Intensive Care Unit Management Research Articles

Machine learning-derived blood culture classification with both predictive and prognostic values in the intensive care unit: A retrospective cohort study

ObjectivesDiagnosis and management of intensive care unit (ICU)-acquired bloodstream infections are often based on positive blood culture results. This retrospective cohort study aimed to develop a classification model using data-driven characterisation to optimise the management of intensive care patients with blood cultures. Setting, methodology/designAn unsupervised clustering model was developed based on the clinical characteristics of patients with blood cultures in the Medical Information Mart for Intensive Care (MIMIC)-IV database (n = 2451). It was tested using the data from the MIMIC-III database (n = 2047). Main outcome measuresThe prognosis, blood culture outcomes, antimicrobial interventions, and trajectories of infection indicators were compared between clusters. ResultsFour clusters were identified using machine learning-based k-means clustering based on data obtained 48 h before the first blood culture sampling. Cluster γ was associated with the highest 28-day mortality rate, followed by clusters α, δ, and β. Cluster γ had a higher fungal isolation rate than cluster β (P < 0.05). Cluster δ was associated with a higher isolation rate of Gram-negative organisms and fungi (P < 0.05). Patients in clusters γ and δ underwent more femoral site vein catheter placements than those in cluster β (P < 0.001, all). Patients with a duration of antibiotics treatment of 4, 6, and 7 days in clusters α, δ, and γ, respectively, had the lowest 28-day mortality rate. ConclusionsMachine learning identified four clusters of intensive care patients with blood cultures, which yielded different prognoses, blood culture outcomes, and optimal duration of antibiotic treatment. Such data-driven blood culture classifications suggest further investigation should be undertaken to optimise treatment and improve care. Implications for clinical practiceIntensive care unit-acquired bloodstream infections are heterogeneous. Meaningful classifications associated with outcomes should be described. Using machine learning and cluster analysis could help in understanding heterogeneity. Data-driven blood culture classification could identify distinct physiological states and prognoses before deciding on blood culture sampling, optimise treatment, and improve care.

FRI255 Polyglandular Autoimmune Syndrome Type 2 Presenting With Severe Hyponatremia

Abstract Disclosure: A. West: None. A.N. Davis: None. A. Warner: None. S. Salcin: None. Introduction: Polyglandular autoimmune syndrome type 2 (PAS-2) is a polygenic autoimmune syndrome which presents with two or more specific autoimmune manifestations. The combination of Addison’s disease and Hashimoto’s thyroiditis has been referred to as Schmidt Syndrome. Treatment of hypothyroidism without recognition of concomitant adrenal insufficiency may result in exacerbation of adrenal insufficiency (AI). We present a case of PAS-2 presenting with severe hyponatremia. Case: A 28-year-old male presented to an outside hospital with fatigue and weakness. His sodium was 121mEq/L and TSH &amp;gt;356mcIU/mL, and he was admitted for management of hyponatremia. He was started on oral levothyroxine, urea tablets, and fluid restriction. In the weeks following discharge, the patient had worsening fatigue, weakness, dizziness, nausea, and weight loss, and he presented to our ED. His vital signs were stable without tachycardia or hypotension. He was lethargic but fully oriented. Hyperpigmented areas of the tongue and nose were noted. Laboratory evaluation revealed sodium 111mEq/L, potassium 4.5mEq/L, TSH 43.56 (0.4-4.7mcIU/mL), and free T4 of 1.12 (0.58-1.76ng/dL). He was admitted to the medical intensive care unit for management of severe hyponatremia. Repeat sodium was 112mEq/L with serum cortisol 4.57mcg/dL. Hypertonic saline was given without improvement in hyponatremia. Cortisol level was determined to be inappropriately normal in the setting of severe hyponatremia. Cosyntropin stimulation test was performed with baseline, 30 minute, and 60 minute cortisol levels of 5.31, 6.17, and 6.26, respectively, consistent with AI. ACTH level was not obtained due to the blood sample being hemolyzed. Other results include positive 21-hydroxylase antibody, TPO antibody &amp;gt;900 IU/mL, and undetectable GAD 65 antibody. He received IV stress dose steroids with resolution of his symptoms and his hyponatremia. Oral hydrocortisone replacement therapy was started prior to discharge. Discussion: Patients with one autoimmune endocrinopathy are at risk of developing a second one. Our patient’s hyponatremia was initially attributed to his hypothyroidism without recognition of concomitant AI. Early diagnosis of AI is important prior to initiation of levothyroxine, as treatment of hypothyroidism may exacerbate AI. The sodium level in our patient worsened from 121mEq/L at the previous admission to 111mEq/L when he presented to our hospital, related to worsening of his AI while being treated for his hypothyroidism. Timely diagnosis of associated AI requires high index of suspicion in such patients, particularly in patients with signs or symptoms which may overlap with hypothyroidism, such as hyponatremia in our patient. AI should be considered in any patient who presents with hyponatremia, even those who lack other classic features such as hypotension, hyperkalemia, and hypoglycemia. Presentation: Friday, June 16, 2023

Facilitators and barriers to evidence-based practice in central venous access device insertion and management in an intensive care unit: A qualitative study

IntroductionResearch evidence and clinical practice guidelines exist on preventing central line-associated bloodstream infections. However, there is limited knowledge about the barriers and facilitators to evidence-based central venous access device care. AimThe aim of this study was to investigate the facilitators and barriers to evidence-based central venous access device care in the adult intensive care setting. MethodThis exploratory qualitative study involved focus groups and interviews with registered nurses and physicians involved in central venous access device insertion and management in a tertiary Australian intensive care unit. Purposive sampling was used to recruit staff (n = 26) with varying years of clinical experience and clinical positions. Six focus groups and three individual interviews were conducted. Interviews were audio recorded, transcribed verbatim and analysed using content analysis. ResultsThree overarching categories emerged: work structures to support optimal performance; processes to optimise quality of care, and factors influencing staff members’ behaviour. Perceived facilitators to optimal central venous access device care included explicit language use in procedure documents, work-system integrated strategies, research evidence dissemination, audit, and feedback. However, there was a lack of consistency in practices such as audit, feedback, and patient participation. ConclusionTo bring about effective improvement in central venous access device care, future interventions should be tailored to address identified barriers, including integrating audit and feedback into clinicians’ work processes. Additionally, future research is needed to explore the role of patients and their families in central venous access device care. Implications for clinical practiceWhen developing practice policies or procedure manuals, it is important to use explicit language to ensure clear communication of evidence-based recommendations to clinicians. Strategies integrated into work processes can enhance adherence to evidence-based practice. Large departments with limited educators should explore innovative methods like online education to ensure optimal central venous access device care.

Predictive Performance of Neutrophil Gelatinase Associated Lipocalin, Liver Type Fatty Acid Binding Protein, and Cystatin C for Acute Kidney Injury and Mortality in Severely Ill Patients.

Acute kidney injury (AKI) is a common condition in severely ill patients associated with poor outcomes. We assessed the associations between urinary neutrophil gelatinase-associated lipocalin (uNGAL), urinary liver-type fatty acid-binding protein (uLFABP), and urinary cystatin C (uCysC) concentrations and patient outcomes. We assessed the predictive performances of uNGAL, uLFABP, and uCysC measured in the early phase of intensive care unit (ICU) management and at discharge from the ICU in severely ill patients for short- and long-term outcomes. The primary outcome was the occurrence of AKI during ICU stay; secondary outcomes were 28-day and 1-yr allcause mortality. In total, 1,759 patients were admitted to the ICU, and 728 (41.4%) developed AKI. Median (interquartile range, IQR) uNGAL, uLFABP, and uCysC concentrations on admission were 147.6 (39.9-827.7) ng/mL, 32.4 (10.5-96.0) ng/mL, and 0.33 (0.12-2.05) mg/L, respectively. Biomarker concentrations on admission were higher in patients who developed AKI and associated with AKI severity. Three hundred fifty-six (20.3%) and 647 (37.9%) patients had died by 28 days and 1-yr, respectively. Urinary biomarker concentrations at ICU discharge were higher in non-survivors than in survivors. The areas under the ROC curve (95% confidence interval) of uLFABP for the prediction of AKI, 28-day mortality, and 1-yr mortality (0.70 [0.67-0.72], 0.63 [0.59-0.66], and 0.57 [0.51-0.63], respectively) were inferior to those of the other biomarkers. uNGAL, uLFABP, and uCysC concentrations on admission were associated with poor outcomes. However, their predictive performance, individually and in combination, was limited. Further studies are required to confirm our results.

Anaesthetic management of pregnant patients with severe dengue fever for emergency caesarean section - A case series and review

: Dengue, a mosquito-borne viral infection, can lead to severe complications like dengue shock syndrome and severe thrombocytopenia. Pregnant patients with dengue present unique anaesthetic challenges. In this case series, we present the anaesthetic management of four pregnant patients with dengue who required emergency caesarean delivery.: All patients had severe thrombocytopenia and required platelet transfusions. Two patients developed respiratory distress and pulmonary edema in the perioperative period. One patient had severe liver function abnormalities along with thrombocytopenia, complicating the diagnosis. All patients received intensive care unit (ICU) management. None of the neonates tested positive for dengue.: The pathophysiological changes of pregnancy and dengue infection complicate the anaesthetic management of critically ill dengue patients. Thrombocytopenia and abnormal immune response lead to acute vascular permeability, plasma leakage, circulatory insufficiency, and polyserositis. Abnormal liver function tests and thrombocytopenia must be differentiated from HELLP syndrome. Over-transfusion of fluids due to shock can lead to pulmonary edema.: Pregnant patients with dengue fever pose a high risk of maternal and foetal mortality and morbidity. Successful anaesthetic management requires judicious transfusion of blood products and fluids based on the disease's complications and stage of illness. General anaesthesia is safe in these patients.

Improving environmental sustainability of intensive care units: A mini-review.

The carbon footprint of healthcare is significantly impacted by intensive care units, which has implications for climate change and planetary health. Considering this, it is crucial to implement widespread efforts to promote environmental sustainability in these units. A literature search for publications relevant to environmental sustainability of intensive care units was done using PubMed. This mini-review seeks to equip intensive care unit practitioners and managers with the knowledge necessary to measure and mitigate the carbon cost of healthcare for critically ill patients. It will also provide an overview of the current progress in this field and its future direction.

Ventilator Training through International Telesimulation in Sierra Leone.

The coronavirus disease (COVID-19) pandemic resulted in an increased need for medical professionals with expertise in managing patients with acute hypoxemic respiratory failure, overwhelming the existing critical care workforce in many low-resource countries. To address this need in Sierra Leone, we developed, piloted, and evaluated a synchronous simulation-based tele-education workshop for healthcare providers on the fundamental principles of intensive care unit (ICU) management of the COVID-19 patient in a low-resource setting. Thirteen 2-day virtual workshops were implemented between April and July 2020 with frontline Sierra Leone physicians and nurses for potential ICU patients in hospitals throughout Sierra Leone. Although all training sessions took place at the 34 Military Hospital (a national COVID-19 center) in Freetown, participants were drawn from hospitals in each of the provinces of Sierra Leone. The workshops included synchronous tele-education-directed medical simulation didactic sessions about COVID-19, hypoxemia management, and hands-on simulation training about mechanical ventilation. Measures included pre and postworkshop knowledge tests, simulation checklists, and a posttest survey. Test results were analyzed with a paired sample t test; Likert-scale survey responses were reported using descriptive statistics; and open-ended responses were analyzed using thematic analysis. Seventy-five participants enrolled in the program. On average, participants showed 20.8% improvement (a score difference of 4.00 out of a maximum total score of 20) in scores between pre and postworkshop knowledge tests (P = 0.004). Participants reported satisfaction with training (96%; n = 73), achieved 100% of simulation checklist objectives, and increased confidence with ventilator skills (96%; n = 73). Themes from the participants' feedback included increased readiness to train colleagues on critical care ventilators at their hospitals, the need for longer and more frequent training, and a need to have access to critical care ventilators at their hospitals. This synchronous tele-education-directed medical simulation workshop implemented through partnerships between U.S. physicians and Sierra Leone healthcare providers was a feasible, acceptable, and effective means of providing training about COVID-19, hypoxemia management, and mechanical ventilation. Future ICU ventilator training opportunities may consider increasing the length of training beyond 2 days to allow more time for the hands-on simulation scenarios using the ICU ventilator and assessing knowledge application in long-term follow-up.

Organisational challenges of pain management in neonatal intensive care unit: a qualitative study

ObjectivesDespite credible evidence, optimal neonates’ pain management in the neonatal intensive care unit (NICU) is a challenging issue. In this regard, the organisational context is an essential factor. The existing...

Investigation on the current situation of the development of intensive care units in Inner Mongolia Autonomous Region in 2022

Investigation on the current situation of the development of intensive care units in Inner Mongolia Autonomous Region in 2022

Impact of the COVID-19 pandemic on diabetic ketoacidosis management in the pediatric intensive care unit.

Diabetic ketoacidosis (DKA) is a common endocrine emergency in pediatric patients. Early presentation to health facilities, diagnosis, and good management in the pediatric intensive care unit (PICU) are crucial for better outcomes in children with DKA. This was a single-center, retrospective cohort study conducted between February 2015 and January 2022. Patients with DKA were divided into two groups according to pandemic status and diabetes diagnosis. The study enrolled 59 patients, and their mean age was 11±5 years. Forty (68%) had newly diagnosed type 1 diabetes mellitus (T1DM), and 61% received follow-up in the pre-pandemic period. Blood glucose, blood ketone, potassium, phosphorus, and creatinine levels were significantly higher in the new-onset T1DM group compared with the previously diagnosed group (P=0.01, P=0.02, P<0.001, P=0.01, and P=0.08, respectively). In patients with newly diagnosed T1DM, length of PICU stays were longer than in those with previously diagnosed T1DM (28.5±8.9 vs. 17.3±6.7 hours, P<0.001). The pandemic group was compared with pre-pandemic group, there was a statistically significant difference in laboratory parameters of pH, HCO3, and lactate and also Pediatric Risk of Mortality (PRISM) III score. All patients survived, and there were no neurologic sequelae. Patients admitted during the pandemic period were admitted with more severe DKA and had higher PRISM III scores. During the pandemic period, there was an increase in the incidence of DKA in the participating center compared to that before the pandemic.

Difficult Airway Management in Surgical Intensive Care Unit

Difficult Airway Management in Surgical Intensive Care Unit

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Consensus-Driven Protocol for glucose management in the post-resuscitation intensive care unit adult trauma patient.

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Consensus-Driven Protocol for glucose management in the post-resuscitation intensive care unit adult trauma patient.

Best Practice Recommendations for Dysphagia Management in Intensive Care Unit (ICU): A Delphi Study from Multidisciplinary Experts in Turkey.

There is no study about all aspects of oropharyngoesophageal (OPE) dysphagia from diagnosis to follow-up in a multidisciplinary manner in the world. In order to close this gap, we aimed to create a recommendation study that can be used in clinical practice, addressing all aspects of dysphagia in the ICU in detail with the opinion of experienced multidisciplinary experts. This recommendation paper was generated by a multidisciplinary team, using the seven-step process and a three-modified Delphi round via e-mail. Firstly, 15 open-ended questions were created, and then detailed recommendations including general principles, management, diagnosis, rehabilitation, and follow-up were created with the answers from these questions, Each recommendation item was voted on by the experts as overall consensus (strong recommendation), approaching consensus (weak recommendation), and divergent consensus (not recommended).In the first Delphi round, a questionnaire consisting of 413 items evaluated with a scale of 0-10 was prepared from the opinions and suggestions given to 15 open-ended questions. In the second Delphi round, 55.4% were accepted and revised suggestions were created. At the end of the third Delphi round, the revised suggestion form was approved again and the final proposals containing 133 items were created. This study includes comprehensive and detailed recommendations, including a broad perspective from diagnosis to treatment and follow-up, as detailed as possible, for management of dysphagia in patients with both oropharyngeal- and esophageal-dysphagia in ICU.

Pattern of Patients in Intensive Care Unit in a Tertiary Care Hospital in Lumbini Province Nepal

BACKGROUND Intensive care is a crucial component of hospital care, reserved for patients with potentially recoverable conditions who can benefit from invasive treatment. However, in developing countries like Nepal, resources and availability of intensive care become hurdles in delivering healthcare. This study presents the pattern of admission and outcome of patients' management in a general intensive care unit (ICU) of this tertiary care center in Lumbini Province, Nepal. &#x0D; METHODS A cross sectional study conducted in the Department of Internal Medicine, Bheri Hospital between July 2021 to June 2022. A total of 792 patient’s details were obtained from the record section. Demographic data, diagnosis, duration of stay in ICU, managing units, and outcome were collected and analyzed with Statistical Package for the Social Sciences 20.&#x0D; RESULTS A total of 729 patients were admitted in the study period; 57.82% were male and 42.18% were female. Majority 60% of admissions were from Department of Medicine followed by Cardiology 24% and Surgery 10%. Pneumonia and Chronic Obstructive Pulmonary Disease 18.30% followed by Myocardial Infraction 14.52%, Acute abdomen 10.22% and sepsis 9.84% were the most common morbidity. Mean duration of ICU stay was 3.5. days. Discharge rate was 69.82% and the mortality rate was 17.80 %. &#x0D; CONCLUSION The most common patients admitted in the ICU of Bheri hospital were mostly Medical cases. Surgical and obstetric cases were lesser in number. The outcomes were comparable with other multidisciplinary ICU of similar settings.

Increased burden of MDR bacterial infections; reflection from an antibiogram of ICUs of a tertiary care hospital.

Infectious disease management in intensive care units (ICUs) is becoming more difficult due to increasing antimicrobial resistance. Hence, the aim of this study was to explore the nature of pathogens mostly encountered in an ICU and determine their antibiotic susceptibility through the compilation of ICU-specific antibiogram. A descriptive cross-sectional study of the culture and sensitivity reports of ICU patients was conducted in a tertiary care hospital. An antibiogram was created according to the Clinical Laboratory Standards Institute (CLSI) M39-A4 guidelines. Of the total 597 reports, the most common specimen type were respiratory secretions (n = 174), followed by blood (n = 128), wounds (n = 108), and urine (n = 80). Out of 597 isolates, the most frequently isolated bacteria were Klebsiella species (n = 156), Pseudomonas aeruginosa (n = 117), Escherichia coli (n = 112), Enterobacter species (n = 56), Acinetobacter species (n = 52), Proteus species (n = 39), Staphylococcus aureus (n = 34) and coliform species (n = 31). An 84% multidrug resistance (MDR) rate was reported among the isolates studied, with Acinetobacter species being at the top with a 98% MDR rate. A substantial and alarming MDR rate was observed in our study. Furthermore, our findings demonstrated a potential interest in developing an ICU-specific antibiogram that is informative to clinicians in their clinical decision-making related to antibiotic therapy.

Outcomes After Decompressive Surgery for Severe Cerebral Venous Sinus Thrombosis Associated or Not Associated with Vaccine-Induced Immune Thrombosis with Thrombocytopenia: A Multicenter Cohort Study

BackgroundClinical observations indicated that vaccine-induced immune thrombosis with thrombocytopenia (VITT)-associated cerebral venous sinus thrombosis (CVST) often has a space-occupying effect and thus necessitates decompressive surgery (DS). While comparing with non-VITT CVST, this study explored whether VITT-associated CVST exhibits a more fulminant clinical course, different perioperative and intensive care unit management, and worse long-term outcome.MethodsThis multicenter, retrospective cohort study collected patient data from 12 tertiary centers to address priorly formulated hypotheses concerning the clinical course, the perioperative management with related complications, extracerebral complications, and the functional outcome (modified Rankin Scale) in patients with VITT-associated and non-VITT CVST, both with DS.ResultsBoth groups, each with 16 patients, were balanced regarding demographics, kind of clinical symptoms, and radiological findings at hospital admission. Severity of neurological symptoms, assessed with the National Institute of Health Stroke Scale, was similar between groups at admission and before surgery, whereas more patients with VITT-associated CVST showed a relevant midline shift (≥ 4 mm) before surgery (100% vs. 68.8%, p = 0.043). Patients with VITT-associated CVST tended to undergo DS early, i.e., ≤ 24 h after hospital admission (p = 0.077). Patients with VITT-associated CVST more frequently received platelet transfusion, tranexamic acid, and fibrinogen perioperatively. The postoperative management was comparable, and complications were evenly distributed. More patients with VITT-associated CVST achieved a favorable outcome (modified Rankin Scale ≤ 3) at 3 months (p = 0.043).ConclusionsAlthough the prediction of individual courses remains challenging, DS should be considered early in VITT-associated CVST because an overall favorable outcome appears achievable in these patients.

Damage control surgery in emergency general surgery: What you need to know.

Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.

Optimal discharge of patients from intensive care via a data-driven policy learning framework

Clinical decision support tools rooted in machine learning and optimization can provide significant value to healthcare providers through better management of intensive care units. In particular, it is important that intensive care unit patient discharge decisions account for the nuanced trade-off between decreasing the length of stay and the risk of readmission or death after discharge of a patient. This work introduces a comprehensive framework (i.e., not geared towards any particular disease or condition) for capturing this trade-off and to recommend optimal discharge timing decisions given the electronic health records of a patient. A data-driven approach is used to derive a parsimonious, discrete state space representation to represent the physiological condition of a given patient. Based on this model and a given cost function, an infinite-horizon discounted Markov decision process is formulated and solved numerically to compute an optimal discharge policy, whose performance is assessed using off-policy evaluation strategies. Extensive numerical experiments are performed to validate the proposed framework using real-life intensive care unit patient data.

COVID-19 infection in Libyan chronic hemodialysis patients: Prevalence, risk factors, severity and predictors of mortality

Background: Chronic kidney disease (CKD) is associated with the increased risk of both outpatient and inpatient pneumonia. This association is independent of comorbid diabetes, cardio-vascular disease (CVD), asthma, and chronic obstructive airway disease. Dialysis patients are considered at risk groups for SARS-CoV-2 infection; Short-term mortality in patients on chronic hemodialysis who were hospitalized with COVID-19 was high. Outcomes in those requiring intensive care unit (ICU) and mechanical ventilation management were poor. Aim: This study mainly aimed to identify the prevalence, risk factors, severity and predictors of mortality in Libyan hemodialysis patients infected with COVID- 19. Methods: In this retrospective cohort study, data of CKD patients on maintenance hemodialysis diagnosed with COVID-19 infection from two large dialysis centers in Libya were collected and analyzed using SPSS version 22 for .demographic, clinical and laboratory profiles. Results: The data of 810 patients from two hemodialysis centers in Libya showed infection rate was 10.2 %, and the overall mortality was 26.5% (39/83) 47% of patients needed admission to ICU for supportive mechanical ventilation (SPO2 ranged from 76-92%). The biochemical and laboratory data showed a decreased mean absolute lymphocyte counts. A high neutrophil-lymphocyte ratio (NLR), and a mild decrease in platelet counts. C-reactive protein (CRP), fibrinogen, ferritin, and D-dimer were also high at admission. (22/83, 26.5%) of total patients, and (17/39) 43.6% of ICU patients died in less than 28 days after COVID-19 diagnosis. Conclusions: In CKD patients on maintenance hemodialysis diagnosed with COVID-19 infection; severity of disease at presentation, need for invasive supportive mechanical ventilation, older age, raised serum glutamic oxaloacetic transaminase, and lower level of albumin may have been valuable predictors of mortality and poor outcomes.

Parents' perspectives on their baby's pain management in a surgical neonatal intensive care unit: The parents' awareness and involvement in pain management (PAIN-PAM) study - Part 2

Parents' whose babies underwent surgery, completed five days of stay in the surgical neonatal intensive care unit (NICU) and were literate in English, participated in this exploratory cohort study. Parents provided written responses to two open-ended questions relating to their baby's pain management. Thematic analysis of data from 52 parents revealed four major themes: Information Resources; Communication Practices; Barriers to Parental Role; and Staff Appreciation. The majority of parents wanted information provided in different formats about how to recognise their babies' pain and how to comfort their babies in addition to discussions with clinicians. They also wanted the choice to stay with their baby during painful procedures. A barrier to this was COVID-19 restrictions. Twenty-nine percent of parents responded that no additional resources were required. The findings highlight the need to improve parent-focussed resources and clinician education to better inform and support parents' involvement in managing their babies' pain in the surgical NICU.