Adult General Intensive Care Unit Research Articles

Predictive value of fluid balance before extubation on its outcome in mechanically ventilated adults in the intensive care unit.

Although there are many reasons for extubation failure, maintaining negative or lower positive fluid balances 24 hours before extubation may be a key measure for successful extubation. To assess the predictive value of fluid balance before extubation and its outcome in mechanically ventilated cases in the intensive care unit (ICU). This retrospective cohort study involved collecting clinical data from patients undergoing mechanical ventilation in Lanzhou general adult ICU from January 2022 to December 2022. Based on extubation outcomes, the patients were divided into a successful extubation group and a failed extubation group. Their fluid balance levels 24 h before extubation were compared with analyse the predictive value of fluid balance on extubation outcomes in patients undergoing mechanical ventilation. In this study, clinical data from 545 patients admitted to a general adult ICU were collected. According to the inclusion and exclusion criteria, 265 (48.6%) patients were included, of which 197 (74.3%) were successfully extubated; extubation was unsuccessful in 68 (25.7%) patients. The total intake and fluid balance levels in patients in the failed extubation group 24 h before extubation were significantly higher than those in the successful extubation group, with a median of 2679.00 (2410.44-3193.50) mL versus 2435.40 (1805.04-2957.00) mL, 831.50 (26.25-1407.94) mL versus 346.00 (-163.00-941.50) mL. Receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off value for predicting extubation outcomes was 497.5 mL (sensitivity 64.7%, specificity 59.4%) for fluid balance 24 h before extubation. The area under the ROC curve was 0.627 (95% confidence interval [CI] 0.547-0.707). Based on the logistic regression model, cumulative fluid balance >497.5 mL 24 h before extubation could predict its outcomes in mechanically ventilated patients in the ICU (OR = 5.591, 95% CI [2.402-13.015], p < .05). The fluid balance level 24 h before extubation was correlated with the outcome of extubation in mechanically ventilated patients in the ICU. The risk of extubation failure was higher when the fluid balance level was >497.5 mL. Tracheal intubation is a crucial life support technique for many critically ill patients, and determining the appropriate time for extubation remains a challenge for clinicians. Although there are many reasons for extubation failure, acute pulmonary oedema caused by continuous positive fluid balance and volume overload is one of the main reasons for extubation failure. Therefore, it is very important to study the relationship between fluid balance and extubation outcome to improve the prognosis of patients with invasive mechanical ventilation in ICU.

Investigation of some changes and clonal relationship in enterococci isolates due to relocation of a hospital.

To investigate the isolation rates, antimicrobial resistance rates, minimum inhibitory concentration values of antimicrobial agents, and clonal relationships of Enterococcus faecalis and Enterococcus faeciumdue to the relocation of a hospital to a newly constructed building. The comparative, prospective study was conducted at adult general intensive care units of the Mus State Hospital, Mus, Turkey, in two phases; before the relocation from January 25 to December 1, 2014, and after the relocation from February 10 to May 24, 2015. Rectal swab samples were collected 72 hours post-hospitalisation. Identification of Enterococcus faecalis and Enterococcus faeciumisolates was determined by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, and antimicrobial resistance with minimum inhibitory concentration values was detected with Vitek 2 system. The clonal relatedness among the strains was investigated by pulsed-field gel electrophoresis. Data was analysed using SPSS 23. Of the 69 patients, 37(53.62%) were related to pre-relocation phase; 20(54.1%) females and 17(45.9%) males with mean age 62.81±21.71 years. There were 32(46.37%) patients in the post-relocation phase; 13(40.6%) females and 19(59.4%) males with mean age 62.69±21.35 years (p>0.05). Of the 84 enterococci strains isolated, 51(60.7%) were Enterococcus faecium; 28(55%) before relocation and 23(45%) after relocation (p=0.77). The remaining 33(39.3%) isolates were Enterococcus faecalis; 16(48.5%) before relocation and 17(51.5%) after relocation (p=0.73). Multiple strains were located in 7(18.9%) patients before relocation and in 7(21.9%) after relocation. In 1(3.1%) patient after relocation, 2(8.7%) Enterococcus faecium isolates with different resistance and pulsed-field gel electrophoresis patterns were detected. There were no significant differences between the isolation and antibiotic resistance rates before and after relocation (p>0.05), and a clonal relation between the isolates was not detected (p>0.05). Decreased minimum inhibitory concentration values were noted for some antibiotics. Clonal relationship between the isolates and change in the rates of isolation and antimicrobial resistance of Enterococcus faecalis and Enterococcus faecium was not detected due to relocation. Minimum inhibitory concentration values could be used to reveal relocation-related changes in isolates obtained from patients hospitalised in intensive care units.

Knowledge of Technical Nursing Professionals About the Subject of Brain Death and the Process of OrganDonation and Transplantation

Background: The low percentage of effective organ donations result from challenges encountered by the team in identifying and maintaining potential donors, the need for knowledge regarding the subject, and the health system’s structural adversities. It is the role of nursing to act actively throughout the family decision-making process, expanding the focus beyond the donation of organs and tissues, respecting the suffering of the family and providing integrated care to those involved. Objective: This study aims to verify the knowledge of technical nursing professionals working in an intensive care unit about brain death, organ donation, and transplantation. Method: A cross-sectional study in which the nursing technicians personnel from the General Adult Intensive Care Unit of a university hospital were interviewed and invited to answer a questionnaire containing demographic variables (age and gender), work (work shift, workload, another job, time in the position and if you have already witnessed the performance of a clinical test, and complementary examination of brain death), and the questions related to the process of organ donation and brain death, with descriptive and multiple choice questions. Result: A total of 137 nursing technicians were included in the study, predominantly female (80%). Of these, 97 (71%) did not consider themselves capable of answering questions about organ donation and transplants. When questioned about participation in events and training that addressed the subject of brain death, organ donation and transplants, 112 employees (82%) had never participated. When asked about “which professionals can diagnose brain death?,” 26% correctly answered the professional who is qualified to perform the diagnosis of brain death. Ninety percent of the study participants correctly stated that you must notify your family to be a donor. However, 50% of the technicians believe that it is necessary to register with an identification document valid in the country. Erroneously, 79% of the interviewees answered that it would not be required for the patient to be on mechanical ventilation to start the investigation of brain death. Conclusion: We concluded that there is a deficit in the knowledge of nursing technicians in intensive care units of the referred hospital regarding brain death and organ donation for transplantation.

Terapia ocupacional em unidade de terapia intensiva (UTI) adulto privada: relato de experiências

Abstract Introduction The treatment of critically ill patients has gained prominence in recent years. The health demands of these patients are specific and require hospitalization in intensive care unit (ICU), confirming the need for a specialized, qualified, and multidisciplinary team as recommended by resolution RDC No. 7 of 2010, which addresses the need for the presence of an occupational therapist in ICUs. Objective This study aims to report the experiences of the first year of an occupational therapist in the adult general ICU in a private high-complexity tertiary hospital located in the city of São Paulo, and to reflect on this field of action. Method This is an experience report conducted through the analysis of medical records and occupational therapeutic assessment for later reading of the existing literature. Results The identification of occupational therapeutic interventions involves the use of assistive technology, reception actions, and (re)habilitation of occupations in the ICU environment. Conclusion Occupational therapy has been gaining ground in the context of adult general intensive care unit, where the demonstration of real occupational therapy actions has led to the recognition, by high hospital management, of these approaches with critical patients and the role of this profession in the multiprofessional team.

Clinical Impact and Risk Factors of Intensive Care Unit-Acquired Nosocomial Infection: A Propensity Score-Matching Study from 2018 to 2020 in a Teaching Hospital in China.

Nosocomial infection (NI) is associated with poor prognosis. The present study assessed the clinical and microbiological characteristics of NI patients in the intensive care unit (ICU) and investigated the clinical impact and risk factors for NI in ICU patients. An observational study was conducted in an adult general ICU. The electronic medical records of all patients admitted to the ICU for >2 days from 2018-2020 were analyzed retrospectively. Multivariate regression models were used to analyze the risk factors for NI in ICU patients. Propensity score-matching (PSM) was used to control the confounding factors between the case and control groups, thus analyzing the clinical impact of NIs. The present study included 2425 patient admissions, of which 231 (9.53%) had NI. Acinetobacter baumannii (33.0%) was the most common bacteria. Long-term immunosuppressive therapy, disturbance of consciousness, blood transfusion, multiple organ dysfunction syndromes (MODS), treatment with three or more antibiotics, mechanical ventilation (MV), tracheotomy, the urinary catheter (UC), nasogastric catheter, and central venous catheter (CVC) were risk factors for NI in the ICU patients. After PSM, patients with NI had a prolonged length of stay (LOS) in the ICU and hospital, significant hospitalization expenses (all p<0.001), increased mortality (p=0.027), and predicted mortality (p=0.007). The differences in the ICU and hospital LOSs among three pathogens were statistically significant (p<0.001); the results of the Escherichia coli infection group were lower than the other two pathogenic groups. NI was associated with poor outcomes. The risk factors for NI identified in this study provided further insight into preventing NI.

Regional citrate anticoagulation versus systemic heparin anticoagulation for continuous kidney replacement therapy in intensive care

PurposeMany intensive care units (ICUs) have transitioned from systemic heparin anticoagulation (SHA) to regional citrate anticoagulation (RCA) for continuous kidney replacement therapy (CKRT). We evaluated the clinical and health economic impacts of ICU transition to RCA. Materials and methodsWe surveyed all adult general ICUs in England and Wales to identify transition dates and conducted a micro-costing study in eight ICUs. We then conducted an interrupted time-series analysis of linked, routinely collected health records. ResultsIn 69,001 patients who received CKRT (8585 RCA, 60,416 SHA) in 181 ICUs between 2009 and 2017, transition to RCA was not associated with a change in 90-day mortality (adjusted odds ratio 0.98, 95% CI 0.89–1.08) but was associated with step-increases in duration of kidney support (0.53 days, 95% CI 0.28–0.79), advanced cardiovascular support (0.23 days, 95% CI 0.09–0.38) and ICU length of stay (0.86 days, 95% CI 0.24–1.49). The estimated one-year incremental net monetary benefit per patient was £ − 2376 (95% CI £ − 3841–£ − 911), with an estimated likelihood of cost-effectiveness of <0.1%. ConclusionsTransition to RCA was associated with significant increases in healthcare resource use, without corresponding clinical benefit, and is highly unlikely to be cost-effective over a one-year time horizon.

What are the perceptions of intensive care staff about their sedation practices when caring for a mechanically ventilated patient?: A systematic mixed-methods review.

Sedation is used alongside mechanical ventilation for patients in intensive care units internationally; its use is complex and multifaceted. Existing evidence shows that the ways health care professionals use sedation significantly impacts patient outcomes, including how long someone spends on a ventilator, length of stay in intensive care and recovery. Our study aimed to systematically review and synthesize qualitative and quantitative evidence about how intensive care staff perceive sedation practices when looking after sedated and mechanically ventilated patients. We performed a systematic integrated mixed-methods literature review collecting qualitative and quantitative studies according to inclusion and exclusion criteria. Studies were included if they were published from 2009 and focused on perceptions of staff working in general adult intensive care units and caring for mechanically ventilated patients. General adult intensive care units. Health care professionals working in adult intensive care units. Screening, data extraction and quality appraisal was undertaken by SV. Screening for inclusion and quality issues were reviewed by TR, TM and JS. The following databases: Embase, BNI, PubMed, Scopus, AMED, CINAHL, ASSIA, The Cochrane Library and Google Scholar. We used an assessment tool called the Mixed Methods Appraisal Tool. The studies were assessed and analysed by transforming the qualitative and quantitative data into 'text-in-context' statements. The statements were then synthesized using thematic analysis. Eighteen studies were included from ten countries, fourteen quantitative and four qualitative. Three overarching themes were identified: 'Variation in Decision Making', 'Challenges in Decision Making' and 'Thinking Outside the Box'. Existing studies revealed that there is considerable variation in most aspects of perceived sedation practice. Staff face challenges with interprofessional collaboration and sedation practice, and there are barriers to using sedation protocols and light sedation. There is also evidence that there is a need for health care professionals to develop coping strategies to help them facilitate lighter sedation. A review of a decade of evidence shows that variation in decision making and challenges in decision making should be addressed to improve the care of the sedated and ventilated patient, and improve the caregiving experience for staff. Staff continue to require support with sedation practice, especially in light sedation. Research should now focus on how to help staff cope with looking after lightly sedated patients. In addition, future studies should focus on exploring sedation practices using qualitative methods as there is a dearth of qualitative evidence. Staff perceive a range of complex challenges that explain some of the variability in sedation practice for the ventilated patient in ICU.

Nutrition therapy in the older critically ill patients: A scoping review

There is a lack of guidelines or formal systematic synthesis of evidence for nutrition therapy in older critically ill patients. This study is a scoping review to explore the state of evidence in this population. MEDLINE and Embase were searched from inception until 9 February 2022 for studies that enrolled critically ill patients aged ≥60 years and investigated any area of nutrition therapy. No language or study design restrictions were applied. Thirty-two studies (5 randomised controlled trials) with 6 topics were identified: (1) nutrition screening and assessments, (2) muscle mass assessment, (3) route or timing of nutrition therapy, (4) determination of energy and protein requirements, (5) energy and protein intake, and (6) pharmaconutrition. Topics (1), (3) and (6) had similar findings among general adult intensive care unit (ICU) patients. Skeletal muscle mass at ICU admission was significantly lower in older versus young patients. Among older ICU patients, low muscularity at ICU admission increased the risk of adverse outcomes. Predicted energy requirements using weight-based equations significantly deviated from indirect calorimetry measurements in older vs younger patients. Older ICU patients required higher protein intake (>1.5g/kg/day) than younger patients to achieve nitrogen balance. However, at similar protein intake, older patients had a higher risk of azotaemia. Based on limited evidence, assessment of muscle mass, indirect calorimetry and careful monitoring of urea level may be important to guide nutrition therapy in older ICU patients. Other nutrition recommendations for general ICU patients may be used for older patients with sound clinical discretion.

Urinary Trace Elements Are Biomarkers for Early Detection of Acute Kidney Injury

IntroductionAcute kidney injury (AKI) is common in hospitalized patients and associated with poor outcomes. Current methods for identifying AKI (rise in serum creatinine [sCr] or fall in urine output [UO]) are inadequate and delay detection. Early detection of AKI with easily measurable biomarkers might improve outcomes by facilitating early implementation of AKI care pathways.MethodsFrom a porcine model of AKI, we identified trace elements (TEs) in urine that were associated with subsequent development of AKI. We tested these putative biomarkers in 2 observational cohort studies of patients at high risk of AKI: 151 patients undergoing cardiac surgery and 150 patients admitted to a general adult intensive care unit (ICU).ResultsIn adults admitted to the ICU, urinary cadmium (Cd) (adjusted for urinary creatinine) had area under the receiver operating characteristic curve (AUROC) 0.70 and negative predictive value (NPV) 89%; copper (Cu) had AUROC 0.76 and NPV 91%. In humans (but not pigs), urinary zinc (Zn) was also associated with AKI and, in the ICU study, had AUROC 0.67 and NPV 80%. In patients undergoing cardiac surgery, Zn had AUROC 0.77 and NPV 91%; urinary Cd and Cu had poor AUROC but NPV of 93% and 95%, respectively. In control studies, we found that the urinary biomarkers are stable at room temperature for at least 14 days and are not affected by other confounding factors, such as chronic kidney disease (CKD).ConclusionUrinary Cd, Cu, and Zn are novel biomarkers for early detection of AKI. Urinary trace metals have advantages over proteins as AKI biomarkers because they are stable at room temperature and have potential for cheap point-of-care testing using electrochemistry.

The efficacy and safety of nurse-initiated sedation management in an intensive care unit: A two-phase prospective study in Japan.

This study aimed to evaluate whether nurse-initiated sedation management could provide more appropriate sedation compared to usual care in a Japanese intensive care unit (ICU). We conducted a single-center, prospective observational study before and after implementing nurse-initiated sedation using instruction sheets. Patients who had been admitted to a general adult ICU were enrolled. Before our ICU started nurse-initiated sedation (pre-implementation care), adjustment of sedatives and analgesics was performed only by a physician's written or verbal order; however, after implementing nurse-initiated sedation, nurses titrated drugs using instruction sheets. The primary outcome was the efficacy of nurse-initiated sedation, evaluated by the proportion achieving the target Richmond Agitation-Sedation Scale (RASS) score. The analgesic status evaluated by Critical-Care Pain Observation Tool (CPOT), days of delirium, ventilator days, ICU mortality and hospital mortality were also evaluated. The study examined 30 patients in the pre-implementation care phase and 30 patients in the nurse-initiated sedation phase. The proportions achieving the target RASS were 68% in the nurse-initiated sedation group and 42% in the pre-implementation care group (mean difference, 25%; 95% confidence interval, 13.4%-37.5%; P <.001). Almost all measured CPOT were within the range of 0-3 during both phases. Days of delirium, ventilator days, ICU survival, and hospital survival did not differ significantly between the two groups. Nurse-initiated sedation management achieved a significantly higher degree of target sedation status and was incorporated as part of the care in our ICU. It is a safe approach in countries, such as Japan, where sedation protocols are not widely used.

Medication Errors Require Intensive Care Unit Admission

Objective: To evaluate the incidence and characteristics of medication errors (MEs) requiring intensive care unit (ICU) admissions and to determine the medication associated with MEs. Methods: A 6-month prospective observational study was conducted in the general adult ICU of a teaching hospital (Salmaniya Medical Complex, Bahrain). Patients admitted to the ICU were screened to determine which admissions were related to MEs. The medication errors were categorized based on medication class, polypharmacy, and the main system involved during the admission. Result: A total of 177 patients were included during the study period. MEs related to ICU admission accounted for 14.67% of total ICU admission during the study period. Polypharmacy patients who received more than five medications had a higher incidence of MEs (n= 17; 61.54%). Almost all MEs occurred during the prescribing phase. Anticoagulant medications were associated with one-third of MEs require ICU admissions, with a mortality rate of 62%. The average length of ICU stay in these patients was 7.73 days ± 4.43, with a mortality rate (26.92%; n = 7). The average cost of ICU admissions related to MEs was $213,262 USD. Conclusion: ICU admissions due to MEs are common. Anticoagulant found to be the most common drug class related to MEs and it was associated with a high mortality rate.

Hypernatremia at a Tertiary Hospital Intensive Care Unit in South Africa.

BackgroundHypernatremia in the critical care setting is a major cause of morbidity and mortality. However, data pertaining to this has not been evaluated in South African hospitals. The aim of this study was to evaluate hypernatremia with regards to its prevalence, associated factors, and outcomes at an academic hospital intensive care unit (ICU) in Johannesburg, South Africa.MethodsThe ICU charts of patients admitted to the Charlotte Maxeke Johannesburg Academic Hospital adult general ICU from June 1, 2016 to May 31, 2017 were retrospectively reviewed. Subjects were categorized into three groups namely, ICU-acquired hypernatremia (IAH), pre-admission hypernatremia (PAH), and normonatremia. Data was compared between the three groups.ResultsOf the 833 subjects that were enrolled, 310 (37.2%) were hypernatremic. IAH was present in 144 (17.2%) and PAH in 166 (19.9%) subjects. Hypernatremia was significantly (p <0.05) associated with a higher rate of altered mental status, higher Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) scores, a higher rate and duration of mechanical ventilation, a greater need for inotropic/vasopressor support, longer ICU stay and higher ICU mortality.ConclusionHypernatremia in ICU patients remains a significant contributor to morbidity, mortality, and ICU length of stay. The prevalence of hypernatremia was much higher than that reported in higher-income countries.

Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study.

In the UK, 10% of admissions to intensive care units receive continuous renal replacement therapy with regional citrate anticoagulation replacing systemic heparin anticoagulation over the last decade. Regional citrate anticoagulation is now used in > 50% of intensive care units, despite little evidence of safety or effectiveness. The aim of the Renal Replacement Anticoagulant Management study was to evaluate the clinical and health economic impacts of intensive care units moving from systemic heparin anticoagulation to regional citrate anticoagulation for continuous renal replacement therapy. This was an observational comparative effectiveness study. The setting was NHS adult general intensive care units in England and Wales. Participants were adults receiving continuous renal replacement therapy in an intensive care unit participating in the Intensive Care National Audit & Research Centre Case Mix Programme national clinical audit between 1 April 2009 and 31 March 2017. Exposure - continuous renal replacement therapy in an intensive care unit after completion of transition to regional citrate anticoagulation. Comparator - continuous renal replacement therapy in an intensive care unit before starting transition to regional citrate anticoagulation or had not transitioned. Primary effectiveness - all-cause mortality at 90 days. Primary economic - incremental net monetary benefit at 1 year. Secondary outcomes - mortality at hospital discharge, 30 days and 1 year; days of renal, cardiovascular and advanced respiratory support in intensive care unit; length of stay in intensive care unit and hospital; bleeding and thromboembolic events; prevalence of end-stage renal disease at 1 year; and estimated lifetime incremental net monetary benefit. Individual patient data from the Intensive Care National Audit & Research Centre Case Mix Programme were linked with the UK Renal Registry, Hospital Episode Statistics (for England), Patient Episodes Data for Wales and Civil Registrations (Deaths) data sets, and combined with identified periods of systemic heparin anticoagulation and regional citrate anticoagulation (survey of intensive care units). Staff time and consumables were obtained from micro-costing. Continuous renal replacement therapy system failures were estimated from the Post-Intensive Care Risk-adjusted Alerting and Monitoring data set. EuroQol-3 Dimensions, three-level version, health-related quality of life was obtained from the Intensive Care Outcomes Network study. Out of the 188 (94.9%) units that responded to the survey, 182 (96.8%) use continuous renal replacement therapy. After linkage, data were available from 69,001 patients across 181 intensive care units (60,416 during periods of systemic heparin anticoagulation use and 8585 during regional citrate anticoagulation use). The change to regional citrate anticoagulation was not associated with a step change in 90-day mortality (odds ratio 0.98, 95% confidence interval 0.89 to 1.08). Secondary outcomes showed step increases in days of renal support (difference in means 0.53 days, 95% confidence interval 0.28 to 0.79 days), advanced cardiovascular support (difference in means 0.23 days, 95% confidence interval 0.09 to 0.38 days) and advanced respiratory support (difference in means, 0.53 days, 95% CI 0.03 to 1.03 days) with a trend toward fewer bleeding episodes (odds ratio 0.90, 95% confidence interval 0.76 to 1.06) with transition to regional citrate anticoagulation. The micro-costing study indicated that regional citrate anticoagulation was more expensive and was associated with an estimated incremental net monetary loss (step change) of -£2376 (95% confidence interval -£3841 to -£911). The estimated likelihood of cost-effectiveness at 1 year was less than 0.1%. Lack of patient-level treatment data means that the results represent average effects of changing to regional citrate anticoagulation in intensive care units. Administrative data are subject to variation in data quality over time, which may contribute to observed trends. The introduction of regional citrate anticoagulation has not improved outcomes for patients and is likely to have substantially increased costs. This study demonstrates the feasibility of evaluating effects of changes in practice using routinely collected data. (1) Prioritise other changes in clinical practice for evaluation and (2) methodological research to understand potential implications of trends in data quality. This trial is registered as ClinicalTrials.gov NCT03545750. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 13. See the NIHR Journals Library website for further project information.

Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial

Objective:The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care.Methods:The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia.Conclusion:According to the trial’s best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results. ClinicalTrials.gov registration: NCT03920501

Medication Errors at a Tertiary Hospital Intensive Care Unit.

BackgroundThe intensive care unit (ICU) generates more medication prescriptions per patient day than any other unit in the hospital. The dynamics of the ICU environment, coupled with the complexity of patient pathology, increases the risk of medication errors. This study aimed to evaluate the incidence and spectrum of medication errors in an adult general ICU in Johannesburg, South Africa.MethodsA retrospective chart review was conducted at a 19-bed ICU in a tertiary-level hospital in Johannesburg. Data were independently collected by two of the study investigators. The doctors’ prescription and the nurses’ administration section of patient bedside charts were scrutinized for drug prescription and administration errors.ResultsOf the 656 patient days studied, 3237 drugs (5.6 drugs per patient day) were prescribed. There were a total of 359 medication errors, comprising 237 (66.0%) prescription and 122 (34.0%) administration errors. The total error rate per 1000 patient days was 621.1, while the total error rate per 1000 drug prescriptions was 110.9. The most common errors were incorrect dose prescribed (n=69, 19.2%), incorrect dosing interval prescribed (n=48, 13.4%), incorrect dose administered (n=42, 11.7%) and failure to administer the prescribed drug (n=38, 10.6%).ConclusionThe overall occurrence of medication errors is high but is in keeping with general international trends. Targeted interventions should be implemented to minimize the frequency of medication errors in the ICU and consequent risk to patients.

A newly established pediatric high dependency unit in Norway – Interaction with existing pediatric intensive care

BackgroundIn October 2018, our university hospital opened a 2-bed pediatric high dependency unit. We report interactions between this new unit and existing pediatric intensive care. MethodsWe included patients who met the requirements for extended monitoring and treatment in a retrospective review of ward admissions 29.10.18-28.10.19. Results271 children with 354 ward admissions (’episodes’) with extended monitoring and treatment were admitted to the pediatric high dependency unit (77%), the general pediatric ward, neonatal and adult intensive care, post-operative, and adult high dependency units. Frequent diagnoses were bronchiolitis, epilepsy, pneumonia, diabetic ketoacidosis and therapeutic drug overdose. In 37% of the episodes, non-invasive ventilation was provided. Median (interquartile range) age was 2.2 (0.3-14.2) years and 40% was <1 year. Median length of stay was 29 (15-74) hours and the average bed occupancy in the pediatric high dependency unit 1.6. ConclusionOur results indicate that equipment and staff training should focus on children <1 year of age in need for non-invasive ventilation. There is a potential for more children needing extended monitoring and treatment to be cared for at the pediatric high dependency unit instead of the neonatal and adult intensive care units.

Nasogastric tube placement under sonographic observation: A comparison study of ultrasound and chest radiography in mechanically ventilated patients

BackgroundNasogastric tube insertion in the intensive care setting is common. Placement verification is required to avoid complications of bronchotracheal misplacement that range from aspiration of infused contents to death from associated causes. The gold standard of practice is chest radiography. Ultrasound is a growing modality and is readily available in most intensive care units. ObjectiveThe objective of this study was to examine the diagnostic accuracy of ultrasound imaging of nasogastric tube placements by nonradiologists compared with chest radiography in mechanically ventilated patients. MethodsThis is a dual-centre prospective, single-blind study. Correct placement was captured with a hyperechoic ultrasound image of a nasogastric tube in the oesophagus and epigastrium, which was compared with chest radiography. Patient enrolment included general adult intensive care unit admissions who were mechanically ventilated and required a nasogastric tube for either the treatment or monitoring of their illness. ResultsA total of 25 patients were enrolled (15 men, 10 women), and their mean age was 68.1 ± 13.8 years. Outcome measures were the percentage of correctly identified nasogastric tubes in the oesophagus and epigastrium. The sensitivity of oesophagus ultrasound was 88%, and the positive predictive value was 100%. The subxiphoid sensitivity was 64%, and the positive predictive value was 100%. Comparison sensitivity and specificity of oesophagus versus subxiphoid ultrasound was 64% and 33%, respectively. There was a positive predictive value of 88% and a negative predictive value of 11%. The results showed a variance in detection sensitivity in the ultrasound scans of the oesophagus (0.88) and subxiphoid (0.64) (N = 25, p = 0.012). ConclusionNasogastric tube placement verification via ultrasound in critically ill mechanically ventilated patients conducted by nonradiologists with minimal training is associated with diagnostic accuracy. These results add to the limited evidence in the current literature; however, they should be considered with awareness that placement in the stomach in this study was detected in 64% of cases, alongside the missed captured evidence of the sonographer's ability to identify misplacement.

Variability of environmental sound levels: An observational study from a general adult intensive care unit in the UK.

Intensive care units are significantly louder than WHO guidelines recommend. Patients are disturbed by activities around them and frequently report disrupted sleep. This can lead to slower recovery and long-term health problems. Environmental sound levels are usually reported as LAeq24, a single daily value that reflects mean sound levels over the previous 24-h period. This may not be the most appropriate measure for intensive care units (ICUs) and other similar areas. Humans experience sound in context, and disturbance will vary according to both the individual and acoustic features of the ambient sounds. Loudness is one of a number of measures that approximate the human perception of sound, taking into account tone, duration, and frequency, as well as volume. Typically sounds with higher frequencies, such as alarms, are perceived as louder and more disturbing. Sound level data were collected from a single NHS Trust hospital general adult intensive care unit between October 2016 and May 2018. Summary data (mean sound levels (LAeq) and corresponding Zwicker calculated loudness values) were subsequently analysed by minute, hour, and day. The overall mean LAeq24 across the study duration was 47.4 dBA. This varied by microphone location. We identified a clear pattern to sound level fluctuations across the 24-h period. Weekends were significantly quieter than weekdays in statistical terms but this reduction of 0.2 dB is not detectable by human hearing. Peak loudness values over 90 dB were recorded every hour. Perception of sound is sensitive to the environment and individual characteristics and sound levels in the ICU are location specific. This has implications for routine environmental monitoring practices. Peak loudness values are consistently between 90 and 100dB. These may be driven by alarms and other sudden high-frequency sounds, leading to more disturbance than LAeq24 sound levels suggest. Addressing sounds with high loudness values may improve the ICU environment more than an overall reduction in the 24-h mean decibel value.

Paediatric admissions to a district general hospital adult intensive care unit over a six year period: A single centre retrospective case series, with review of practitioner confidence and competence in paediatric critical care.

Critically ill children presenting to district general hospitals (DGH) are admitted to adult intensive care units (AICUs) for stabilisation prior to transfer to paediatric intensive care units (PICUs). Current training in PICU for adult intensive care physicians is only three months. This single centre retrospective case series examines the case mix of children presenting to a DGH AICU and a multidisciplinary survey assesses confidence and previous experience, highlighting continued training needs for DGH AICU staff. all paediatric admissions to AICU and paediatric retrievals were reviewed over a 6-year period (2014-2019). Cases were identified from the Electronic Patient Record (EPR) and from data provided by the regional paediatric retrieval service. A questionnaire survey was sent to AICU doctors and nurses to assess confidence and competence in paediatric critical care. Between 2014-2019, 284 children were managed by AICU. In total 35% of cases were <1 y, 48% of cases were <2 y and 64% of cases were <5 y, and 166/284 (58%) children were retrieved. Retrieval reduced with increasing age (OR 0.49 [0.40-0.60], p < 0.0001). The survey had an 82% response rate, and highlighted that only 13% of AICU nurses and 50% of doctors had received prior PICU training. At least one critically unwell child presents to the AICU each week. Assessment, stabilisation and management of critically unwell children are vital skills for DGH AICU staff, but confidence and competence are lacking. Formalised strategies are required to develop and maintain paediatric competencies for AICU doctors and nurses.

Knowledge acquisition and retention among nurses after an educational intervention on endotracheal cuff pressure.

Nurses play a key role in the proper management of endotracheal tube (ETT) cuff pressure, which is important for patients' safety, so it is vital to improve nurses' knowledge on safe cuff management practices. This study aimed to evaluate the effectiveness of an educational intervention related to ETT cuff pressure management on improving and retaining critical care nurses' knowledge. A single group pre-post interventional study was conducted involving 112 registered nurses (RNs) from a 24-bed adult general intensive care unit at a teaching hospital in Malaysia. The educational intervention included a theoretical session on endotracheal cuff pressure management and demonstration plus hands-on practice with the conventional cuff pressure monitoring method. Nurses' knowledge was measured using a self-administered questionnaire pre- and post-intervention. Data were analysed using repeated measure analysis of variance and bivariate analysis. In this study, 92% of the total number of RNs in the unit participated. A significant difference in mean knowledge score was noted between the pre- (mean=8.13; SD=1.53) and post-intervention phases (3months [mean=8.97; SD=1.57) and 9 months post-intervention [mean=10.34; SD=1.08), P< .001), indicating significant knowledge acquisition and retention between the phases. Knowledge gained between the pre- and 9 months post-intervention phases significantly differed according to nurses' educational level. This study supports existing evidence that ongoing educational interventions are essential to improve nurses' knowledge. However, further exploration is suggested to assess how well this knowledge is translated into clinical practice. Regular educational programmes with current updates would enhance nurses' knowledge through proper practice and clinical decision-making skills; this, in turn, would help to standardize cuff management practices.