pathophysiology, the role of various drugs and the long-term implications for kidney health. Key topics include oliguria, anuria, urine output, hypervolemia and the interactions among them, as well as role of diuretic nephrotoxicity and the glomerular filtration rate. Concepts of electrolytes, acid–base balance and renal perfusion assessment are presented. Basic principles of intensive care unit (ICU) management, renal replacement therapy and the association with multiorgan failure are described. Additionally, the article discusses the potential long-term outcomes of AKI, including the risk of chronic kidney disease, hypertension and proteinuria.

TAVI for treating severe aortic valve disease in cardiogenic shock: a single centre experience

Abstract Introduction Recent evidence shows the safety and efficacy of TAVI in patients with aortic valve disease (AVD) presenting in cardiogenic shock (CS). However, there is limited data regarding CS management in the cardiac intensive care unit (CICU) and its outcomes. We aimed to describe the CS features, pre-TAVI management and short-term clinical outcomes of a cohort of CS patients (pts) submitted to TAVI. Methods Single-centre retrospective registry of consecutive pts with AVD undergoing TAVI in CS, from January 2020 to October 2023. CS was defined as pre-procedural hypotension/hypoperfusion requiring vasoactive drugs or mechanical circulatory support (MCS) devices. The severity of CS was defined according to the SCAI classification. Procedural related outcomes according to the VARC-3 criteria and 30-day mortality were assessed. Results A total of 16 pts (1% of our global TAVI cohort, 62% male, mean age 79±5 years) meet the inclusion criteria. The majority (n=13) presented severe aortic stenosis, two had degenerated aortic bioprosthesis with severe regurgitation and one had native valve severe regurgitation. 6 pts (38%) had isolated left ventricle (LV) dysfunction and 10 (62%) had biventricular dysfunction. The admission LVEF was 33±8% and the mean transaortic gradient for those with aortic stenosis was 46±13mmHg. The EuroSCORE II estimated for a single non-CABG emergency procedure was 37±15%. All patients were refused for surgical treatment upon Heart Team discussion. At admission, 12 (75%) patients presented in CS SCAI-C, 1 (6%) in SCAI-D and 3 (19%) in SCAI-E. These last 3 patients presented in cardiac arrest upon admission to the CICU (time to ROSC from 2 to 15 minutes). The peak lactate level at 48 hours was 3.4 mmol/L [2.1-5.1] and the highest Vasoactive-Inotropic Score (VIS) during admission was 21 [11-45]. None of the patients needed MCS pre-TAVI. 5 (31%) patients required invasive mechanical ventilation and 5 (31%) renal replacement therapy. Median time between CICU admission and transfemoral TAVI was 2.5 days [IQR 1-7]. Procedural success was 100%, with 57% receiving a balloon-expandable and 43% a self-expandable valve. Post-TAVI CICU length of stay was 6 days [IQR 5-9]. Most common procedural complication were the need for permanent pacemaker implantation (n=2, 12%) and access-related bleeding (n=2, 12%). Hospital length-of-stay was 20±15 days. Thirty-day mortality was 12% (n=2). Conclusion In this cohort of CS patients selected for TAVI treatment, procedural success was achieved in all cases. While complications were similar to the general TAVI population, in-hospital mortality remained high but very acceptable. These results suggest that, if correctly selected, aortic valve disease patients in CS represent a niche for whom brief stabilization and urgent percutaneous valve treatment might impact their dismal prognosis.

Serious Game Development for Public Health: Participatory Design Approach to COVID-19 Quarantine Policy Education.

Public health education plays a crucial role in effectively addressing infectious diseases such as COVID-19. However, existing educational materials often provide only foundational information, and traditional group education faces challenges due to social distancing policies. Addressing these gaps, our study introduces a serious game called "Flattening the Curve." This interactive experience immerses learners in the role of quarantine policy managers, offering unique insights into the effects and challenges of social distancing policies. The development of the game adhered to the SERES framework, ensuring a scientifically designed foundation. To achieve its learning objectives, the game incorporated learning and game mechanics including an agent-based infection model, a social distancing policy model, and an economic model, which were developed based on previous literature. After defining a broad concept of scientific and design foundations, we used a participatory design process. This study included 16 undergraduates and took place over one semester. Participants played the game, gave feedback, and answered surveys. The game was improved based on participants' feedback throughout the process. Participants' feedback was analyzed based on the Design, Play, and Experience framework. Surveys were conducted before and after the activity and analyzed to assess participants' evaluation of and satisfaction with the game. The game successfully achieved its learning objectives, encompassing a comprehensive understanding of infectious disease characteristics; the disease transmission process; the necessity and efficacy of quarantine policies and their delicate balance with economic factors; and the concept of flattening the curve. To achieve this, the game includes the following: (1) an agent-based infection model based on the modified Susceptible-Exposed-Infectious-Hospitalized-Recovered (SEIHR) model with five infectious disease scenarios; (2) a quarantine policy model with social distancing, travel control, and intensive care unit management; and (3) an economic model that allows users to consider the impact of quarantine policies on a community's economy. In response to participatory design feedback, the game underwent meticulous modifications, including refining game systems, parameters, design elements, the user interface, and interactions. Key feedback included requests for more scenarios and engaging yet simple game elements, as well as suggestions for improving the scoring system and design features. Notably, concerns about the fairness of the outcome evaluation system (star rating system), which could incentivize prioritizing economic activity over minimizing casualties, were raised and addressed by replacing the star rating system with a progress-based vaccine development system. Quantitative evaluation results reflect participants' positive assessments of the game through the learner-centric approach. The serious game "Flattening the Curve," developed through a participatory design approach, emerges as a valuable tool for public health education, particularly concerning social distancing policies. The game and its source code are openly accessible online, enabling widespread use for research and educational purposes.

Machine learning to improve the quality of nursing care in open heart intensive care unit: Challenges & opportunities

Open heart intensive care unit (ICU) encounter distinctive challenges due to the critical condition of patients and the intricate nature of required care [1]. Meanwhile, machine learning has emerged as a potent tool to augment decision-making and patient management in this high-stakes setting [2]. This examination delves into how machine learning applications can transform nursing practices, bolster real-time clinical decision-making, and elevate patient outcomes. In this context, research has showcased the effectiveness of machine learning in various facets of ICU management, including real-time monitoring and predictive analytics. For example, machine learning algorithms have effectively anticipated complications like cardiac arrest and acute kidney injury, enabling proactive interventions [3]. Within the realm of open heart ICUs, machine learning models analyze data from continuous monitoring devices to forecast hemodynamic instability [4]. Additionally, machine learning has facilitated personalized care plans by adapting treatments based on individual patient data trends, thereby refining the accuracy of nursing care [5].

Impact of head-of-bed elevation angle on the development of pressure ulcers and pneumonia in patients on mechanical ventilation: a systematic review and meta-analysis

BackgroundMechanical ventilation is crucial for patient management in intensive care units, but it comes with complications such as pressure ulcers and ventilator-associated pneumonia (VAP). The impact of head-of-bed elevation angles on these complications remains a critical area for investigation.MethodsThis systematic review and meta-analysis followed PRISMA guidelines and involved searches across PubMed, Embase, Web of Science, and Cochrane Library, conducted on September 19, 2023, with no date or language restrictions. We included randomized controlled trials that compared different head-of-bed elevation angles in adult ICU patients on mechanical ventilation. Data were extracted on study characteristics, quality assessed using the Cochrane risk of bias tool, and statistical analyses performed using chi-square tests for heterogeneity and fixed or random-effects models based on heterogeneity results.ResultsSix studies met inclusion criteria out of an initial 601 articles. These studies showed minimal heterogeneity (I2 = 0.0% for pressure ulcers, p = 0.930; and for VAP, p = 0.797), supporting the use of fixed-effect models. Results indicated that a higher elevation angle (45°) significantly increased the risk of pressure ulcers (OR = 1.95, 95% CI: 1.12–3.37, p < 0.05) and decreased the incidence of VAP compared to a lower angle (30°) (OR = 0.51, 95% CI: 0.31–0.84, p < 0.05).ConclusionsWhile higher head-of-bed elevation can reduce the risk of VAP in mechanically ventilated patients, it may increase the risk of pressure ulcers. Clinical strategies should carefully balance these outcomes to optimize patient care in ICU settings.RegistrationPROSPERO 2024 CRD42024570232.

Neonatal hyperinsulinism: a retrospective study of presentation and management in a tertiary neonatal intensive care unit in the UK

ObjectiveReports of hyperinsulinism typically focus on infants managed by highly specialised services. However, neonates with hyperinsulinism are initially managed by neonatologists and often not referred to specialists. This study aimed...

The Impact of Sedative Choice in the Management of Aneurysmal Subarachnoid Hemorrhage: A Scoping Review.

Aneurysmal subarachnoid hemorrhage (aSAH) is characterized by high mortality and morbidity. This scoping review assesses the current evidence regarding the use of sedatives and analgesics in the acute intensive care unit management of aSAH. We conducted a systematic search of Ovid MEDLINE, Ovid Embase, Ovid EmCare, APA PsycInfo, CINAHL, and the Cochrane Database of Systematic Reviews from inception to June 2023. Studies were included if they enrolled intensive care unit patients aged 18 or older with a significant proportion (> 20%) who had aSAH and evaluated the impact of one or more commonly used analgosedatives on physiological parameters in the management of aSAH. The methodological quality of the studies was assessed using the Methodological Index for Nonrandomized Studies score. Of 2,583 articles, 11 met the inclusion criteria. The median sample size was 47 (interquartile range 10-127), and the median Methodological Index for Nonrandomized Studies score was 9.5 (interquartile range 8-11). The studies' publication years ranged from 1980 to 2023. Dexmedetomidine and ketamine showed potential benefits in reducing the incidence of cortical spreading depolarization and delayed cerebral ischemia. Propofol and opioids appeared safe but lacked robust evidence for efficacy. Benzodiazepines were associated with increased delayed cerebral ischemia-related cerebral infarctions and cortical spreading depolarization events. The evidence available to guide the use of analgosedative medications in aSAH is critically inadequate. Dexmedetomidine and ketamine warrant further exploration in large-scale prospective studies because of their potential benefits. Improved study designs with consistent definitions and a focus on patient-centered outcomes are necessary to inform clinical practice.

Acute respiratory distress syndrome in patients with hematological malignancies: a one-year retrospective nationwide cohort study

BackgroundAcute respiratory distress syndrome (ARDS) occurring in patients with hematological malignancies (HM) is a life-threatening condition with specific features. Mortality rate remains high but improvement has been described over the past several years. We aimed to describe characteristics and outcomes of ARDS in HM patients admitted in French ICUs (Intensive Care Units) during a one year-period. Data for this nationwide cohort study were collected from the French national hospital database (Programme de Médicalisation des Systèmes d’Information (PMSI)). All patients (18 years or older) admitted to French ICUs in 2017 and with a diagnosis of ARDS were included. Three groups were compared according to the presence of an HM, a solid cancer or no cancer. The primary endpoint was 90-day mortality. Secondary endpoints were the description of ICU management, etiologies of ARDS and mortality risk factors.ResultsA total of 12 846 patients with ARDS were included. Among them, 990 had HM and 2744 had a solid cancer. The main malignancies were non-Hodgkin lymphoma (NHL) (28.5%), acute myeloid leukemia (AML) (20.4%) and multiple myeloma (19.7%). Day-90 mortality in patients with HM was higher than in patients with no cancer (64.4% vs. 46.6% p = 0.01) but was not different from that of patients with solid cancer (64.4% vs. 61.4%,p = 0.09). Intubation rate was lower in patients with HM in comparison with both groups (87.7% vs. 90.4% p = 0.02 for patients with solid cancer and 87.7% vs. 91.3%; p < 0.01 with no cancer). Independent predictors of mortality for patients with HM were a diagnosis of lymphoma or acute leukemia, age, a high modified SAPS II score, a renal replacement therapy, invasive fungal infection, and a septic shock. Bacterial pneumonia, extrapulmonary infections and non-invasive ventilation were protective.ConclusionMortality remains high in patients with HM admitted in ICU with ARDS in comparison with patients without cancer. Mortality predictors for this population were a diagnosis of lymphoma or acute leukemia, age, a high modified SAPS II score, a renal replacement therapy, invasive fungal infection and a septic shock.

Vasopressor-Inotropic Score: Review of Literature.

Patients undergoing cardiac surgery often receive vasopressor and inotropic medications during the surgical procedure and during intensive care unit (ICU) management following surgery. Patients with cardiogenic shock, septic shock, and other clinical disorders associated with shock also receive vasopressor medications during their ICU care. The level of support and the duration of support are likely associated with outcomes, including mortality and new organ dysfunction, such as acute kidney injury. The vasopressor-inotropic score provides a simple method to determine the level of support during the care of these patients; this score includes the infusion rates of norepinephrine, epinephrine, dopamine, dobutamine, and other inotropic medications. It has been studied in patients undergoing cardiac surgery, coronary artery bypass grafting, cardiac transplantation, left ventricular assist device implantation, septic shock, and traumatic brain injury. Higher scores are associated with poor outcomes and complications during ICU care. The studies analyzed in this review demonstrate the utility of the vasopressor-inotropic score in a variety of clinical disorders associated with shock. Electronic medical record systems should develop algorithms to calculate this score and provide continuous up-to-date measurements. This could help clinicians identify patients at risk for mortality and important complications, such as acute kidney injury.

Alarm Management in Provisional COVID-19 Intensive Care Units: Retrospective Analysis and Recommendations for Future Pandemics.

In response to the high patient admission rates during the COVID-19 pandemic, provisional intensive care units (ICUs) were set up, equipped with temporary monitoring and alarm systems. We sought to find out whether the provisional ICU setting led to a higher alarm burden and more staff with alarm fatigue. We aimed to compare alarm situations between provisional COVID-19 ICUs and non-COVID-19 ICUs during the second COVID-19 wave in Berlin, Germany. The study focused on measuring alarms per bed per day, identifying medical devices with higher alarm frequencies in COVID-19 settings, evaluating the median duration of alarms in both types of ICUs, and assessing the level of alarm fatigue experienced by health care staff. Our approach involved a comparative analysis of alarm data from 2 provisional COVID-19 ICUs and 2 standard non-COVID-19 ICUs. Through interviews with medical experts, we formulated hypotheses about potential differences in alarm load, alarm duration, alarm types, and staff alarm fatigue between the 2 ICU types. We analyzed alarm log data from the patient monitoring systems of all 4 ICUs to inferentially assess the differences. In addition, we assessed staff alarm fatigue with a questionnaire, aiming to comprehensively understand the impact of the alarm situation on health care personnel. COVID-19 ICUs had significantly more alarms per bed per day than non-COVID-19 ICUs (P<.001), and the majority of the staff lacked experience with the alarm system. The overall median alarm duration was similar in both ICU types. We found no COVID-19-specific alarm patterns. The alarm fatigue questionnaire results suggest that staff in both types of ICUs experienced alarm fatigue. However, physicians and nurses who were working in COVID-19 ICUs reported a significantly higher level of alarm fatigue (P=.04). Staff in COVID-19 ICUs were exposed to a higher alarm load, and the majority lacked experience with alarm management and the alarm system. We recommend training and educating ICU staff in alarm management, emphasizing the importance of alarm management training as part of the preparations for future pandemics. However, the limitations of our study design and the specific pandemic conditions warrant further studies to confirm these findings and to explore effective alarm management strategies in different ICU settings.

Risk-scoring system predicting need for hospital-specific interventional care after peroral endoscopic myotomy.

Early identification of patients needing hospital-specific interventional care (HIC) following endoscopic treatment is valuable for optimizing postoperative hospital stays. We aimed to develop and validate a risk-scoring system for predicting HIC in patients who underwent peroral endoscopic myotomy (POEM). This study included patients with esophageal motility disorders who underwent POEM at our hospital between April 2015 and March 2023. HIC was defined as any of the following situations: fasting for gastrointestinal rest to manage adverse events (AEs); intravenous administration of medications such as antibiotics and blood transfusion; endoscopic, radiologic, and surgical interventions; intensive care unit management; or other life-threatening events. A risk-scoring system for predicting HIC after postoperative day (POD) 1 was developed using multivariable logistic regression and was internally validated using bootstrapping and decision curve analysis. Of the 589 patients, 50 (8.5%) experienced HIC after POD1. Risk scores were assigned for four factors as follows: age (0 points for <70 years, 1 point for 70-79 years, 2 points for ≥80 years), preoperative prognostic nutritional index (0 points for >45, 1 point for 40-45, 4 points for <40), postoperative surgical site AEs on second-look endoscopy (7 points), and postoperative pneumonia on chest radiography (6 points). The discriminative ability (concordance statistics, 0.85; 95% confidence interval, 0.78-0.91) and calibration (slope 1.00; 0.74-1.28) were satisfactory. The decision curve analysis demonstrated its clinical usefulness. This risk-scoring system can predict the HIC after POD1 and provide useful information for determining discharge.

Patient recall of intensive care delirium: A qualitative investigation.

Many patients in the Intensive Care Unit (ICU) experience delirium. Understanding the patient perspective of delirium is important to improve care and reduce suffering. The aim of our study was to investigate the subjective patient experience of delirium, delirium-related distress, and delirium management in ICU. Our study had a qualitative multicenter design applying individual interviews and thematic analysis. Participants were critically ill adult patients that were determined delirium positive according to validated delirium screening tools during ICU admission. The interviews were conducted after ICU discharge when patients were delirium-free as assessed by the "Rapid clinical test for delirium" (4AT) and able to participate in an interview. We interviewed 30 patients choosing the main themes deductively: Delirium experience; Delirium related distress; and Delirium management. Despite variations in recollection detail, ICU survivors consistently reported delirium-related distress during and after their ICU stay, manifesting as temporal confusion, misinterpretations, and a sense of distrust towards ICU staff. Delusions were characterized by a blend of factual and fictional elements. Impaired short-term memory hindered communication and intensified feelings of isolation, neglect, and loss of control. The ICU survivors in our study recalled delirium as an unpleasant and frightening experience, often leading to delirium-related distress during and after their ICU stay, indicating the necessity for enhanced assessment and treatment.

Practice survey on recent changes in post cardiac arrest care and temperature management in French intensive care units

BackgroundRecent guidelines for post-cardiac arrest (CA) management have undergone significant changes regarding targeted therapeutic management (TTM), transitioning from hypothermia to temperature control. We aimed to assess changes in post-CA management in French intensive care units following the new recommendations. MethodsTwo declarative web surveys were conducted from March to August 2023. We compared the doctors' survey to that previously published in 2015. We contacted 389 departments from 276 French centers. ResultsThree hundred thirty-four physicians from 189 distinct ICUs departments participated in the survey. TTM was used by 95.5 % of respondents. TTM with temperature feedback device was used by 64 % of respondents. In multivariate analysis, use of TTM with temperature feedback was associated with university hospital responder [OR 1.99 (1.19–3.34, p = 0.009)], high CA admissions rate [OR 2.25 (1.13–4.78, p = 0.026)], use of a written CA procedure [OR 1.76 (1.07–2.92, p = 0.027)] and presence of a cath-lab performing coronary angiography [OR 2.42 (1.33–4.44, p = 0.004)]. The targeted temperature rose from 32 to 34 °C in 2015, to 35–36 °C in 2023 (p < 0.001). Proportions of TTM with temperature feedback devices switched from 45 % to 65 % (p < 0.001). 660 nurses responses from 150 ICUs were analyzed. According to TTM users, gel-coated water circulating pads and intravascular cooling were considered the most effective devices and were found to be easily adjustable. ConclusionsThese surveys provide insights into post-resuscitation care and TTM practice in France. One year after their publication, the latest recommendations concerning TTM have not been fully implemented, as the majority of ICUs continue to use moderate hypothermia. They widely reported employing specific TTM, with the use of TTM with temperature feedback devices increasing significantly. Heterogeneity exists regarding the TTM systems used, with a significant proportion lacking temperature feedback. This aspect requires specific attention, depending on local constraints and devices costs.

Severe Neuropathic Back Pain as the Initial Presentation in Angiostrongylus cantonensis Infection: The Role of ICU Management in Overcoming Diagnostic and Analgosedation Challenges

Introduction: Angiostrongylus cantonensis is a parasitic nematode that typically inhabits the pulmonary arteries of rats but can also reside in the central nervous systems of rats and mollusks. Humans can become infected with A. cantonensis by eating infected hosts or consuming contaminated food, especially if it is raw or undercooked. This infection can lead to various neurological symptoms, including neuropathic pain, which is often an early indication of the condition. In this report, we present a case in which the patient experienced neuropathic pain as the initial clinical manifestation of A. cantonensis infection. Case Presentation: We present a rare case of a 27-year-old female who required intensive care unit (ICU) monitoring due to heavy sedation after receiving high doses of sedative-analgesics for back pain. The patient reported experiencing severe, slow-progressing low back pain radiating to her arms and legs. The pain was described as sharp, tingling, and numbing, severely limiting her movements. To manage the pain, a combination of morphine, intermittent fentanyl, ketamine, dexmedetomidine, duloxetine, and pregabalin was administered. Consequently, the patient had to be intubated due to the effects of the analgesics. During the first two weeks in the ICU, diagnosis proved challenging as the MRI was normal and the initial lumbar puncture revealed only an eosinophilic infection. However, during a follow-up lumbar puncture, multiple parasites were discovered in the cerebrospinal fluid, which were identified as A. cantonensis. The patient remains on a ventilator as the infection has affected the spinal nerve roots, cord, meninges, and brain. We explore the crucial role of ICU care in providing both supportive and definitive treatment for this patient. Conclusions: This report underscores the critical role of the ICU in providing care for a patient with a progressively deteriorating condition without an initial definitive diagnosis. The ICU's ability to deliver optimal pain relief and sedation, advanced monitoring, and prompt therapy for deteriorating symptoms was of utmost significance. Furthermore, the multidisciplinary team in the ICU was instrumental in managing the continuum of care for the patient.

Impact of a 'Catheter Bundle' on Infection Rates and Economic Costs in the Intensive Care Unit: A Retrospective Cohort Study.

Catheter-related infections (CBRSIs) are a widespread problem that increase morbidity and mortality in intensive care unit (ICU) patients and management costs. The main aim of this study was to assess the prevalence of CBRSIs in an intensive care unit following international literature guidelines for managing vascular lines in critically ill patients. These guidelines include changing vascular lines every 7 days, using needle-free devices and port protectors, standardising closed infusion lines, employing chlorhexidine-impregnated dressings, and utilising sutureless devices for catheter securement. This single-centre retrospective observational study was conducted in a general Italian ICU. This study included all eligible patients aged > 1 year who were admitted between January 2018 and December 2022. During the study period, 1240 patients were enrolled, of whom 9 were diagnosed with a CRBSI. The infection rate per 1000 catheters/day was as follows: femorally inserted central catheter, 1.04; centrally inserted central catheter, 0.77; pulmonary arterial catheter 0.71, arterial catheter, 0.1; and peripherally inserted central catheter and continuous veno-venous haemodialysis dialysis catheters equal to 0. No difference in CRBSI was observed between the years included in the study (p = 0.874). The multivariate analysis showed an association between the diagnosis of CBRSI and Nursing Activities Score (per single point increase β = 0.04-95%CI: -0.01-0.09, p = 0.048), reason for ICU admission-trauma (β = 0.77-95%CI: -0.03-1.49, p = 0.039), and use of therapeutic hypothermia (β = 2.06, 95%CI: 0.51-3.20, p < 0.001). Implementing the study protocol revealed a cost of EUR 130.00/patient, equivalent to a daily cost of EUR 15.20 per patient. This study highlights the importance of implementing a catheter care bundle to minimise the risk of CRBSI and the associated costs in the ICU setting. A policy change for infusion set replacement every 7 days has helped to maintain the CRBSI rate below the recommended rate, resulting in significant cost reduction and reduced production of ICU waste.

Intensive Care Unit Management of Right Heart Failure and Lung Transplantation for Pulmonary Hypertension

: Pulmonary hypertension is associated with worse outcomes across systemic and cardiopulmonary conditions. Right ventricular (RV) dysfunction often leads to poor outcomes due to a progressive increase in RV afterload. Recognition and management of RV dysfunction are important to circumvent hospitalization and improve patient outcomes. Early recognition of patients at risk for RV failure is important to ensure that medical therapy is optimized and, where appropriate, referral for lung transplant assessment is undertaken. Patients initiated on parenteral prostanoids and those with persistent intermediate to high risk for poor outcomes should be referred. For patients with RV failure, identifying reversible causes should be a priority in conjunction with efforts to optimize RV preload and strategies to reduce RV afterload. Admission to a monitored environment where vasoactive medications can treat RV failure and its sequelae, such as renal dysfunction, is essential in patients with severe RV failure. Exit strategies need to be identified early on, with consideration and implementation of extracorporeal support for those in whom recovery or transplantation are viable options. Enlisting the skills and support of a palliative care team may improve the quality of life for patients with limited options and those with ongoing symptoms from heart failure in the face of medical treatments.

A study of a loss system with priorities

The Erlang loss formula, also known as the Erlang B formula, has been known for over a century and has been used in a wide range of applications, from telephony to hospital intensive care unit management. It provides the blocking probability of arriving customers to a loss system involving a finite number of servers without a waiting room. Because of the need to introduce priorities in many services, an extension of the Erlang B formula to the case of a loss system with preemptive priority is valuable and essential. This paper analytically establishes the consistency between the global balance (steady state) equations for a loss system with preemptive priorities and a known result obtained using traffic loss arguments for the same problem. This paper, for the first time, derives this known result directly from the global balance equations based on the relevant multidimensional Markov chain. The paper also addresses the question of whether or not the well-known insensitivity property of the Erlang loss system is also applicable to the case of a loss system with preemptive priorities, provides explanations, and demonstrates through simulations that, except for the blocking probability of the highest priority customers, the blocking probabilities of the other customers are sensitive to the service time distributions and that a larger service time variance leads to a lower blocking probability of the lower priority traffic.