Hospital Intensive Care Unit Research Articles

Severe sepsis-associated acute kidney injury and outcomes: a longitudinal cohort study.

Sepsis-associated acute kidney injury (SA-AKI) is common among patients admitted to the intensive care unit (ICU) with sepsis. This study aimed to demonstrate an association between an episode of SA-AKI and progression to dialysis dependence, with a view to identifying a cohort who may be suitable for intensive nephrology follow-up. Design: Retrospective data-linkage cohort study. Alice Springs Hospital ICU, 10-bed regional facility, housed in a 200-bed regional hospital, located in Central Australia. All patients admitted with a diagnosis code associated with sepsis between 2015 and 2017. Primary outcome was a composite measure comprising death or initiation of maintenance dialysis within 5 years of the index case of sepsis leading to ICU admission. The unadjusted risk of the composite outcome was significantly higher in the SA-AKI group (odds ratio (OR) 3.22, 95% confidence interval (CI) 1.81-5.74, P < 0.01). This effect remains after adjustment for age, illness severity and co-morbidities (adjusted OR (aOR) 2.64, 95% CI 1.22-5.68, P = 0.01). Progression to maintenance dialysis was the primary driver of this effect (OR 7.56, 95% CI 2.23-25.65, P = 0.02), although it was modified by the effect of confounders (aOR 7.3, 95% CI 0.7-75.94, P = 0.10). These results demonstrate an association between an index episode involving SA-AKI and the composite outcome in a defined population. Identification of this group may allow intensive nephrology follow-up and secondary prevention with the goal of mitigating the risk of progression of disease with significant economic and personal benefits.

Clinical features and factors associated with outcomes of antibody-negative autoimmune encephalitis in patients requiring intensive care

Background and objectivesAntibody-negative autoimmune encephalitis (AE) is a form of encephalitis characterized by the absence of detectable autoimmune antibodies, despite immunological evidence. However, data on management of patients with antibody-negative AE in the intensive care unit (ICU) are limited. This study aimed to explore the characteristics and subtypes of antibody-negative AE, assess the effects of immunotherapy, and identify factors independently associated with poor functional outcomes in patients requiring intensive care.MethodsThis retrospective, single-center study analyzed consecutive adult patients diagnosed with antibody-negative AE and admitted to the ICU of a large tertiary hospital between 2019 and 2023. Multivariate regression analysis was used to identify factors linked to poor functional outcomes six months after ICU admission, as defined by a modified Rankin Scale score of 3–6. Generalized linear mixed models were applied to evaluate the effect of immunotherapy on longitudinal changes in the Clinical Assessment Scale in Autoimmune Encephalitis and modified Rankin Scale scores.ResultsOf the 1220 patients with severe encephalitis admitted to the ICU, 107 were diagnosed with antibody-negative AE and included in the analysis. Six months after ICU admission, 67 patients (62.6%) had poor functional outcomes, including 28 deaths (26.2%). Factors independently associated with poor outcomes were high-dose corticosteroid therapy (odds ratio [OR] 8.734, 95% confidence interval [CI] 2.483–30.717), older age at onset (OR 1.063, 95% CI 1.028–1.099), acute respiratory failure at ICU admission (OR 10.931, 95% CI 2.062–57.751), and dyskinesia/dystonia (OR 14.109, 95% CI 1.336–148.957). The generalized linear mixed model also indicated that high-dose corticosteroid therapy was associated with poorer longitudinal outcomes.ConclusionsWhile high-dose corticosteroids are frequently used to treat AE, their risks may outweigh their benefits in severe antibody-negative AE cases. Older patients and those with dyskinesia/dystonia or respiratory failure, may require more careful monitoring and timely intervention for improved outcomes. However, prospective validation of these findings is necessary to confirm their applicability and guide future treatment strategies.

Prevalence of and risk factors analysis for post-intensive care syndrome among survivors of critical care during 3-month longitudinal follow-up.

Patients discharged from the intensive care unit (ICU) can experience post-intensive care syndrome (PICS), which is comprised of cognitive, physical and psychological impairments. The objective of this study was to identify the prevalence of and risk factors associated with all three domains of PICS at the first and third month after ICU discharge. A prospective descriptive-analytic study was conducted in two ICUs of a Chinese university hospital. We used the Healthy Aging Brain Care Monitor Self-Report Chinese version, a scale from 1 to 57, with 57 indicating the worst outcome, to comprehensively assess PICS at the first and third month follow-ups after patients left the ICU. We performed an analysis of stepwise multiple linear regression to explore the relationship between risk factors and PICS. We enrolled 654 and 584 participants at the first- and third-month follow-ups, respectively. More than 60% of patients experienced different degrees of PICS, with the most severe impairment being in the physical domain. We classified risk factors associated with PICS, categorized as patient-related, disease-related, and ICU-related factors. Among these risk factors, only being the main income provider for the family, the diagnosis of digestive system disease, trauma and the number of invasive catheters at ICU discharge significantly predicted PICS at both follow-ups. ICU-related risk factors should be given greater attention, given their potential for modification. The prevalence and severity of PICS were high in this population after their ICU stay. ICU nurses and medical staff members should collaborate to pay more attention to the comprehensive risk factors and implement targeted preventive measures. ICU staff must have a holistic view of PICS and a comprehensive understanding of its risk factors to proactively evaluate patients at high risk of PICS upon admission to the hospital.

Efficacy of serum lactate/albumin ratio as a prognostic biomarker in patients with ventilator-associated pneumonia

Aims: This study aims to evaluate the efficacy of the serum lactate/albumin ratio (LAR) as a prognostic marker in patients with ventilator-associated pneumonia (VAP) who are hospitalized in the intensive care unit (ICU). Methods: This single-center retrospective observational clinical study was conducted between January 1, 2022, and October 1, 2024. The study group comprised 58 patients admitted to the ICUs of Malatya Training and Research Hospital, Turkiye, with intubation but without a diagnosis of pneumonia at the time of admission. These patients were diagnosed with VAP 48 hours after intubation. The serum LAR was calculated within the first 24 hours after admission to the ICU and correlated with mortality and morbidity. Results: The mean age of the patients was 68 years, with the majority being over 65 years of age. Of the 58 patients included in the study, 43 (74.1%) ultimately succumbed to their illness. The LAR of those who died in the study was significantly higher than that of those who survived. The LAR was identified as a reliable predictor, exhibiting a sensitivity of 83.7% and a specificity of 60% when a cutoff value of 1.13 was applied. The survival time of patients with a LAR of ≤1.13 was significantly longer than that of patients with a ratio of &gt;1.13. Conclusion: In our study, the mortality prediction performance of the LAR in patients with VAP was superior to that of the serum lactate level or serum albumin level alone. Therefore, the LAR may be a useful and readily available prognostic factor for early risk stratification of VAP patients.

Early urea-to-creatinine ratio to predict rapid muscle loss in critically ill patients with sepsis: a single-center retrospective observational study

BackgroundPatients with sepsis in the intensive care unit (ICU) often experience rapid muscle loss. The urea-to-creatinine ratio (UCR) is thought to reflect muscle breakdown (creatinine) and catabolism (urea) and is commonly used to assess nutritional and metabolic status. This study aimed to investigate whether changes in UCR (ΔUCR) can predict the development of rapid muscle loss in patients with sepsis.MethodsThis retrospective observational study was conducted in a university ICU between 2014 and 2021, involving adult patients (≥ 18 years) diagnosed with sepsis. The primary outcome was the incidence of rapid muscle loss during ICU hospitalization. Changes in the cross-sectional muscle area at the third lumbar vertebra (L3SMA) were measured using CT images to evaluate muscle loss. Rapid muscle loss was defined as a change in ΔL3SMA greater than 2% per day. Multivariable logistic regression was used to examine the association between UCR or ΔUCR and rapid muscle loss. The area under the receiver operating characteristic curve (AUC) was calculated to assess the predictive performance of UCR or ΔUCR for rapid muscle loss.ResultsOf the 482 patients, 141 (29.2%) experienced rapid muscle loss during their ICU stay. Multivariable logistic regression analysis revealed that ΔUCR was significantly associated with an increased risk of rapid muscle loss, with an odds ratio (OR) of 1.02 [95% CI: 1.01, 1.02]. The AUC for ΔUCR in predicting rapid muscle loss was 0.76 [95% CI: 0.68–0.83], with a threshold value of 19.4 µmol urea/µmol creatinine for ΔUCR.ConclusionThe results demonstrate that ΔUCR is independently associated with rapid muscle loss in patients with sepsis and the AUC of the ROC curve for the ability of ΔUCR to predict rapid muscle loss was 0.76. Though additional prospective data are needed, our results suggest that ΔUCR may be useful in the early identification of critically ill patients with sepsis at risk of rapid muscle loss.

Association Between the Ultrasound Evaluation of Muscle Mass and Adverse Outcomes in Critically Ill Patients: A Prospective Cohort Study.

Computed tomography (CT)-derived low muscle mass is associated with adverse outcomes in critically ill patients. Muscle ultrasound is a promising strategy for quantitating muscle mass. We evaluated the association between baseline ultrasound rectus femoris cross-sectional area (RF-CSA) and intensive care unit (ICU) mortality. Secondary outcomes were the determinants of RF-CSA, and the diagnostic performance of RF-CSA after adjustment for body size. A prospective, single-center, observational cohort study was conducted in 3 ICUs (general, neuroscience, coronavirus disease-2019 [COVID-19]) of a university-affiliated hospital. Consecutive, mechanically ventilated patients with predicted length of stay >72 hours were included. RF-CSA was assessed at the dominant leg by ultrasound. Association with ICU mortality was tested using multivariable logistic regression. Diagnostic performance of RF-CSA was compared after adjustment by sex (CSA-sex), body surface area (CSA-BSA), and squared height (CSA-H2). A total of 316 patients were enrolled: age 69 [60-76], 211 men and 183 ICU survivors. Older age (odds ratio, OR [95% confidence interval, CI], 1.03 [1.01-1.05]), the type of ICU (neuroscience: 0.82 [0.38-1.79], COVID-19: 4.1 [2.01-8.38]), a higher modified Nutrition and Rehabilitation Investigators Consortium (NUTRIC) score (1.43 [1.21-1.70]), and a lower RF-CSA (0.41 [0.29-0.58]) were associated with ICU mortality. Baseline RF-CSA was lower in women, with higher nutritional risk, older age, and larger body size. Unadjusted RF-CSA had an area under the receiver operating characteristic (ROC) curve for ICU mortality of 0.720 [0.663-0.776], and this value was not significantly different from that of CSA-sex, CSA-BSA, and CSA-H2 (P = .1487). Low baseline RF-CSA was associated with increased ICU mortality. Admission RF-CSA was lower in women, with high nutritional risk, in older subjects and with lower body size. Absolute muscle mass was significantly associated with mortality, with no significant increase in this relationship when adjusting for sex or body size.

Impact of Country Income Level on Outcomes in Patients with Acute Brain Injury Requiring Invasive Mechanical Ventilation: A Secondary Analysis of the ENIO Study.

Invasive mechanical ventilation can present complex challenges for patients with acute brain injury (ABI) in middle-income countries (MICs). We characterized the impact of country income level on weaning strategies and outcomes in patients with ABI. A secondary analysis was performed on a registry of critically ill patients with ABI admitted to 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Patients were classified as high-income country (HIC) or MIC. The primary outcome was ICU mortality. Secondary outcomes were days to first extubation, tracheostomy, extubation failure, ICU length of stay, and hospital mortality. Multivariable analyses were adjusted for clinically preselected covariates such as age, sex, body mass index, neurological severity, comorbidities, and ICU management. Extubation and tracheostomy outcomes were also adjusted for arterial blood gas values and ventilatory settings. Of 1512 patients (median age = 54years, 66% male), 1170 (77%) were from HICs, and 342 (23%) were from MICs. Median age was significantly lower in MICs [35 (range 26-52) vs. 58 (range 45-68) years in HICs]. Neurosurgical procedures (47.7% vs. 38.2%) and decompressive craniectomy (30.7% vs. 15.9%) were more common in MICs, whereas intracranial pressure monitoring (12.0% vs. 51.5%) and external ventricular drain (7.6% vs. 35.6%) were less common. Compared with HICs, patients from MICs had 2.27 times the odds of ICU mortality [p = 0.009, 95% confidence interval (CI) 1.22-4.21]. Frequency of extubation failure was lower in MICs but not significant after adjustment. Patients from MICs had 3.38 times the odds of tracheostomy (p ≤ 0.001, 95% CI 2.28-5.01), 5.59days shorter mean ICU stay (p < 0.001, 95% CI - 7.82 to - 3.36), and 1.96 times the odds of hospital mortality (p = 0.011, 95% CI 1.17-3.30). In an international registry of patients with ABI requiring invasive mechanical ventilation, MICs had higher odds of ICU mortality, tracheostomy placement, and hospital mortality compared with HICs, which may be due to difference in neurocritical care resources and management.

Changes in anaphylaxis trends and characteristics in emergency department admissions in Türkiye: From 2015 to 2021 based on the Ministry of Health database.

The incidence of anaphylaxis is increasing worldwide. However, there is a lack of data on anaphylaxis trends in Türkiye. This study aims to analyse trends in anaphylaxis-related emergency department (ED) visits and examines factors associated with fatal anaphylaxis in Türkiye. We retrospectively analyzed data from Türkiye's Ministry of Health database from 2015 to 2022. Codes from the International Classification of Diseases, 10th revision (ICD-10), were used to identify anaphylaxis. During the study period, a total 21,370 ED admissions for anaphylaxis were identified, and anaphylaxis admissions increased 1.23-fold from 3.90 to 4.79 per 105 population per year. The anaphylaxis trigger was unknown in 79.9% of cases, followed by drugs (11.7%), food (5.7%) and venom (2.7%). Epinephrine was administered in 49.6% of cases, and a total of 424 patients (2.1% of total cases) died. The frequency of intensive care unit (ICU) hospitalization increased 6.0-fold from 2015 to 2021, and age-adjusted average-weighted mortality rate for anaphylaxis was 0.66 per million. Older age, presence of asthma, and ICU hospitalization were found to be significantly associated with fatal anaphylaxis (p<0.001 for all). Frequencies of death were 9.1% for venom anaphylaxis, 1.2% in drug anaphylaxis, and 0.2% for food anaphylaxis. Epinephrine autoinjector (EAI) was prescribed for 6.9% of all patients. This is the first study of ED admissions for anaphylaxis using a large, nationwide data from Türkiye. Increasing numbers of ED admissions, ICU hospitalizations and mortality show that anaphylaxis is an important public health issue in Türkiye.

Associated Factors of Trauma Severity and Mortality in Pediatric Patients Admitted to Intensive Care Unit; a 10-Year Retrospective Study.

Trauma is a significant global public health concern and the leading cause of morbidity and mortality in children. This study aimed to assess the independent predictors of trauma severity as well as mortality in pediatric patients admitted to the intensive care unit (ICU). In this cross-sectional study, following the STROBE checklist, we retrospectively analyzed the clinical and baseline characteristics of pediatric patients with trauma injuries admitted to the ICU of Children's Hospital of Zhejiang University School of Medicine, China, over a decade. 951 pediatric patients with a mean age of 4.79 ± 3.24 years (60.78% Boys) were studied (mortality rate 8.41%). Significant associations were observed between ISS and place of residence (p = 0.021), location of the injury (p = 0.010), year of injury (p <0.001), and injury mechanism (p <0.001). The two independent factors of trauma severity were the year of injury (β = 0.47; 95%CI: 0.28 - 0.65) and injury mechanism (β = -0.60; 95%CI: -0.88 - -0.31). Significant differences were observed between survived and non-survived regarding age (p <0.001), ISS score (p <0.001), time elapsed from injury to ICU (p <0.001), duration of mechanical ventilation (p <0.001), GCS score (p <0.001), and the proportion of patients requiring mechanical ventilation (p <0.001 ). The results of multivariate analysis indicated that age (OR = 0.805; 95%CI: 0.70 - 0.914; p = 0.001) and GCS score at ICU admission (OR = 0.629; 95%CI: 0.53 - 0.735; p < 0.001) acted as protective factors, whereas mechanical ventilation in the ICU (OR = 7.834; 95%CI: 1.766 - 34.757; p = 0.007) and ISS score at ICU admission (OR = 1.088; 95%CI: 1.047 - 1.130; p < 0.001) served as risk factors for mortality. Automobile-related injuries represent the leading cause of trauma in children, with escalating severity scores year over year among pediatric patients admitted to the ICU with trauma injuries. Based on the findings the independent predictors of mortality of pediatric trauma patients admitted to the ICU were age, GCS score at ICU admission; mechanical ventilation in the ICU, and ISS score at ICU admission. Also, the year of injury and injury mechanism were independent predictors of trauma severity.

Patient and Family Experience: Targets for Improvements in Care and Communication in the ICU.

This process improvement project sought to further explore the experience of patients and family members within an intensive care unit (ICU) hospital setting to develop specific interventions that can be executed to provide better patient-centered outcome. We surveyed 103 family members using the satisfaction with care subscale of Family Satisfaction with the ICU survey (FS-ICU) (validated ICU experience survey). 103 patients also completed FS-ICU subscale with a modification to make it applicable to patients. Additional questions explored their interest in supportive services and factors contributing to distress with the goal of understanding the gaps in multidisciplinary care and supportive services. Overall, the findings of this project emphasize the importance of (1) understanding patients' experience and satisfaction with care, in addition to families', (2) gathering data with measurement tools that is specific enough to the care environment allowing for unique feedback and areas for improvement, and (3) identifying psychological needs and faith-based support to intervene on challenging experiences.

Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses Vs Continuous Infusion in Diabetic Patients with Septic Shock: A Prospective Cohort Study

Background &amp; Objectives: Septic shock is a serious condition associated with a high mortality rate because of the multiorgan dysfunction caused by dysregulated host immune responses to infection. Giving low dose steroids in septic shock patients has been shown to hasten the reversal of shock and current Surviving Sepsis Guidelines (SSG) also suggest using low dose steroids for the same. Also, the use of steroids causes hyperglycaemia particularly in diabetic patients. The current SSG does not specify the method of administration. The primary objective of our study was to compare continuous infusion vs intermittent boluses of hydrocortisone to obtain a better glycaemic control. Methods: A prospective cohort study was conducted in diabetic patients with septic shock admitted in Multi Disciplinary Intensive Care Unit (MDICU) of PRS hospital from July 2022 to February2023. Hydrocortisone was given as continuous infusion in 55 subjects and the remaining 55 received intermittent boluses of hydrocortisone and average blood glucose values were measured in both the groups. Results: Among 110 patients, 55 patients each received continuous infusion and intermittent boluses of hydrocortisone respectively. The mean blood glucose values in continuous infusion group were 161.1 ± 22.7 and 172.5 ± 21.0 (mg/ dl) in intermittent boluses group which was statistically significant with a p value of 0.007. There was no statistically significant difference among the groups in 28-day mortality, ICU length of stay (LOS), hospital LOS, or other secondary safety outcomes. Conclusions: This study infers that giving hydrocortisone as continuous infusions in septic shock patients leads to better glycaemic control when compared to intermittent boluses of hydrocortisone, without any difference in 28-day mortality.

A Comprehensive Evaluation of Antibiotic Usage: Establishing a Foundation for Effective Antimicrobial Stewardship

Background: The intensive care unit (ICU) is a significant area of antibiotic use, accounting for a substantial proportion of the overall antibiotic consumption. The inappropriate use of antibiotics in such settings has a notable impact on the emergence of antimicrobial resistance. Objective: This study evaluated the rationality of antibiotic use in the ICU of RSUD Abdul Moeloek Hospital in Lampung Province. Methods: This study was conducted between December 2022 and February 2023 using a prospective method and purposive sampling. An evaluation was conducted using the Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) system for quantitative analysis and Gyssens criteria for qualitative assessment. The research subjects comprised 55 individuals, the majority of whom were male (58.2%), aged &gt; 65 years (29.1%), remained in the ICU for less than seven days (78.2%), and subsequently continued their treatment in a non-ICU (69.1%). Results: Quantitative analysis demonstrated that the total number of antibiotics administered in this study was 394.83 DDD, with a DDD/100 patient-day value of 113.78. Ceftriaxone was the most frequently prescribed antibiotic (219 DDD), whereas gentamicin was the least frequently prescribed (1 DDD). Qualitative analysis revealed that 17.6% of the patients exhibited irrational antibiotic use. Conclusion: Irrational use of antibiotics was observed in the following categories: IV A (1.1%); IV D (2.2%); III A (2.2%); III B (2.2%) IIA, (3.3%); IIB (5.5%); and I (1.1%). The study concluded that there was still a considerable degree of irrational antibiotic use.

Butterfly Touch massage as a technique to support opening up communication between parent and mechanically ventilated child at home

A child’s stay in a hospital intensive care unit is a challenging experience for both the child and his parents. It limits opportunities for contact with loved ones and requires compliance with medical procedures during the visit. Touch and contact with an adult may be associated by the child with discomfort and pain, on top of which the limited number of contacts may affect communication between them and the rebuilding of relationships. Returning a child home who is mechanically ventilated as a result of the effects of the disease causes his or her room to become, in part, a hospital room. The parents’ focus on adapting to the new situation can push the child’s needs for communication and relationship-building with other loved ones into the background. After learning how to operate medical equipment and getting used to it, caregivers look for ways to communicate, open up communication, and provide positive emotions and a cheerful touch to the child. Massage Touch Butterfly by Eva Reich can help with this.

Diagnostic value of digital continuous bowel sounds in critically ill patients with acute gastrointestinal injury: A prospective observational study.

Acute gastrointestinal injury (AGI) is common in intensive care unit (ICU) and worsens the prognosis of critically ill patients. The four-point grading system proposed by the European Society of Intensive Care Medicine is subjective and lacks specificity. Therefore, a more objective method is required to evaluate and determine the grade of gastrointestinal dysfunction in this patient population. Digital continuous monitoring of bowel sounds and some biomarkers can change in gastrointestinal injuries. We aimed to develop a model of AGI using continuous monitoring of bowel sounds and biomarkers. To develop a model to discriminate AGI by monitoring bowel sounds and biomarker indicators. We conducted a prospective observational study with 75 patients in an ICU of a tertiary-care hospital to create a diagnostic model for AGI. We recorded their bowel sounds, assessed AGI grading, collected clinical data, and measured biomarkers. We evaluated the model using misjudgment probability and leave-one-out cross-validation. Mean bowel sound rate and citrulline level are independent risk factors for AGI. Gastrin was identified as a risk factor for the severity of AGI. Other factors that correlated with AGI include mean bowel sound rate, amplitude, interval time, Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation II score, platelet count, total protein level, blood gas potential of hydrogen (pH), and bicarbonate (HCO3 -) level. Two discriminant models were constructed with a misclassification probability of < 0.1. Leave-one-out cross-validation correctly classified 69.8% of the cases. Our AGI diagnostic model represents a potentially effective approach for clinical AGI grading and holds promise as an objective diagnostic standard for AGI.

Early Life Stress, DNA Methylation of NR3C1 and HSD11B2, and Oral Feeding Skill Development in Preterm Infants: A Pilot Study.

Early life stress exposure in preterm infants may alter DNA methylation of NR3C1 and HSD11B2, disrupting neurobehaviors needed for oral feeding (PO) skill development. To (1) examine the feasibility of the study protocol; (2) describe early life stress, DNA methylation of NR3C1 and HSD11B2, and PO skill development; and (3) explore the association between DNA methylation of NR3C1 and HSD11B2 and infant characteristics, early life stress, and PO skill development. We employed a longitudinal descriptive pilot study (N=10). Infant characteristics were collected from the infant's electronic medical record. Early life stress was assessed via the modified Neonatal Infant Stressor Scale. DNA methylation of NR3C1 exon 1F and HSD11B2 promoter regions was analyzed from the infant's buccal samples. PO skill development was evaluated using the Early Feeding Skills Assessment. Infants who experienced more acute and chronic stress during their neonatal intensive care unit hospitalization demonstrated higher DNA methylation at CpG 17 and 31 of the NR3C1 exon 1F and at CpG 4 and 28 of the HSD11B2 promoter regions. Infants with higher DNA methylation at these CpG sites also exhibited less optimal PO skill development and experienced longer transition from first to full PO. Our findings revealed relationships among early life stress, DNA methylation of NR3C1 and HSD11B2, and PO skill development in preterm infants. Future research is warranted to examine the multiomics pathways whereby early life stress influences the phenotypes of infant outcomes.

Individual-, Hospital-, and Community-Level Factors Associated with Sudden Unexpected Infant Death Among Infants Born Preterm in 5 US States.

To investigate individual-, hospital-, and community-level factors associated with sudden unexpected infant death (SUID) among infants born preterm. The following linked dataset from 5 states (California, Michigan, Oregon, Pennsylvania, and South Carolina) from 2005 through 2020 was used: (1) infant birth and death certificates; (2) maternal and infant birth hospitalization discharge records; (3) birthing hospital data from the American Hospital Association; and (4) community-level data from the Social Vulnerability Index (SVI).) Multivariable models were used to assess the independent association between these multilevel factors and SUID, adjusting for several maternal and infant characteristics. Overall, we found that maternal demographic factors (race and ethnicity, education, insurance) and infant gestational age were significant predictors of SUID. There was no difference in SUID odds by state, urban influence code, and maternal complications of pregnancy. Compared with mothers who lived in areas with the lowest SVI, those who resided in the highest SVI were more likely to experience SUID. There was no difference in SUID odds between infants who did or did not experience one or more complications of prematurity. For hospital-level factors, there was no difference in SUID odds among infants cared for in teaching vs nonteaching hospitals or in low vs high volume preterm birth hospitals. Individual- and community-level factors were associated with SUID among infants born preterm. The neonatal intensive care unit hospitalization may provide a critical window of opportunity to engage families about SUID-risk reducing practices.

Acquired pneumonia in patients with assisted ventilation systems due to poor oral hygiene in the intensive care unit of the iess ambato hospital. An observational study.

Patients admitted to the Intensive Care Unit (ICU) require rigorous attention. It has been shown that proper oral hygiene of patients admitted to the ICU can have a direct impact on the patient's life. In the present observational, descriptive, cross-sectional, prospective study, data was collected, involving health personnel who provide their services in the ICU of the IESS Ambato hospital, including professionals aged 21 years and older, which aims to explain the care required by the patient, preventing them from contracting pathological microorganisms, revealing the number of trained professionals. In addition, the use of toothbrushes, generally with soft bristles for the care of patients in ICU, is shown through proper reviews, considering also feasible the use of hard bristles toothbrush, activat

Association between length of hospital stay before and after surgery and nutritional risk according to NRE-2017 - A secondary analysis of a cohort study.

Aim: to evaluate the predictive ability of the Nutritional Risk Emergency - 2017 (NRE) to predict prolonged length of stay, ICU admission intra-mortality and readmission, severe postoperative complications. Methods: a prospective cohort was conducted with surgical patients admitted in a public tertiary hospital. The NRE-2017 tool was applied for detecting malnutrition risk in hospitalized patients. Surgical complications were assessed by Clavien-Dindo. Patients were followed during hospitalization to identify length of stay as well as stay after surgery in the Intensive Care Unit (ICU). Regression analysis was performed to assess the association between risk of malnutrition and clinical outcomes. Results: we included 162 elective surgery patients; 79 patients were identified with nutritional risk using the NRE-2017 (≥ 1.5) tool and 83 without nutritional risk. Patients with nutritional risk were at higher risk of prolonged hospitalization [18 (10-36) days vs. 13 (7-23 days); p: 0.006] and ICU hospitalization [6 (2-14 days vs. 3.5 (1-7 days; p: 0.020]. There was an association between surgical complications and nutritional risk independently, but the significance was lost when adjusting the analysis. There was no association with mortality and readmission in this sample of patients. Conclusion: the NRE-2017 tool was associated with hospital stay in those patients at nutritional risk, however there was no association with mortality and readmission.

Can early diaphragm dysfunction in critically ill ventilated patients predict clinical outcomes? A pilot study.

Diaphragm dysfunction (DD) is a keystone factor in difficult weaning from invasive mechanical ventilation (IMV). Diaphragm ultrasound (DUS) is the preferred method for the evaluation of diaphragm function in the Intensive Care Unit (ICU) setting, namely through the diaphragm thickening fraction (DTF). However, its potential role in the decision-making process of mechanical ventilation weaning is yet to be established. We aimed to assess the incidence of early DD and its role as a predictor of prolonged IMV. We conducted a prospective, non-interventional study in a university hospital ICU. Non-consecutive adult patients subject to at least 48h of IMV were enrolled. Exclusion criteria was a prior period of IMV in the past three months. DUS was performed at 48h of IMV. End-inspiratory and end-expiratory diaphragm thickness were measured using M-mode, with a high-frequency linear probe placed at the zone of apposition of the diaphragm. The mean values of three measurements were used to calculate DTF. Interobserver measurement variability was not evaluated. Forty-five patients were included. Thirty-eight percent were female, average age was 62.3 years. Mean Simplified Acute Physiology Score (SAPS) II and Sequential Organ Failure Assessment (SOFA) at admission were 50.9 and 9.02, respectively. Mean DTF was 23.46%±17.15. Average IMV duration was 9.36±7.66 days. Half of patients had DD at 48h of IMV. A weak negative correlation was observed between DTF, days of endotracheal intubation (Sp -0.27; p=0.07) and days of IMV (Sp -0.25; p=0.09). Using DTF cut-off values of 20% and 30%, DTF at 48h of IMV was not associated with prolonged IMV (p-values 0.17 and 0.58, respectively). In our study, there was a high prevalence of DD at 48h of IMV, as suggested in previous literature. Diaphragm dysfunction at 48h when measured through DTF did not seem to predict prolonged IMV. Late VAP incidence was associated with DD. Diaphragm ultrasound is well-established for diaphragm functional assessment, but further research regarding its trajectory during critical illness is needed to clarify its application in clinical practice.

Evaluation of Response to Weight-based Dosing Strategies of Continuous, Fixed-Rate Atracurium Infusions in Critically Ill, Obese Adults With Acute Respiratory Distress Syndrome.

Fixed-rate infusions of weight-based neuromuscular blocking agents (NMBAs) were adopted during the COVID pandemic to limit caregiver exposure during titrations. Although fixed-rate infusions are supported in studies of acute respiratory distress syndrome (ARDS), the optimal scalar for weight-based NMBAs in patients with obesity remains controversial. This study sought to compare change in oxygenation using two weight-based dosing strategies for atracurium in obese patients with ARDS. Secondary outcomes included total atracurium dose, mortality, and intensive care unit (ICU) and ventilator-free days. Following an institutional practice update to use ideal body weight (IBW) for patients with obesity, we retrospectively compared adults (≥18 years) with ARDS and a body mass index (BMI) ≥ 30 kg/m2 who received atracurium (15 µg/kg/min) based on actual body weight (ABW) with those using IBW. The primary outcome was change in PaO2/FiO2 ratio (P/F) 48 hours after atracurium initiation. Analysis-of-covariance compared change in P/F between groups after adjustment for confounders. The IBW group (n = 123), compared with the ABW group (n = 133), had lower baseline P/F (85.0 [71.0, 118.3] vs 93.3 [76.0, 128.3], P = 0.025) and sequential organ failure assessment (SOFA) score (9.7 ± 2.6 vs 10.5 ± 2.6, P = 0.015), with greater use of steroids (96% vs 89%, P = 0.032) and prone positioning (72% vs 58%, P = 0.015). No difference was detected in change in P/F at 48 hours (adjusted least squares mean [95% confidence interval, CI]: 55.8 [37.0, 74.5] vs 56.9 [39.6, 74.1], P = 0.90). Atracurium doses were higher in the ABW group (97.4 mg/h [84.4, 110.3] vs 55.4 [47.2, 65.7], P < 0.001). There was no difference in hospital mortality, ICU mortality, and ICU-free days or ventilator-free days. In patients with obesity with ARDS receiving fixed-rate atracurium infusions, the change in P/F at 48 hours did not differ based on weight. Atracurium dosed on IBW may use less total drug without compromising ability to improve oxygenation. This is the first study comparing the dosing weight used for continuous infusion atracurium in hospitalized, critically ill ARDS patients with obesity. Additional studies are warranted to optimize dosing in obese patients.