Intensive Care Unit Management Research Articles

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.

Chronic pain characteristics in COVID-19 survivors after an ICU stay. A cross-sectional study

BackgroundThe onset and characteristics of chronic pain following an intensive care unit (ICU) stay for COVID-19 have never been thoroughly investigated. Study designA multicenter cohort study was conducted to describe chronic pain, according to ICD-11, among COVID-19 survivors. The chronic pain was assessed during face-to-face consultations with a pain specialist. ResultsAmong 204 COVID-19 ICU survivors, 143 patients with mean age of 60 ± 14 years were included nine months after discharge from the ICU. More than half (54%) of patients experienced new-onset chronic pain. In total, 102 different forms of pain were reported in these patients. Secondary pain was the most frequent type, comprising musculoskeletal (40%), post-traumatic (34%), neuropathic (25%), and visceral (13%). Primary chronic pain was rare (7%).The three most common sites of pain were the shoulders, chest, and head. Pain was moderate to severe in 75% of cases, and higher intensity was associated with a greater impact on daily life. Anxiety, depression, post-traumatic stress, perceived stress, and debilitating pain were frequently associated. Intubation was more frequent in patients with chronic pain. Specialized pain centre follow-up was required for 21% of the survivors, which represented 40% of the patients who developed new-onset chronic pain. ConclusionNew-onset chronic pain is common after an ICU stay for COVID-19 and may manifest in various forms. Secondary pain caused by ICU management is the most frequent. Patients should undergo screening after ICU discharge to facilitate prompt, thorough, and personalized pain management. Clinical trial registrationNCT04940208.

Clotted blood samples in the neonatal intensive care unit: A retrospective, observational study to evaluate interventions to reduce blood sample clotting.

Blood draws for laboratory investigations are essential for patient management in neonatal intensive care units (NICU). When blood samples clot before analysis, they are rejected, which delays treatment decisions and necessitates repeated sampling. To decrease the incidence of rejected blood samples taken for laboratory investigation as a result of clotted sample. This retrospective observational study used routine data on blood draws from preterm infants collected between January 2017 and June 2019 in a 112-cot NICU in Qatar. Quality improvement interventions to reduce the rate of clotted blood samples included: awareness raising and safe sampling workshops with NICU staff, involvement of the neonatal vascular access team, development of a complete blood count (CBC) sample collection pathway, review of sample collection equipment, introducing the Tenderfoot® heel lance, establishment of benchmarks and provision of dedicated blood extraction equipment. First attempt blood draw occurred in 10 706 cases, representing a 96.2% success rate. In 427 (3.8%) cases, the samples were clotted requiring repeat collection. The overall rate of clotted specimens decreased from 4.8% in 2017 and 2018 to 2.4% in 2019, with odds ratios of 1.42 (95% confidence interval [CI] 1.13-1.78, p = .002), 1.46 (95% CI 1.17-1.81, p < .001) and 0.49 (95% CI 0.39-0.63, p < .001), respectively. The majority (87%-95%) of blood samples were by venepuncture using an intravenous (IV) catheter or the NeoSafe™ blood sampling device. Heel prick sampling was the second (2%-9%) most common method. Clotted samples were most frequently associated with needle use, 228 of 427 (53%), and IV cannula, 162 of 427 (38%), with odds ratios of 4.14 (95% CI 3.34-5.13, p < .001) and 3.11 (95% CI 2.51-3.86, p < .001), respectively. Our interventions over 3 years were associated with reduced rates of sample rejection due to clotting, and this led to improved patient experience through fewer repeated samplings. The insights gained from this project can help to improve patient care. Interventions that reduce the rate of blood sample rejection by clinical laboratories can lead to economic savings, timelier diagnostic and treatment decisions, and contribute to an improved quality care experience for all critical care patients, irrespective of age, by reducing the need for repeated phlebotomy and the risk of related complications.

Barriers to Deceased Donor Procurements: The Saudi Experience.

Barriers to Deceased Donor Procurements: The Saudi Experience.

Clinical presentation, ICU management and outcome in severe COVID-19 disease – A prospective observational study

Aim: We conducted a prospective, observational study to describe the clinical characteristics, management, and outcomes of patients with moderate to severe coronavirus disease admitted to the Intensive Care Unit (ICU). Methods: The study was conducted from 1st July 2020 to 31st December 2020. The criteria for ICU admission included a positive Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) for the novel Coronavirus (SARS-CoV-2) and oxygen saturation of less than 90% with or without oxygen. Results: A total of 621 patients were included (median age, 59 years [interquartile range {IQR}, 48-68]; 75.8% were males. The common comorbidities were hypertension (323 [52%]), and diabetes mellitus. 96 (15.5%) patients underwent mechanical ventilation, 18 (2.9%) received renal replacement therapy, and 223 (36%) died. The median age in non-survivors was significantly higher [63 years (IQR 55-71)] vs. 57 years (IQR 46-66)] (p &lt; 0.001). Hypoxia (oxygen saturation (SpO2 &lt; 90%) and shortness of breath suggestive of impending respiratory failure were the most common symptoms necessitating ICU admission. A low absolute lymphocyte count (ALC), and high levels of inflammatory biomarkers which persisted for seven days after diagnosis were significantly associated with non-survival. Multivariate logistic regression analysis showed shortness of breath (SOB), hypoxia (SpO2 &lt; 90% on oxygen), use of neuromuscular blockers, and chronic kidney disease as independent risk factors associated with mortality as were the severity scores (APACHE and SOFA). Conclusion: This single-center case series provides clinical characteristics and outcomes of patients with confirmed COVID-19 disease admitted to the COVID ICU. These findings are important for guiding research and preparing for future pandemics.

Identification of complications requiring interventions after gastrointestinal cancer surgery from real-world data: An external validation study.

Recently, real-world data have been recognized to have a significant role for research and quality improvement worldwide. The decision on the existence or nonexistence of postoperative complications is complex in clinical practice. This multicenter validation study aimed to evaluate the accuracy of identification of patients who underwent gastrointestinal (GI) cancer surgery and extraction of postoperative complications from Japanese administrative claims data. We compared data extracted from both the Diagnosis Procedure Combination (DPC) and chart review of patients who underwent GI cancer surgery from April 2016 to March 2019. Using data of 658 patients at Kyoto University Hospital, we developed algorithms for the extraction of patients and postoperative complications requiring interventions, which included an invasive procedure, reoperation, mechanical ventilation, hemodialysis, intensive care unit management, and in-hospital mortality. The accuracy of the algorithms was externally validated using the data of 1708 patients at two other hospitals. In the overall validation set, 1694 of 1708 eligible patients were correctly extracted by DPC (sensitivity 0.992 and positive predictive value 0.992). All postoperative complications requiring interventions had a sensitivity of >0.798 and a specificity of almost 1.000. The overall sensitivity and specificity of Clavien-Dindo ≥grade IIIb complications was 1.000 and 0.995, respectively. Patients undergoing GI cancer surgery and postoperative complications requiring interventions can be accurately identified using the real-world data. This multicenter external validation study may contribute to future research on hospital quality improvement or to a large-scale comparison study among nationwide hospitals using real-world data.

Increasing the Accuracy of Extracorporeal Membrane Oxygenation Critical Event Management in the Medical Intensive Care Unit

Extracorporeal membrane oxygenation (ECMO) is an intervention that replaces cardiopulmonary function temporarily to reduce injury to vital organs. As important members of the ECMO medical team, intensive care unit nurses must be well trained and alert to possible critical events. Failure to troubleshoot and manage ECMO promptly and correctly significantly increases the risk of mortality. A previous ECMO critical event in our unit resulted in lingering concerns and stress among nurses related to implementing this intervention. A survey conducted among our medical intensive care unit (MICU) nurses identified an implementation accuracy level for ECMO critical event management of only 59.1%. This poor result was attributed to a lack of technical assessment standards, in-service training, clinical experience, and instruction materials and the failure to offer online courses. This study was designed to increase the accuracy of ECMO critical event management implementation among intensive care unit nurses to >86%. We conducted a problem-based training project to improve ECMO critical event management that: introduced a technical assessment sheet and technical simulation exercise, organized in-service training, implemented irregular simulation exercises, and produced multiple different instructional materials. The accuracy of ECMO critical event management implementation among the intensive care unit nurses increased from 59.1% pretest to 95.9% posttest. This project improved the ECMO care ability of MICU nurses in our hospital significantly, resulting in increased ECMO critical event management implementation accuracy, better patient care, higher nursing staff confidence, and lower perceived stress among nursing staff.

Neurocognitive Outcomes

The brain is the most complex and sensitive organ in the body, so it is no wonder that major physiological disruptions can affect it in several ways. Functional disturbances in neurocognitive performance are the most common events impacting patients following cardiac surgery, yet are often not discussed with patients. Delirium occurs in up to 50% of older patients and can have long-term consequences including persistent cognitive decline. Other neurocognitive disorders such as delayed neurocognitive recovery (often described as poor short-term memory or “brain fog”) can be seen in around one-third of patients in the days to weeks following surgery. Even at 3 months, >10% of patients may suffer from a neurocognitive disorder. Impaired baseline cognitive function is a risk factor, amplified by the inflammatory and other responses to major surgery. It is possible that anaesthesia and intensive care unit management strategies can play a protective role to some extent, and there is increasing evidence that anaesthesia per se is not harmful in most circumstances. Perioperative care involves identifying at-risk individuals and implementing multidisciplinary care throughout the hospital stay. This presentation will discuss evidence for underlying mechanisms and what can be done now and in the future to mitigate this. It is also likely that better preparing patients for surgery, both physically and cognitively, may improve their outcomes.

Preoperative Base Excess as a Predictor of Perioperative Complications in Patients with Nonidiopathic Scoliosis who Have High Risk Associated with General Anesthesia.

Patients with nonidiopathic scoliosis often have a high risk associated with general anesthesia because of cardiac or pulmonary dysfunction secondary to underlying diseases. Base excess has been reported as a predictor in the management of trauma and cancer, although not yet in scoliosis. This study was performed to clarify the surgical outcomes and the association of perioperative complications with base excess in patients with nonidiopathic scoliosis who have a high risk associated with general anesthesia. Patients with nonidiopathic scoliosis who were referred to our institution from 2009 to 2020 because of their high risk associated with general anesthesia were retrospectively enrolled. High-risk factors for anesthesia were determined by a senior anesthesiologist and categorized into circulatory or pulmonary dysfunction. Perioperative complications were analyzed using the Clavien-Dindo classification; severe complications were defined as grade ≥III. We investigated high-risk factors for anesthesia, underlying diseases, preoperative and postoperative Cobb angle, surgery-related factors, base excess, and postoperative management. These variables were statistically compared between patients with and without complications. Thirty-six patients (mean age, 17.9 years old; range, 11-40 years old) were enrolled (two patients declined surgery). High-risk factors were circulatory dysfunction in 16 patients and pulmonary dysfunction in 20 patients. The mean Cobb angle improved from 85.1° (36°-128°) preoperatively to 43.6° (9°-83°) postoperatively. Three intraoperative complications and 23 postoperative complications occurred in 20 (55.6%) patients. Severe complications occurred in 10 (27.8%) patients. All patients underwent postoperative intensive care unit management after posterior all-screw construction. A large preoperative Cobb angle (p=0.021) and base excess outliers (>3 or <-3 mEq/L) (p=0.005) were significant risk factors for complications. Patients with nonidiopathic scoliosis who have a high risk associated with general anesthesia have a higher complication rate. Preoperative large deformity and base excess (>3 or <-3 mEq/L) could be predictors of complications.

Leveraging the placenta to advance neonatal care.

The impact of placental dysfunction and placental injury on the fetus and newborn infant has become a topic of growing interest in neonatal disease research. However, the use of placental pathology in directing or influencing neonatal clinical management continues to be limited for a wide range of reasons, some of which are historical and thus easily overcome today. In this review, we summarize the most recent literature linking placental function to neonatal outcomes, focusing on clinical placental pathology findings and the most common neonatal diagnoses that have been associated with placental dysfunction. We discuss how recent technological advances in neonatal and perinatal medicine may allow us to make a paradigm shift, in which valuable information provided by the placenta could be used to guide neonatal management more effectively, and to ultimately enhance neonatal care in order to improve our patient outcomes. We propose new avenues of clinical management in which the placenta could serve as a diagnostic tool toward more personalized neonatal intensive care unit management.

Palliative Care in Severe Neurotrauma Patients in the Intensive Care Unit

Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide and many patients with TBI require intensive care unit (ICU) management. When facing a life-threatening illness, such as TBI, a palliative care approach that focuses on noncurative aspects of care should always be considered in the ICU. Research shows that neurosurgical patients in the ICU receive palliative care less frequently than the medical patients in the ICU, which is a missed opportunity for these patients. However, providing appropriate palliative care to neurotrauma patients in an ICU can be difficult, particularly for young adult patients. The patients’ prognoses are often unclear, the likelihood of advance directives is small, and the bereaved families must act as decision-makers. This article highlights the different aspects of the palliative care approach as well as barriers and challenges that accompany the TBI patient population, with a particular focus on young adult patients with TBI and the role of their family members. The article concludes with recommendations for physicians for effective and adequate communication to successfully implement the palliative care approach into standard ICU care and to improve quality of care for patients with TBI and their families.

Current approach to fever of unknown origin in the intensive care unit

This study examines the effects of the interventions in alarm management in intensive care units on reducing alarms on the basis of current evidence.This systematic review and meta-analysis study was conducted between January 1, 2010 and October 31, 2021 by searching 16 databases through an independent search by three researchers. The acronym of PICOS was used and the keywords as well as inclusion/exclusion criteria were determined. The Joanna Briggs Institute meta-Analysis of Statistics Assessment and Review Instruments (JBI-MAStARI) were used to assess methodological quality. Professional meta-analysis Software (ProMeta 3) statistical software package was used for data analysis. The study is preregistered on PROSPERO (CRD42021286770).Intensive care units.The systematic review included 25 studies, whereas the meta-analysis included 15. According to the heterogeneity test in the study, alarm-reducing interventions yielded a heterogeneous distribution. The overall effect size value of all studies, which was found using the random-effects model, was determined to be −0.03 [95 % confidence interval (CI)], a value between −0.16 and 0.10 CI. Based on the results, individual studies showed that the strategies suggesting to ensure alarm safety were effective in reducing the number of alarms; the combined results of the studies in this meta-analysis showed that the interventions made to reduce alarms had too little effect.This study showed that the interventions have a very weak effect size on reducing the number of alarms.

Subphenotyping heterogeneous patients with chronic critical illness to guide individualised fluid balance treatment using machine learning: a retrospective cohort study.

The great heterogeneity of patients with chronic critical illness (CCI) leads to difficulty for intensive care unit (ICU) management. Identifying subphenotypes could assist in individualized care, which has not yet been explored. In this study, we aim to identify the subphenotypes of patients with CCI and reveal the heterogeneous treatment effect of fluid balance for them. In this retrospective study, we defined CCI as an ICU length of stay over 14 days and coexists with persistent organ dysfunction (cardiovascular Sequential Organ Failure Assessment (SOFA) score ≥1 or score in any other organ system ≥2) at Day 14. Data from five electronic healthcare record datasets covering geographically distinct populations (the US, Europe, and China) were studied. These five datasets include (1) subset of Derivation (MIMIC-IV v1.0, US) cohort (2008-2019); (2) subset Derivation (MIMIC-III v1.4 'CareVue', US) cohort (2001-2008); (3) Validation I (eICU-CRD, US) cohort (2014-2015); (4) Validation II (AmsterdamUMCdb/AUMC, Euro) cohort (2003-2016); (5) Validation III (Jinling, CN) cohort (2017-2021). Patients who meet the criteria of CCI in their first ICU admission period were included in this study. Patients with age over 89 or under 18 years old were excluded. Three unsupervised clustering algorithms were employed independently for phenotypes derivation and validation. Extreme Gradient Boosting (XGBoost) was used for phenotype classifier construction. A parametric G-formula model was applied to estimate the cumulative risk under different daily fluid management strategies in different subphenotypes of ICU mortality. We identified four subphenotypes as Phenotype A, B, C, and D in a total of 8145 patients from three countries. Phenotype A is the mildest and youngest subgroup; Phenotype B is the most common group, of whom patients showed the oldest age, significant acid-base abnormality, and low white blood cell count; Patients with Phenotype C have hypernatremia, hyperchloremia, and hypercatabolic status; and in Phenotype D, patients accompany with the most severe multiple organ failure. An easy-to-use classifier showed good effectiveness. Phenotype characteristics showed robustness across all cohorts. The beneficial fluid balance threshold intervals of subphenotypes were different. We identified four novel phenotypes that revealed the different patterns and significant heterogeneous treatment effects of fluid therapy within patients with CCI. A prospective study is needed to validate our findings, which could inform clinical practice and guide future research on individualized care. This study was funded by 333 High Level Talents Training Project of Jiangsu Province (BRA2019011), General Program of Medical Research from the Jiangsu Commission of Health (M2020052), and Key Research and Development Program of Jiangsu Province (BE2022823).

Abnormal serum levels of magnesium, phosphate, and zinc in ICU patients-Characteristics, management, and outcomes: The WhyTrace cohort study.

Abnormal serum levels of magnesium, phosphate, and zinc appear common in intensive care unit (ICU) patients, but the epidemiology, management, and associations with outcomes are less well described. We described these factors and estimated associations with outcomes in a large dataset of Danish ICU patients. We included adults who were acutely admitted to 10 general ICUs in Denmark between October 2011 and January 2018. From the dataset, we obtained characteristics of patients who had serum levels measured of magnesium, phosphate, or zinc, including data on supplementation. We used joint models with death as a competing outcome to estimate the associations between abnormal serum levels and time to successful extubation and, for magnesium, also incident tachyarrhythmia. We included 16,517 of 36,514 patients in the dataset. The cumulative probability of hypomagnesemia within 28 days was 64% (95% confidence interval [CI] 62-66); of hypophosphatemia 74% (95% CI 72-75); and of hypozincemia 98% (95% CI 98-98). Supplementation of magnesium was used in 3554 out of 13,506 (26%) patients, phosphate in 2115 out of 14,148 (15%) patients, and zinc in 4465 out of 9869 (45%) patients. During ICU stay, 38% experienced hypermagnesemia, 58% hyperphosphatemia, and 1% hyperzincemia. Low serum levels of magnesium, phosphate, and zinc were associated with shorter time to successful extubation, and high serum magnesium and phosphate and low serum zinc with the competing risk of increased mortality, but too few serum measurements made the results inconclusive. In this multicenter cohort study of acutely admitted ICU patients, most experienced low serum levels of magnesium, phosphate, or zinc during ICU stay, many received supplementation, and experiencing both low and high serum levels during ICU stay was not uncommon. Associations between serum levels and clinical outcomes appeared inconclusive because the data proved unfit for these analyses.

The Impact of Respiratory Therapist Performed Point-of-Care Lung Ultrasound on the Respiratory Care in Neonates, Manitoba Experience, Canada.

We aimed to evaluate the impact of the registered respiratory therapist (RRT) performed point-of-care lung ultrasound (POC-LUS) on patient management in the neonatal intensive care unit (NICU). This is a retrospective cohort study of neonates who had RRT performed POC-LUS in two level III NICUs in Winnipeg, Manitoba, Canada. The analysis aims mainly to describe the implementation process of the POC-LUS program. The primary outcome was the prediction of the change in clinical management. A total of 136 neonates underwent 171 POC-LUS studies during the study period. POC-LUS resulted in a change in clinical management following 113 POC-LUS studies (66%), while it supported continuing the same management in 58 studies (34%). The lung ultrasound severity score (LUSsc) was significantly higher in the group with worsening hypoxemic respiratory failure and on respiratory support than infants on respiratory support and stable or not on respiratory support, p < 0.0001. LUSsc was significantly higher in infants on either noninvasive or invasive than those not on respiratory support, p-value <0.0001. RRT performed POC-LUS service utilization in Manitoba improved and guided the clinical management of a significant proportion of patients who received the service.

CORRELATION OF SERUM FERRITIN AND LDH ON CRITICALLY ILL PATIENTS OF COVID-19 DISEASE DURING 1ST AND 2ND WAVE OF COVID 19 PANDEMIC IN TERTIARY CARE HOSPITAL, INDIA

In both the earlier waves of COVID-19 variants, severe and fatal respiratory disease like acute respiratory distress syndrome (ARDS) became more fatal in population with comorbid conditions. Therefore, early identication of severe COVID-19 is very important for individual's precise management, including antiviral, oxygen support and intensive care unit (ICU) management. First case of COVID-19 got reported in the medical record of India on 30th January 2020 in a student who had returned from Wuhan, China. In 2020 and 2021 it was found that individuals with increased serum ferritin and LDH level landed up with severe and very severe COVID-19 if not treated timely and correctly. So correlation between S. Ferritin and LDH in 1st and 2nd wave was required to evaluate the condition of patients who remained admitted in critical care unit with or without comorbid conditions. This is hospital based cross- sectional observational study on 50-50 (total-100) critically ill patients admitted during 2020 and 2021 respectively. We found that In 2020 during the 1st wave serum LDH and serum Ferritin levels were signicantly high with the mean value of 481.65 U/L and 532.56 ng/ml respectively and in 2021 during 2nd wave serum LDH and serum Ferritin levels were again signicantly high with the mean value of 488.43 U/L and 667.27 ng/ml respectively. In 2020 patients with comorbid conditions showed S. LDH and Ferritin mean value of 543.47 U/L and 582.63 ng/ml respectively and in 2021 during 2nd wave it showed S.LDH and Ferritin levels mean value of 672.72 U/L and 727.38 ng/ml respectively. Both inammatory markers were signicantly more increased in the critically ill patients who presented with co-morbidities. This study will provide improved condence to health workers working in remote areas and COVID-19 hospitals in predicting transfer of COVID-19 patients to tertiary care hospitals for critical care management at the earliest.

Outcome of patients with newly diagnosed AML admitted to the ICU, including preemptive admission - a multi-center study.

Acute myeloid leukemia (AML) can lead to life-threatening complications that may require intensive care unit (ICU) management. It has been advocated that early preemptive (ePE) ICU admission, before the onset of organ failure, could benefit some high-risk patients such as those with hyperleukocytosis. The aim of this study was to retrospectively analyze the outcome of newly diagnosed AML patients who required ICU admission in five academic centers with a special focus on patients with an ePE admission strategy, i.e., those transferred to the ICU without any organ failure (modified SOFA score ≤ 2 [omitting thrombocytopenia] and no life-sustaining intervention in the first 24h following ICU admission) before the start of induction therapy. Between January 2017 and December 2019, 428 patients were included among which 101 were admitted to the ICU. Among patients requiring life-sustaining interventions (n = 83), 18 (22%) died while in the ICU but ICU survivors had the same survival as those not admitted to the ICU. Patients with an ePE admission (n = 18) had more comorbidities and high-risk disease features such as hyperleukocytosis but required no life-sustaining interventions while in the ICU. In a subgroup analysis of patients with hyperleukocytosis ≥ 50 G/l at diagnosis (n = 85), patients not admitted to the ICU and those admitted with an ePE strategy had similar outcomes. This study provides encouraging results about ICU outcome in AML patients during induction therapy but the potential benefit of an ePE strategy must be confirmed prospectively.

Case Studies.

British Journal of NursingVol. 32, No. Sup7 Case StudiesCase StudiesGema Munoz-Mozas, Colin Fairhurst, Simon ClareGema Munoz-MozasVascular Access Advanced Nurse Practitioner and Lead Vascular Access Nurse, Royal Marsden NHS Foundation TrustSearch for more papers by this author, Colin FairhurstVascular Access Advanced Clinical Practitioner, University Hospitals Plymouth NHS TrustSearch for more papers by this author, Simon ClareResearch and Practice Development Director, the Association for Safe Aseptic PracticeSearch for more papers by this authorGema Munoz-Mozas; Colin Fairhurst; Simon ClarePublished Online:10 Apr 2023https://doi.org/10.12968/bjon.2023.32.Sup7.S11AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Akhtar N, Lee L. Utilization and complications of central venous access devices in oncology patients. Current Oncology. 2021;281:367-377. https://doi.org/10.3390/curroncol28010039 Crossref, Medline, Google ScholarBD. BD ChloraPrep: summary of product characteristics. 2021. www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-smpc-pil-msds (accessed 2 November 2022) Google ScholarBD. Chloraprep 10.5ml applicator. 2022a. www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-patient-preoperative-skin-preparation-product-line/chloraprep-105-ml-applicator (accessed 26 September 2022) Google ScholarBD. Chloraprep 3ml applicator. 2022b. www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-patient-preoperative-skin-preparation-product-line/chloraprep-3-ml-applicator (accessed 26 September 2022) Google ScholarCenters for Disease Control and Prevention. Website. 2021. www.cdc.gov/cancer/preventinfections/providers.htm (accessed 26 September 2022) Google ScholarCeylan G, Topal S, Turgut N, Ozdamar N, Oruc Y, Agin H, Devrim I. Assessment of potential differences between pre-filled and manually prepared syringe use during vascular access device management in a pediatric intensive care unit. J Vasc Access. 2021:11297298211015500. https://doi.org/10.1177/11297298211015500 Google ScholarClare S, Rowley S. Best practice skin antisepsis for insertion of peripheral catheters. Br J Nurs. 2021;30(1):8-14. https://doi.org/10.12968/bjon.2021.30.1.8 Link, Google ScholarCaguioa J, Pilpil F, Greensitt C, Carnan D. HANDS: standardised intravascular practice based on evidence. Br J Nurs. 2012;21(14):S4-S11. https://doi.org/10.12968/bjon.2012.21.Sup14.S4 Link, Google ScholarEasterlow D, Hoddinott P, Harrison S. Implementing and standardising the use of peripheral vascular access devices. J Clin Nurs. 2010;19(5-6):721-727. https://doi.org/10.1111/j.1365-2702.2009.03098.x Crossref, Medline, Google ScholarFlorman S, Nichols RL. Current approaches for the prevention of surgical site infections. Am J Infect Dis. 2007;31:51-61. https://doi.org/10.3844/ajidsp.2007.51.61 Crossref, Google ScholarGorski LA, Hadaway L, Hagle M et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(S1):S1-S224. https://doi.org/10.1097/NAN.0000000000000396 Crossref, Medline, Google ScholarGuenezan J, Marjanovic N, Drugeon B, et al. Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, openlabel, single centre, randomised-controlled, two-by-two factorial trial [published correction appears in Lancet Infect Dis. 2021 Apr 6]. Lancet Infect Dis. 2021;21(7):1038-1048. https://doi.org/10.1016/S1473-3099(20)30738-6 Crossref, Medline, Google ScholarGunka V, Soltani P, Astrakianakis G, Martinez M, Albert A, Taylor J, Kavanagh T. Determination of ChloraPrep® drying time before neuraxial anesthesia in elective cesarean delivery: a prospective observational study. Int J Obstet Anesth. 2019;38:19-24. https://doi.org/10.1016/j.ijoa.2018.10.012 Crossref, Medline, Google ScholarIshikawa K, Furukawa K. Staphylococcus aureus bacteraemia due to central venous catheter infection: a clinical comparison of infections caused by methicillin-resistant and methicillin-susceptible strains. Cureus. 2021;137:e16607. https://doi.org/10.7759/cureus.16607 Medline, Google ScholarLoveday HP, Wilson JA, Pratt RJ et al. Epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86(S1):S1-70. https://doi.org/10.1016/S0195-6701(13)60012-2 Crossref, Medline, Google ScholarNational Patient Safety Agency. Promoting safer use of injectable medicines. 2007. https://healthcareea.vctms.co.uk/assets/content/9652/4759/content/injectable.pdf (accessed 3 October 2022) Google ScholarRoyal College of Nursing. Standards for infusion therapy. 4th edn. 2016. www.rcn.org.uk/clinical-topics/Infection-prevention-and-control/Standards-for-infusion-therapy (accessed 26 September 2022) Google ScholarTaxbro K, Chopra V. Appropriate vascular access for patients with cancer. Lancet. 2021;39810298:367-368. https://doi.org/10.1016/S0140-6736(21)00920-X Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 2 April 2023Volume 32Issue Sup7ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 10 April 2023 Published in print 2 April 2023 Information© MA Healthcare LimitedPDF download

Sedation for adult ICU patients: A narrative review including a retrospective study of our own data.

The optimization of patients' treatment in the intensive care unit (ICU) needs a lot of information and literature analysis. Many changes have been made in the last years to help evaluate sedated patients by scores to help take care of them. Patients were completely sedated and had continuous intravenous analgesia and neuromuscular blockades. These three drug classes were the main drugs used for intubated patients in the ICU. During these last 20 years, ICU management went from fully sedated to awake, calm, and nonagitated patients, using less sedatives and choosing other drugs to decrease the risks of delirium during or after the ICU stay. Thus, the usefulness of these three drug classes has been challenged. The analgesic drugs used were primarily opioids but the use of other drugs instead is increasing to lessen or wean the use of opioids. In severe acute respiratory distress syndrome patients, neuromuscular blocking agents have been used frequently to block spontaneous respiration for 48 hours or more; however, this has recently been abolished. Optimizing a patient's comfort during hemodynamic or respiratory extracorporeal support is essential to reduce toxicity and secondary complications.

SPECIAL CONSIDERATIONS IN CRITICAL CARE OF THE CONGENITAL HEART DISEASE PATIENT.

Outcomes of congenital heart disease have improved markedly over the last 20 years, with survival to adulthood now close to 90%. The mean age of admission to an intensive care unit (ICU) is 40 years. The incidence of hospital and critical care admissions have increased significantly as a consequence of this improved survival. Intensivists are now confronted with the management of complex adult congenital heart disease (ACHD) lesions not only from a cardiac perspective but also extra-cardiac organ consequences of years of abnormal circulation following surgical or palliative correction. Kidney and liver dysfunction, respiratory and hematological abnormalities are very common in this population. ACHD patients can present to the ICU for a vast number of reasons, these are classified in this review as medical non-cardiac, medical cardiac and surgical. Community/hospital acquired infections, cerebrovascular accidents, respiratory failure, alongside arrhythmias and heart failure are responsible for medical admissions. Surgical admissions include post-operative management after correction or palliation, but also medical optimization and work-up for advanced therapies. ICU management of this large heterogeneous group requires a thorough understanding of the pathophysiology in order to apply conventional adult critical care modalities; left ventricular or right ventricular dysfunction, pulmonary hypertension, intracardiac, extracardiac, palliative surgical shunts can be present and require additional consideration. This review focuses on the pathophysiology, long term sequelae, and different treatment modalities to supply a framework for the ICU physician caring for these patients. Successful outcome, especially in complex lesions is dependent on early involvement of specialized ACHD centers.