Treatment In Intensive Care Unit Research Articles

Effect of Low-Dose Ketamine Infusion in the Intensive Care Unit on Postoperative Opioid Consumption and Traumatic Memories After Hospital Discharge: A Randomized Controlled Trial

BACKGROUND: Low-dose ketamine may have an opioid-sparing effect in critically ill patients but may also predispose them to traumatic memories. We evaluated the effects of low-dose ketamine infusion in the intensive care unit (ICU) on fentanyl consumption and traumatic memories after hospital discharge. METHODS: This randomized, double-blind, controlled trial was conducted at a university-based surgical ICU. 118 adult patients who were admitted to the ICU after noncardiac, nonneuro, nontrauma surgery between March 2019 and May 2021 were randomized to receive ketamine 1.5 µg/kg/min (n = 60) or placebo (n = 58). Fentanyl was given to achieve pain control (10-point numerical rating scale pain score [NRS] < 4) and sedation control (Richmond Agitation and Sedation Scale [RASS] level between −2 and 0). A secondary study was conducted by a telephone interview after ICU discharge using the Thai version of the posttraumatic stress disorder (PTSD) questionnaire to evaluate signs and symptoms of PTSD and traumatic memories to the time spent in the ICU. RESULTS: 24-hour fentanyl consumption was lower in patients who received ketamine compared with placebo (399 µg [95% confidence interval {CI}, 345–454] vs 468 µg [95% CI, 412–523], difference −68 µg; 95% CI, −67 to −69; P = .041); RASS and NRS scores did not differ between the 2 groups. Exploratory effect modification analysis suggested that the opioid-sparing effect of ketamine may be more relevant in patients with intraabdominal surgery (P-for-interaction = 0.012, difference, −177 µg; 95% CI, −204 to −149 µg; P = .001). No acute adverse effects of ketamine were observed. The secondary study included the information from 91 patients from the primary study. Long-term follow-up data was available for 45 patients (23 in the control group, 22 in the ketamine group), and the evaluations were taken 43 ± 8 months after ICU discharge. In this secondary study, ketamine use was associated with a higher incidence of frightening and delusional memories of critical illness and ICU treatment (65% vs 41%, P = .035). CONCLUSIONS: Low-dose ketamine is associated with a small but statistically significant reduction (15%) of postoperative opioid consumption in the ICU. Our secondary study revealed that patients who received low-dose ketamine during fentanyl-based postoperative pain therapy in the ICU recalled more frightening and delusional memories after ICU discharge.

Effect of an intensive care unit virtual reality intervention on relatives´ mental health distress: a multicenter, randomized controlled trial

BackgroundRelatives of intensive care unit (ICU) patients often endure symptoms of post-traumatic stress, anxiety, and depression during and after treatment of a family member’s hospitalization. The aim of this study was to evaluate the effect of ICU-specific virtual reality (ICU-VR) on mental health among relatives, 6 months after patient’s ICU discharge.MethodsThis multicenter, randomized controlled trial included relatives of ICU patients who were assigned to receive either standard care or standard care plus ICU-VR, by randomizing the ICU patients. Relatives were assessed up to 6 months after patient discharge from the ICU for post-traumatic stress, anxiety, depression, quality of life, relatives’ understanding of ICU care, and appreciation of ICU-VR.ResultsOne hundred relatives of 81 patients and 89 relatives of 80 patients were randomized to the intervention and control groups, respectively. Relatives’ median age was 48 years and 53% were female. Compared to the control group, relatives who received ICU-VR did not experience a decrease in post-traumatic stress (23% vs. 18%; p = 0.99), anxiety (22% vs. 30%; p = 0.35), or depression (17% vs. 23%; p = 0.44). There was no significant difference between median mental quality of life (50.2 vs. 52.6; p = 0.51), physical quality of life (56.1 vs. 54.3; p = 0.16), or understanding of ICU care between groups. Patients in the intervention group highly endorsed ICU-VR (90%), favoring it over traditional informational brochures and the majority (82%) stated it improved their understanding of ICU treatment.ConclusionICU-VR did not significantly improve mental health distress symptoms among relatives 6-months after a patient’s discharge. Relatives highly endorsed ICU-VR and self-reported that it improved their understanding of ICU treatment.

Longitudinal outcomes of a parent-administered sensorimotor intervention in preterm infants at 4 and 18months.

Despite the increasing focus on early parent-delivered interventions in neonatal intensive care units to enhance infant development, there remains a research gap concerning the sustained benefits of such interventions in preterm infants. This study evaluated the impact of the parent-administered sensorimotor intervention (PASI) on developmental outcomes of infants previously enrolled in a randomized clinical trial (RCT). A prospective longitudinal follow-up study following the RCT at 4 and 18months corrected gestational age (CGA) was conducted. A blinded examiner conducted the follow-up assessments. The study outcomes developmental outcome at both time points and the child's health-related quality of life at 18months CGA using various means: Test of Infant Motor Performance (TIMP), the Feeding and Developmental Milestone Questionnaire (FDM), diagnosis of severe neurological disorder, the Infant Development Inventory (IDI) and Pediatric Quality of Life Inventory (PedsQL). At 4months CGA, 47 infants participated in the follow-up, with more infants in the experimental group receiving direct breastfeeds compared to the control group (38% vs. 12%, p=0.032). At 18months CGA, 51 infants were followed, showing no significant differences in developmental outcomes or health-related quality of life between groups. However, more parents in the control group reported developmental concerns about their child compared to those in the experimental group. The PASI appears to have lasting positive effects on breastfeeding outcomes for infants and on parents' perceptions of developmental concerns. These findings underscore the importance of early postnatal experiences in influencing the long-term developmental trajectories of infants born preterm.

Slide laryngotracheopexy for idiopathic subglottic stenosis.

Idiopathic subglottic stenosis (iSGS) is a rare fibroinflammatory disorder characterized by scar tissue formation in the subglottic and tracheal regions. This study evaluated the long-term outcomes of a novel, single-step surgical technique that redefines the glottic and subglottic airway using local tracheal grafts. Thirteen patients (2 male and 11 female) diagnosed with iSGS who underwent slide laryngotracheopexy were enrolled in this study. The diagnosis of iSGS was confirmed through endoscopic assessment, CT scanning, and autoimmune blood testing. Patients completed post-operative Voice Handicap Index (VHI), Quality of Life (QoL), and MD Anderson Dysphagia Inventory (MDADI) questionnaires, and spirometry assessments were conducted. All patients were successfully extubated in the operating room following surgery. None of the patients required intensive care unit treatment. The average hospital stay was 14 days. A temporary tracheotomy was needed in one case because of excessive crusting. Adjuvant endolaryngeal laser surgery was performed in three cases. In one case, mitomycin-C therapy was administered to treat granulation. Post-operative quality of life (QoL) assessment, peak inspiratory flow (PIF), and scores from the MDADI and VHI questionnaires were 9.0 (± 2.2), 2.8l/s (± 0.83), 95.6 (± 4.3), and 18.7 (± 13.4), respectively. Slide laryngotracheopexy was a safe and dependable technique for cases classified as Cotton-Myers II-IV grade iSGS. The use of a tracheal flap was advantageous to ensure optimal mucosal function. Slide laryngotracheopexy may be employed following multiple endolaryngeal interventions, whereas adjuvant CO2 laser surgery or mitomycin-c therapy may be considered in cases involving granulation tissue formation. Retrospective case series review.

P-229. Epidemiology of Catheter-Related Bloodstream Infections in Italian Intensive Care Units: Data from the Italian Network for the Evaluation of ICU Interventions

Abstract Background Intensive care unit (ICU) acquired bloodstream infections (BSIs) are an important cause of morbidity and mortality. The use of invasive devices, such as endovascular catheters is associated with greater risk of developing such infections. Our study focuses on the epidemiology of ICU-acquired catheter-related BSIs (CR-BSIs) in Italy from 2014 to 2022.Table 1.Characteristics of ICU admitted patients from 2014 to 2022.LOS, length of stay; SD, standard deviation; CVC, central venous catheter; BSI, bloodstream infection; CR-BSI, catheter-related bloodstream infection. With intensive care treatment need we mean the number and percentage of patients who were admitted to ICU for intensive care treatment, therefore excluding those admitted for post-surgical monitoring or invasive procedure execution. Methods We retrieved data from the PROSAFE project, a prospective, observational, multicentric study involving 135 Italian ICUs. Clinical data were continuously collected by physicians from January 2014 to December 2022. CR-BSIs episodes were defined in accordance with the National Healthcare Safety Network. Multi-drug resistant Gram-negative bacteria (MDR-GNB) were defined as resistant to at least one carbapenem. Continuous variables were summarized with mean and standard deviation, while categorical data were presented as counts and percentages.Figure 1.Percentage of species isolated from blood cultures of patients with ICU-acquired catheter-related bloodstream infection from 2014 to 2022.S. aureus, Staphylococcus aureus; CoNS, Coagulase negative Staphylococci; GPB, Gram positive bacteria, GNB; Gram negative bacteria. Other GPB include Streptococci and Enterococci. Results A total of 271654 patients were included in our study (Table 1). The number of episodes of CR-BSIs was 3361. The in-ICU mortality of patients with CR-BSIs was 28.5%. The incidence of CR-BSIs slightly increased through the years (1.1% in 2014 vs 1.9% in 2022), peaking in 2020-2021. Regarding the microbiology, most bacteria were Gram positive (GP), representing around half of the involved pathogens (Figure 1). CR-BSIs due to coagulase-negative staphylococci (CoNS) increased over the years (from 28.9% in 2014 to 41.2% in 2022), particularly since the COVID-19 pandemic. More than a third of CR-BSIs were caused by GNB, 22.7% of which were MDR. The most common pathogen was Klebsiella pneumoniae, which represented 13.4% of all CR-BSIs. An overall decrease of MDR-GNB was noted (Figure 2). CR-fungemias represented almost 9% of all CR-BSIs, with a peak at 12% in 2020.Figure 2.Percentage of resistant pathogens isolated from blood cultures of patients with ICU-acquired catheter-related bloodstream infection from 2014 to 2022. Resistant pathogens were defined as resistant to methicillin for Staphylococcus aureus, resistant to vancomycin for Enterococci and resistant to at least one carbapenem for Gram-negative rods. CR-BSI, catheter-related bloodstream infection; MRSA, methicillin-resistant Staphylococcus aureus, E. faecium, Enterococcus faecium; E. faecalis, Enterococcus faecalis; K. pneumoniae, Klebsiella pneumoniae; E. coli, Escherichia coli; P. aeruginosa, Pseudomonas aeruginosa; A. baumannii, Acinetobacter baumannii. Conclusion Our study highlights the significant burden of CR-BSIs in Italian ICUs. Despite efforts to mitigate these infections, the incidence of CR-BSIs has shown a concerning upward trend, particularly driven by the rise in CoNS infections, notably since the onset of the COVID-19 pandemic. These findings underscore the ongoing challenge of combating CR-BSIs and emphasize the importance of continued surveillance and targeted interventions to mitigate their impact on patient outcomes in ICUs. Disclosures All Authors: No reported disclosures

Risk factors and preventive measures for severe orofacial and neck infections: a three-year observational study

BackgroundThe purpose of this study was to identify the risk factors of severe orofacial and neck infections and the factors that could prevent them and reduce their severity.MethodsA three-year prospective observational study was conducted from 8.15.2016 to 8.31.2019 at a tertiary care hospital. 94 patients participated the study. The criteria for inclusion in the study were that the patients were adults with neck and severe orofacial infections that required treatment in hospital. Patients under the age of 18 and patients who did not consent to participate in the study were excluded. The responses to the questionnaire designed for this study were collected, as was supplemental data from medical records. The patient data were analyzed. Length of stay (LOS), intensive care unit (ICU) stay, complications and mortality were used as the main outcome variables, and various pre-admission factors and clinical and laboratory parameters were used as the predictor variables. The method used was univariate analysis.ResultsIn 79 (84.0%) cases, surgery confirmed an abscess and pus. Age (p = 0.001) and underlying diseases (p = 0.024) contributed to complications. Bulging of the lateral pharyngeal wall or laryngeal swelling on admission was significantly related to the need for intensive care treatment (p < 0.001). The spaces most often involved were the submandibular (n = 15; 16.0%), sublingual (n = 15; 16.0%) and parapharyngeal (n = 14; 14.9%) spaces. Sixty-three cases (67.0%) were of odontogenic origin, and 58.5% of the patients reported having attended previous health care appointments due to an acute dental problem. The patients with odontogenic infections had poor oral hygiene and most likely did not brush their teeth daily (p = 0.029). “Dishwater” pus was associated with longer hospitalization (p < 0.001), intensive care treatment (p < 0.001), and surgical revisions (p < 0.001). One lethal outcome (1.1%) was reported.ConclusionAge and underlying illnesses should be considered complicating factors, and lateral pharyngeal or laryngeal edema should be considered risk factors for ICU treatment. This study also emphasized the preventive role of good dental hygiene and the importance of patients’ follow-up treatment after acute dental interventions.

P0820 Video-assisted anal fistula treatment (VAAFT) in Crohn´s perianal disease: a Brazilian single-center prospective cohort study

Abstract Background Perianal involvement is identified in one-third of patients with Crohn’s disease, including fistulas, fissures and skin tags. Perianal Crohn´s disease (PCD) is associated with decreased quality of life, due to significant physical and psychologic symptoms. Video-assisted anal fistula treatment [VAAFT] is a minimally invasive surgical technique for anal fistulas, accessing primary and secondary fistula tracks for drainage and fulguration of inflammatory tissue. Our study reports the use of VAAFT for management of PCD fistulas along with medical therapy, aiming to improve symptoms and promote healing. Methods A single-center prospective study was conducted in consecutive patients with symptomatic PCD fistulas submitted to VAAFT, from January 2020 to January 2024. The surgical procedure involved an perianal exam under analgesia and VAAFT for fistuloscopy and cauterization of fistula tracks, with setons installation and\or replacement in order to maintain postoperative drainage. The primary endpoint was completion of the ‘Perianal Disease Activity Index (PDAI)’ questionnaire at 8 weeks postoperatively. Secondary outcome measure was ´IBDQol´ questionnaire at 8 weeks postoperatively, postoperative complications and the 30-day re-operation rate. Results Thirty-nine patients underwent VAAFT procedure for PCD during the study period. In total, 34/39 patients [87%] provided PDAI data, demonstrating a statistically significant improvement in scores of discharge, pain and sexual activity scores. In total, 34/39 patients [87%] provided IBDQol data, demonstrating a statistically significant improvement. The only complication was sepsis in one female 28-year old patient at the immediate postoperative period, successfully managed with clinical treatment in intensive care unit. There was no re-operation in 30-day period. Conclusion Our study demonstrates the feasibility, safety and importantly an improvement in patient-reported outcomes of patients undergoing VAAFT for management of PCD fistulas. VAAFT reduced the symptoms of discharge and paiin patients with complex refractory PCD fistulas.

Sphingosine-1-Phosphate, a Marker of Endothelial Injury and Disease Severity in Preeclampsia.

Preeclampsia is a hypertensive pregnancy disorder marked by endothelial damage. Healthy endothelium is covered by a protective glycocalyx layer, which, when degraded, releases detectable products into the blood. Sphingosine-1-phosphate (S1P) is a cardiovascular biomarker involved in glycocalyx preservation, linked to placentation and preeclampsia development. The study aimed to test the hypothesis that plasma S1P is altered alongside glycocalyx degradation products in severe preeclampsia compared with controls. We included 121 females: 41 with severe preeclampsia requiring treatment in the intensive care unit, 40 with preeclampsia but no need of intensive care unit treatment, and 40 with normotensive pregnancies. Plasma levels of S1P and glycocalyx degradation products-hyaluronic acid, SDC-1 (syndecan-1), and HSPG2 (heparan sulfate proteoglycan-2)-were analyzed from blood samples taken within 27 hours postpartum. Postpartum plasma S1P was significantly lower in the intensive care unit cohort compared with both preeclampsia controls and normotensive controls (P<0.001). Hyaluronic acid and SDC-1 levels were elevated in the intensive care unit group versus normotensive controls (P=0.009 and P=0.023), while HSPG2 was lower (P<0.001). Plasma S1P correlated with hyaluronic acid and blood pressure. Intensive care patients with severe preeclampsia have lower plasma S1P levels and higher concentrations of glycocalyx degradation products, indicating more pronounced endothelial damage. These findings suggest that S1P is associated with preeclampsia severity and may serve as a biomarker to assess vascular damage in this patient population. Further studies are needed to explore the potential role of S1P in long-term cardiovascular risk assessment for patients with preeclampsia.

Inpatient Audiologic Services Facilitate Early Hearing Detection.

Infants needing neonatal intensive care unit (NICU) intervention have protracted timelines for diagnosis after not passing their newborn hearing screening despite being at higher risk for congenital hearing loss. The primary aim of this study was to evaluate the outcomes of early hearing detection for infants with a history of NICU admission. The secondary aim was to determine if diagnostic audiology services within the NICU setting accelerated diagnosis and intervention. A retrospective chart review was completed for infants referred for diagnostic audiologic testing from 2018 to 2021 at a tertiary urban-setting children's hospital. After exclusion criteria were applied, 367 infants with NICU history were included in the analysis. Various factors were recorded from electronic medical records. Time to diagnosis was derived and compared across (a) NICU location, (b) insurance type, and (c) race/ethnicity. Analysis of infants with NICU history revealed that 70% of infants had a diagnosis by 3 months corrected age. The level of in-NICU audiologic care did not significantly impact corrected age at diagnosis; however, loss to follow-up (LTFU) rates were higher for NICUs that did not provide in-hospital diagnostic services (10.0%) when compared to the NICU setting with inpatient audiology services (6.8%). In-NICU testing occurred on average 5.7 weeks prior to discharge, expediting diagnosis of hearing status compared to having to wait for an outpatient evaluation after discharge. Timely hearing detection is feasible in the medically complex NICU population. Inpatient audiology diagnostic testing may help reduce LTFU and facilitate early hearing detection and intervention.

Dexmedetomidine improves clinical outcomes in sepsis-induced myocardial injury: a retrospective cohort study.

The efficacy of dexmedetomidine (DEX) in treating sepsis-induced myocardial injury (SIMI) remains unclear. In this study, we explored the relationship between DEX use and clinical outcomes of patients with SIMI, focusing on the dosage and treatment duration. In this retrospective cohort analysis, we identified patients with SIMI from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and categorized them into the DEX and non-DEX groups based on intensive care unit treatment. The baseline bias was reduced through propensity score matching (PSM). The primary outcome was 28-day mortality, whereas the secondary outcomes were in-hospital mortality and mortality rates at 7days, 90days, and 1year. The association between DEX use and in-hospital mortality was assessed using Kaplan-Meier analysis and Cox proportional hazards models. After PSM, 373 patients in the DEX group were matched with 579 patients in the non-DEX group to achieve a balanced distribution of the covariates. The Cox regression model demonstrated a significant reduction in the 28-day mortality associated with DEX use, yielding a hazard ratio (HR) of 0.61 (95% confidence interval [CI]: 0.47-0.78, P < 0.001). In-hospital mortality also significantly decreased (HR = 0.43, 95% CI: 0.33-0.57, P < 0.001). Lower mortality rates were observed at 7days, 90days, and 1year. DEX doses >0.4μg/kg/h, particularly in the range of 0.400-0.612μg/kg/h, total doses >3.113mg during hospitalization, and treatment durations exceeding 72h were associated with improved mortality risk at all intervals. Regarding DEX efficacy at 28days, our subgroup analyses indicated a significant interaction between the Sequential Organ Failure Assessment score and invasive mechanical ventilation. DEX administration was associated with improved in-hospital mortality and reduced mortality rates at 7days, 28days, 90days, and 1year in patients with SIMI. These findings require validation in future studies.

Patient perspectives on stress after ICU and a short primary care based psychological intervention – results from a qualitative sub‑study of the PICTURE trial

BackgroundApproximately 20–25% of patients who survive medical treatment at an intensive care unit (ICU) develop post-traumatic stress symptoms. There is currently a gap in follow-up care for them. As part of the PICTURE study, general practitioners (GPs) carried out a brief interview-based intervention. The aim of this sub-study is to record the most distressing memories of ICU treatment from the patient’s perspective and their evaluation of a GP-based brief psychological intervention.MethodsParticipants were recruited from the intervention group of the main PICTURE study using selective sampling. All of them had experienced an ICU stay with mechanical ventilation and severe organ failure in the previous two years. They were interviewed about their experience of psychological stress during their ICU stay and their retrospective evaluation of the intervention. Semi-structured, guideline-based telephone interviews were conducted for this purpose, processed, and analyzed using the structuring qualitative content analysis based on Mayring.FindingsWhen asked N = 8 patients about the most stressful memory of their stay at ICU, the main themes were helplessness, pain, fixation, inability to communicate and sleep disturbances. The question of amnesia regarding the stay in the ICU was answered affirmatively by half of the interviewees but was not experienced as stressful. The brief trauma-focused intervention carried out by their GPs was well received by all respondents.ConclusionsThe interviewees confirm that aversive traumatizing experiences are often associated with intensive care treatment and reinforce each other. These are due to the treatment setting but should be reduced wherever possible. In view of chronification and the lack of specific follow-up treatment options for these patients and the long waiting times for psychotherapy, the implementation of low-threshold treatment options by GPs appears to be ideally suited to closing this gap in care, particularly for patients with mild to moderate symptoms of a post-traumatic stress disorder.Trial registrationThe main trial was registered at ClinTrials gov (NCT03315390) and at the German Register of Clinical Trials (DRKS, DRKS00012589) on 17/10/2017.

Autologous Nonmyeloablative Hematopoietic Stem Cell Transplantation for Diffuse Cutaneous Systemic Sclerosis: Identifying Disease Risk Factors for Toxicity and Long-Term Outcomes in a Prospective, Single-Arm Trial.

Two randomized trials for patients with diffuse systemic sclerosis (SSc) demonstrated an overall survival (OS) and event-free survival (EFS) advantage of autologous hematopoietic stem cell transplantation (AHSCT) using CD34+ selected peripheral blood stem cells (PBSCs) compared with monthly cyclophosphamide (CY). We asked if an unmodified PBSC graft followed by maintenance mycophenolate mofetil (MMF) after AHSCT, instead of a CD34+ selected graft, could provide comparable AHSCT outcomes. Twenty patients with high-risk SSc were enrolled in a prospective, single-arm trial with CY 200 mg/kg and horse antithymocyte globulin (ATG; CY200/ATG), followed by unmanipulated autologous PBSC, and then MMF maintenance starting at 2 months after AHSCT. Point estimates of OS and EFS at 5 years after AHSCT were 85% (95% confidence interval [CI] 60.4%-94.9%) and 75% (95% CI 50%-88.7%), respectively. Median follow-up was 7.5 years (range 5.6-11.6) after transplant for living patients. Eight patients (40%) required intensive care unit treatment early after transplant. Early transplant-related mortality occurred in two patients (10%). Five patients developed relapse/progression of SSc after AHSCT. Four of nine patients with anti-RNA polymerase III antibodies had prior scleroderma renal crisis and the lowest quartile of estimated glomerular filtration rate (eGFR) on study entry; all four patients developed prolonged organ failure/death early after transplant. We observed favorable OS and EFS after AHSCT for patients with SSc, using CY200/ATG, unmanipulated PBSCs, and MMF posttransplant maintenance, which was comparable to trials with CD34+ graft selection. We identified a possible risk factor, pretransplant low eGFR, for adverse outcomes after AHSCT.

Tracheostomy Practice in the Italian Intensive Care Units: A Point-Prevalence Survey.

Background and Objectives: A tracheostomy is a frequently performed surgical intervention in intensive care units (ICUs) for patients requiring prolonged mechanical ventilation. This procedure can offer significant benefits, including reduced sedation requirements, improved patient comfort, and enhanced airway management. However, it is also associated with various risks, and the absence of standardized clinical guidelines complicates its implementation. This study aimed to determine the prevalence of tracheostomy among ICU patients, while also evaluating patient characteristics, complication rates, and overall outcomes related to the procedure. Materials and Methods: We conducted an observational, cross-sectional, point-prevalence survey across eight ICUs in Italy. Data were collected over two 24 h periods in March and April 2024, with a focus on ICU characteristics, patient demographics, the details of tracheostomy procedures, and associated complications. Results: Among the 92 patients surveyed in the ICUs, 31 (33.7%) had undergone tracheostomy. The overall prevalence of tracheostomy was found to be 9.1%, translating to a rate of 1.8 per 1000 admission days. The mean age of patients with a tracheostomy was 59.5 years (SD = 13.8), with a notable predominance of male patients (67.7%). Neurological conditions were identified as the most common reason for ICU admission, accounting for 48.4% of cases. Tracheostomy procedures were typically performed after a mean duration of 12.9 days of mechanical ventilation, primarily due to difficulties related to prolonged weaning (64.5%). Both early and late complications were observed, and 19.35% of tracheostomized patients did not survive beyond one month following the procedure. The average length of stay in the ICU for these patients was significantly extended, averaging 43.0 days (SD = 34.3). Conclusions: These findings highlight the critical role of tracheostomy in the management of critically ill patients within Italian ICUs. The high prevalence and notable complication rates emphasize the urgent need for standardized clinical protocols aimed at optimizing patient outcomes and minimizing adverse events. Further research is essential to refine current practices and develop comprehensive guidelines for the management of tracheostomy in critically ill patients.

Outcomes Following Close Collaboration With Parents Intervention in Neonatal Intensive Care Units

Family-centered care (FCC) in neonatal intensive care units (NICUs) is critical for parental involvement and infant well-being, yet few studies have evaluated the impact of FCC interventions on practice or examined how implementation fidelity may affect these outcomes. To evaluate the association between the Close Collaboration With Parents intervention and FCC practices and how implementation fidelity may modify these outcomes. This nonrandomized clinical trial had a before-and-after design. It was conducted between March 2021 and June 2023 at 6 NICUs in Estonia and included the parents of all newborns and all staff. Close Collaboration With Parents is an educational intervention for multiprofessional NICU staff including e-learning and bedside practices combined with reflection sessions. It aims to improve FCC culture by developing staff skills in communication and collaboration with parents and parenting support. The quality of FCC was assessed using a 1-time questionnaire for the parents with 9 questions from the Digi Family-Centered Care-Parent version tool, and daily questions for the staff using Digi Family-Centered Care-Nurse version tool. The association between implementation fidelity, defined as the proportion of staff who completed the full education, and the quality of FCC was also analyzed. A total of 186 infants (with responses from 186 mothers and 22 fathers) were included in the preintervention period. The median (IQR) gestational age was 37.4 (34.0-39.9) weeks, 94 infants (50.5%) were male, and the median (IQR) parental age was 32 (28-36) years. A total of 208 infants (with responses from 208 mothers and 55 fathers) were included in the postintervention period. The median (IQR) gestational age was 38.1 (35.4-39.9) weeks, 114 infants (55.1%) were male, and median (IQR) parental age was 32 (27-35) years. From the staff, 7448 and 6717 daily responses were analyzed in the preintervention and postintervention periods, respectively. The total rating was significantly higher after the intervention than before, by both the parents (r = 0.07; P < .001) and the staff (r = 0.10; P < .001). The median ratings did not, however, change: the parents' median (IQR) overall rating before and after was 7.0 (6.0-7.0), and the staff's median (IQR) overall rating was 6.0 (5.0-7.0) before and 6.0 (6.0-7.0) after. Implementation fidelity ranged from 4 of 30 health care professionals (13.3%) to 37 of 45 (82.2%) at the NICUs. The NICUs with high fidelity, as opposed to low fidelity, had significantly greater improvement in FCC ratings by the staff after the intervention (β = 2.1 [95% CI, 0.8-3.4]; P = .002). In this nonrandomized clinical trial, FCC practices were rated higher by the staff and parents after the Close Collaboration With Parents intervention. Implementation fidelity was identified as an important factor. ClinicalTrials.gov Identifier: NCT06258655.

Occupational Therapy Interventions and Early Engagement for Patients in Intensive Care: A Systematic Review.

Patients in intensive care units (ICUs) experience complex functional, physical, and cognitive needs that affect their engagement in activities of daily living (ADLs). Occupational therapy practitioners are uniquely positioned to address these needs to optimize patients' functional recovery. To examine occupational therapy-specific interventions as they relate to early engagement for patients in the ICU. CINAHL, PubMed, ProQuest, OTseeker, and Cochrane Library databases. The Cochrane methodology was used to collect, evaluate, and analyze articles, then reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines for conducting a systematic review. Articles published from January 2012 to December 2021 evaluating adults who received occupational therapy interventions in ICUs with Level 1b, 2b, or 3b evidence were included. Nine articles met the inclusion criteria and the research objective. Findings showed moderate evidence for ADLs, physical rehabilitation, and cognitive interventions in promoting functional outcomes for patients in the ICU. This systematic review introduces the term early engagement to describe occupational therapy-specific interventions for patients recovering in the ICU and supports occupational therapy's role in this setting. Further research is needed to strengthen the evidence for occupational therapy-specific interventions and early engagement in the ICU. Plain-Language Summary: Patients in the intensive care unit experience complex needs that affect their participation in activities of daily living (ADLs). Current research demonstrates moderate evidence for early engagement with ADLs, physical rehabilitation, and cognitive interventions performed by occupational therapy practitioners. This systematic review introduces the term early engagement, which captures how occupational therapy practitioners provide holistic interventions for patients in the intensive care unit to promote patient well-being and functional recovery.

Outcomes of Patients with Hematological Malignancies Admitted to the Intensive Care Unit at a Tertiary Care Center in Saudi Arabia

Abstract Background: Patients with hematological malignancies (HM) are at risk for complications, including neutropenia and admission to the intensive care unit (ICU). Granulocyte colony-stimulating factors (GCSF) can accelerate progenitor cells’ proliferation and differentiation, and thus compensate for neutropenia. In patients with HM admitted to ICUs in Saudi Arabia, the outcome and impact of GCSF use on neutropenia duration and severity is understudied. Objective: To evaluate the outcome and impact of GCSF on neutropenia in patients with HM admitted to the ICU of a tertiary care center in Saudi Arabia. Methods: This retrospective study included all consecutive patients diagnosed with an HM admitted to the ICU at King Saud University Medical City, Riyadh, Saudi Arabia, from 2018 to 2022. Data on demographics, clinical information, ICU admission, and outcomes were collected. Results: A total of 44 patients with HM admitted to the ICU were included, of which 43.2% were females and the mean age was 50.2 ± 21.1 years. The mean length of ICU stay was 12.3 ± 14.7 (range: 0–62) days. ICU mortality was 61.4%, with no further mortality within 90 days after discharge. There was no significant association between survival and age (P = 0.205), gender (P = 0.7), and neutropenia (P = 0.566) or the use of GCSF prior to ICU admission (P = 0.882). There was a significant association between the category of ICU intervention and survival (P = 0.007). Conclusion: Patients with hematological malignancies who were admitted to an ICU in Saudi Arabia had a high mortality, regardless of neutropenia or the use of granulocyte colony-stimulating factor.

KNOWLEDGE, ATTITUDE AND PRACTICES OF INTENSIVE CARE UNIT NURSES ABOUT PHYSICAL RESTRAINT AT TERTIARY CARE HOSPITAL LAHORE

Physical restraint is a common intervention in intensive care units (ICUs) to ensure patient safety and prevent harm. However, its inappropriate use poses ethical and clinical challenges, particularly in resource-constrained healthcare systems like Pakistan. Objective: To assess the knowledge, attitudes, and practices of ICU nurses regarding physical restraint in a tertiary care hospital in Lahore, Pakistan. Methods: A descriptive cross-sectional study was conducted among 137 ICU nurses using a structured questionnaire. The data were analyzed using SPSS version 26, with results presented as frequencies and percentages. Results: The study revealed that 47.1% of nurses demonstrated moderate knowledge of physical restraint, while 33.1% exhibited good knowledge. Attitudes were mixed, with 52.2% displaying positive attitudes and 47.8% exhibiting negative attitudes. Good practices were reported by 61.8% of nurses, whereas 38.2% showed poor adherence to recommended protocols. Nurses with higher qualifications and greater experience demonstrated significantly better knowledge and practices. Conclusion: Despite moderate knowledge and adherence to some practices, gaps in attitudes and inconsistent protocol adherence remain challenges in ICU settings. Targeted education, institutional support, and clear policies are essential to enhance nurses' competency in the ethical and effective use of physical restraints.

Association between phosphorus-to-calcium ratio at ICU admission and all-cause mortality in acute pancreatitis: Insights from the MIMIC-IV database.

Serum phosphorus and serum calcium are important electrolytes in the body. The relationship between them and acute pancreatitis (AP) has been previously discussed. However, the results seem to lack credibility due to the neglect of mutual influence between them. Thus, a comprehensive indicator is needed. In this study, AP patients with intensive care unit (ICU) treatment were extracted from Medical Information Mart for Intensive Care (MIMIC) database. The outcomes included in-hospital mortality and ICU mortality. Kaplan-Meier survival analysis, Cox proportional hazard regression model and restricted cubic spline were employed to investigate the association between the phosphorus-to-calcium ratio (PCR) index and clinical outcomes. A total of 719 AP patients (57.2% male) were enrolled. The in-hospital and ICU mortality were 11.4% and 7.5%, respectively. After adjusting for confounders, Cox proportional hazard analysis indicated patients with a higher PCR index had a significant association with in-hospital mortality (adjusted hazard ratio, 2.88; 95% confidence interval, 1.34-6.19; p = .007). Restricted cubic splines revealed that a progressively increasing risk of all-cause mortality was associated with an elevated PCR index. The PCR index has a strong correlation with in-hospital and ICU all-cause mortality in AP, which provides a reference for clinical decision-making.

The Aachen ACLF ICU score predicts ICU mortality in critically ill patients with acute-on-chronic liver failure.

Acute-on-chronic liver failure (ACLF) defines a heterogeneous syndrome involving acute decompensation in patients with pre-existing liver disease accompanied by (multi-)organ failure. This study aimed to develop a simple, reliable machine learning (ML) model to predict mortality in ACLF patients receiving intensive care unit (ICU) treatment. Data from 206 patients admitted to the ICU at RWTH Aachen University Hospital between 2015 and 2021 were retrospectively analyzed with ICU mortality as the primary outcome. An ICU mortality prediction model was developed by logistic regression and validated by 5-fold cross validation. Performance metrics were assessed to evaluate the model's accuracy and compare to existing mortality scores. ICU mortality was 60%. The chronic-liver-failure-consortium ACLF score (CLIF-C ACLFs) was the best predictor of ICU mortality. ML generated seven models using five to thirteen features. The best-performing model included CLIF-C ACLFs, number of organ failures, Horovitz quotient (FiO2/PaO2), FiO2 and lactate. The newly developed Aachen ACLF ICU (ACICU) score demonstrated exceptional predictive accuracy for ICU mortality (AUROC 0.96), underscoring its potential for mortality and futility assessment in critically ill ACLF patients complementing existing prognostic tools. The ACICU score www.acicu-score.com is an easy-to-use tool for predicting ICU mortality in patients with ACLF offering high predictive performance.

Clinical features and treatment of stroke-like episodes in mitochondrial disease: a cohort-based study

BackgroundStroke-like episode (SLE) is a subacute evolving brain syndrome in patients with primary mitochondrial diseases. Despite previous research, the understanding of the clinical spectrum, treatment, and outcomes of mitochondrial SLEs is far from complete. In this single centre study, we report the clinical symptoms and radiological findings as well as the medical treatment and outcomes of SLEs in patients with mitochondrial disease.MethodsThis retrospective, observational study during years 2000–2023 was based on a cohort of patients diagnosed with mitochondrial disease at Turku University Hospital (TUH; Turku, Finland) in the region of Southwest Finland. Data were obtained from the hospital electronic medical record system.ResultsThe investigated cohort consisted of 76 patients (37 men, 39 women) with a diagnosis of mitochondrial disease. Among these, 12 patients had a history of at least one SLE; the total number of SLEs was 20. The most common genetic aetiology among patients with SLEs was m.3243A > G (N = 7). The mean age at first SLE was 40 years (range: 5–66 years), and the mean interval between episodes was 4.8 years (range: 4 months—10 years). The duration of episodes varied between 1 and 193 days (median 14 days, mean 37 days); 10 patients needed intensive care unit (ICU) treatment. The mean survival time between the first SLE and death was 3.6 years (range: 0–16 years).ConclusionOur study highlights the importance of early recognition and prompt management of SLE symptoms, especially epileptic seizures, in this life-threatening entity.