Intensive Care Unit Population Research Articles

Abstract Su907: Post-Cardiac Arrest Potassium Abnormalities Associated With Unfavorable Functional Outcome

Background: Abnormal potassium levels are common findings in the intensive care unit (ICU) population. We aimed to determine the incidence of dyskalemias at ICU admission and their association with functional outcome in comatose patients resuscitated from cardiac arrest. Hypothesis: We hypothesized that both hypokalemia and hyperkalemia are associated with unfavorable functional outcome. Methods: Pooled data from four randomized clinical trials in comatose post-cardiac arrest patients admitted to ICU after return of spontaneous circulation (ROSC). Reference potassium levels were defined as between 3 and 4.9 mmol/L, as proposed in the Simplified Acute Physiology Score II. Favorable functional outcome was defined as a Cerebral Performance Category of 1 or 2 at 180 days. Results: We included 1133 patients (557 from HYPERION, 346 from TTH48, 120 from COMACARE and 110 from Xe-HYPOTHECA) with a median age of 64 (IQR: 55-72) years and a predominance of males (72%). Overall, 421 (36%) patients had favorable functional outcome. On admission, 221 (19.5%) patients experienced hyperkalemia and 35 (3.1%) patients experienced hypokalemia. More patients in the normokalemia group (364/877, 41.5%) had a favorable functional outcome, as compared to the hypokalemia (11/35, 31.4%) and hyperkalemia (41/221, 18.6%) groups p<0.001). In a mixed-effects logistic regression model including initial rhythm, delay from collapse to ROSC, bystander cardiopulmonary resuscitation, lactate, and urea and with normokalemia as reference group, hyperkalemia was associated with higher odds for unfavorable functional outcome (OR 1.85, 95% CI 1.10-3.12, p=0.02) whereas hypokalemia was not (OR 1.36 95% CI 0.51-3.60, p=0.53). Conclusions: One fifth of unconscious cardiac arrest patients experienced dyskalemia on ICU admission. Hyperkalemia was associated with unfavorable functional outcome at 180 days compared to normokalemia, whereas hypokalemia was not an independent predictor of outcome.

Development and validation of the prediction score for augmented renal clearance in critically Ill Japanese adults.

Augmented renal clearance (ARC) decreases the therapeutic concentration of drugs excreted by the kidneys in critically ill patients. Several ARC prediction models have been developed and validated; however, their usefulness in Japan has not been comprehensively investigated. Thus, we developed a unique ARC prediction model for a Japanese mixed intensive care unit (ICU) population and compared it with existing models. This retrospective study enrolled a mixed ICU population in Japan from January 2019 and June 2022. The primary outcome was the development and validation of a model to predict ARC onset based on baseline information at ICU admission. Patients admitted until May 2021 were included in the training set, and external validation was performed on patients admitted thereafter. A multivariate logistic regression model was used to develop an integer-based predictive scoring system for ARC. The new model (the JPNARC score) was externally validated along with the ARC and Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) scores. A total of 2,592 critically ill patients were enrolled initially, with 651 patients finally included after excluding 1,941 patients. The training and validation datasets comprised 456 and 195 patients, respectively. Multivariate analysis was performed to develop the JPNARC score, which incorporated age, sex, serum creatinine, and diagnosis upon ICU admission (trauma or central nervous system disease). The JPNARC score had a larger area under the receiver operating characteristic curve than the ARC and ARCTIC scores in the validation dataset (0.832, 0.633, and 0.740, respectively). An integer-based scoring system was developed to predict ARC onset in a critically ill Japanese population and showed high predictive performance. New models designed to predict the often-unrecognized ARC phenomenon may aid in the decision-making process for upward drug dosage modifications, especially in resource- and labor-limited settings.

The Predictive Validity of the Full Outline of UnResponsiveness Score Compared to the Glasgow Coma Scale in the Intensive Care Unit: A Systematic Review.

The Full Outline of UnResponsiveness (FOUR) score was developed to overcome the limitations of the Glasgow Coma Scale (GCS) when assessing individuals with impaired consciousness. We sought to review the evidence regarding the predictive validity of the GCS and FOUR score in intensive care unit (ICU) settings. This review was prospectively registered in PROSPERO (CRD42023420528). Systematic searches of CINAHL, MEDLINE, and Embase were undertaken. Prospective observational studies were included if both GCS and FOUR score were assessed in adults during ICU admission and if mortality and/or validated functional outcome measure scores were collected. Studies were excluded if they exclusively investigated patients with traumatic brain injury. Screening, data extraction, and quality assessment using the Quality in Prognosis Studies tool were conducted by two reviewers. Twenty studies of poor to moderate quality were included. Many studies only included patients with neurological illness and excluded sedated patients, despite high proportions of intubated patients. The FOUR score achieved higher area under the receiver operating characteristic curve values for mortality prediction compared with the GCS, and the FOUR score achieved significantly higher area under the receiver operating characteristic curve values for predictions of ICU mortality. Both coma scales showed similar accuracy in predicting "unfavorable" functional outcome. The FOUR score appeared to be more responsive than the GCS in the ICU, as most patients with a GCS score of 3 obtained FOUR scores between 1 and 8 due to preserved brainstem function. The FOUR score may be superior to the GCS for predicting mortality in ICU settings. Further adequately powered studies with clear, reliable methods for assessment of index and outcome scores are required to clarify the predictive performance of both coma scales in ICUs. Inclusion of sedated patients may improve generalizability of findings in general ICU populations.

Exploring Antibacterial Usage and Pathogen Surveillance over Five Years in a Tertiary Referral Teaching Hospital Adult General Intensive Care Unit (ICU)

Antimicrobial resistance is a globally recognised health emergency. Intensive care is an area with significant antimicrobial consumption, particularly increased utilisation of broad-spectrum antibacterials, making stewardship programmes essential. We aimed to explore antibacterial consumption, partnered with pathogen surveillance, over a five-year period (2018 to 2023) in a tertiary referral adult general intensive care unit (ICU). The mean number of admissions was 1645 per annum. A comparison between the ICU populations admitted before and after the COVID-19 pandemic peak (2020/21) identified several notable differences with increased average daily unit bed occupancy (21.6 vs. 25.2, respectively) and a higher proportion of admissions with sepsis (28.4% vs. 32.5%, respectively) in the post-pandemic period. Over the entire five years, the overall proportion of antibacterial use by the WHO AWaRe classification was 42.6% access, 54.7% watch and 2.6% reserve. One hundred and forty-seven positive blood culture isolates were reported, with the most concerning antibacterial resistance identified in 7.5% (9 Escherichia coli and 2 Klebsiella pneumoniae isolates). The COVID-19 pandemic peak year was associated with increased ICU bed occupancy, as well as a greater number of positive blood cultures but lower antibacterial consumption. Despite an increasingly complex workload, a large proportion of overall antibacterial consumption remained within the access category. However, the mortality rate and the incidence of most concerning antimicrobial resistance with respect to pathogens remained satisfyingly consistent, suggesting the positive consequences of real-world antibiotic stewardship in an intensive care setting.

"The definition of predictor and outcome variables in mortality prediction models: a scoping review and quality of reporting study".

Mortality prediction models are promising tools for guiding clinical decision-making and resource allocation in intensive care units (ICUs). Clearly specified predictor and outcome variables are necessary to enable external validation and safe clinical application of prediction models. The objective of this study was to identify the predictor and outcome variables used in different mortality prediction models in the ICU and investigate their reporting. For this scoping review, MEDLINE, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Studies developed within a general ICU population reporting on prediction models with mortality as a primary or secondary outcome were eligible. The selection criteria were adopted from a review by Keuning et al. Predictor and outcome variables, variable characteristics (defined as units, definitions, moments of measurement and methods of measurement), and publication details (defined as first author, year of publication and title) were extracted from the included studies. Predictor and outcome variable categories were demographics, chronic disease, care logistics, acute diagnosis, clinical examination and physiological derangement, laboratory assessment, additional diagnostics, support and therapy, risk scores, and (mortality) outcomes. A total of 56 mortality prediction models containing 204 unique predictor and outcome variables were included. The predictor variables most frequently included in the models were age (40 times), admission type (27 times), and mechanical ventilation (21 times). We observed that single variables were measured with different units, according to different definitions, at a different moment, and with a different method of measurement in different studies. The reporting of the unit was mostly complete (98% overall, 95% in the laboratory assessment category), whereas the definition of the variable (74% overall, 63% in the chronic disease category) and method of measurement (70% overall, 34% in the demographics category) were most often lacking. Accurate and transparent reporting of predictor and outcome variables is paramount to enhance reproducibility, model performance in different contexts, and validity. Since unclarity about the required input data may introduce bias and thereby affect model performance, this study advocates that prognostic ICU models can be improved by transparent and clear reporting of predictor and outcome variables and their characteristics.

Rezafungin versus caspofungin for patients with candidaemia or invasive candidiasis in the intensive care unit: pooled analyses of the ReSTORE and STRIVE randomised trials

BackgroundRezafungin is an echinocandin approved in the US and EU to treat candidaemia and/or invasive candidiasis. This post-hoc, pooled analysis of the Phase 2 STRIVE and Phase 3 ReSTORE trials assessed rezafungin versus caspofungin in patients with candidaemia and/or invasive candidiasis (IC) in the intensive care unit (ICU) at randomisation.MethodsSTRIVE and ReSTORE were randomised double-blind trials in adults with systemic signs and mycological confirmation of candidaemia and/or IC in blood or a normally sterile site ≤ 96 h before randomisation. Data were pooled for patients in the ICU at randomisation who received intravenous rezafungin (400 mg loading dose then 200 mg once weekly) or caspofungin (70 mg loading dose then 50 mg once daily) for ≤ 4 weeks. Outcomes were Day 30 all-cause mortality (primary outcome), Day 5 and 14 mycological eradication, time to negative blood culture, mortality attributable to candidaemia/invasive candidiasis, safety, and pharmacokinetics.ResultsOf 294 patients in STRIVE/ReSTORE, 113 were in the ICU at randomisation (rezafungin n = 46; caspofungin n = 67). At baseline, ~ 30% of patients in each group had impaired renal function and/or an Acute Physiologic Assessment and Chronic Health Evaluation II score ≥ 20. One patient (in the caspofungin group) was neutropenic at baseline. Day 30 all-cause mortality was 34.8% for rezafungin versus 25.4% for caspofungin. Day 5 and 14 mycological eradication was 78.3% and 71.7% for rezafungin versus 59.7% and 65.7% for caspofungin, respectively. Median time to negative blood culture was 18 (interquartile range, 12.6–43.0) versus 38 (interquartile range, 15.9–211.3) h for rezafungin versus caspofungin (stratified log-rank P = 0.001; nominal, not adjusted for multiplicity). Candidaemia/IC-attributable deaths occurred in two rezafungin patients versus one caspofungin patient. Safety profiles were similar between groups. Overall, 17.4% (rezafungin) versus 29.9% (caspofungin) of patients discontinued due to treatment-emergent adverse events. Rezafungin exposure following the initial 400-mg dose was comparable between patients in the ICU at randomisation (n = 50) and non-ICU patients (n = 117).ConclusionsRezafungin was well tolerated and efficacious in critically ill, mainly non-neutropenic patients with candidaemia and/or IC. This analysis provides additional insights into the efficacy and safety of rezafungin in the ICU population.

Epidemiology of cardiogenic shock using the Shock Academic Research Consortium (SHARC) consensus definitions.

The Shock Academic Research Consortium (SHARC) recently proposed pragmatic consensus definitions to standardize classification of cardiogenic shock (CS) in registries and clinical trials. We aimed to describe contemporary CS epidemiology using the SHARC definitions in a cardiac intensive care unit (CICU) population. The Critical Care Cardiology Trials Network (CCCTN) is a multinational research network of advanced CICUs coordinated by the TIMI Study Group (Boston, MA). Cardiogenic shock was defined as a cardiac disorder resulting in SBP < 90 mmHg for ≥30 min [or the need for vasopressors, inotropes, or mechanical circulatory support (MCS) to maintain SBP ≥ 90 mmHg] with evidence of hypoperfusion. Primary aetiologic categories included acute myocardial infarction-related CS (AMI-CS), heart failure-related CS (HF-CS), and non-myocardial (secondary) CS. Post-cardiotomy CS was not included. Heart failure-related CS was further subcategorized as de novo vs. acute-on-chronic HF-CS. Patients with both cardiogenic and non-cardiogenic components of shock were classified separately as mixed CS. Of 8974 patients meeting shock criteria (2017-23), 65% had isolated CS and 17% had mixed shock. Among patients with CS (n = 5869), 27% had AMI-CS (65% STEMI), 59% HF-CS (72% acute-on-chronic, 28% de novo), and 14% secondary CS. Patients with AMI-CS and de novo HF-CS were most likely to have had concomitant cardiac arrest (P < 0.001). Patients with AMI-CS and mixed CS were most likely to present in more severe shock stages (SCAI D or E; P < 0.001). Temporary MCS use was highest in AMI-CS (59%). In-hospital mortality was highest in mixed CS (48%), followed by AMI-CS (41%), similar in de novo HF-CS (31%) and secondary CS (31%), and lowest in acute-on-chronic HF-CS (25%; P < 0.001). SHARC consensus definitions for CS classification can be pragmatically applied in contemporary registries and reveal discrete subpopulations of CS with distinct phenotypes and outcomes that may be relevant to clinical practice and future research.

Modernization of Cardiac Advanced Life Support: Role and Value of Cardiothoracic Anesthesiologist Intensivist in Post–Cardiac Surgery Arrest Resuscitation

Cardiac arrest in the post-operative cardiac surgery patient requires a unique set of management skills that deviates from traditional cardiopulmonary resuscitation and Advanced Cardiovascular Life Support (ACLS). Cardiac Advanced Life Support (CALS) was first proposed in 2005 to address these intricacies. The hallmark of CALS is early chest reopening and internal cardiac massage within five minutes of the cardiac arrest in patients unresponsive to basic life support. Since the introduction of CALS, the landscape of cardiac surgery has continued to evolve.Cardiac intensivists encounter more patients who undergo cardiac surgical procedures performed via minimally invasive techniques such as lateral thoracotomy or mini sternotomy, in which an initial bedside sternotomy for cardiac massage is not applicable. Given the heterogeneous nature of the patient population in the cardiothoracic intensive care unit (CTICU), personnel must expeditiously identify the most appropriate rescue strategy. As such, we have proposed a modified CALS approach to (1) adapt to a newer generation of cardiac surgery patients and (2) incorporate advanced resuscitative techniques. These include rescue-focused cardiac ultrasound to aid in the early identification of underlying pathology and guide resuscitation and early institution of extracorporeal cardiopulmonary resuscitation (ECPR) instead of chest re-opening. While these therapies are not immediately available in all cardiac surgery centers, we hope this creates a framework to revise guidelines to include these recommendations to improve outcomes and how cardiac anesthesiologist intensivists' evolving role can aid resuscitation.

Factors influencing management modifications following fiberoptic bronchoscopy in critically ill ICU patients.

Fiberoptic bronchoscopy (FOB) has evolved into a crucial diagnostic and therapeutic procedure for respiratory tract conditions over the years. Despite its benefits, this approach poses increased risks to critically ill patients. This study aimed to identify clinical parameters that influence management modifications after FOB in the general intensive care unit (ICU) population, an area not extensively explored. In this retrospective study, critically ill adults admitted to a medical ICU in Bangkok, Thailand, who underwent FOB between January 2013 and December 2022 were enrolled. Clinical parameters, imaging findings, and indications were analyzed to identify factors associated with modifications in post-bronchoscopic management. A total of 118 patients were reviewed and management modifications occurred in 69 patients (58.5%), in which antibiotic modification (78.3%) was the leading reason. Chronic steroid use and suspected interstitial lung disease were associated with management modifications after FOB, while alveolar infiltration on chest radiography was not. Although management modifications showed a trend toward lower mortality, statistical significance was not reached. Multivariate analysis identified chronic steroid use as the only independent factor [adjusted odds ratio (aOR): 2.26; 95% confidence interval (CI): 1.01-5.06; P=0.048]. Among critically ill patients, chronic steroid use was a predictor of management modifications after FOB and is likely to be beneficial.

Predictive factors of postoperative complications related to free flap reconstruction in head and neck cancer patients admitted to intensive care unit: a retrospective cohort study

BackgroundThe epidemiology and risk factors for postoperative complications related to free flap reconstruction in head and neck cancer patients admitted to the Intensive Care Unit (ICU) are unknown.MethodsWe performed a retrospective cohort study of patients with free flap reconstruction of head and neck cancer between September 2015 and April 2023 admitted to the ICU of Beijing Tongren Hospital. The univariate and multivariate analyses were used to explore the risk factors for postoperative complications related to free flap reconstruction admitted to ICU, including flap necrosis, bleeding, fistula, and infection.ResultsA total of 239 patients were included in this study, and 38 (15.9%) patients had postoperative complications related to free flap reconstruction. The median length of ICU stay was 1 day (interquartile range, 1–2 days). Multivariate analysis found that low BMI (P < 0.001), high postoperative CRP (P = 0.005), low hemoglobin (P = 0.012), and inadequate fluid intake (P < 0.05) were independent risk factors for complications.ConclusionsPostoperative complications related to free flap reconstruction were common in this ICU population. Careful fluid management and monitoring of CRP and hemoglobin levels may reduce complications.

Tongue-tie in the Neonatal Intensive Care Unit Compared to Healthy Newborns.

We sought to characterize the prevalence of ankyloglossia in our neonatal intensive care unit (NICU) population and to determine characteristics of this cohort compared to infants in the birth center (BC). Prospective data were collected using a standardized flow sheet. Breastfeeding infants undergoing evaluation for tongue-tie in the BC and NICU were included. Coryllos type, tip to frenulum length, tongue function, frequency of frenotomy, and breastfeeding outcomes were compared. Of 20,879 infants birthed at or admitted to the institution during the study period, there were fewer patients diagnosed with ankyloglossia in the BC compared to the NICU (3.3% BC vs. 5.4% NICU, p < 0.01). Of these, 163 underwent frenotomy: 86 in the BC and 77 in the NICU. For those undergoing frenotomy, gestational age (39.1 ± 1.3 BC, 34.4 ± 4.4 NICU, p < 0.01) and age at time of procedure (3.2 days BC, 29.2 NICU, p < 0.01) were the only demographic factors significantly different between the groups. There was no difference in Coryllos type or function score. In a subset of NICU infants with multiple assessments over time, function scores after frenotomy were significantly improved compared to pre-frenotomy (p < 0.01). Standard assessment tools appear to be appropriate for use in infants in the NICU, despite the higher rates of prematurity, low birth weights, and increased comorbidities. Assessment and intervention for tongue-tie can be one critical intervention to move these patients closer to oral feeding and discharge to home. Level 3 Laryngoscope, 2024.

Pre-existing cardiovascular disease in the intensive care population: a national data study in scotland

Abstract Introduction/Background Each year, nearly 17,000 patients are admitted to Intensive Care Units (ICU) in Scotland. Forty percent of these patients suffer from one or more pre-existing co-morbidity. Pre-existing co-morbid disease is a known risk factor for readmission to ICU, increased healthcare use, protracted recovery and reduced health-related quality of life. Nonetheless, it is unknown which group of patients is most affected. Given the heterogeneity of the ICU population and in consideration of more "targeted" care, understanding the influence of co-morbidities and identification of specific patient groups is necessary. In tandem, the association between cardiovascular disease and critical illness is under researched. Yet it is known that 20% of ICU patients suffer from cardiovascular disease (CVD), with some evidence to suggest CVD is linked to increased 5-year mortality in this group of patients. Purpose To understand the prevalence of pre-existing CVD and other pre-existing co-morbidities in the critically ill population and to determine the influence of pre-existing CVD on hospital readmission rates (within one year of index hospital discharge). Methods This study is a retrospective cohort analysis using routinely collected data on ICU admissions between 2010 and 2019 in Scotland. Following public benefit and privacy panel (PBPP) approval and university integrity committee review, data was accessed via a secure National Safe Haven platform. Demographic data are presented alongside correlation analysis. Results More than 100,000 patients were admitted to ICU between 2010 and 2019. Of these patients, around 10% suffered from pre-existing CVD, with 30% suffering from any co-morbid disease, as defined by Charlson Co-morbidity index. It was identified that around 10% of ICU patients were readmitted to ICU within one year and a further 20% readmitted to hospital within one year. Of those patients readmitted to ICU, 10% suffer from pre-existing CVD. Conclusion This study identified that CVD is prevalent amongst the critically ill population with many experiencing a further admission to ICU. Despite this, little is known about the follow-up care provided to these patients with regards to managing CVD.

Clearing the Air, Breathe Easy: Intensive Care Unit Remodeling Unveils Insights into Aspergillosis Prevention

Background: Invasive aspergillosis (IA) poses a substantial threat to morbidity and mortality, particularly among immunocompromised individuals. In 2023, a New York City Intensive Care Unit (ICU) experienced an aspergillus outbreak following a structural water leak, resulting in two patients diagnosed with Invasive Aspergillus niger in their bronchial cultures. Immediate interventions, including patient relocation and ICU reconstruction were implemented to mitigate further impacts. This study aims to assess the impact of timely relocation of patients and renovation of the ICU, on the incidence of invasive aspergillosis. Method: A quasi-experimental study design of ICU patients over a nine month period included surveillance by the Infection Prevention department from March 1 to December 1, 2023. Surveillance included review of microbiology reports, environmental cultures, and patient chart reviews. The Pre-intervention spanned March 1 to May 1, and the post-intervention from May 4 to December 1. Indoor mold assessments of pre- and post-intervention involved testing wall surfaces for moisture, air sample collection for fungal spores, and surface swabs for direct fungal analysis. The intervention included relocating all seventeen patients from the impacted ICU and comprehensive reconstruction. Reconstruction involved the removal and replacement of all sheetrock within the unit extending four feet from the floor with moisture-resistant sheetrock. Additionally, moisture resistant single sheet welded vinyl flooring and cove-bases were installed. All heating, ventilation, and air-conditioning (HVAC) systems were inspected and cleaned. Construction activities strictly adhered to Infection Control Risk Assessment (ICRA) guidelines, with emphasis on maintaining negative pressure, to ensure a safe environment. Result: Environmental swab samples from 50% of ICU rooms indicated growth of Aspergillus/Penicillium, Chaetomium, and Stachybotrys/Memnoniella type spores during the pre-intervention phase. Environmental microbiology results strongly suggest the indoor environment as the fungal spore source, with the presence of fruiting structures indicating surface mold growth. Indoor air samples, when compared to outdoor samples collected during pre-intervention, showed rare (2-6 raw count) growth of Aspergillus in 55% of the sampled rooms and subequently no growth post-intervention. Prospective surveillance revealed no further aspergillus growth in the ICU population and environment. Conclusion: Our findings highlight a potential correlation between environmental modifications and reduced IA incidence. Swift mitigation and structural interventions are crucial in averting potentially fatal outcomes, marking a significant advancement of prevention strategies for inner-city hospital settings. Although promising, study limitations include the inability to speciate environmental aspergillus for comparison to patient bronchial cultures and the absence of baseline bronchial cultures for affected patients on admission.

Stenotrophomonas maltophilia: The Landscape in Critically Ill Patients and Optimising Management Approaches.

The aim of this review is to synthesise the key aspects of the epidemiology, current microbiological diagnostic challenges, antibiotic resistance rates, optimal antimicrobial management, and most effective prevention strategies for Stenotrophomonas maltophilia (SM) in the intensive care unit (ICU) population. In recent years, resistance surveillance data indicate that SM accounts for less than 3% of all healthcare-associated infection strains, a percentage that doubles in the case of ventilator-associated pneumonia (VAP). Interestingly, SM ranks as the third most isolated non-glucose fermenter Gram-negative bacilli (NFGNB). Although this NFGNB genus has usually been considered a bystander and colonising strain, recently published data warn about its potential role as a causative pathogen of severe infections, particularly pneumonia and bloodstream infections (BSI), not only for the classical immunocompromised susceptible host patients but also for critically ill ones even without overt immunosuppression. Indeed, it has been associated with crude 28-day mortality as high as 54.8%, despite initial response following targeted therapy. Additionally, alongside its intrinsic resistance to a wide range of common antimicrobials, various worldwide and local surveillance studies raise concerns about an increase in ICU settings regarding resistance to first-line drugs such as cotrimoxazole or tigecycline. This scenario alerts ICU physicians to the need to reconsider the best stewardship approach when SM is isolated in obtained samples from critically ill patients. Despite the coverage of this multidrug-resistant bacterium (MDRB) provided by some traditional and a non-negligible number of current pipeline antimicrobials, an ecological and cost-effective strategy is needed in the present era.

Skin integrity preservation using a nurse-constructed silicone adhesive Foley catheter.

Skin breakdown is common in the intensive care unit (ICU). This pilot evaluation aimed to determine whether a nurse-constructed urinary catheter securement device using a silicone adhesive could reduce the complications of blistering and other skin breakdowns in a high-risk ICU population with Foley catheters. A prospective, non-randomised performance improvement study using a convenience sample was carried out. The study sample consisted of 29 patients with urethral Foley catheters and any degree of thigh oedema in a surgical ICU at an academic quarternary medical center. Patients were fitted with a standard acrylic-adhesive catheter securement device on one thigh and a nurse-constructed device on the contralateral thigh. At the beginning of each 12-hour shift, the nurse moved the Foley catheter from one securement device to the other; the nurse recorded the assessment findings at the end of the shift. The average age of the 29 patients was 61±16 (range 20-87) years. Visible skin compromise occurred in 21% of the time with the standard acrylic securement device; an equal percentage of men and women developed skin breakdown. Oedema status was a significant factor related to skin breakdown. There was no visible damage to the skin associated with the nurse-constructed silicone-adhesive device. A silicone adhesive urinary catheter securement device causes less skin damage than one with acrylic adhesive. One-step application, pain-free and atraumatic removal, and reliable securement are essential considerations in product development.

Automated surveillance of antimicrobial consumption in intensive care, northern Sweden: an observational case study

BackgroundThe digitalization of information systems allows automatic measurement of antimicrobial consumption (AMC), helping address antibiotic resistance from inappropriate drug use without compromising patient safety.ObjectivesDescribe and characterize a new automated AMC surveillance service for intensive care units (ICUs), with data stratified by referral clinic and linked with individual patient risk factors, disease severity, and mortality.MethodsAn automated service collecting data from the electronic medical record was developed, implemented, and validated in a healthcare region in northern Sweden. We performed an observational study from January 1, 2018, to December 31, 2021, encompassing general ICU care for all ≥18-years-olds in a catchment population of 270000 in secondary care and 900000 in tertiary care. We used descriptive analyses to associate ICU population characteristics with AMC outcomes over time, including days of therapy (DOT), length of therapy, defined daily doses, and mortality.ResultsThere were 5608 admissions among 5190 patients with a median age of 65 (IQR 48-75) years, 41.2% females. The 30-day mortality was 18.3%. Total AMC was 1177 DOTs in secondary and 1261 DOTs per 1000 patient days and tertiary care. AMC varied significantly among referral clinics, with the highest total among 810 general surgery admissions in tertiary care at 1486 DOTs per 1000 patient days. Case-mix effects on the AMC were apparent during COVID-19 waves highlighting the need to account for case-mix. Patients exposed to more than three antimicrobial drug classes (N = 242) had a 30-day mortality rate of 40.6%, with significant variability in their expected rates based on admission scores.ConclusionWe introduce a new service and instructions for automating local ICU-AMC data collection. The versatile long-term ICU-AMC metrics presented, covering patient factors, referral clinics and mortality outcomes, are expected to be beneficial in refining antimicrobial drug use.

The predictors of outcome in patients that require management in intensive care units: A narrative review

Intensive care units stand as the frontline battlegrounds where medical warriors combat the most critical illnesses and injuries. Within the labyrinth of intensive care units, where every moment teeters between life and death, prognostic markers emerge as beacons of guidance amidst uncertainty. In recent years, researchers have identified several novel mortality predictors in the intensive care population. In this review, we aimed to examine the clinical and laboratory markers that have been proposed in recent years to evaluate prognosis in the intensive care unit population and to review the literature on this topic. Management of patients in intensive care units is a dynamic process and reliable risk stratification models and prognostic markers are needed for this purpose. Novel prognostic indicators could serve as reliable diagnostic and prognostic tools in critically ill patients.

A Comparison of Different Intensive Care Unit Definitions Derived from the German Administrative Data Set: A Methodological, Real-World Data Analysis from 86 Helios Hospitals

Background: The intensive care unit (ICU) is a scarce resource in all health care systems, necessitating a well-defined utilization. Therefore, benchmarks are essential; and yet, they are limited due to heterogenous definitions of what an ICU is. This study analyzed the case distribution, patient characteristics, and hospital course and outcomes of 6,204,093 patients in the German Helios Hospital Group according to 10 derived ICU definitions. We aimed to set a baseline for the development of a nationwide, uniform ICU definition. Methods: We analyzed ten different ICU definitions: seven derived from the German administrative data set of claims data according to the German Hospital Remuneration Act, three definitions were taken from the Helios Hospital Group’s own bed classification. For each ICU definition, the size of the respective ICU population was analyzed. Due to similar patient characteristics for all ten definitions, we selected three indicator definitions to additionally test statistically against IQM. Results: We analyzed a total of 5,980,702 completed hospital cases, out of which 913,402 referred to an ICU criterion (14.7% of all cases). A key finding is the significant variability in ICU population size, depending on definitions. The most restrictive definition of only mechanical ventilation (DOV definition) resulted in 111,966 (1.9%) cases; mechanical ventilation plus typical intensive care procedure codes (IQM definition) resulted in 210,147 (3.5%) cases; defining each single bed individually as ICU or IMC (ICUᴧIMC definition) resulted in 411,681 (6.9%) cases; and defining any coded length of stay at ICU (LOSi definition) resulted in 721,293 (12.1%) cases. Further testing results for indicator definitions are reported. Conclusions: The size of the population, utilization rates, outcomes, and capacity assumptions clearly depend on the definition of ICU. Therefore, the underlying ICU definition should be stated when making any comparisons. From previous studies, we anticipated that 25–30% of all ICU patients should be mechanically ventilated, and therefore, we conclude that the ICUᴧIMC definition is the most plausible approximation. We suggest a mandatory application of a clearly defined ICU term for all hospitals nationwide for improved benchmarking and data analysis.

A Review of Chlorhexidine Oral Care in Patients Receiving Mechanical Ventilation.

Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Optimal concentrations and frequencies remain unclear, as do adverse events related to mortality in various intensive care unit populations. To examine the current evidence for the efficacy of chlorhexidine gluconate in reducing the incidence of ventilator-associated events, mortality, intensive care unit length of stay, and duration of mechanical ventilation in patients receiving ventilator support. In this integrative review, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and Health Source: Nursing/Academic Edition were searched using terms related to mechanical ventilation and chlorhexidine gluconate oral care with dates ranging from 2012 to 2023. Seventeen articles were included in this review: 8 systematic reviews, 8 randomized clinical trials (3 of which were not included in any systematic review), and 1 quasi-experimental study. Chlorhexidine gluconate oral care was associated with a reduced incidence of ventilator-associated events, but efficacy depended on concentration and frequency of administration. With stratification by intensive care unit population type, a nonsignificant trend toward increased mortality was found among non-cardiac surgical patients who received this care. The evidence regarding the efficacy of chlorhexidine gluconate oral care in reducing ventilator-associated events in specific intensive care unit populations is contradictory. Recently published guidelines recommend de-implementation of chlorhexidine gluconate oral care in all patients receiving mechanical ventilation. Such care may be beneficial only in the cardiac surgical population.

Indirect calorimetry directed feeding and cycling in the older ICU population: a pilot randomised controlled trial

BackgroundOlder critically ill patients experience rapid muscle loss during stay in an intensive care unit (ICU) due to physiological stress and increased catabolism. This may lead to increased ICU length of stay, delayed weaning from ventilation and persistent functional limitations. We hypothesized that with optimal nutrition and early physical therapy acting in synergism, we can reduce muscle mass loss and improve functional outcomes.MethodsThis was a prospective, single blinded randomized, controlled single-center pilot study to compare the lean muscle mass (measured at bilateral quadriceps femoris using ultrasound) of older ICU patients at 4 time points over 14 days between the control and intervention groups. The control group received standard weight-based empiric feeding and standard ICU physiotherapy. The intervention group received indirect calorimetry directed feeding adjusted daily and 60 min per day of cycle ergometry. 21 patients were recruited and randomized with 11 patients in the control arm and 10 patients in the intervention arm. Secondary outcome measures included ICU and hospital mortality, length of stay, functional assessments of mobility and assessment of strength.ResultsMedian age was 64 in the control group and 66 in the intervention group. Median calories achieved was 24.5 kcal/kg per day in the control group and 23.3 kcal/kg per day in the intervention group. Cycle ergometry was applied to patients in the intervention group for a median of 60 min a day and a patient had a median of 8.5 sessions in 14 days. Muscle mass decreased by a median of 4.7cm2 in the right quadriceps femoris in the control group and 1.8cm2 in the intervention group (p = 0.19), while the left quadriceps femoris decreased by 1.9cm2 in the control group and 0.1cm2 in the intervention group (p = 0.51).ConclusionIn this pilot study, we found a trend towards decrease muscle loss in bilateral quadriceps femoris with our combined interventions. However, it did not reach statistical significance likely due to small number of patients recruited in the study. However, we conclude that the intervention is feasible and potentially beneficial and may warrant a larger scale study to achieve statistical significance.Trial RegistrationThis study was registered on Clinicaltrials.gov on 30th May 2018 with identifier NCT03540732.