Intensive Care Unit Management Research Articles

RAND appropriateness panel to determine the applicability of UK guidelines on the management of acute respiratory distress syndrome (ARDS) and other strategies in the context of the COVID-19 pandemic

BackgroundCOVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from ‘classical’ ARDS. A Research and...

Role of chest radiograph in MERS-Cov pneumonia: a single tertiary referral center experience in the United Arab Emirates

BackgroundThe Middle East respiratory syndrome coronavirus (MERS-Cov) continues to be a source of concern due to intermittent outbreaks. Serial chest radiographic changes in MERS-Cov patients were analyzed for various variables that could be compared to the patients’ final outcomes in a cluster of MERS-Cov patients and to identify a predictor of mortality in the United Arab Emirates.ResultsA total of 44 MERS-Cov cases were reviewed. The mean age of the patients was 43.7 ± 14.7 years. The chest radiograph was abnormal in 14/44 (31.8%). The commonest radiology features include ground-glass opacities (seven of 14, 50%), ground-glass and consolidation (seven of 14, 50%), pleural effusion (eight of 14, 57.1%), and air bronchogram (three of 14, 21.4%). The mortality rate was 13.6% (six of 44); the deceased group (6 of 44, 13.6%) was associated with significantly higher incidence of mechanical ventilation (p < 0.001), pleural effusion (p < 0.001), chest radiographic score (8.90 ± 6.31, p < 0.001), and type 4 radiographic progression of disease (p < 0.001). A chest radiographic score at presentation was seen to be an independent and strong predictor of mortality (OR [95% confidence interval] 3.20 [1.35, 7.61]). The Cohen κ coefficient for the interobserver agreement was k = 0.89 (p = 0.001).ConclusionThe chest radiographic score, associated with a higher degree of disease progression (type 4), particularly in patients with old age or with comorbidity, may indicate a poorer prognosis in MERS-Cov infection, necessitating intensive care unit management or predicting impending death.

Dual Degree Training: Balancing Clinical Aptitude and Medical Licensure Requirements

Dual Degree Training: Balancing Clinical Aptitude and Medical Licensure Requirements

Savable but Lost Lives when ICU Is Overloaded: a Model from 733 Patients in Epicenter Wuhan, China

Coronavirus Disease 2019 (COVID-19) causes a sudden turnover to bad at some checkpoints and thus needs the intervention of intensive care unit (ICU). This resulted in urgent and large needs of ICUs posed great risks to the medical system. Estimating the mortality of critical in-patients who were not admitted into the ICU will be valuable to optimize the management and assignment of ICU. Retrospective, 733 in-patients diagnosed with COVID-19 at a local hospital (Wuhan, China), as of March 18, 2020. Demographic, clinical and laboratory results were collected and analyzed using machine learning to build a predictive model. Considering the shortage of ICU beds at the beginning of disease emergence, we defined the mortality for those patients who were predicted to be in needing ICU care yet they did not as Missing-ICU (MI)-mortality. To estimate MI-mortality, a prognostic classification model was built to identify the in-patients who may need ICU care. Its predictive accuracy was 0.8288, with an AUC of 0.9119. On our cohort of 733 patients, 25 in-patients who have been predicted by our model that they should need ICU, yet they did not enter ICU due to lack of shorting ICU wards. Our analysis had shown that the MI-mortality is 41%, yet the mortality of ICU is 32%, implying that enough bed of ICU in treating patients in critical conditions.

Impact of Contrast Echocardiography on Outcomes in Critically Ill Patients

Limited data suggests ultrasound enhancing agent (UEA) use is associated with changes in clinical management and lower mortality in intensive care unit (ICU) patients. We conducted a retrospective observational study to determine if contrast echocardiography (vs non-contrast echocardiography) is associated with differences in length of stay (LOS) and subsequent resource utilization in the ICU setting. The Premier Healthcare Database (Charlotte, NC) was analyzed to identify patients receiving Definity vs. no use of contrast during the initial rest transthoracic echocardiogram (TTE) in an ICU setting. The primary outcomes of interest were subsequent TTE and transesophageal echocardiography (TEE) during the index hospitalization, and ICU LOS. Propensity scoring was used to statistically model treatment selection to minimize selection bias. A total of 1,538,864 patients from 773 hospitals were identified as undergoing resting TTE in the ICU with use of DEFINITY in 51,141 (3.3%) patients and no contrast agent use in 1,487,723 (96.7%) patients. After adjusting for patient, clinical, and hospital characteristics, patients in the Definity cohort were less likely to undergo a subsequent TTE or TEE as compared to those in the no contrast cohort (odds ratio = 0.704 for TTE, odds ratio = 0.841 for TEE; p < 0.0001 for both). Adjusted mean ICU LOS for the Definity cohort was shorter than that of the no contrast cohort (4.59 vs 4.15 days, p < 0.0001). In conclusion, Definity-enhanced echocardiography in the ICU setting (in comparison with non-contrast TTE) is associated with lower rates of subsequent TTE and TEE during the index hospitalization, and shorter ICU LOS.

Assessment of potential differences between pre-filled and manually prepared syringe use during vascular access device management in a pediatric intensive care unit.

Central line-associated bloodstream infection is one of the four primary health-care-associated infections applicable to pediatric intensive care units defined by The Centers for Disease Control and Prevention. According to current guidelines, it is essential to flush vascular access devices before each infusion to assess catheter function and prevent catheter-related complications. This prospective trial aimed to assess the potential differences between pre-filled and manually prepared saline syringe use during vascular access device management in a pediatric intensive care unit. Volunteered registered pediatric intensive care unit nurses were asked to implement the flushing solution to an extension line of a central venous catheter in vitro. After the randomization process with opaque sealed envelopes, they have started either with manual preparation or used sterile pre-filled saline syringes. Sterile application steps forms were used for monitoring the manual preparation of saline syringes versus the pre-filled saline syringes phase. Each volunteer repeated the steps for 3, 5, and 10 mL syringe volumes with the manually prepared and pre-filled saline syringes. After completing the procedures, failed steps and durations were transferred into a database to be analyzed by a blinded investigator. A total of 41 nurses volunteered and 123 forms for three attempts per one nurse were filled for each group. In the manual preparation group, the number of at least one failure in the necessary steps was 89 (72.3%) and the same number in the pre-filled syringe group was 6 (4.9%), and significantly lower in the pre-filled saline syringe group (p < 0.001). The overall time for preparing to flush was 86.0 ± 22.3 s (ranging from 46 to 173 s) for manual prepared syringes and 35.2 ± 9.4 s (ranging from 18 to 100 s) (p < 0.001) for pre-filled saline syringes. Our results demonstrate that the risk for breaking the aseptic no-touch technic was higher in the manual preparation group. We have also demonstrated that the flushing time was shorter with pre-filled syringes compared to manually prepared ones, which may contribute to decreasing the workload of the nurses and may increase the quality of care in the intensive care units. The use of pre-filled saline syringes may decrease the central line-associated bloodstream infections incidence and may increase the quality of care by saving extra time in the pediatric intensive care unit.

Nutritional management of individuals with obesity and COVID-19: ESPEN expert statements and practical guidance

The COVID-19 pandemics has created unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Among other important risk factors for severe COVID-19 outcomes, obesity has emerged along with undernutrition-malnutrition as a strong predictor of disease risk and severity. Obesity-related excessive body fat may lead to respiratory, metabolic and immune derangements potentially favoring the onset of COVID-19 complications. In addition, patients with obesity may be at risk for loss of skeletal muscle mass, reflecting a state of hidden malnutrition with a strong negative health impact in all clinical settings. Also importantly, obesity is commonly associated with micronutrient deficiencies that directly influence immune function and infection risk. Finally, the pandemic-related lockdown, deleterious lifestyle changes and other numerous psychosocial consequences may worsen eating behaviors, sedentarity, body weight regulation, ultimately leading to further increments of obesity-associated metabolic complications with loss of skeletal muscle mass and higher non-communicable disease risk. Therefore, prevention, diagnosis and treatment of malnutrition and micronutrient deficiencies should be routinely included in the management of COVID-19 patients in the presence of obesity; lockdown-induced health risks should also be specifically monitored and prevented in this population. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing clinical practice guidance for nutritional management of COVID-19 patients with obesity in various clinical settings.

Preparation for airway management in Australia and New Zealand ICUs during the COVID -19 pandemic.

BackgroundThis paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM).Methods and findingsProspective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE “spotters” (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%).ConclusionThere was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines.

U.S. Neurosurgical Response to COVID-19: Forging a Path Toward Disaster Preparedness.

ABSTRACTIntroductionThe worldwide COVID-19 pandemic poses challenges to healthcare capacity and infrastructure. The authors discuss the structure and efficacy of the U.S. Navy’s response to COVID-19 and evaluate the utility of this endeavor, with the objective of providing future recommendations for managing worldwide healthcare and medical operational demands from the perspective of Navy Neurosurgery.Materials and MethodsThe authors present an extensive review of topics and objectively highlight the efforts of U.S. Navy Neurosurgery as it pertains to the humanitarian mission during the COVID-19 pandemic.ResultsDuring the humanitarian mission (March 27, 2020–April 14, 2020), the response of active duty and reserve neurosurgeons in the U.S. Navy was robust. Neurosurgical coverage was present on board the U.S. Navy Ships Mercy and Comfort, with additional neurosurgical deployment to New York City for intensive care unit management and coverage.ConclusionsThe U.S. Navy neurosurgical response to the COVID-19 pandemic was swift and altruistic. Although neurosurgical pathologies were limited among the presenting patients, readiness and manpower continue to be strong influences within the Armed Forces. The COVID-19 response demonstrates that neurosurgical assets can be rapidly mobilized and deployed in support of wartime, domestic, and global humanitarian crises to augment both trauma and critical care capabilities.

Promotion of Neonatal Pain Management in Neonatal Intensive Care Unit: A participatory Action Research

Introduction: Pain management is especially important for infants who are not able to verbally express their pain. The objective of this study was to promote pain management in Neonatal Intensive Care Unit (NICU). Methods: The present study was conducted using an action research based on Kemmis and McTaggart’s action research cycle on 35 participants including nurses, physicians, and center managers involved in the care of neonates. Four qualitative methods including interviews, focus group discussions, strategic meetings, and field notes were used for data collection. The content analysis approach was also used to analyze the data. Two action cycles were designed, with four stages of “identification, planning, implementation, and observation and reflection”. Results: Based on the results of this study, the source of the challenges was categorized into four areas of human resources management, pain control policy, workplace conditions, and management factors. The steps for the follow-up and implementation of the proposed solutions and strategies included training workshops, preparation of pain control policy, provision of facilities and equipment, and participation of senior managers in the implementation of neonatal pain management. The results of data analysis in the final evaluation revealed two themes of “comfort” and “improvement” in pain management in the NICU. Conclusion: The results of this study showed positive experiences of the participants on implementation of pain management in the NICU. The results also demonstrated that pain management problems in NICU can be reduced, without imposing high costs, by forming multidisciplinary teams and engaging various disciplines in the process of neonatal pain management.

Typhoid and Enteric Fevers in Intensive Care Unit.

Enteric fever (typhoid and paratyphoid)is caused by Salmonella typhi and Salmonella paratyphi. It is spread by fecal-oral route, largely through contamination of water and foodstuff. Developing countries are the worst affected. It takes 7 – 21 days from ingestion of the organism to manifestation of symptoms which are generally Fever, relative bradycardia, and pain abdomen. Hepatosplenomegaly, intestinal bleeding, and perforation are the features at various stages of the disease. The bacteria invade the submucous layer and proliferate in the Payer's patches. Blood culture is the gold standard for diagnosis but it is only rarely positive. Fluroquinolones, cephalosporins, and azithromycin are antibiotics of choice. There is increasing evidence of the development of resistance to all antibiotics. Salmonella sepsis, though uncommon, can occur. Intestinal perforation, peritonitis, and secondary sepsis are complications that may require intensive care unit management.How to cite this article: Ray B, Raha A. Typhoid and Enteric Fevers in Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2):S144–S149.

Nutrition evaluation and management of critically ill patients with COVID-19 during post-intensive care rehabilitation.

BackgroundAmong hospitalized patients with coronavirus disease 2019 (COVID‐19), up to 12% may require intensive care unit (ICU) management. The aim of this prospective cohort study is to assess nutrition status and outcome in patients with COVID‐19 following ICU discharge.MethodsPatients requiring a minimum of 14 days’ stay in the ICU with mechanical ventilation were included. Nutrition status was assessed at inclusion (ICU discharge) and follow‐up (after 15, 30, and 60 days). All patients had standardized medical nutrition therapy with defined targets regarding energy (30 kcal/kg/d) and protein intake (1.5 g/kg/d).ResultsFifteen patients were included (67% males); the median age was 60 (33–75) years old. Body mass index at ICU admission was 25.7 (IQR, 24–31) kg/m². After a median ICU stay of 33 (IQR, 26–39) days, malnutrition was present in all patients (11.3% median weight loss and/or low muscle mass based on handgrip strength measurement). Because of postintubation dysphagia in 60% of patients, enteral nutrition was administered (57% nasogastric tube; 43% percutaneous endoscopic gastrostomy). After 2 months, a significant improvement in muscle strength was observed (median handgrip strength, 64.7% [IQR, 51%–73%] of the predicted values for age vs 19% [IQR, 4.8%–28.4%] at ICU discharge [P < 0.0005]), as well as weight gain of 4.3 kg (IQR, 2.7–6.7 kg) (P < 0.0002).ConclusionsCritically ill patients with COVID‐19 requiring ICU admission and mechanical ventilation have malnutrition and low muscle mass at ICU discharge. Nutrition parameters improve during rehabilitation with standardized medical nutrition therapy.

Intensive Care and Treatment of Severe Guillain-Barré Syndrome.

Guillain–Barré syndrome (GBS) is an acute polyneuropathy mostly characterized by acute flaccid paralysis with or without sensory/autonomous nerve dysfunction. Current immuno therapies including intravenous immunoglobulin (IVIg), plasma exchange (PE), and newly developed biological drugs benefit patients by alleviating hyperreactive immune responses. Up to 30% of patients develop respiratory failure during hospitalization and require mechanical ventilation and intensive care. Immunotherapies, mechanical ventilation, supportive care, and complication management during the intensive care unit (ICU) stay are equally emphasized. The most important aspect of intensive care and treatment of severe GBS, that is, mechanical ventilation, has been extensively reviewed elsewhere. In contrast to immunotherapies, care and treatment of GBS in the ICU setting are largely empirical. In this review, we intend to stress the importance of intensive care and treatment, other than mechanical ventilation in patients with severe GBS. We summarize the up-to-date knowledge of pharmacological therapies and ICU management of patients with severe GBS. We aim to answer some key clinical questions related to the management of severe GBS patients including but not limited to: Is IVIg better than PE or vice versa? Whether combinations of immune therapies benefit more? How about the emerging therapies promising for GBS? When to perform tracheal intubation or tracheostomy? How to provide multidisciplinary supportive care for severe cases? How to avert life-threatening complications in severe cases?

Nursing Responsibilities and Roles in Delirium Management in Pediatric Intensive Care Unit

Deliryum, bilinç durumunda dalgalanmaya neden olan akut başlangıçlı mental bir durumdur. Yoğun bakım ünitelerinde tedavi gören çocuk hastalarda, ortamın gürültülü ve sürekli aydınlık olması, tıbbi cihazların varlığı, sağlık ekibinin tekrarlayan müdahaleleri ve mekanik ventilasyon ihtiyacı gibi nedenlerle görülme sıklığı %80’e kadar çıkmaktadır. Çocuk hastalarda deliryum yüksek mortalite oranlarıyla ilişkili, sık görülen bir sağlık sorunu olmasına rağmen çocuk gelişim düzeylerindeki farklılıklar, bilgi eksikliği, yapılan çalışmaların azlığı ve rutin değerlendirmede aksamalar nedeniyle pediatrik deliryum vakaları sağlık ekibi üyeleri tarafından ya erken dönemde fark edilememekte ya da depresyon gibi farklı bir tanı ile karıştırılabilmektedir. Bu durumda tablo daha da ilerlemekte, çocukların oryantasyonu, düşünce süreçleri, uyku düzenleri bozulmakta, hastanede kalış süresi uzamakta ve hatta hasta kaybedilebilmektedir. Yoğun bakımda tedavi gören çocuk hastalarla tedavi ve bakım gereği sürekli temas ve iletişim halinde olan hemşireler, hastada oluşabilecek ufak bir değişikliğin bile fark edilmesi, pediatrik deliryumun erken dönemde tanılanması ve tedavisinin sağlanmasında kritik rol oynamaktadır. Bu derlemede hemşirelerin pediatri yoğun bakımlarda deliryum yönetimindeki sorumluluk ve rollerinin vurgulanması amaçlanmıştır.

Use of volatile agents for sedation in the intensive care unit: A national survey in France

Current intensive care unit (ICU) sedation guidelines recommend strategies using non-benzodiazepine sedatives. This survey was undertaken to explore inhaled ICU sedation practice in France. In this national survey, medical directors of French adult ICUs were contacted by phone or email between July and August 2019. ICU medical directors were questioned about the characteristics of their department, their knowledge on inhaled sedation, and practical aspects of inhaled sedation use in their department. Among the 374 ICUs contacted, 187 provided responses (50%). Most ICU directors (73%) knew about the use of inhaled ICU sedation and 21% used inhaled sedation in their unit, mostly with the Anaesthetic Conserving Device (AnaConDa, Sedana Medical). Most respondents had used volatile agents for sedation for <5 years (63%) and in <20 patients per year (75%), with their main indications being: failure of intravenous sedation, severe asthma or bronchial obstruction, and acute respiratory distress syndrome. Sevoflurane and isoflurane were mainly used (88% and 20%, respectively). The main reasons for not using inhaled ICU sedation were: "device not available" (40%), "lack of medical interest" (37%), "lack of familiarity or knowledge about the technique" (35%) and "elevated cost" (21%). Most respondents (80%) were overall satisfied with the use of inhaled sedation. Almost 75% stated that inhaled sedation was a seducing alternative to intravenous sedation. This survey highlights the widespread knowledge about inhaled ICU sedation in France but shows its limited use to date. Differences in education and knowledge, as well as the recent and relatively scarce literature on the use of volatile agents in the ICU, might explain the diverse practices that were observed. The low rate of mild adverse effects, as perceived by respondents, and the users' satisfaction, are promising for this potentially important tool for ICU sedation.

In Vivo Observation of Lidocaine-Encapsulated Polymyxin/Glycol Nanoparticles Wound Dressing for the Treatment and Care of Abdominal Pain Incision in Intensive Care Unit

The developments of lidocaine chloride loaded nanoparticles are encouraging biomaterials, which could be used for wound healing applications for abdominal pain management. The current work presents the composition of wound dressings based on lidocaine chloride (LCH) (anesthetic drug)-loaded Polymyxin (PMN)/Glycol (GLY). The LCH nanocomposite (LCH@PMN/GLY) were fabricated by the LCH oxide solutions within the PMN/GLY matrix. The influences of different experimental limitations on PMN/GLY nanoparticles formations were examined. The PMN/GLY and LCH@PMN/GLY nanoparticle sizes were evaluated by high resolution-scanning electron microscopy (HR-SEM). Additionally, the antibacterial efficacy of PMN/GLY and LCH@PMN/GLY was developed for gram-positive and negative microorganisms. Moreover, we examined in vivo healing of skin wounds formed in mouse models over 20 days. In contrast to the untreated wounds, rapid healing was perceived in the LCH@PMN/GLY-treated wound with less damage. These findings indicate that LCH@PMN/GLY-based bandaging materials could be a potential innovative biomaterial for tissue repair and implantation and nursing care for wound healing applications for abdominal pain incision in intensive care unit (ICU) management in an animal model.

Cost and clinical outcomes of postoperative intensive care unit versus general floor management in head and neck free flap reconstructive surgery patients

PurposeTo compare clinical, surgical, and cost outcomes in patients undergoing head and neck free-flap reconstructive surgery in the setting of postoperative intensive care unit (ICU) against general floor management. MethodsRetrospective analysis of head and neck free-flap reconstructive surgery patients at a single tertiary academic medical center. Clinical data was obtained from medical records. Cost data was obtained via the Mayo Clinic Rochester Cost Data Warehouse, which assigns Medicare reimbursement rates to all professional billed services. ResultsA total of 502 patients were included, with 82 managed postoperatively in the ICU and 420 on the general floor. Major postoperative outcomes did not differ significantly between groups (Odds Ratio[OR] 1.54; p = 0.41). After covariate adjustments, patients managed in the ICU had a 3.29 day increased average length of hospital stay (Standard Error 0.71; p < 0.0001) and increased need for take-back surgery (OR 2.35; p = 0.02) when compared to the general floor. No significant differences were noted between groups in terms of early free-flap complications (OR 1.38;p = 0.35) or late free-flap complications (Hazard Ratio 0.81; p = 0.61). Short-term cost was $8772 higher in the ICU (range = $5640–$11,903; p < 0.01). Long-term cost did not differ significantly. ConclusionPostoperative management of head and neck oncologic free-flap patients in the ICU does not significantly improve major postoperative outcomes or free-flap complications when compared to general floor care, but does increase short-term costs. General floor management may be appropriate when cardiopulmonary compromise is not present.

Role of Optical Neuromonitoring in Neonatal Encephalopathy-Current State and Recent Advances.

Neonatal encephalopathy (NE) in term and near-term infants is a significant global health problem; the worldwide burden of disease remains high despite the introduction of therapeutic hypothermia. Assessment of injury severity and effective management in the neonatal intensive care unit (NICU) relies on multiple monitoring modalities from systemic to brain-specific. Current neuromonitoring tools provide information utilized for seizure management, injury stratification, and prognostication, whilst systemic monitoring ensures multi-organ dysfunction is recognized early and supported wherever needed. The neuromonitoring technologies currently used in NE however, have limitations in either their availability during the active treatment window or their reliability to prognosticate and stratify injury confidently in the early period following insult. There is therefore a real need for a neuromonitoring tool that provides cot side, early and continuous monitoring of brain health which can reliably stratify injury severity, monitor response to current and emerging treatments, and prognosticate outcome. The clinical use of near-infrared spectroscopy (NIRS) technology has increased in recent years. Research studies within this population have also increased, alongside the development of both instrumentation and signal processing techniques. Increasing use of commercially available cerebral oximeters in the NICU, and the introduction of advanced optical measurements using broadband NIRS (BNIRS), frequency domain NIRS (FDNIRS), and diffuse correlation spectroscopy (DCS) have widened the scope by allowing the direct monitoring of oxygen metabolism and cerebral blood flow, both key to understanding pathophysiological changes and predicting outcome in NE. This review discusses the role of optical neuromonitoring in NE and why this modality may provide the next significant piece of the puzzle toward understanding the real time state of the injured newborn brain.

Long-term outcome of prolonged critical illness: A multicentered study in North Brisbane, Australia.

Although critical illness is usually of high acuity and short duration, some patients require prolonged management in intensive care units (ICU) and suffer long-term morbidity and mortality. To describe the long-term survival and examine determinants of death among patients with prolonged ICU admission. A retrospective cohort of adult Queensland residents admitted to ICUs for 14 days or longer in North Brisbane, Australia was assembled. Comorbid illnesses were classified using the Charlson definitions and all cause case fatality established using statewide vital statistics. During the study a total of 28,742 adult Queensland residents had first admissions to participating ICUs of which 1,157 (4.0%) had prolonged admissions for two weeks or longer. Patients with prolonged admissions included 645 (55.8%), 243 (21.0%), and 269 (23.3%) with ICU lengths of stay lasting 14-20, 21-27, and ≥28 days, respectively. Although the severity of illness at admission did not vary, pre-existing comorbid illnesses including myocardial infarction, congestive heart failure, kidney disease, and peptic ulcer disease were more frequent whereas cancer, cerebrovascular accidents, and plegia were less frequently observed among patients with increasing ICU lengths of stay lasting 14-20, 21-27, and ≥28 days. The ICU, hospital, 90-day, and one-year all cause case-fatality rates were 12.7%, 18.5%, 20.2%, and 24.9%, respectively, and were not different according to duration of ICU stay. The median duration of observation was 1,037 (interquartile range, 214-1888) days. Although comorbidity, age, and admitting diagnosis were significant, neither ICU duration of stay nor severity of illness at admission were associated with overall survival outcome in a multivariable Cox regression model. Most patients with prolonged stays in our ICUs are alive at one year post-admission. Older age and previous comorbidities, but not severity of illness or duration of ICU stay, are associated with adverse long-term mortality outcome.

Invasive neuromonitoring and neurological intensive care unit management in life-threatening central nervous system infections.

Patients with infectious diseases of the central nervous system (CNS) commonly require treatment in the intensive care unit (ICU). In a subset of patients with a life-threatening course, a more aggressive and invasive management is required. Treatment relies on the expertise of the intensivists as most recommendations are currently not based on a high level of evidence. Published data suggest that an invasive brain-focused management should be considered in life-threatening CNS infections. Brain resuscitation by adequate control of intracranial pressure (ICP) and optimization of cerebral perfusion, oxygen and glucose delivery supports the idea of personalized medicine. Recent advances in monitoring techniques help to guide clinicians to improve neurocritical care management in these patients with severe disease. Robust data on the long-term effect of decompressive craniectomy and targeted temperature management are lacking, however, these interventions can be life-saving in individual patients in the setting of a potentially fatal situation such as refractory elevated ICP. Advances in the neurocritical care management and progress in monitoring techniques in specialized neuro-ICUs may help to preserve brain function and prevent a deleterious cascade of secondary brain damage in life-threatening CNS infections.