Intensive Care Unit Management Research Articles

Correlation of Ultrasound Guided Inferior Vena Cava Collapsibility Index with Central Venous Pressure to Assess the Volume Status in Postoperative Intensive Care Unit Patients: A Prospective Observational Study

Background: Accurate assessment of intravascular volume status is a vital aspect of management of intensive care unit (ICU) patients. Inferior vena cava (IVC) diameter and IVC collapsibility index have surfaced as promising methods to accurately predict hypovolemia. But no such study has evaluated it’s their utility in postoperative patients.
 Methods: The study aimed to assess the correlation between ultrasound guided IVC collapsibility index (IVC CI) and CVP for volume status in intensive care unit patients. Hundred spontaneously breathing patients receiving postoperative care in our surgical ICU between November 2019 to march 2021were enrolled into the study. Maximum IVC diameter (IVCdmax) at end-expiration, minimum IVC diameter at end-inspiration (IVCdmin) and IVC CI were measured. Simultaneous CVP recordings were obtained.
 Results: A positive correlation was noted between IVC maximum diameter and CVP (p = <0.001) and between IVC Minimum Diameter and CVP. (p = <0.001) A negative correlation between IVC CI and CVP was seen (p = <0.001). Mean IVC CI was highest in the hypovolemic group. The area under the ROC curve (AUROC) for IVC CI predicting hypovolemia was 0.943 (95% CI: 0.9 - 0.986), thus demonstrating excellent diagnostic performance. At a cut off of ≥58.416%, IVC CI predicts hypovolemia with a sensitivity of 93.8%, and a specificity of 84%.
 Conclusion: IVC CI can be used to guide fluid therapy due to its excellent diagnostic accuracy in predicting hypovolemia in postoperative patients in ICU.

Temporal Trends in Mortality of Critically Ill Patients with Sepsis in the United Kingdom, 1988-2019.

Rationale: Sepsis is a frequent cause of ICU admission and mortality. Objectives: To evaluate temporal trends in the presentation and outcomes of patients admitted to the ICU with sepsis and to assess the contribution of changing case mix to outcomes. Methods: We conducted a retrospective cohort study of patients admitted to 261 ICUs in the United Kingdom during 1988-1990 and 1996-2019 with nonsurgical sepsis. Measurements and Main Results: A total of 426,812 patients met study inclusion criteria. The patients had a median (interquartile range) age of 66 (53-75) years, and 55.6% were male. The most common sites of infection were respiratory (60.9%), genitourinary (11.5%), and gastrointestinal (10.3%). Compared with patients in 1988-1990, patients in 2017-2019 were older (median age, 66 vs. 63 yr), were less acutely ill (median Acute Physiology and Chronic Health Evaluation II acute physiology score, 14 vs. 20), and more often had genitourinary sepsis (13.4% vs. 2.0%). Hospital mortality decreased from 54.6% (95% confidence interval [CI], 51.0-58.1%) in 1988-1990 to 32.4% (95% CI, 32.1-32.7%) in 2017-2019, with an adjusted odds ratio of 0.64 (95% CI, 0.54-0.75). The adjusted absolute hospital mortality reduction from 1988-1990 to 2017-2019 was 8.8% (95% CI, 5.6-12.1). Thus, of the observed 22.2-percentage point reduction in hospital mortality, 13.4 percentage points (60% of total reduction) were explained by case mix changes, whereas 8.8 percentage points (40% of total reduction) were not explained by measured factors and may be a result of improvements in ICU management. Conclusions: Over a 30-year period, mortality for ICU admissions with sepsis decreased substantially. Although changes in case mix accounted for the majority of observed mortality reduction, there was an 8.8-percentage point reduction in mortality not explained by case mix.

Predictors of time to full enteral feeding in low birth weight neonates admitted to neonatal intensive care unit: a prospective follow up study

BackgroundSurvival of LBW infants has increased in recent years because of novel perinatal interventions, but the introduction and advancement of enteral feeds for low birth weight infants is challenging. In Ethiopia the proportion of low birth weight infants is thought to be 17.3%. The purpose of this study was to determine the time to full enteral feeding (FEF) and its predictors in LBW neonates admitted to neonatal intensive care unit in selected hospitals of Addis Ababa, Ethiopia.MethodAn institutional based prospective follow up study was conducted from March 15 to June 15, 2022 among 282 LBW neonates admitted to six randomly selected hospitals. Both primary and secondary data was used by interviewing mothers and prospective medical chart review of neonates. The Cox regression model was used and variables having a p-value less than 0.05 with 95% CIs in a multivariable analysis were declared as statistically significant association with time to full enteral feeding.ResultOut of 282 neonates involved in this study, 211 (74.8%) of them reached at FEF. The overall median time to full enteral feeding was 5 days. Predictors significantly associated with time to full enteral feeding were educational level, birth weight, cesarean delivery, hospital acquired infection, being on antibiotics, age at initiation of trophic feeding, routine gastric residual evaluation and NICU location (hospital).ConclusionsThis study demonstrated the difficulty of understanding which low birth weight neonate will attain FEF in a timely manner and factors that affect time to FEF. There is a delay in full enteral feeding achievement among low birth weight neonates and there is a great deal of heterogeneity of practice among health care providers regarding feeding of infants as it was evidenced by a variation in feeding practice among hospitals. Nutrition should be considered as part of the management in neonatal intensive care units since low birth weight neonates are developing edematous malnutrition while they are in the NICU. There should be standard feeding protocol to avoid heterogeneity of practice and additional study should be conducted for each categories of GA and BW with long follow up time.

Sounds in intensive care units: Perspectives of patients and parents. A qualitative study

Sounds in intensive care units: Perspectives of patients and parents. A qualitative study Abstract: Background: Sound levels in intensive care units exceed internationally recommended limits. This can have negative effects on patients, relatives, and staff. There is a lack of evidence on noise-reducing measures. Aim: The aim of the study was the implementation and evaluation of ward-specific noise management in intensive care units. In the present article, the question of the noise and stress experience of intensive care patients and parents of neonatal intensive care patients was explored. Methods: 33 semi-structured interviews with intensive care patients and parents of neonatal intensive care patients in three intensive care units were conducted and analysed. Results: Sounds in intensive care units can be stressful (especially alarms) but also be interpreted as meaningful. This is not only related to the context of the ICU, but also to individual experiences and the social aspects of the sounds. In order to avoid or reduce stress, participants apply individual noise (stress) management. In contrast, ward-related noise management had no specific effect on the participants. Conclusions: The findings offer indications for suitable measures to reduce the noise exposure of intensive care patients and parents of neonatal intensive care patients. Research about measures such as concepts for supporting the attribution and differentiation of sounds could follow.

Challenges in management of refractory pain and sedation in infants.

The survival of preterm infants continues to improve, along with an increased in neonatal intensive care unit (NICU) management of chronic infants who are medically complex infants who have prolonged hospital stays, sometimes up until 2years of age. Despite advances in neonatal and infant care, the management of pain and sedation in chronic NICU patients continues to be a challenge. Challenges such as development of appropriate pain, sedation, and withdrawal scales along with unfamiliarity of the NICU care team with pediatric disease states and pharmacotherapy complicate management of these patients. Opioid induced hyperalgesia (OIH) and delirium may play a large role in these refractory cases, yet are often not considered in the NICU population. Drug therapy interventions such as gabapentin, ketamine, risperidone, and others have limited data for safety and efficacy in this population. This article summarizes the available literature regarding the evidence for diagnosis and management of infants with refractory pain and sedation along with the challenges that clinicians face when managing these patients.

Evaluation and Treatment of Dysphagia in Public and Private Intensive Care Units (ICUs) in Greece.

Introduction Dysphagia is a significant but underrecognized clinical issue in the intensive care unit (ICU), and it is associated with various complications. Despite its clinical importance, there is limited research and no Greek ICU-specific guidelines for managing dysphagic patients. Additionally, only a few ICUs in Greece have dysphagia specialists, specifically speech-language pathologists (SLPs) providing their expertise. Objective Τo identify the current practices for dysphagia management (screening, assessment, treatment) and gain insight into ICU directors' awareness/perceptions of the prevalence, complications, and risk of dysphagia. Materials and Methods We identified 138 Greek ICUs. Data were collected from ICU (including pediatric and neonatal) directors, working in public and private hospitals, via a 24-item, anonymous online questionnaire, within a 4-month period. Results Our survey was completed by 45 ICU directors. Most participants (84.4%) reported that dysphagia is a relevant clinical problem in their ICU, and 51.1% estimated a frequency rate < 20%. Non-instrumental approaches are mainly utilized to screen and diagnose dysphagia, whereas enteral nutrition and diet modifications are used to manage dysphagia. Additionally, 64.4% of ICU directors agreed that SLPs are essential for the management of dysphagic patients, and 66.7%, that awareness of dysphagia in their ICU could be increased. Conclusion The current study documented the methods and approaches used to manage dysphagic patients in Greek ICUs. The ICU directors seem to recognize the clinical significance of dysphagia and its complications. According to our findings, the employment of SLPs could result in a more comprehensive and intensive approach and improve the quality of care for these patients.

Cognitive fatigue management in Australian paediatric intensive care units

Cognitive fatigue management in Australian paediatric intensive care units

Pain Management Strategies in Intensive Care Unit: Challenges and Best Practice.

Pain management in the ICU (intensive care unit) is a very complex problem which involves a wide variety of conditions, lack of sufficient tools for use, and high personnel to patient ratio. In the last three decades, pain as a clinical issue has become well analyzed, and treatment protocols based on scientific evidence have been established. Besides medication, some non-pharmacological methods such as music therapy, relaxation, and massage have been proven to be very much practical and manageable in pain management of ICU. The main opioids are utilized predominantly due to their power but NSAIDs and local anesthesia are combined with opioids with the aim to reduce the pain as much as possible. Yet more research now has to prove that pain evaluation and management is effective. This article discusses on the issues and the best approaches to solving them when managing pain in ICU patients.

Effectiveness of Prophylactic Ketamine on Shivering in Cesarean Section after Spinal Anesthesia

Background: Regional anesthesia, including spinal or epidural techniques, can disrupt the body's ability to regulate temperature, leading to a heightened risk of shivering. Studies have indicated that shivering occurs in up to 55% of patients undergoing procedures under regional anesthesia. To address this issue, numerous medications have been explored for their potential to prevent post-anesthetic shivering. Objective: To assess the effectiveness of prophylactic ketamine on shivering in cesarean section after spinal anesthesia. Study Design: Prospective, randomized, double blind, clinical trial. Settings: Department of Anesthesiology, Surgical Intensive Care Unit and Pain Management, Civil Hospital Karachi Pakistan. Duration: Six months from August 2019 to January 2020. Methods: A total of 60 patients undergoing spinal anesthesia for elective cesarean section were included in this study. Two groups A and B were formed and patients were equally divided into these groups by lottery method. Group A were treated with ketamine 0.5 mg/kg I/V and group B treated with normal saline 0.05ml/kg/I/V. Grade 0-1 shivering was labeled as effective and shivering grade 2, 3 or 4 at 15 minutes after administration of the drug, was considered ineffective. Results: The average age of the patients was 28.33 ± 5.67 Years. Rate of shivering was significantly high in patients who were treated with normal saline than ketamine in which shivering was not observed (53.3 vs. 0% respectively; P value of 0.0005). This implies that effectiveness was significantly high in groups A than group B (100% vs. 46.7%). Conclusion: Ketamine observed to be the effective drug for the treatment of postanesthetic shivering. It should be considered prophylactically in any patient undergoing spinal anesthesia.

Utilization of Teleradiology by Intensive Care Units: A Cohort Study.

Imaging is indispensable to the diagnostic and treatment process. By facilitating access to rapid timely image interpretation, teleradiology plays a prominent role in improving access, quality of critical care, and management of the patients in intensive care units (ICU). The aim of the study is to investigate the role of teleradiology in ICU patient care and management. In our study, a total of 22,081 studies of a cohort of 14,900 patients which had been transmitted from intensive care units of 80 hospitals located across the United States of America through a teleradiology reporting workflow, were interpreted by the American Board Certified Radiologists empanelled by a teleradiology service provider, located in India. Among all modalities, the highest percentage of studies performed were computed tomography scan (47%) followed by radiographs (37.22%). Out of 22,081 cases under the study, 16,582 cases were reported during nighttime with a mean turnaround time (TAT) of 46.66 minutes 95% CI (46.27-47.04) while 5,499 cases were reported during daytime with a mean TAT of 44.66 minutes 95% CI (45.40-43.92). Setting up teleradiology service connectivity with a teleradiology service provider located in India, providing high-quality diagnostic interpretations and lower turnaround time with the ICUs in the US hospitals reduces the interval to intervention time and leads to efficient patient care management. Moreover, it also provides time advantage for US hospitals when on-site radiologists at night are unable to provide immediate coverage. The ICU teleradiology service model designed in the study would greatly help overcome the shortfall of radiologists in the hospitals, provide better patient management and care by quality reporting in short turnaround time, not only during daytime but also in the night hours or on holidays when on-site radiologists are unable to provide immediate coverage. Rao P, Mathur N, Kalyanpur A. Utilization of Teleradiology by Intensive Care Units: A Cohort Study. Indian J Crit Care Med 2024;28(1):20-25.

Factors Affecting Nurses’ Performance of Noise Management in Adult Intensive Care Units

The aim of this study was to identify factors affecting the noise management performance of adult intensive care unit (ICU) nurses in Korea. The ICU environment is exposed to various types of noises due to the use of medical devices for the treatment of critically ill patients. The noise has an adverse effect on nurses’ health and their nursing performance, which might potentially threaten patient safety. A cross-sectional study was conducted with a total of 148 nurses working in adult ICUs from two university hospitals in Korea. Data were collected using self-administered questionnaires, which included various aspects such as noise knowledge, response to noise, patient safety culture, and noise management performance. Multiple regression analysis revealed that teamwork (β = 0.33, p=0.004), patient safety policy, and procedure (β = 0.25, p=0.037), which were subscales of patient safety culture, as well as frequency of noise experience (β = 0.16, p=0.030) were significant factors affecting adult ICU nurses’ performance of noise management. This study provides a significant basis for promoting adult ICU nurses’ performance in noise management. A structured policy and procedure for noise management should be established for reducing noise in adult ICUs. In terms of nursing education, it is necessary to consider and develop team-based training programs to promote noise management performance in the ICU. Nurse managers and nursing organizations should consider how to create conditions in which nurses can recognize the importance of noise reduction and perform well in noise management.

Intensive care risk and long-term outcomes in pediatric allogeneic hematopoietic cell transplant recipients

AbstractAllogeneic hematopoietic cell transplantation (HCT) can be complicated by life-threatening organ toxicity and infection necessitating intensive care. Epidemiologic data have been limited by single-center studies, poor database granularity, and a lack of long-term survivors. To identify contemporary trends in intensive care unit (ICU) use and long-term outcomes, we merged data from the Center for International Blood and Marrow Transplant Research and the Virtual Pediatric Systems databases. We identified 6995 pediatric patients with HCT aged ≤21 years who underwent first allogeneic HCT between 2008 and 2014 across 69 centers in the United States or Canada and followed patients until the year 2020. ICU admission was required for 1067 patients (8.3% by day +100, 12.8% by 1 year, and 15.3% by 5 years after HCT), and was linked to demographic background, pretransplant organ toxicity, allograft type and HLA-match, and the development of graft-versus-host disease or malignancy relapse. Survival to ICU discharge was 85.7%, but more than half of ICU survivors required ICU readmission, leading to 52.5% and 42.6% survival at 1- and 5-years post-ICU transfer, respectively. ICU survival was worse among patients with malignant disease, poor pretransplant organ function, and alloreactivity risk factors. Among 1-year HCT survivors, those who required ICU in the first year had 10% lower survival at 5 years and developed new dialysis-dependent renal failure at a greater rate (P<.001). Thus, although ICU management is common and survival to ICU discharge is high, ongoing complications necessitate recurrent ICU admission and lead to a poor 1-year outcome in select patients who are at high risk.

A Serendipitous Outcome of COVID-19: Modifications to ICU Management.

Nosocomial infections are common in intensive care units (ICUs) and often cause increased morbidity and mortality rates in ICU patients. With the emergence of the highly infectious COVID-19, the high prevalence of hospital-acquired infections (HAIs) in ICU has caused much more concern because patients admitted to the ICU have a more severe and prolonged form of the disease. These patients are more likely to develop HAIs than non-ICU patients. Medical communities adopted several measures to make ICU management safer during the pandemic all over the world. In this study, we re-examined the challenges faced and the changes made in ICU management during the pandemic to speculate how these changes will be relevant post-pandemic and can be permanently incorporated into the ICU to improve safety, management, and critical care and make critical care better equipped for future disease breakouts.

The role of early rehabilitation in the ICU management of a severe COVID-19 patient: a case report

Patients admitted to the intensive care unit (ICU) with severe COVID-19, are at high risk of developing ICU acquired weakness and deconditioning syndrome. Early rehabilitation is a critical therapeutic intervention to reduce the complications of immobilization. We present the case of a 51-year-old woman with acute respiratory distress syndrome (ARDS) due to COVID-19. The patient underwent early rehabilitation program, starting from her fourth day after ICU admission. The rehabilitation program included: (1) prone and semi- prone positioning; (2) respiratory exercises, such as diaphragmatic deep breathing, chest stretch, and effective coughing; (3) other exercises which included mobilization, range of motion exercises, and joint relaxation. The patient’s respiratory function eventually improved (as indicated by improved SpO2. Her ability to perform activities of daily living also improved so that she was able to walk independently to the toilet without respiratory distress. Although further research is required, this report suggests that patients with severe COVID-19 admitted to the ICU will benefit from early rehabilitation program.&#x0D; Key words: SARS CoV-2; COVID-19; Early Rehabilitation; Mobilization; Breathing Exercises&#x0D; Citation: Rosyalynda H. The role of early rehabilitation in the ICU management of a severe COVID-19 patient: a case report. Anaesth. pain intensive care 2023;27(6):783−785; DOI: 10.35975/apic.v27i6.2092&#x0D; Received: September 03, 2023; Reviewed: September 16, 2023; Accepted: September 16, 2023

Clinical impact and efficacy of bedside echocardiography on patient management in pediatric intensive care unit: A single center study

BackgroundCritically ill pediatric patients often have multi-system involvement that can overlap different clinical diagnoses, making proper assessment and management challenging. Using echocardiography is increasing as a bedside and noninvasive tool for accurate hemodynamic assessment and guiding treatment. ObjectivesThis study aimed to determine the indication and value of bedside echocardiography in patient management in the pediatric intensive care unit (PICU) at Fayoum University Hospital and the relationship to the Pediatric Risk of Mortality Score III (PRISM). MethodsA total of 200 critically ill pediatric patients admitted to the PICUs of Fayoum University Hospital between January 2020 and January 2021 were prospectively evaluated. Detailed clinical examinations and requested echocardiography were conducted by intensivists and cardiologists. Results200 critically ill pediatric patients had an age range of 0.2–12 years, with 134 patients (67 %) under two years old. The most common admission diagnosis was pulmonary disease in 51 patients (26 %), followed by cardiac disease in 44 (22 %). The most common indication for echocardiography was left ventricle function assessment in 68 patients (34 %). Among the 108 patients (54 %) who underwent echocardiographic assessment, no difference in the management was found, while in the remaining 92 patients (46 %), supplemental information or decision help in management was obtained. There was a positive correlation between the effective value of echocardiography in the management of patients with primary cardiac disease (p-value = 0.001), shock (p-value = 0.001), and hypoxia (p-value = 0.009). Additionally, there was no correlation between the PRISM score and the effectiveness of echocardiographic assessment. ConclusionThe most common clinical indication for bedside echocardiography is assessing cardiac function. Echocardiography is an effective tool in PICU patient management, particularly in cases with primary cardiac disease, hypoxia, and shock, but its effectiveness does not increase according to the severity of the disease.

Three patterns of symptom communication between patients and clinicians in the intensive care unit: A fieldwork study.

To describe different patterns of communication aimed at preventing, identifying and managing symptoms between mechanically ventilated patients and clinicians in the intensive care unit. We conducted a fieldwork study with triangulation of participant observation and individual interviews. Participant observation of nine patients and 50 clinicians: nurses, physiotherapists and physicians. Subsequent individual face-to-face interviews with nine of the clinicians, and six of the patients after they had regained their ability to speak and breathe spontaneously, were fully alert and felt well enough to sit through the interview. Symptom communication was found to be an integral part of patient care. We identified three communication patterns: (1) proactive symptom communication, (2) reactive symptom communication and (3) lack of symptom communication. The three patterns co-existed in the cases and the first two complemented each other. The third pattern represents inadequate management of symptom distress. Recognition of symptoms in non-speaking intensive care patients is an important skill for clinicians. Our study uncovered three patterns of symptom communication, two of which promoted symptom management. The third pattern suggested that clinicians did not always acknowledge the symptom distress. Proactive and reactive symptom assessment of non-speaking patients require patient verification when possible. Improved symptom prevention, identification and management require a combination of sound clinical judgement and attentiveness towards symptoms, implementation and use of relevant assessment tools, and implementation and skill building in augmentative and alternative communication. This study addressed the challenges of symptom communication between mechanically ventilated patients and clinicians in the intensive care unit. Our findings may have an impact on patients and clinicians concerned with symptom management in intensive care units. We used the consolidated criteria for reporting qualitative research. A user representative was involved in the design of the study.

Intensive care unit mortality and cost-effectiveness associated with intensivist staffing: a Japanese nationwide observational study

BackgroundJapan has four types of intensive care units (ICUs) that are divided into two categories according to the management fee charged per day: ICU management fees 1 and 2 (ICU1/2) (equivalent to high-intensity staffing) and 3 and 4 (ICU3/4) (equivalent to low-intensity staffing). Although ICU1/2 charges a higher rate than ICU3/4, no cost-effectiveness analysis has been performed for ICU1/2. This study evaluated the clinical outcomes and cost-effectiveness of ICU1/2 compared with those of ICU3/4.MethodsThis retrospective observational study used a nationwide Japanese administrative database to identify patients admitted to ICUs between April 2020 and March 2021 and divided them into the ICU1/2 and ICU3/4 groups. The ICU mortality rates and in-hospital mortality rates were determined, and the incremental cost-effectiveness ratio (ICER) (Japanese Yen (JPY)/QALY), defined as the difference between quality-adjusted life year (QALY) and medical costs, was compared between ICU1/2 and ICU3/4. Data analysis was performed using the Chi-squared test; an ICER of < 5 million JPY/QALY was considered cost-effective.ResultsThe ICU1/2 group (n = 71,412; 60.7%) had lower ICU mortality rates (ICU 1/2: 2.6% vs. ICU 3/4: 4.3%, p < 0.001) and lower in-hospital mortality rates (ICU 1/2: 6.1% vs. ICU 3/4: 8.9%, p < 0.001) than the ICU3/4 group (n = 46,330; 39.3%). The average cost per patient of ICU1/2 and ICU3/4 was 2,249,270 ± 1,955,953 JPY and 1,682,546 ± 1,588,928 JPY, respectively, with a difference of 566,724. The ICER was 718,659 JPY/QALY, which was below the cost-effectiveness threshold.ConclusionsICU1/2 is associated with lower ICU patient mortality than ICU3/4. Treatments under ICU1/2 are more cost-effective than those under ICU3/4, with an ICER of < 5 million JPY/QALY.

Evaluating an educational program for enhancing neonatal intensive and special care nurses’ and midwives’ competence with neonatal pain management: A quasi-experimental study

Competence in neonatal pain management is influenced by the clinician’s knowledge, attitudes, and skills. The impact of an educational program on enhancing competence among Thai neonatal nurses and midwives has never been explored. This study aims to evaluate the impact of an educational program to increase nurses’ and midwives’ competence in neonatal pain management in Thai neonatal intensive and special care units (NI/SCUs). A web-based learning package with pre-, post-, and follow-up online questionnaire was administered to 68 neonatal nurses and midwives. There was a substantial increase in the total mean scores of knowledge, attitudes, and perceived self-competence in the post- and follow-up phases compared to the pre-test phase (p < 0.001). The educational program had a significant impact on Thai NI/SCU nurse and midwife competence regarding neonatal pain management. Ongoing education is needed to sustain clinicians’ competence in this area.

Development of a Randomized Trial Comparing ICP-Monitor-Based Management of Severe Pediatric Traumatic Brain Injury to Management Based on Imaging and Clinical Examination Without ICP Monitoring-Research Algorithms.

The efficacy of our current approach to incorporating intracranial pressure (ICP) data into pediatric severe traumatic brain injury (sTBI) management is incompletely understood, lacking data from multicenter, prospective, randomized studies. The National Institutes of Health-supported Benchmark Evidence from Latin America-Treatment of Raised Intracranial Pressure-Pediatrics trial will compare outcomes from pediatric sTBI of a management protocol based on ICP monitoring vs 1 based on imaging and clinical examination without monitoring. Because no applicable comprehensive management algorithms for either cohort are available, it was necessary to develop them. A consensus conference involving the 21 intensivists and neurosurgeons from the 8 trial sites used Delphi-based methodology to formulate management algorithms for both study cohorts. We included recommendations from the latest Brain Trauma Foundation pediatric sTBI guidelines and the consensus-based adult algorithms (Seattle International Brain Injury Consensus Conference/Consensus Revised Imaging and Clinical Examination) wherever relevant. We used a consensus threshold of 80%. We developed comprehensive management algorithms for monitored and nonmonitored cohort children with sTBI. We defined suspected intracranial hypertension for the nonmonitored group, set minimum number and timing of computed tomography scans, specified minimal age-adjusted mean arterial pressure and cerebral perfusion pressure targets, defined clinical neuroworsening, described minimal requisites for intensive care unit management, produced tiered management algorithms for both groups, and listed treatments not routinely used. We will study these protocols in the Benchmark Evidence from Latin America-Treatment of Raised Intracranial Pressure-Pediatrics trial in low- and middle-income countries. Second, we present them here for consideration as prototype pediatric sTBI management algorithms in the absence of published alternatives, acknowledging their limited evidentiary status. Therefore, herein, we describe our study design only, not recommended treatment protocols.

Non-pharmacological management in a neonatal intensive care unit- a systematic review

Non-pharmacological management in a neonatal intensive care unit- a systematic review