Management Of Patients In Intensive Care Unit Research Articles

Assessment of urine CCL2 as a potential diagnostic biomarker for acute kidney injury and septic acute kidney injury in intensive care unit patients

Acute kidney injury (AKI) is a prevalent and serious condition in the intensive care unit (ICU), associated with significant morbidity and mortality. Septic acute kidney injury (SAKI) contributes substantially to AKI cases in the ICU. However, current diagnostic methods have limitations, necessitating the exploration of novel biomarkers. In this study, we investigated the potential of plasma and urine CCL2 levels as diagnostic markers for AKI and SAKI in 216 ICU patients. Our findings revealed significant differences in plasma (p < 0.01) and urine CCL2 (p < 0.0001) levels between AKI and non-AKI patients in the ICU. Notably, urine CCL2 demonstrated promising predictive value for AKI, exhibiting high specificity and sensitivity (AUC = 0.8976; p < 0.0001). Furthermore, we observed higher urine CCL2 levels in SAKI compared to non-septic AKI (p < 0.001) and urine CCL2 could also differentiate SAKI from non-septic AKI (AUC = 0.7597; p < 0.0001). These results suggest that urine CCL2 levels hold promise as early biomarkers for AKI and SAKI, offering valuable insights for timely intervention and improved management of ICU patients.

Diastology in the intensive care unit: Challenges for the assessment and future directions.

Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.

Automated Process Mining and Learning of Therapeutic Actions in the Intensive Care Unit.

In this study, we implemented a hybrid approach, incorporating temporal data mining, machine learning, and process mining for modeling and predicting the course of treatment of Intensive Care Unit (ICU) patients. We used process mining algorithms to construct models of management of ICU patients. Then, we extracted the decision points from the mined models and used temporal data mining of the periods preceding the decision points to create temporal-pattern features. We trained classifiers to predict the next actions expected for each point. The methodology was evaluated on medical ICU data from the hypokalemia and hypoglycemia domains. The study's contributions include the representation of medical treatment trajectories of ICU patients using process models, and the integration of Temporal Data Mining and Machine Learning with Process Mining, to predict the next therapeutic actions in the ICU.

Effect of Music Therapy in Relieving the Symptom Experiences and Improving Outcomes of Critical Care Patients: A Systematic Review

BACKGROUND: The critical care patients often have unpleasant experiences while facing critical care activities that may impact on physiological and psychological changes. Music therapy is a simple complementary therapy that can promote relaxation, potentially affecting some outcomes for critical care patients. However, a systematic review related to the application of music therapy and the results obtained from music therapy is still limited. AIM: This systematic review aimed to explore and evaluate the effectiveness of music therapy interventions in relieving symptom experiences and improving outcomes of critical care patients. METHODS: We conducted a systematic review of research articles focused on music therapy in critical care areas using three electronic databases, namely PubMed, CINAHL, and Science Direct. We selected English articles that had a Randomized Control Trial (RCT) design and published from 2005 to 2020. PICO format used to search literature; “Adult, Critical Care, Intensive Care Unit (ICU), Critically Ill Patients, Intensive Care, Surgical ICU, Cardiac Surgical ICU, Medical-Surgical ICU, Therapy Music, Music Therapy, Pain, Agitation, Stress. Anxiety, Delirium, Mobility, Sleep, Physiological, and Psychological. The risk of bias from 19 articles was evaluated by JBI. Furthermore, we assessed the manner and effect of music therapy on various symptoms. RESULTS: The researchers found 743 articles. After manual review, 19 RCTs (1711 participants) were identified and assessed. Based on the review, it was reported that music with a relaxed rhythm, soft tone, slow rhythm; duration from 15 to 60 min; 60–80 beats/min, and using headphones, has a significant effect on pain, anxiety, stress, delirium, mobilization, sleep quality, sedation levels, and physiological parameters. CONCLUSION: Music therapy has proved effective in reducing symptoms experiences of critical care patients. It is suggested to be used as a viable option in symptoms management of patients in ICU.

Platelet transfusions and thrombocytopenia in intensive care units: Protocol for an international inception cohort study (PLOT‐ICU)

IntroductionThrombocytopenia is frequent in intensive care unit (ICU) patients and has been associated with worse outcome. Platelet transfusions are often used in the management of ICU patients with severe thrombocytopenia. However, the reported frequencies of thrombocytopenia and platelet transfusion practices in the ICU vary considerably. Therefore, we aim to provide contemporary epidemiological data on thrombocytopenia and platelet transfusion practices in the ICU.MethodsWe will conduct an international inception cohort, including at least 1000 acutely admitted adult ICU patients. Routinely available data will be collected at baseline (ICU admission), and daily during ICU stay up to a maximum of 90 days. The primary outcome will be the number of patients with thrombocytopenia (a recorded platelet count < 150 × 109/L) at baseline and/or during ICU stay. Secondary outcomes include mortality, days alive and out of hospital, days alive without life‐support, the number of patients with at least one bleeding episode, at least one thromboembolic event and at least one platelet transfusion in the ICU, the number of platelet transfusions and the indications for transfusion. The primary and secondary outcomes will be presented descriptively. In addition, we will assess risk factors for developing thrombocytopenia during ICU stay and the association between thrombocytopenia at baseline and 90‐day mortality using logistic regression analyses.ConclusionThe outlined international PLOT‐ICU cohort study will provide contemporary epidemiological data on the burden and clinical significance of thrombocytopenia in adult ICU patients and describe the current platelet transfusion practice.

Clinical Outcomes and Severity of Acute Respiratory Distress Syndrome in 1154 COVID-19 Patients: An Experience Multicenter Retrospective Cohort Study

Background: Acute Respiratory Distress Syndrome (ARDS) is caused by non-cardiogenic pulmonary edema and occurs in critically ill patients. It is one of the fatal complications observed among severe COVID-19 cases managed in intensive care units (ICU). Supportive lung-protective ventilation and prone positioning remain the mainstay interventions. Purpose: We describe the severity of ARDS, clinical outcomes, and management of ICU patients with laboratory-confirmed COVID-19 infection in multiple Saudi hospitals. Methods: A multicenter retrospective cohort study was conducted of critically ill patients who were admitted to the ICU with COVID-19 and developed ARDS. Results: During our study, 1154 patients experienced ARDS: 591 (51.2%) with severe, 415 (36.0%) with moderate, and 148 (12.8%) with mild ARDS. The mean sequential organ failure assessment (SOFA) score was significantly higher in severe ARDS with COVID-19 (6 ± 5, p = 0.006). Kaplan–Meier survival analysis showed COVID-19 patients with mild ARDS had a significantly higher survival rate compared to COVID-19 patients who experienced severe ARDS (p = 0.023). Conclusion: ARDS is a challenging condition complicating COVID-19 infection. It carries significant morbidity and results in elevated mortality. ARDS requires protective mechanical ventilation and other critical care supportive measures. The severity of ARDS is associated significantly with the rate of death among the patients.

Diagnostic Modalities in Critical Care: Point-of-Care Approach.

The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.

Clinical significance of Catheter-Associated Urinary Tract Infection (CAUTI) in Intensive Care Units: Three Year Experience at a Single Centre

Introduction: Catheter Acquired Urinary Tract Infection (CAUTI) is one of the most common Health Care Acquired Infections (HCAI); most of these infections are attributable to use of an indwelling urethral catheter. The aim of this study was to investigate patients with catheter-associated urinary tract infection over three years at a single hospital’s Intensive Care Unit (ICU) and to identify meaningful risk factors and causative organisms. &#x0D; Methods: A retrograde analysis was performed on patients with indwelling catheters in ICU of Armed Forces Medical College, Pune, India. CAUTI was defined as isolated bacterial growth of 100,000 colony-forming units or more either 48 hours after transfer to the ICU if a urinary catheter was placed before the transfer or 48 hours after insertion if the catheter was inserted in the ICU. Only the patients whose culture results were negative before ICU admission were included.&#x0D; Result: Among 350 samples collected in medical and surgical ICU, 38 patients (10.85%) had CAUTI. Using multivariate logistic regression analysis, the study showed that those with diabetes were 4.51 (p＜0.001) times likely to have occurrences of CAUTI than those without and also showed an increased incidence of CAUTI &gt; 1.19 fold (p＜0.01) among patient with longer duration of an indwelling catheter.&#x0D; Conclusions: CAUTI is a preventable HCAI and thus the risk factors and causative organisms contributing to its development in the management of ICU patients must be considered to prevent the occurrence of UTIs in this setting.

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?

Conservative oxygen supplementation versus usual oxygen supplementation among septic medical intensive care units patients: A before-after investigation.

Patients admitted in the intensive care unit (ICU) are always managed with excessive high fraction of inspired oxygen and have hyperoxia for a significant period of time, which has potential harms. The guidelines for the management of patients in ICUs do not provide the target values for partial pressure of oxygen or arterial oxyhemoglobin saturations. The study was a before-after investigation comparing two time periods in which different oxygenation strategies were applied. Data of oxygen control, outcome measures, and mortality of a total of 273 patients (>18 years) admitted at least for 2 days in ICUs and received treatment for the sepsis were retrospectively collected and analyzed. Patients were received usual oxygen supplementation (targeted partial pressure of oxygen: 150 mmHg; a high fraction of inspired oxygen: 0.4; UOS cohort; n = 142) or conservative oxygen supplementation (targeted partial pressure of oxygen: 70-100 mmHg; a high fraction of inspired oxygen as low as possible; COS cohort; n = 131). Mechanical ventilation-free hours were significantly higher for patients of COS cohort than those of UOS cohort (77.99 ± 21.26 h/patient vs 70.01 ± 23.57 h/patient, p = 0.016). ICUs length of stays of patients of COS cohort was fewer than those of UOS cohort (7.05 ± 2.13 days/patient vs 7.69 ± 2.43 days/patients, p = 0.016). The probability of survival of patients was higher among patients of COS cohort than those of UOS cohort (p = 0.049). A higher number of patients from UOS cohort needed vasopressors than those from COS cohort (55 vs 35, p = 0.039). Conservative oxygen supplementation to maintain partial pressure of oxygen was improved outcome measures and decreases mortality as compared to that of usual oxygen supplementation.Level of Evidence: III.Technical Efficacy Stage: 4.

Comparison of point-of-care device DiaSpect against the HemoCue and laboratory analyser in an ICU population

Background: Haemoglobin levels guide many diagnostic and therapeutic interventions. They form part of the basic daily management of ICU patients. Laboratory results are frequently delayed. This can have important clinical consequences, including withholding potentially life-saving interventions. Point-of-care devices, if accurate, provide a solution to this problem. Inaccurate devices may provide misleading results leading to unnecessary and hazardous blood transfusions or under-estimation of disease severity. The aim was to compare the accuracy and reliability of the DiaSpect Hemoglobin T (DiaSpect. Medical GmbH, Sailauf, Germany) haemoglobinometer with the HemoCue (HemoCue AB, Angelholm Sweden) haemoglobinometer and the gold standard laboratory analyser for this trial (XT-200i Sysmex/Coulter LH750). Methods: Venous blood samples were collected via a central venous line from Intensive Care Unit (ICU) patients (n = 265) for determination of haemoglobin (Hb) concentration by DiaSpect as well as the HemoCue, and the automated haemoglobin analysers: XT-200i Sysmex or the Coulter LH750. Agreement between the methods was tested using Bland–Altman plots. A Hb variation of 0.5 g/dl was considered clinically significant. There were a significant number of wasted samples with the DiaSpect, as a total of 350 cuvettes were used but only 214 complete samples obtained. This wastage was attributed to errors in sampling, cuvette shortage, lack of experience with the device and lack of ‘user-friendliness’. Results: A total of 265 samples were obtained, of which 207 had complete data sets and were analysed further in the study. There were 58 incomplete samples, of which 51 were DiaSpect samples. Mean haemoglobin was 9.11 (standard deviation ± 1.74), 9.07 (standard deviation ± 1.96) and 9.02 (standard deviation ± 2.06) using the laboratory analyser, HemoCue and DiaSpect respectively. Laboratory and HemoCue: the mean difference between the two readings was -0.04 (95% limits of agreement -2.15 to 2.07 g/dl) with an average between 5.00 g/dl and 15.10 g/dl. Laboratory and DiaSpect: the mean difference between the readings was -0.09 (95% limits of agreement -2.64 to 2.46 g/dl) with an average between 5.10 g/dl and 14.9 g/dl. HemoCue and DiaSpect: the mean difference between the two haemoglobin levels was 0.04 (95% limits of agreement 2.73 to -2.64 g/dl). Both methods returned measurements within the pre-defined clinical acceptable limits of ± 0.5 g/dl. Conclusion: The haemoglobin concentration assessment by the HemoCue and DiaSpect showed an acceptable limit of agreement when compared against the laboratory analyser. There were a significant number of wasted samples when using the DiaSpect.

COVID-19 severe pneumonia: Prospective multicentre study on demands on intensive care capacities.

The aim of the study was to obtain data on demands on the intensive care capacities to treat COVID-19 patients, and to identify predictors for in-hospital mortality. The prospective observational multicentre study carried out from 1 March till 30 June 2020 included adult patients with confirmed SARS-CoV-2 infection with respiratory failure requiring ventilatory support or high-flow nasal oxygen therapy (HFNO). Seventy-four patients, 46 males and 28 females, median age 67.5 (Q1-Q3: 56-75) years, were included. Sixty-four patients (86.5%) had comorbidity. Sixty-six patients (89.2%) were mechanically ventilated, four of them received extracorporeal membrane oxygenation therapy. Eight patients (10.8%) were treated with non-invasive ventilation and HFNO only. The median of intensive care unit (ICU) stay was 22.5 days. Eighteen patients (24.3%) needed continuous renal replacement therapy. Thirty patients (40.5%) died. Age and acute kidney injury were identified as independent predictors of in-hospital death, and chronic kidney disease showed trend towards statistical significance for poor outcome. Sufficient number of intensive care beds, organ support equipment and well-trained staff is a decisive factor in managing the COVID-19 epidemic. The study focused on the needs of intensive care in the COVID-19 patients. Advanced age and acute kidney injury were identified as independent predictors for in-hospital mortality. When compared to clinical course and ICU management of patients with severe community-acquired pneumonia caused by other pathogens, we observed prolonged need for ventilatory support, high rate of progression to acute respiratory distress syndrome and significant mortality in studied population.

Application, verification and correction from an elaborate checklist with some of the recommendations (“do and do not do”) of the SEMICYUC working groups

ObjectiveBased on some of the recommendations of the SEMICYUC working groups, we developed a checklist and applied it in two periods, analyzing their behavior as a tool for improving safety. DesignA comparative pre- and post-intervention longitudinal study was carried out. SettingThe Intensive Care Unit (ICU) of a 400-bed university hospital. PatientsRandom cases series in two periods separated by 6 months. InterventionsWe developed a checklist with 24 selected indicators that were randomly applied to 50 patients. Verification was conducted by a professional not related to care (prompter). We analyzed the results and compliance index and carried out corrective measures with training. With 6 months of preparation, we again applied the random checklist to 50 patients (post-intervention period) and compared the compliance indexes between the two timepoints. ResultsThere were no differences in demographic characteristics or evolution between the periods. The compliance index at baseline was 0.86±0.12 versus 0.91±0.52 in the post-intervention period (P=.023). An acceptable compliance index was obtained with the 24 indicators, though at baseline the compliance index was <0.85 for 5 recommendations. These detected non-compliances were worked upon through training in the second phase of the study. The post-intervention checklist evidenced improvement in compliance with the recommendations. ConclusionsThe checklist used to assess compliance with a selection of recommendations of the SEMICYUC applied and moderated by a prompter was seen to be a useful instrument allowing us to identify points for improvement in the management of ICU patients, increasing the quality and safety of care.

Intensive care and anesthetic management of patients with Brugada syndrome and COVID-19 infection.

Coronavirus disease 2019 (COVID‐19) spreads across the world, and the intensive care unit (ICU) community must prepare for the challenges associated with this pandemic viral infection. Rapid diagnosis, isolation, and intensive clinical management are very important for all patients with COVID‐19, especially for those with cardiac diseases as Brugada syndrome (BrS). BrS is an arrhythmogenic disease reported to be one among the leading causes of sudden cardiac death. In these patients, episodes of lethal arrhythmias may be induced by several factors or situations, and for this reason management during ICU permanence or anesthesia must provide some precautions, avoiding factors that are known to have the potential to worsen the probability to induce arrhythmias. For ICU practitioners, management of acute respiratory failure, hemodynamics, and cardiovascular complications certainly are the key for the best treatment of these patients but to date specific data on supportive ICU care for these patients are lacking, and current recommendations are based on existing evidence from other viral infections and general intensive care management. We want to focus on some general rules, resulted from cases series and clinical practice, to be followed during the ICU management of patients with BrS and concomitant COVID‐19 infection.

Understanding patients' experiences of being mechanically ventilated in the Intensive Care Unit: Findings from a meta-synthesis and meta-summary.

To synthesise the evidence reported in qualitative studies concerning the lived experiences of adult patients receiving mechanical ventilation in Intensive Care Unit (ICU). Critically ill patients receiving mechanical ventilation in the ICU have been reported to suffer from severe physical and emotional responses such as hopelessness, anxiety, high levels of frustration and stress. Recent improvements in the field of mechanical ventilation and sedative medications as experienced by patients that can inform nursing care have not been summarised to date. A systematic review of qualitative studies followed by a meta-synthesis and a meta-summary was performed. Four electronic databases were searched by two authors in June 2019. A total of nine studies were included and evaluated based on their methodological quality using the Critical Appraisal Skills Programme checklist. A total of 24 codes emerged from the abstraction process, which were categorised into 11 categories and four themes: (a) "The effect of the intense stress on the body's systems," (b) "The induced negative emotional situations," (c) "The feeling of being cared for in a hospital setting" and (d) "The perceived support from the family and loved ones." Furthermore, the most frequent codes across studies were "Being afraid," "Feeling supervised," "Feeling comforted," "Failing to communicate," and "Experiencing difficulties in breathing," with an intensity of 66.6%. Patients receiving mechanical ventilation have expressed a general sense of vulnerability, of which critical care nurses need to be aware. Findings suggest the need for improvements at the nursing, unit, educational and policy levels; furthermore, more research is also required at the international levels given the current trends towards no sedation protocols for the management of ICU patients: listening to their experiences becomes imperative, in order to ensure an awake, comfortable and ventilator-tolerant patient.

Nursing in a critical care hyperbaric unit at Merida, Yucatan, Mexico: report of a case of an acute pediatric burn patient

Hyperbaric oxygen therapy (HBOT) for intensive care unit (ICU) patients places special technical and knowledge-based skills demands on nurses inside hyperbaric chambers. Probably the best clinical contributions of HBOT are in the acute cases, in the ischemia reperfusion injury. Nevertheless in the last years, hyperbaric units have focused more in chronic wounds. The first golden rule to treat an ICU patient in a hyperbaric chamber is that you can maintain the same quality of care inside the chamber as in the ICU. This means that the hyperbaric unit has to have the technology means as well as the proficiency and competency of its personnel to provide intensive care inside the chamber. These require competent nursing personnel. We present a case of a 5-year-old pediatric patient who suffered a deep second-degree thermal burn that compromised 32% of the total body surface; including the face, neck, thorax and both arms. The patient received medical support, HBOT and daily wound care. He received a total of 14 treatments and underwent complete healing of the burned areas. The hospital stay was of 17 days, which is lower than expected for a severe burned patient (average of 27.5±1.2 days). He experienced neither secondary effects nor complications. The management of ICU patients inside the chamber requires an experienced and competent team of physicians and nurses. When instituted early, HBOT in the management of thermal burns, makes great impact in the pathophysiology, reduction of surgical procedures and hospital stay.

The Critical-Care Pain Observation Tool: A useful tool for pain assessment in intensive care units

Pain is a major concern in all intensive care units (ICUs). The proper assessment and management of pain is one of the main goals of patient care in ICUs. Improper evaluation of pain and its over or under treatment can cause significant problems in the process of patient management in ICU. Since most ICU patients are unable to communicate correctly with the ICU team and explain their level of pain, pain assessment can be challenging. Thus, several assessment tools for the evaluation of pain were developed, few of which were validated. Critical Care Pain Observation Tool is a valid and reliable instrument for pain assessment in different ICUs.

Diagnostic yield and therapeutic impact of open lung biopsy in the critically ill patient.

BackgroundOpen lung biopsy (OLB) is a rare procedure in intensive care units (ICUs) for therapeutic management of acute respiratory failure (ARF). The purpose of this study was to analyze the diagnostic yield, therapeutic contribution and complications of OLB in ICU patients with ARF of unclear etiology, including acute respiratory distress syndrome (ARDS) and ARDS mimics.MethodsRetrospective study conducted in a 10-bed ICU over a 13-year period. Patients undergoing OLB for ARF with undiagnosed infiltrates on CT scan were included. ARDS was defined according to Berlin criteria, and ARDS mimics as a condition looking like ARDS except for the presence of a known cause. OLB was contributive when the OLB findings yielded a specific diagnosis resulting in a change in the patients’ treatment or management.ResultsForty six patients were included (sex ratio = 2.5, median and [interquartile range] age = 69 [59–77] years, and admission SAPS II = 42 [33–50]. ARF corresponded to ARDS in 22 patients and to ARDS mimics in 16. OLB yielded 61 diagnoses in 45 patients including diffuse alveolar damage (N = 21), lung fibrosis (N = 18), and organizing pneumonia (N = 11). OLB was contributive in 37 patients (80%), including 13/16 ARDS mimickers. The main contributions of OLB were the introduction or maintenance of steroids (N = 32) and discontinuation of antibiotics (N = 9). In 4 patients OLB resulted directly in the decision to forgo life-sustaining treatment. OLB complications occurred in 16 patients (35%), in one case associated with fatal outcome.ConclusionOLB can play a useful role in the management of ICU patients with ARF of undetermined origin, including ARDS mimickers. Further studies should be done to identify the groups of ICU patients likely to benefit from the procedure with minimum risk.

Clinical Utility of a Structured Program to Reduce the Risk of Health-Related Quality of Life Impairment after Discharge from Intensive Care Unit: A Real-World Experience.

Background Postdischarge deterioration in health-related quality of life (HRQoL) is a major clinical issue for patients after an intensive care unit (ICU) hospitalization. A significant proportion of these patients is known to develop a progressive worsening of mental and physical performance—the so-called post-intensive care syndrome (PICS). Aim We aimed at exploring the effects of a structured program for the management of ICU patients, aimed at improving postdischarge HRQoL and reducing the risk of PICS. Methods A total of 159 patients hospitalized in our ICU with a length of stay >72 hours were enrolled in an institutional management protocol including specific recommendations: adequate sedation and analgesia protocols, to ensure a valid delirium prevention strategy, and to provide a planned midterm after discharge. The main endpoint was the occurrence of PICS at the 6-month follow-up visitation, defined as an abnormal physical or mental score in the SF-12 questionnaire in the presence of clinical evidence of new or worsening impairment in physical, cognitive, or mental health status. An additional questionnaire was administered, to assess the effects of ICU-related memories. Results Most patients positively rated their health at the 6-month follow-up and had no significant impairment in physical or mental health status. The mean normalized values of the physical and mental component of the SF-12 score were 46 ± 11 and 48 ± 14, suggesting a normal physical and mental health status in most patients. Twenty-nine patients (18.2%) showed evidence of PICS. Similar good results were found by the questionnaire of memories. In multivariable analysis, no variable was found to predict the risk of PICS in our population. Conclusion In this real-world analysis that lacks a control group, patients who used a program aimed at minimizing the risk of HRQoL deterioration and PICS reported a good perception of their state of health with a relatively low prevalence of PICS.

Implementation of Continuous Video-Electroencephalography at a Community Hospital Enhances Care and Reduces Costs.

Despite data indicating the importance of continuous video-electroencephalography (cvEEG) monitoring, adoption has been slow outside major academic centers. Barriers to adoption include the need for technologists, equipment, and cvEEG readers. Advancements in lower-cost lead placement templates and commercial systems with remote review may reduce barriers to allow community centers to implement cvEEG. Here, we report our experience, lessons learned, and financial impact of implementing a community hospital cvEEG-monitoring program. We implemented an adult cvEEG service at Duke Regional Hospital (DRH), a community hospital affiliate, in June of 2012. Lead placement templates were used in the implementation to reduce the impact on technologists by using other bedside providers for EEG initiation. Utilization of the service, study quality, and patient outcomes were tracked over a 3-year period following initiation of service. Service was implemented at essentially no cost. Utilization varied from a number of factors: intensive care unit (ICU) attending awareness, limited willingness of bedside providers to perform lead placement, and variation in practice of the consulting neurologists. A total of 92 studies were performed on 88 patients in the first 3years of the program, 24 in year one, 27 in year two, and 38 in year three, showing progressive adoption. Seizures were seen in 25 patients (27%), 19 were in status, of which 18 were successfully treated. Transfers to the main hospital, Duke University Medical Center, were prevented for 53 patients, producing an estimated cost savings of $145,750. The retained patients produced a direct contribution margin of about $75,000, and the margin was just over $100,000 for the entire monitored cohort. ICU cvEEG service is feasible and practical to implement at the community hospital level. Service was initiated at little to no cost and clearly enhanced care, increased breadth of care, increased ICU census, and reduced transfers. The system allowed for successful management of ICU patients with underlying seizures and eliminated interfacility transfers, producing a savings of $145,750. The savings combined with the retained patient revenue produced a total revenue of over $250,000 with additional revenue in professional services as well. These results suggest expansion of cvEEG monitoring to community ICUs is practical, financially sustainable, improves the level and quality of care, and reduces costs.