Medical Intensive Care Unit Research Articles

Gut colonization with vancomycin-resistant Enterococcus shapes the gut microbiome in the intensive care unit.

Gut pathogen colonization with Vancomycin-resistant Enterococcus (VRE) is common in the intensive care unit (ICU) and is associated with worse clinical outcomes, yet the timing of VRE colonization and its collateral effects on the gut microbiome are incompletely understood. Medical ICU patients admitted with sepsis and receiving broad-spectrum antibiotics were sampled via deep rectal swabs at ICU admission and on ICU Day 3, 7, 14, and 30. Rectal swabs were cultured for VRE on selective media and analyzed via 16S rRNA gene sequencing. Ninety patients were sampled (340 longitudinal swabs). VRE positivity rose from 20% at ICU admission to a peak of 33% by ICU Day 14 and then modestly declined to 31% by ICU Day 30. Paralleling this, alpha diversity fell while Enterococcus relative abundance rose through ICU Day 14 with both returning to baseline by ICU Day 30. The median relative abundance of Enterococcus was 38% (IQR 7.4 to 75%) for VRE positive samples compared to 0.01% (IQR 0 to 19%) for VRE negative samples (rank-sum p<0.01); 38 samples had ≥90% Enterococcus and 8 samples were 100% Enterococcus by sequencing. VRE was associated with lower alpha diversity (median Shannon index of 1.90 (IQR 0.89 to 2.66) if VRE positive versus 2.64 (IQR 1.58 to 3.22) if VRE negative, p<0.01). VRE gut colonization peaked at ICU Day 14 followed by a modest decline and was associated with low alpha diversity. Improved understanding of dynamic changes in the gut microbiome may facilitate successful future ICU interventions.

Efficacy of adjuvant use of midodrine in patients with septic shock: An open label randomized controlled trial.

Midodrine has been primarily studied as an adjunctive oral therapy to reduce the need for vasopressors in intensive care units (ICU). Nonetheless, the available results evaluating midodrine as an adjuvant therapy in the treatment of septic shock are limited and inconclusive. This study aims to evaluate the efficacy of midodrine, specifically focusing on its effect on mortality outcomes in patients with septic shock. This was an open-label randomized controlled trial. Patients with septic shock (n = 100) were randomized to either the control group, who received intravenous norepinephrine, or the midodrine group, who received intravenous norepinephrine and midodrine 10 mg every 8 h. The primary outcome was the 28-day in-hospital mortality. Secondary outcomes were 7-day ICU mortality, average dose of norepinephrine, duration of intravenous norepinephrine, ICU length of stay (LOS), and in-hospital LOS. The 28-day mortality rate was 68% in the control group compared to 54% in the midodrine group (risk difference -14% (95% confidence interval (CI)) -32.9% to 4.9%). Similarly, the 7-day ICU mortality rate was 56% in the control group and 42% in the midodrine group (risk difference -14% (95% CI -33.4% to 5.4%)). The average intravenous norepinephrine dose in the midodrine group was significantly lower compared to the control group (mean difference 0.06 (95% CI 0.01-0.11), p = 0.002). However, midodrine did not have a significant impact on the duration of intravenous norepinephrine use (mean difference 0.66 (95% CI -0.56 to 1.88)). Midodrine did not significantly shorten the course of hospitalization. There was no significant difference in median ICU LOS between the control group and the midodrine group (4 vs. 5 days, respectively). The findings did not demonstrate a significant reduction in mortality with adjuvant midodrine use in the treatment of septic shock. Midodrine appears to reduce the need for vasopressors. However, our findings did not support that midodrine shortens the duration of vasopressor use nor the course of hospitalization for patients with septic shock.

Postextubation dysphagia in intensive care unit : Epidemiology, clinical course, and management

Postextubation dysphagia (PED) is common in intensive care units (ICU), affecting about 20% of patients of mixed medical surgical ICU populations. PED is an independent risk factor for increased 28-day and 90-day mortality in both neurological and nonneurological ICU patients (28-day mortality: plus 9%). The increased mortacity risk can be demonstrated for up to approximately one year after the ICU stay. Due to the consequences of PED, all ICU patients should undergo systematic dysphagia screening after extubation/decannulation (e.g., water swallow test) and fiberoptic endoscopic evaluation of the swallowing (FEES) to confirm the diagnosis. Treatment is interdisciplinary with nutrition adaptation/nutrition introduction or food restriction, physical/speech therapy and, if necessary, interventional procedures in the future.

Accuracy of Intensivist Prognostications of within-ICU Deterioration and Development of Persistent Critical Illness: A Prospective Cohort Study.

Persistent critical illness (PerCI) is costly, rising in incidence, and not reliably predicted with existing risk-prediction tools. To assess whether attending intensivists can identify patients at heightened risk of developing PerCI. We conducted a prospective longitudinal assessment from August 2020 to January 2023. Intensivists were assessed on each patient within 24 hours of admission to the medical intensive care unit (ICU) and on ICU day three. We measured intensivists' prognostication of within-ICU events (late-onset shock and/or acute hypoxic respiratory failure [AHRF] and PerCI) and self-rated confidence in prognostications. Test characteristics were calculated for both outcomes, at each timepoint, and stratified by self-rated confidence. 1,295 assessments were completed (response rate: 87.9%), assessing 875 ICU admissions by 18 intensivists. Late-onset shock/AHRF and PerCI occurred in 7.3% and 16.0% of ICU admissions, respectively. C-statistics for intensivist prognostication of late-onset shock/AHRF were 0.5 (95%CI:0.5-0.6) and 0.6 (95%CI:0.5-0.6) on admission and day three, respectively. C-statistics for PerCI were 0.7 (95%CI:0.7-0.7) and 0.7 (95%CI:0.7-0.8), respectively. C-statistics for late-onset shock/AHRF were no different for confident vs unconfident assessments. C-statistics for PerCI were higher for confident vs unconfident assessments (0.8 vs 0.6, p<0.01) on admission, but not different on day three (0.7 vs 0.7, p=0.20). Intensivist prognostications have poor discriminatory accuracy for the development of late-onset shock/AHRF and moderate accuracy for development of PerCI. Further research is needed to understand what factors influence intensivists' prognostications of within-ICU deterioration and how this information is conveyed to patients and families.

Descriptive Analysis of the Relationship Between Continuous Intravenous Insulin Infusion and Triglyceride Levels in Critically Ill Patients Receiving Propofol Infusion

Background/Objectives: Propofol is a preferred agent for ICU sedation. Hypertriglyceridemia occurs in up to 45% of patients on propofol and has been linked with adverse effects. Data extrapolated from acute pancreatitis suggests intravenous (IV) insulin infusions may be effective in reducing serum triglyceride (TG) values in patients with propofol-induced elevated TG. The objective is to describe and compare serum TG levels in critically ill patients receiving concomitant insulin infusions and propofol versus propofol alone. Methods: This is a retrospective cohort study of mechanically ventilated adult patients admitted to a medical intensive care unit who received a propofol infusion alone or propofol and IV insulin infusions and who had a minimum of two serum TG levels while on propofol infusion. The primary outcome was median change in the serum TG concentration in patients receiving concomitant propofol and IV insulin infusions, as compared to those receiving propofol alone. Results: A total of 263 patients were screened and 32 met inclusion criteria (16 in each group). The median change between first and last obtained TG level was 0.35 (−0.31–1.33) vs. −0.07 (−1.08–+0.42) mmol/L (p = 0.051) in the propofol vs. propofol and IV insulin groups, respectively. Each day on propofol was associated with an estimated 0.21 mmol/L (95% confidence interval (CI) 0.0.004 to 0.41, p = 0.046) increase in TG, and each additional day of IV insulin was associated with a 0.14 mmol/L (95% CI −0.63 to 0.35, p = 0.571) decrease in TG. Conclusions: Each additional day of propofol was associated with an increase in serum TG levels. IV insulin infusions did not lead to a significant difference in triglyceride values.

Leptin and Iinterlukin-6 relationship and influence of mortality in sepsis

BackgroundSepsis is a severe and life-threatening disease involving multiple risk factors. Leptin has been suggested to play a role in modulating the inflammatory response in sepsis and improving outcomes; however, there are conflicting results regarding the outcome of sepsis. The present study aims to clarify the expression of leptin in patients with sepsis, and its association with other cytokines.MethodThe retrospective study enrolled 165 adults with sepsis from medical intensive care units (ICU)s, and collected leptin, glucose levels, and cytokines such as IL-6, IL-1RA, IL-10, IL-17, TNF-α, IFN-γfor analysis. Leptin levels were divided into three groups based on concentration: Low (≤ 3.78 ng/mL), Medium (3.78 < leptin ≤ 23.2 ng/mL), and High (> 23.2 ng/mL). Survival curve analysis and comparisons among groups were performed. A subgroup analysis by sex (male and female) was also conducted. Finally, a multiple-factor logistic regression model was used to evaluate the interaction between leptin and other factors.ResultThe high leptin groups were the oldest (low vs. medium vs. high: 60 vs. 66 vs. 78, p < 0.0001) and had the highest body mass index (BMI) (19.8 vs. 23.9 vs. 24.2, p < 0.0001), the highest percentages of women (28.6 vs. 34.1 vs. 65.9 p = 0.001), and the most comorbidities (1 vs. 1 vs. 2, p = 0.001). After controlling IL-6, day 1 leptin had a trend associated with lower mortality in the hospital (β = 0.984, p = 0.062). The highest IL-6 group had a significantly higher mortality rate among three IL-6 level patients (p = 0.015), but in the high leptin subgroup analysis, the significant effect of high IL-6 on mortality disappeared. Besides, the subgroup analysis of men, the high leptin group had a trend of better survival than the medium and low leptin groups.ConclusionHigh leptin levels may mitigate the adverse prognostic impact of elevated IL-6 on septic mortality. At comparable IL-6 levels, leptin could serve as a predictor of septic outcomes. Leptin might act as a protective factor in men. Future research should explore leptin’s role in IL-6-mediated inflammation and its potential protective effect in high IL-6 sepsis cases.

Dissecting causal relationships between gut microbiota, inflammatory factors, and acute kidney injury: A Mendelian randomization study.

Acute kidney injury (AKI) is common in critically ill patients in the medical intensive care unit (ICU), and it is associated with increased morbidity and mortality. Recent studies suggest a significant link between AKI and disturbances in the gut microbiota (GM). We used summary genome-wide association studies (GWAS) data from MiBioGen for GM and AKI data from the FinnGen cohort. Causal relationships were primarily assessed using the inverse variance weighted (IVW) method, with MR-PRESSO and MR-Egger tests to address potential horizontal pleiotropy. Heterogeneity was evaluated using Cochran's Q and I2 values. The IVW method revealed a causal association between 14 gut microbial taxa and AKI. The Phylum Firmicutes (id. 1672), Order Pasteurellales (id. 3688), Genus unknowngenus (id. 2071), Genus RuminococcaceaeUCG010 (id. 11367), Genus RuminococcaceaeUCG005 (id. 11363), Genus Haemophilus (id. 3698), Genus Flavonifractor (id. 2059), Genus ErysipelotrichaceaeUCG003 (id. 11384), Genus Dialister (id. 2183), Genus Coprococcus2 (id. 11302), and Family Pasteurellaceae (id. 3689) were negatively associated with AKI risk. Conversely, Genus Victivallis (id. 2256), Genus RuminococcaceaeUCG013 (id. 11370), and Genus Erysipelatoclostridium (id. 11381) were positively associated with AKI risk. Additionally, hepatocyte growth factor (HGF), interleukin-10 (IL-10), fibroblast growth factor-23 (FGF-23), and tumor necrosis factor alpha (TNF-α) were potentially causative in AKI onset. This study emphasizes the significant role of gut microbiota interactions with inflammatory factors in AKI pathogenesis. The identified risk factors underscore their essential role in both the onset and progression of AKI.

Effects of Implementing an ICU Discharge Readiness Checklist on Patient Safety Culture: A Quasi-Experimental Research Study.

Background: Discharging patients from intensive care units (ICUs) poses significant risks for adverse events (AEs), contributing to hospital morbidity and mortality. To mitigate premature transitioning, an ICU discharge readiness checklist (ICU-DRC) was developed. Enhanced patient safety culture (PSC) is crucial for reducing AEs and improving outcomes. Given the pressing need to enhance PSC in ICUs, this study evaluates the impact of ICU-DRC implementation on PSC, aiming to address a critical gap in quality improvement. Methods: A prospective quasi-experimental study assessed PSC before and after a year-long ICU-DRC intervention at Merkur Clinical Hospital in Zagreb, Croatia. Healthcare providers from two distinct ICUs participated voluntarily in the Hospital Survey on Patient Safety Culture. The surgical ICU, where the intervention was applied, employed 106 providers, while the medical ICU, which did not implement the intervention, had 42 providers. Results: Initial response rates were 58% for the intervention group and 45% for the control group, with post-intervention rates of 53% and 48%, respectively. The ICU-DRC was utilized with a fidelity of 65.7%. Due to the non-normal distribution found for most variables, non-parametric analytical procedures were applied. In baseline measurements, the control group outperformed the intervention group in three out of fourteen PSC dimensions. Post-intervention, PSC scores in the intervention group significantly improved in one dimension, whereas three dimensions in the control group showed significant declines, resulting in superior PSC outcomes for four dimensions in the intervention group during the second measurement. Conclusions: Applying the ICU-DRC as an isolated safety intervention aimed at optimizing ICU patient throughput resulted in observable patterns of improvement in several PSC dimensions, with statistically significant changes in specific areas.

The Impact of Intraoperative Respiratory Patterns on Morbidity and Mortality in Patients with COPD Undergoing Elective Surgery.

Background/Objectives: Surgical procedures in chronic obstructive pulmonary disease (COPD) patients carry a high risk of postoperative respiratory failure, often causing the need for mechanical ventilation and prolonged intensive care unit (ICU) stays. Accompanying COPD with heart failure further increases the risk of complications. This study aimed to identify predictors of mortality, prolonged ICU and hospital stays, the need for mechanical ventilation, and vasoactive drug usage in ICU patients with moderate to severe COPD undergoing elective non-cardiac surgery. Methods: This retrospective cohort study analyzed eICU-CRD data, including adult patients with moderate to severe COPD admitted to the ICU from the operating room following elective non-cardiac surgery. Spearman's correlation analysis was performed to assess associations between intraoperative ventilation parameters and ICU/hospital length of stay, postoperative laboratory parameters, and their perioperative dynamics. Results: This study included 680 patients (21% with severe COPD). Hospital and ICU mortality were 8.6% and 4.4%, respectively. Median ICU and hospital stays were 1.9 and 6.6 days, respectively. Intraoperative tidal volume, expired minute ventilation, positive end-expiratory pressure, mean airway pressure, peak inspiratory pressure, and compliance had no statistically significant association with mortality, postoperative mechanical ventilation, its duration, or the use of vasopressors/inotropes. Tidal volume correlated positively with changes in monocyte count (R = 0.611; p = 0.016), postoperative lymphocytes (R = 0.327; p = 0.017), and neutrophil count (R = 0.332; p = 0.02). Plateau pressure showed a strong positive association with the neutrophil-to-lymphocyte ratio (R = 0.708; p = 0.001). Conclusions: Intraoperative ventilation modes and parameters in COPD patients appear to have no significant impact on the outcomes or laboratory markers, except possibly for the neutrophil-to-lymphocyte ratio, although its elevation cause remains unclear.

Prevalence of bacterial resistance in critically ill patients with neutropenic fever at National Cancer Institute of Egypt

BackgroundFebrile neutropenia (FN) is a life-threatening complication in cancer patients that include serious infections with different microorganisms. Unfortunately, resistant pathogens rapidly progressed over the last two decades with a direct impact on survival and health of FN patients. we tried to study the prevalence of bacterial resistance at different infection sites in these patients.Patients and methodsThis was a retrospective observational cohort study to assess prevalence of bacterial resistance in 1257 patients with neutropenic fever and positive cultures from different sites of infections, admitted to the Medical Oncology intensive care unit (ICU) at national cancer institute (NCI), Egypt, from May 2021 to May 2023.ResultsOne thousand two hundred fifty-seven patients were included, total number of detected organisms was 2221, 1895 were bacterial organisms, most of these isolates were extensively drug-resistant (XDR) gram-negative (57.9%) followed by methicillin resistant coagulase negative staphylococci MR_CONS (18.6%) and multidrug resistant (MDR) gram-negative (14.9%), with emergence of pan-drug resistant (PDR) gram-negative bacteria (2.4%).ConclusionResistant bacteria are now predominant in patients with neutropenic fever especially with gram-negative bacteria being commonly XDR with an emergence of PDR organisms.

ABO blood group and COVID-19 severity: Associations with endothelial and adipocyte activation in critically ill patients.

ABO blood group has been implicated both in susceptibility to, and severity of, SARS-CoV-2 infection. The aim of this study was to explore a potential association between ABO blood group and severity of COVID-19 infection in critically ill patients and the following biological mechanisms: inflammatory cytokines, endothelial injury, and adipokines. We conducted a retrospective study of 128 critically ill COVID-19 patients admitted to Vancouver General Hospital from March 2020-March 2021. Outcomes including 28-day mortality, need for mechanical ventilation and length of intensive care unit (ICU) stay were compared between patients with A & AB blood type vs. B & O blood type. Likewise, serum inflammatory markers, markers of endothelial activation, and adipokines were compared. The association between ABO and severity of disease was confirmed. Patients with A&AB blood group had more frequent ventilation requirements compared to patients with blood group B&O (N(%): 35 (71%) vs 41 (52%), p = 0.041), higher total ICU mortality (14 (29%) vs 9 (11%), p = 0.018), longer median ICU stay (days, median [interquartile range]: 10 [6-19], vs 7 [3-14], p = 0.016) and longer median hospital stay (26 [14-36] vs. 17 [10-30] p = 0.034). No association was found between ABO blood group and serum inflammatory cytokines or their receptors [IL-6, IL-1b, IL-10, TNF, sIL-6R, sgp130] measured within the first 10 days of ICU stay. No association was found between ABO and plasma markers of endothelial injury [Thrombomodulin, ADAMTS13, sP-Selectin, Factor IX, Protein C, Protein S, vWF]. Among the plasma adipokines, there were no differences between lipocalin-2, PAI-1 or resistin. Notably, however, median adipsin was higher in patients with A&AB blood group compared to O&B (16.3 [4.2-38.5] x106 pg/mL vs. 9.61 [3.0-20.8] x 106 pg/mL, p = 0.048). This retrospective single-center study confirms an association between A and AB blood type with more severe COVID-19. While an underlying mechanism was not identified, the finding of higher adipsin levels in patients with type A/AB blood warrants further investigation in larger prospective studies.

Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal in the Medical Intensive Care Unit (ICU): A Retrospective Cohort Study

Background: Phenobarbital (PHB) is a safe and efficacious alternative to benzodiazepines (BZD) for treating severe alcohol withdrawal (AWS). However, the safety of utilizing PHB for patients initially treated with BZD is unknown. Objective: To evaluate the safety and efficacy of PBH compared to BZDs in severe AWS in the medical intensive care unit (ICU). Methods: This was a retrospective cohort study comparing critically ill patients admitted for AWS who received BZDs or PHB. The primary outcome was time to persistent resolution of altered mentation. Secondary outcomes included development and duration of delirium, need for mechanical ventilation, development of withdrawal seizures, and ICU and hospital length of stay. Results: Ninety-five patients were evaluated (53 in PHB group, 42 in BZD group). Before study medication, less BZD patients demonstrated abnormal mentation compared with PHB patients (RASS < -2: 2.39% vsvs. 28.12%, respectively, and RASS > +2: 9.9% vsvs. 48.76%; P <0.001 for both). No difference was seen between groups for the primary outcome (1.8 hours for BZD cohort vsvs. 13.81 hours for PHB cohort; P =0.22). More patients in the BZD cohort developed a seizure after study medication administration (5.67% vs 0%, respectively; P =0.02). No significant difference was seen in other secondary outcomes. Conclusions: This study provides support for use of PHB after BZD if patients remain in uncontrolled withdrawal. Despite significant doses of BZDs before PHB, patients in the PHB cohort demonstrated similar clinical and safety outcomes compared to BZD alone.

Prevention and Sustained Reduction of Health Care-Associated Infections in a Medical Intensive Care Unit.

Prevention and Sustained Reduction of Health Care-Associated Infections in a Medical Intensive Care Unit.

621 Efforts Used to Increase Nursing Barcode Scan Rates on a Burn Unit

Abstract Introduction Medication administration errors pose significant risks to patient safety, particularly in high-acuity settings such as burn units. Barcode medication administration (BCMA) systems are designed to reduce such errors. According to DeYoung (2009), medication-related errors decreased by 56% in a medical intensive care unit once a BCMA system was utilized robustly. Unfortunately, nursing compliance with scanning protocols can be inconsistent. Increasing barcode scan rates is critical to ensuring patient safety and improving outcomes. In this project, the goal is for each nurse to achieve a scan rate of both the patient wristband and the medication label 95% of the time or more. Moving forward, “met goal” in this project refers to nursing staff achieving this percentage. This project aims to evaluate the effectiveness of targeted interventions designed to increase the barcode scan rate to meet the stated goal by comparing scan rates before and after the implementation of the interventions. This unit was identified to have low BCMA compliance in the months leading up to this project (January, February, and March 2024) with only 58%, 33%, and 50%, respectively, of nursing staff meeting goal. Methods In this quality improvement project, a mixed-methods approach was employed throughout an eight month period (April through December of 2024) on a burn unit. Interventions included staff education on BCMA importance via huddles, posting individuals’ BCMA rates publicly, and the revision of workflows to address barriers, such as the implementation of smartphones with access to the electronic health records and scanning capabilities. Pre- and post-intervention data on scan rates were collected through the electronic health record. Results The final analysis will include results from April 2024 to December 2024. Efforts to increase scanning compliance were implemented starting in April 2024. The percentage of staff that met goal in April and May are 52% and 48% respectively. The existing data from June, July, August, and September 2024 shows a modest improvement in staff meeting goal to 67%, 68%, 67%, and 83% respectively. Conclusions This project could demonstrate the efficacy of education via huddles, posting medication scan rates, and the implementation of smartphones as tools to increase nurse compliance with barcode scanning on a burn unit. Continuous BCMA monitoring and support for nurses, along with addressing technological limitations, are essential to sustaining high compliance and ensuring optimal patient safety. Applicability of Research to Practice In the current healthcare system where safety is the top priority, these initiatives could assist nurses in increasing BCMA compliance and preventing errors. Funding for the Study N/A

574 How Long Do We Have?: A Retrospective Review of Palliative Extubation in the Burn Unit

Abstract Introduction Palliative extubation (PE) is the termination of mechanical ventilation as a comfort measure for imminently dying patients. Anticipating a patient’s survival time after palliative extubation is an important part of counseling patient families and can facilitate individualized palliative care and organ donation processes. While this has been studied within neurological, pediatric, surgical, and medical intensive care unit (ICU) populations, this has not been explored in burns. Prior studies have associated shorter life expectancy in patients with higher vasopressor requirements, elevated ventilator requirements, APACHE II scores, and presence of comorbid illnesses such as diabetes. This study was performed to identify factors associated with death within one hour of palliative extubation within our adult burn unit population. Methods This is a retrospective cohort study. Adult patients admitted to our burn unit who underwent PE from 7/10/2015 to 6/30/2023 were identified in our institution’s burn registry. Patients who died prior to extubation were excluded. Demographics, comorbidities, injuries, and clinical parameters were collected. Variables with a p-value ≤ 0.1 in univariate analysis as well as age, sex, and TBSA (%) were included in multivariate models. Binary logistic regression was conducted using the forward Wald approach. P&amp;lt; 0.05 was considered significant. Results A total of 47 patients underwent PE within the study period. Of these, 25 (53.2%) died within 60 minutes of PE. There were no significant differences in age, gender, total body surface area burned, or presence of inhalation injury. In univariate analysis, higher vasopressor requirements, higher SOFA score, larger anion gap, higher phosphorus, higher lactic acid level, lower mean arterial pressure, acidosis, and the absence of a history of cerebrovascular disease were associated with death less than 60 minutes after PE with p ≤ 0.01. Bivariate logistic regression demonstrated that higher SOFA scores (OR = 2.851 [95% CI 1.173-6.931]) and anion gaps (OR = 1.687 [95% CI 1.014-2.806]) were associated with death within 60 minutes of PE. Conclusions Higher SOFA score and anion gap were associated with death within 60 minutes after PE. This aligns with prior literature correlating time to death with illness severity scales. While some uncertainty will always be present when predicting time to death after PE, our study provides a guide to be used in family discussions. Applicability of Research to Practice Patients with higher SOFA scores and anion gaps may be more likely to die earlier following PE. Further studies are warranted to evaluate the predictive value of these variables. Funding for the Study N/A

0.9% sodium chloride versus ringer's lactate in the management of severe diabetic ketoacidosis: A randomized trial.

0.9% sodium chloride versus ringer's lactate in the management of severe diabetic ketoacidosis: A randomized trial.

981 PI Project: Reduction of Hospital-Acquired Infection Transference Through Optimization of Ultraviolet-C System Placement in BICU

Abstract Introduction Hospital-acquired infections (HAIs) are a major concern in the healthcare field. In the Burn Intensive Care Unit (BICU), patient’s infection is a leading cause of morbidity and mortality in burn patients. Additionally, HAI transference from patient-to-patient in the BICU is a well documented occurrence. In this process improvement (PI) project, ultraviolet-C (UVC) systems were implemented and assessed, leading to a change in terminal cleaning policy and optimization of disinfection. It is hypothesized that this optimization of UVC system placement in terminal cleaning led to a decrease in patient-to-patient HAI transference. Methods A framework was developed to standardize and optimize the placement of the UVC systems in the BICU. Shape and size of BICU rooms were the main considerations in determining the placements of the UVC systems such that BICU rooms would get complete and adequate dosage of UVC. Efficacy of this framework was measured by tracking the incidence of suspected cross-contamination HAIs before and after implementation. Results Development of optimal marking placements for UVC systems in the BICU led to optimized decontamination in the terminal cleaning of the rooms. After implementation of the standardized terminal cleaning policy, suspected HAIs from cross-contamination in the BICU decreased from 3 cases the previous year to 0 the following year. Conclusions Standardizing UVC system placement ensures complete coverage and proper UVC disinfection of the BICU rooms as well as decreasing the incidence of potential environmental cross-contamination, transference, and HAIs. Complete and proper UVC decontamination of any hospital room is important and should be ascertained, especially in medical surgical ICUs and other units where infection transference risk is high. Applicability of Research to Practice Standardizing the placement of decontamination systems to optimize cleaning may help reduce cross-contamination in BICU rooms. Funding for the Study N/A

Exploring Peripheral and Respiratory Muscle Weakness and Functional Impairments in ICU Patients: Insights From a Resource-Constrained Setting.

The aim of this study was to explore peripheral and respiratory muscle structure and strength from unit admission to hospital discharge among ICU patients in a resource-constrained setting. Prospective, observational study. Tertiary academic hospital. Newly intubated critically ill adults admitted to the medical and surgical ICUs and expected to be mechanically ventilated for more than 48 hours were included in the study. Ultrasonography of the right hemi-diaphragm and quadriceps muscles were taken at admission for 3 consecutive days. Respiratory and peripheral muscle strength were evaluated using the Medical Research Council-Sum Score, dynamometry and maximal inspiratory pressure (MIP) at awakening, ICU discharge and hospital discharge. Forty-five participants were included, with a median (interquartile range) age of 34.5 (24.3-47.4) years and 73% were male. Most of the change in diaphragm thickness was observed on day 3, with 5 (22%) participants showing a decrease of more than 10% from baseline. Minimal changes in rectus femoris cross-sectional area were noted during the first 3 days. Eleven participants (44%) presented with ICU-acquired weakness at awakening, which decreased to 7 (29%) participants at ICU discharge and 5 (24%) participants at hospital discharge. The mean ± sd percentage of predicted quadriceps force was 22.2 ± 5.1 N at hospital discharge. The mean ± sd percentage of predicted MIP scores was 29.6% ± 10.5% at ICU discharge and 29.1% ± 8.6% at hospital discharge. Patients discharged from the ICU in a resource-constrained setting presented with peripheral and respiratory muscle weakness, with minimal change in muscle structure shown by ultrasonography, despite short ICU stays, low Acute Physiology and Chronic Health Evaluation II scores, and a relatively young age. Future research should explore whether these findings indicate a distinct phenotype of critical illness in such environments.

Impact of a Sleep-Promoting Schedule on Sleep Quality in the Intensive Care Unit.

Hospitalized patients often experience sleep disruption that fragments their sleep and disturbs their circadian rhythms, putting them at risk for sleep deprivation. The risk increases with greater severity of illness and is especially high in intensive care unit patients. Sleep deprivation can prolong the intensive care unit stay, contribute to emotional and physiological distress, and even increase the patient's risk of death. Critical care nurses in a 28-bed medical intensive care unit reported that patients often complained of sleep disruption or exhibited emotional and physical distress resulting from sleep deprivation. An analysis of the gap between recommended evidence-based best practice and current practices in the unit revealed numerous opportunities to improve patients' sleep. The aim of this evidence-based quality improvement project was to increase interprofessional adherence to an existing sleep-promoting schedule to reduce avoidable interruptions and improve patient sleep quality. To promote sleep, staff member interactions with patients between midnight and 4 am were minimized, if appropriate. Documented patient encounters and call bell initiation were evaluated as process measures. Patients' self-perceived sleep quality, an outcome measure, was evaluated using the Richards-Campbell Sleep Questionnaire. Adherence to a sleep-promoting schedule reduced patient sleep interruptions between midnight and 4 am by as much as two-thirds while increasing patients' overall self-perceived sleep quality by 6.7 percentage points. An interprofessional effort to minimize patient interruptions at night in an intensive care unit setting led to improved patient sleep quality and sustainable practice changes.

101 US Capacity for Burn Care in a Mass Causality Incident

Abstract Introduction Preparedness for a Mass Causality Incident (MCI) involving burns is important to ensure national safety. Burn care is particularly vulnerable to becoming overwhelmed given the intensity of resources required to care for a severely injured burn patient juxtaposed to a limited number of burn centers in the US. We aimed to characterize capacity for severely injured burn patients across the US and simulate preparedness for an MCI across Core Base Statistical Areas (CBSA). Methods The COVID-19 pandemic prompted the Department of Health and Human Service to record bed occupancy and capacity for all US hospitals on a weekly basis from January 1st, 2020 to May 1, 2024. Hospitals were grouped into their CBSA according to the Department of Housing and Urban Development. Hospitals were characterized based on burn center status (defined by Centers for Medicare &amp; Medicaid Services Provider of Service file) and level-1 trauma center status (American College of Surgeons), given many mechanisms of burn-related MCI would require trauma care. MCI scenarios were considered with 10, 25, and 50 critically injured burn patients requiring intensive care unit (ICU) beds. Population level estimates for preparedness were based upon number of lives in each CBSA in 2023. Results There were 150 burn centers across 104 CBSAs. Of CBSAs with burn centers, 57 (55%) had combined burn/trauma centers. Post-pandemic (2022 onward), median ICU bed occupancy at hospitals with burn centers was 81.0% (IQR 64.8%, 89.0%). Occupancy was higher if a burn center was also a level-1 trauma center (86.1% vs 72.3%, p&amp;lt; 0.001). Post-pandemic by CBSA, the median number of open ICU beds per million residents at hospitals with burn centers was 14.0 (IQR 4.6, 36.3); at combined burn/trauma centers it was 15.4 (IQR 4.9, 40.0). 29% of CBSAs did not have sufficient ICU beds to manage &amp;gt;10 severely burned patients. 75% of CBSAs did not have sufficient ICU beds to manage &amp;gt;25 or more severely burn patients. Only 4% of CBSA had enough open ICU beds to manage 50 severely burned patients. Per capita, the bottom quartile of CBSAs for open ICU beds at hospitals with burn centers represented 35% of the entire US population, indicating constrained capacity in regions at high risk for MCI. Conclusions 45% of CBSAs with burn centers were not equipped to care for polytrauma burn patients. The most vulnerable regions of the US for a burn MCI were also the more densely populated. Applicability of Research to Practice These real-world data show a mismatch between need and capacity of burn and combined burn/trauma ICU beds across the US in event of a burn MCI. Funding for the Study N/A