Medical-surgical Intensive Care Unit Research Articles

Dynamic changes of hepatic vein Doppler velocities predict preload responsiveness in mechanically ventilated critically ill patients

BackgroundAssessment of dynamic parameters to guide fluid administration is one of the mainstays of current resuscitation strategies. Each test has its own limitations, but passive leg raising (PLR) has emerged as one of the most versatile preload responsiveness tests. However, it requires real-time cardiac output (CO) measurement either through advanced monitoring devices, which are not routinely available, or echocardiography, which is not always feasible. Analysis of the hepatic vein Doppler waveform change, a simpler ultrasound-based assessment, during a dynamic test such as PLR could be useful in predicting preload responsiveness. The objective of this study was to assess the diagnostic accuracy of hepatic vein Doppler S and D-wave velocities during PLR as a predictor of preload responsiveness.MethodsProspective observational study conducted in two medical–surgical ICUs in Chile. Patients in circulatory failure and connected to controlled mechanical ventilation were included from August to December 2023. A baseline ultrasound assessment of cardiac function was performed. Then, simultaneously, ultrasound measurements of hepatic vein Doppler S and D waves and cardiac output by continuous pulse contour analysis device were performed during a PLR maneuver.ResultsThirty-seven patients were analyzed. 63% of the patients were preload responsive defined by a 10% increase in CO after passive leg raising. A 20% increase in the maximum S wave velocity after PLR showed the best diagnostic accuracy with a sensitivity of 69.6% (49.1–84.4) and specificity of 92.8 (68.5–99.6) to detect preload responsiveness, with an area under curve of receiving operator characteristic (AUC–ROC) of 0.82 ± 0.07 (p = 0.001 vs. AUC–ROC of 0.5). D-wave velocities showed worse diagnostic accuracy.ConclusionsHepatic vein Doppler assessment emerges as a novel complementary technique with adequate predictive capacity to identify preload responsiveness in patients in mechanical ventilation and circulatory failure. This technique could become valuable in scenarios of basic hemodynamic monitoring and when echocardiography is not feasible. Future studies should confirm these results.

Auditing plasma transfusion in intensive care: Use of decision time interval analysis.

To present a new method for displaying blood utilization data based on analysis of decision time intervals (DTIs). Retrospective study of patients treated in a medical intensive care unit (ICU), surgical ICU, or postcardiac surgery ICU at an academic hospital between January 2018 and June 2023. Each patient's episode of care was divided into a series of DTIs. Transfusions during each time interval were recorded. In total, 16,562 patients received 6980 units of plasma and 21,034 units of red blood cells during 111,557 time intervals of care. Patients had international normalized ratio (INR) values ranging from less than 1.0 to more than 4.0. Data on plasma transfusion at different INR values were displayed as the number of transfusion episodes, number of units given, or the proportion of DTIs with transfusion. Clinicians transfused plasma on 1.5% of occasions when the INR was 1.5 or less and on 2.2% of occasions when the INR was less than 2.0. Plasma was transfused without red blood cells in only 0.75% of DTIs. Transfusion practice was statistically different among the 3 ICUs. Compared with traditional methods of displaying the results of blood audits, DTI analysis displays information regarding the decision both to transfuse and to not transfuse. Utilization reviews that display data based on decision time analysis reveal clinical practice patterns very different from those suggested by traditional displays of plasma audit data.

The impact of frailty and rapid response team activation on patients admitted to the intensive care unit: A case-control matched, observational, single-centre cohort study.

Frailty is a multi-dimensional syndrome associated with mortality and adverse outcomes in patients admitted to the intensive care unit (ICU). Further investigation is warranted to explore the interplay among factors such as frailty, clinical deterioration triggering a medical emergency team (MET) review, and outcomes following admission to the ICU. Single-centre, retrospective observational case-control study of adult patients (>18 years) admitted to a medical-surgical ICU with (cases) or without (controls) a preceding MET review between 4 h and 14 days prior. Matching was performed for age, ICU admission diagnosis, Acute Physiology and Chronic Health Evaluation III (APACHE III) score and the 8-point Clinical Frailty Scale (CFS). Cox proportional hazard regression modelling was performed to determine associations with 30-day mortality after admission to ICU. A total of 2314 matched admissions were analysed. Compared to non-frail patients (CFS 1-4), mortality was higher in all frail patients (CFS 5-8), at 31% vs. 13%, and in frail patients admitted after MET review at 33%. After adjusting for age, APACHE, antecedent MET review and CFS in the Cox regression, mortality hazard ratio increased by 26% per CFS point and by 3% per APACHE III point, while a MET review was not an independent predictor. Limitations of medical treatment occurred in 30% of frail patients, either with or without a MET antecedent, and this was five times higher compared to non-frail patients. Frail patients admitted to ICU have a high short-term mortality. An antecedent MET event was associated with increased mortality but did not independently predict short-term survival when adjusting for confounding factors. The intrinsic significance of frailty should be primarily considered during MET review of frail patients. This study suggests that routine frailty assessment of hospitalised patients would be helpful to set goals of care when admission to ICU could be considered.

Gut barrier dysfunction and the risk of ICU-acquired bacteremia- a case–control study

BackgroundImpaired intestinal barrier function can enable passage of enteric microorganisms into the bloodstream and lead to nosocomial bloodstream infections during critical illness. We aimed to determine the relative importance of gut translocation as a source for ICU-acquired enterococcal bacteremia of unknown origin.MethodsWe conducted a nested case–control study in two mixed medical-surgical tertiary ICUs in the Netherlands among patients enrolled between 2011 and 2018. We selected 72 cases with ICU-acquired bacteremia due to enterococci (which are known gastrointestinal tract commensals) and 137 matched controls with bacteremia due to coagulase-negative staphylococci (CoNS) (which are of non-intestinal origin). We measured intestinal fatty acid-binding protein, trefoil factor-3, and citrulline 48 h before bacteremia onset. A composite measure for Gut Barrier Injury (GBI) was calculated as the sum of standardized z-scores for each biomarker plus a clinical gastrointestinal failure score.ResultsNo single biomarker yielded statistically significant differences between cases and controls. Median composite GBI was higher in cases than in controls (0.58, IQR − 0.36–1.69 vs. 0.32, IQR − 0.53–1.57, p = 0.33) and higher composite measures of GBI correlated with higher disease severity and ICU mortality (p < 0.001). In multivariable analysis, higher composite GBI was not significantly associated with increased occurrence of enterococcal bacteremia relative to CoNS bacteremia (adjusted OR 1.12 95% CI 0.93–1.34, p = 0.22).ConclusionsWe could not demonstrate an association between biomarkers of gastrointestinal barrier dysfunction and an increased occurrence of bacteremia due to gut compared to skin flora during critical illness, suggesting against bacterial translocation as a major vector for acquisition of nosocomial bloodstream infections in the ICU.

Adaptation and validation of the Physical Restraint-Theory of Planned Behaviour Questionnaire to the paediatric context.

To create and test psychometrically a paediatric version of the Physical Restraint-Theory of Planned Behaviour Questionnaire to assess paediatric critical care nurses' intention to use physical restraint. A psychometric study. Five medical-surgical Paeditric Intensive care Units from five hospitals in Spain. The study took place in three phases. In phase 1, the questionnaire was adapted. In phase 2, the content validity of each item was determined, and a pilot test was conducted. In phase 3, we administered the questionnaire and determined its psychometric properties. The assessment of the intention to use physical restraint was extended to all critical paediatric patients, two items were eliminated from the initial questionnaire, four new items were included, and the clinical scenarios of the intention subscale were expanded from three to six. Overall content validity index for the full instrument of 0.96 out of 1. The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire is made up of four subscales (attitude, subjective norms (SN), perceived behavioural control (PBC), and intention) subdivided into 7 factors and 51 items. The internal consistency for the attitude subscale obtained a Cronbach's Alpha of 0.80 to 0.73, for the SN it was 0.72 to 0.89, for the PBC it was from 0.80 to 0.73 and for the intention subscale it was 0.75. The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire is an instrument composed of seven factors and 51 items that validly and reliably assesses the intention of paediatric nurses to apply PR in PICUs. Having this instrument will help health centres move towards restraint-free care by allowing managers to assess professionals' attitudes, beliefs, and intentions around the use of PR in PICUs.

Knowing your team in the intensive care unit: an ethnographic study on familiarity

ABSTRACT Effective interprofessional team function is integral to high-quality care in the intensive care unit (ICU). However, little is known about how familiarity develops among teams, which may be an important antecedent to effective team function and quality care. To examine team familiarity and how it impacts ICU team function and care, we conducted an ethnographic study in four ICUs (two medical ICUs, one mixed medical-surgical ICU, and one surgical ICU) in two community hospitals and one academic medical center. We conducted 57.5 h of observation, 26 shadowing experiences, and 26 interviews across the four ICUs sequentially. We used thematic analysis to examine familiarity among the team. We found that ICU team members become familiar with their team through interpersonal, relational interactions, which involved communication, time working together, social interactions, trust, and respect. Our findings underscore the relational aspect of effective teams and demonstrate that time working together, social interactions, communication, developing trust, and respect are pathways to familiarity and optimal team function. Leveraging unique and creative ways to enhance the relational aspects of ICU teams could be an area for future research and lead to improved ICU outcomes.

Impact of Individual and Job Characteristics on Nurses’ Scope of Practice in Spanish Hospital Units

Background. Nurses are one of the largest and costliest groups in healthcare organizations; therefore, it is important to comprehend their scope of practice. Aim. To contribute to the improvement of nursing resource management in medical-surgical and Intensive Care Units by identifying factors that influence the scope of nursing practice. The hypothesis was that the activities carried out by nurses in medical-surgical units and intensive care units are influenced by individual and job-related factors, with job characteristics having an additive and moderating effect on individual characteristics. Materials and Methods. Cross-sectional correlational design to test the relationship between the individual and job characteristics on the nursing scope of practice measured by the Actual Scope of Nursing Practice (ASCOP) questionnaire. The sample consisted of 270 nurses. Linear mixed effects models analysis (LME) was used with the aleatory effect of the intensive care unit (ICU). Results. Belonging to the ICU decreased the scope of practice of nurses. We found a statistically significant effect of psychological demand, practice environment, role ambiguity, and growth need strength on the scope of nursing practice. The models explained a variance up to 24%. Conclusions. Although the survey results revealed the existence of broader scope of practice levels in Spanish hospital units than in the original Canadian study, the use of scope of nursing practice remains suboptimal. Higher levels on the psychological demand, the practice environment and in the individual growth need strength were related with a broader scope of practice. Otherwise, role ambiguity negatively affected the scope of practice. Implications for Nursing Management. This article provides an analysis of the impact of individual and job-related characteristics on the nursing scope of practice. It serves as a valuable resource for both managers and nurses, offering insights to improve nurses’ working conditions and obtain more efficient workforces.

The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort.

There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes. This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016-2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed effects models to estimate the effect of hospital level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality and secondary outcomes included length of stay (LOS), and a composite outcome of 30-day readmission or mortality. Factors associated with improved GIB 30d mortality included large hospital size (defined as beds>400, OR: 0.93 (0.90, 0.97)), greater case volume (OR 0.97 (0.96, 0.98)) increased residents and nurse staffing (OR: 0.88 (0.83, 0.94)), and blood donor center designation (OR: 0.93 (0.88, 0.99)). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced ICU capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared to those hospitalized in a hospital with none of these services (OR: 0.78 (0.68, 0.91)). However, LOS increased with additional services. Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.

Measuring evidence-based clinical guideline compliance in the paediatric intensive care unit

BackgroundEvidence-based clinical care guidelines improve medical treatment by reducing error, improving outcomes and possibly lowering healthcare costs. While some data exist on individual guideline compliance, no data exist on overall...

Characteristics and risk factors associated with mortality during the first cycle of prone secondary to ARDS due to SARS-CoV-2 pneumonia

ObjectiveTo analyze characteristics, changes in oxygenation, and pulmonary mechanics, in mechanically ventilated patients with ARDS due to SARS-CoV-2 treated with prone position and evaluate the response to this maneuver. DesignCohort study including patients with PaO2/FiO2 <150mmHg requiring prone position over 18 months. We classified patients according to PaO2/FiO2 changes from basal to 24h after the first prone cycle as: 1) no increase 2) increase <25%, 3) 25%–50% increase 4) increase >50%. Setting33-bed medical-surgical Intensive Care Unit (ICU) in Argentina. Patients273 patients. InterventionsNone. Main variables of interestEpidemiological characteristics, respiratory mechanics and oxygenation were compared between survivors and non-survivors. Independent factors associated with in-hospital mortality were identified. ResultsBaseline PaO2/FiO2 was 116 [97–135]mmHg (115 [94–136] in survivors vs. 117 [98–134] in non-survivors; p=0.50). After prone positioning, 22 patients (8%) had similar PaO2/FiO2 values; 46(16%) increased PaO2/FiO2 ≤25%; 55 (21%) increased it 25%–50%; and 150 (55%), >50%. Mortality was 86%, 87%, 72% and 50% respectively (p<0.001). Baseline PaO2/FiO2, <100mmHg did not imply that patients were refractory to prone position. Factors independently associated with mortality were age, percentage increase in PaO2/FiO2 after 24h being in prone, and number of prone cycles. ConclusionsOlder patients unable to improve PaO2/FiO2 after 24h in prone position and who require >1 cycle might early receive additional treatments for refractory hypoxemia. After the first 24h in the prone position, a low percentage of PaO2/FiO2 increase over baseline, beyond the initial value, was independently associated with higher mortality.

The neurological wake-up test in severe pediatric traumatic brain injury: a long term, single-center experience.

To describe the use and outcomes of the neurological wake-up test (NWT) in pediatric severe traumatic brain injury (pTBI). Retrospective single-center observational cohort study. Medical-surgical tertiary pediatric intensive care unit (PICU) in a university medical center and Level 1 Trauma Center. Children younger than 18 years with severe TBI [i.e., Glasgow Coma Scale (GCS) of ≤8] admitted between January 2010 and December 2020. Subjects with non-traumatic brain injury were excluded. Of 168 TBI patients admitted, 36 (21%) met the inclusion criteria. Median age was 8.5 years [2 months to 16 years], 5 patients were younger than 6 months. Median initial Glasgow Coma Scale (GCS) and Glasgow Motor Scale (GMS) was 6 [3-8] and 3 [1-5]. NWTs were initiated in 14 (39%) patients, with 7 (50%) labelled as successful. Fall from a height was the underlying injury mechanism in those seven. NWT-failure occurred in patients admitted after traffic accidents. Sedation use in both NWT-subgroups (successful vs. failure) was comparable. Cause of NWT-failure was non-arousal (71%) or severe agitation (29%). Subjects with NWT failure subsequently had radiological examination (29%), repeat NWT (43%), continuous interruption of sedation (14%) or intracranial pressure (ICP) monitoring (14%). The primary reason for not doing NWTs was intracranial hypertension in 59%. Compared to the NWT-group, the non-NWT group had a higher PRISM III score (18.9 vs. 10.6), lower GCS/GMS at discharge, more associated trauma, and circulatory support. Nine patients (25%) died during their PICU admission, none of them had an NWT. We observed limited use of NWTs in pediatric severe TBI. Patients who failed the NWT were indistinguishable from those without NWT. Both groups were more severely affected compared to the NWT successes. Therefore, our results may indicate that only a select group of severe pTBI patients qualify for the NWT.

Coexistence of a fluid responsive state and venous congestion signals in critically ill patients: a multicenter observational proof-of-concept study

BackgroundCurrent recommendations support guiding fluid resuscitation through the assessment of fluid responsiveness. Recently, the concept of fluid tolerance and the prevention of venous congestion (VC) have emerged as relevant aspects to be considered to avoid potentially deleterious side effects of fluid resuscitation. However, there is paucity of data on the relationship of fluid responsiveness and VC. This study aims to compare the prevalence of venous congestion in fluid responsive and fluid unresponsive critically ill patients after intensive care (ICU) admission.MethodsMulticenter, prospective cross-sectional observational study conducted in three medical–surgical ICUs in Chile. Consecutive mechanically ventilated patients that required vasopressors and admitted < 24 h to ICU were included between November 2022 and June 2023. Patients were assessed simultaneously for fluid responsiveness and VC at a single timepoint. Fluid responsiveness status, VC signals such as central venous pressure, estimation of left ventricular filling pressures, lung, and abdominal ultrasound congestion indexes and relevant clinical data were collected.ResultsNinety patients were included. Median age was 63 [45–71] years old, and median SOFA score was 9 [7–11]. Thirty-eight percent of the patients were fluid responsive (FR+), while 62% were fluid unresponsive (FR−). The most prevalent diagnosis was sepsis (41%) followed by respiratory failure (22%). The prevalence of at least one VC signal was not significantly different between FR+ and FR− groups (53% vs. 57%, p = 0.69), as well as the proportion of patients with 2 or 3 VC signals (15% vs. 21%, p = 0.4). We found no association between fluid balance, CRT status, or diagnostic group and the presence of VC signals.ConclusionsVenous congestion signals were prevalent in both fluid responsive and unresponsive critically ill patients. The presence of venous congestion was not associated with fluid balance or diagnostic group. Further studies should assess the clinical relevance of these results and their potential impact on resuscitation and monitoring practices.

Global trends in nonsusceptibility rates of Escherichia coli isolates to meropenem and ceftazidime/avibactam: Data from the Antimicrobial Testing Leadership and Surveillance (ATLAS) programme, 2014–21

ObjectiveTo understand the global changes in the nonsusceptibility rates of Escherichia coli to meropenem and ceftazidime-avibactam (CZA), we conducted a study using the Antimicrobial Testing Leadership and Surveillance database. MethodsA total of 49 394 E. coli isolates were collected during the 8-year study period. ResultThe countries with the highest nonsusceptible rates for meropenem were India (16.6%), followed by Pakistan (6.7%), Ukraine (5.4%), Qatar (5.3%), and Guatemala (3.2%). For CZA, the nonsusceptible rate was highest in India (15.6%), followed by Qatar (4.0%), Guatemala (3.9%), China (2.6%), and Thailand (2.5%). During the study period, the nonsusceptible rates of meropenem and CZA in E. coli increased in Asia, Latin America, and Africa/Middle East. Isolates from the medical ICU (odds ratio [OR], 4.62) and surgical ICU (OR, 3.98) were associated with a higher risk of CZA nonsusceptible rates. Compared to intestinal specimens, respiratory and genitourinary specimens had the highest OR (2.32 and 2.17) associated with CZA resistance. Further analysis of carbapenemase distribution showed an increase in the percentage of blaNDM-positive isolates and a decrease in blaKPC-positive isolates worldwide, especially in Latin America. Additionally, we observed a gradual decline in the prevalence of blaOXA-positive E. coli without concomitant carriage of metallo-β-lactamase genes in the worldwide surveillance. ConclusionsFurther surveillance is necessary to determine whether blaNDM -positive E. coli (i.e., CZA-resistant isolates) is increasing and leading to more superbugs spreading worldwide.

Nurse-Driven Fluid Responsiveness Evaluation in Patients With Septic Shock: A Quality Improvement Initiative.

Fluid responsiveness should be assessed in patients with septic shock because only 50% of patients are fluid responsive. Dynamic measures of fluid responsiveness, like pulse pressure variation measured after a passive leg raise maneuver, are recommended to guide fluid administration in patients with sepsis after initial fluid resuscitation. The purpose of the project was to evaluate outcomes after implementing a nurse-driven fluid responsiveness evaluation using passive leg raise and pulse pressure variation measurement in patients with septic shock. The project included 30 adult patients with septic shock in a 24-bed medical-surgical intensive care unit at a community hospital. A new nursing process was initiated for bedside fluid responsiveness evaluation (pulse pressure variation measurement after passive leg raise). Staff members received in-person individual training sessions. Preintervention and 20-week postintervention patient outcomes data were collected to estimate the project's impact on incidence of fluid overload and acute kidney injury, duration of mechanical ventilation, and intensive care unit length of stay. Preintervention and postintervention staff satisfaction surveys assessed nurses' perception of the project's value. Before intervention, 24 of 37 patients (65%) met criteria of fluid overload. The project resulted in a 28% decrease in the incidence of fluid overload. Staff satisfaction surveys revealed a significant increase in nurses' feelings of empowerment to positively affect patient outcomes; all nurses agreed that the new process was efficient. The results indicate that the project had a positive impact on patient outcomes and nurse autonomy.

Association of early dietary fiber intake and mortality in septic patients with mechanical ventilation based on MIMIC IV 2.1 database: a cohort study

BackgroundWhether early dietary fiber intake in septic patients is associated with a better clinical prognosis remains unclear, especially the time and the amount. Therefore, we assessed the association between early dietary fiber intake and clinical outcomes in septic patients by examining an extensive database.MethodsWe conducted a retrospective cohort study using data from the MIMIC IV 2.1 database, focusing on consecutive septic patients requiring mechanical ventilation in medical or mixed medical-surgical ICUs. We collected patient demographics and nutritional data. Dietary fiber amounts were calculated according to enteral nutrition instructions from manufacturers within the first 72 h after admission. After adjusting for covariates, we employed restricted cubic spline (RCS) regression to investigate the relationship between fiber intake (FI) and 28-day mortality. Patients were categorized into three groups based on their fiber index (FI) within 72 h of admission: low fiber index (LFI) group when FI was < 3 g/(%), medium fiber index (MFI) group when FI ranged from 3 to 35 g(%), and high fiber index (HFI) group when FI ≥ 35 g(%). Univariate and multivariate Cox proportional hazards regression models were utilized to assess the association between early FI and 28-day mortality. We ultimately employed Kaplan–Meier (KM) curves and log-rank test visually represent the association between FI and 90-day mortality. The second outcomes include ICU-acquired infections and the hospital and ICU death, length of hospital and ICU stay, and length of mechanical ventilation.ResultsAmong 1057 subjects, 562 (53.2%) were male, with a median age of 64.8 years (IQR 53.4–75.2). We observed a J-shaped relationship between FI and 28-day mortality. The MFI group exhibited the lowest 28-day mortality [adjusted HR 0.64 (0.45–0.91), p = 0.013] and the lowest rate of hospital mortality [adjusted OR 0.60 (0.39–0.93), p = 0.022], with no statistically significant differences noted in the HFI group when compared to the LFI group. Similar patterns were observed for 60-day and 90-day mortality. However, no statistically significant differences were observed in other secondary outcomes after adjusting for covariates.ConclusionEarly medium fiber index intake improved 28-day mortality and lower hospital mortality in septic M/SICU patients on mechanical ventilation.

Exploring Cerebral Perfusion Transcranial Doppler Parameters in Patients Admitted to Combined Medical Surgical Intensive Care Unit

Introduction: Encephalopathy, a common complication in Intensive Care Unit (ICU) patients, is often linked to poor outcomes. Transcranial Doppler (TCD), a non-invasive tool assesses cerebral perfusion via the Pulsatility Index (PI), Resistivity Index (RI), and Time-Averaged Peak (TAP) or Mean Flow Velocity (MFV). These parameters may offer insights into cerebral perfusion and outcomes in encephalopathic patients. Aim: To describe the PI, RI of the Middle Cerebral Artery (MCA), and MFV or TAP measured by TCD in patients admitted to the ICU, comparing those with and without encephalopathy at the time of admission. Materials And Methods: This cross-sectional observational study was conducted from January 2019 to November 2020, in a combined medical-surgical ICU of a tertiary care hospital, involving 45 enrolled patients. Patients were evaluated within 24 hours of admission and subsequently every 24 hours until ICU discharge, death, or discharge against medical advice. Bilateral Middle cerebral artery TCD studies were conducted using a 1-5 MHz phased array probe or TCD mode through the transtemporal window. The PI, RI, and MFV were measured on both sides, with the higher value used for analysis, and all statistical analyses were performed using Statistics and Data 13 software. Results: In the present study, 88% (n=40) of patients had encephalopathy (GCS&lt;15 and RAAS less than or more than 0). The mean APACHE II score was 19 (14-25), indicating severe illness with a predicted mortality of 30-40%. Patients with encephalopathy had significantly higher APACHE II scores compared to those without (19.5 (16-25) vs 10 (4-19)). Although there was a trend towards a higher Pulsatility Index in encephalopathic patients at admission (1.11±0.378 vs 1.07±0.12, p=0.81), PI, RI, and TAP values did not significantly differ in non-survivors (1.12±0.49 vs 1.11±0.33, p=0.750). Persistent encephalopathy was associated with a trend towards higher PI at admission (1.05±0.24 vs 1.16±0.46; p=0.756), and a moderate correlation was found between decreasing PI and improvement in GCS (rho=-0.489, p=0.001). Conclusions: PI, RI, and TAP at the time of admission were not found to be associated with occurrence and recovery of encephalopathy as well as mortality. The trend of change in PI moderately correlated with improvement in GCS suggesting the importance of trends rather than absolute values.

Nurses’ perceptions on barriers for implementing peptic ulcers preventive measures among critically ill patients at a tertiary teaching hospital, Tanzania

ObjectivesTo explore nurse’s perceptions on barriers for Implementing Peptic Ulcers Preventive Measures among critically ill patients. Research DesignAn exploratory qualitative study design was employed. In-depth interviews were conducted with 15 nurses to explore their perceptions on barriers for preventing pressure ulcers among critically ill patient. Qualitative thematic analysis approach was used to analyze data. Study settingsMedical high dependent unit, surgical high dependent unit, medical Intensive Care unit and surgical intensive care units at tertiary teaching hospital. FindingsSeven themes emerged that describes nurses’ perceptions on barriers for implementing pressure ulcers preventive measures among patients with critical illness. The themes are: Restrictions from therapeutic interventions and severity of patient condition; Shortage of staff and equipment for pressure ulcer prevention; Unbalanced shift staffing and competing need for patient care; health care providers’ incompetence and carelessness; Lack of guidelines on implementing best practice for pressure ulcer prevention; Lack of accountability measures for negligence; and Minimal management’s commitment for PUs prevention. ConclusionThis study reveals contextual based barriers for effective prevention of ppressure ulcers among critically ill patients. Nurses should be continuously empowered with competence for pressure ulcers prevention. This should go along with staffing and equipping critical care settings for pressure ulcers prevention. Managerial oversight is required for effective implementation of pressure ulcer preventive measures. This should include development of guidelines and policies, establishing accountability measures for negligence, malpractice as well as initiating clinical audit for reflective learning purpose.

Device-Associated Nosocomial Infections in Intensive Care Units at Al-Ahsa Hospitals, Saudi Arabia.

Introduction Patients admitted to intensive care units (ICU), especially those with devices used to support their condition, are at a higher risk of getting healthcare-associated infections (HAIs). The aim of the present study was to analyze the surveillance data and assess the device-associated infection (DAI) rates such as central line-associated blood-stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP) and ventilator-associated event (VAE) in ICUs of the Ministry of Health (MoH) hospitals in Al-Ahsa region. Methodology The study was conducted retrospectively using the surveillance data of governmental hospitals' intensive care units in the Al-Ahsa region. The surveillance data was collected from 10 ICUs at six MoH hospitals in the Al-Ahsa region during the year 2022. The data from the participating hospitals was entered into the Health Electronic Surveillance Network (HESN) plus program by trained infection prevention control practitioners of the respective hospitals. Results An overall CLABSI rate of 4.29 per 1000 central line days was reported during the study period. The CAUTI rate was 0.55 with a range from 0 to 1.29 cases per 1000 urinary catheter days. VAP rate ranged from 0.33 to 2.21 cases per 1000 ventilator days (average of 1.17). The study reported VAE only for the adult medical-surgical ICU (3.36 per 1000 ventilator days). Conclusion The present study revealed that the most common DAIs in the Al-Ahsa region are CLABSI and CAUTI. DAI rates generated from this study may be used as benchmarks for regional hospitals. An educational program regarding the prevention and control of DAIs targeting all healthcare workers, especially ICU staff, has to be done in the Al-Ahsa region.

Psychological symptoms and health-related quality of life in intubated and non-intubated intensive care survivors: A multicentre, prospective observational cohort study

ObjectiveTo compare long-term psychological symptoms and health-related quality of life (HRQOL) in intubated versus non-intubated ICU survivors. DesignProspective, multicentre observational cohort study. SettingFour tertiary medical-surgical ICUs in Australia. ParticipantsIntubated and non-intubated adult ICU survivors. Main outcome measuresPrimary outcomes: clinically significant psychological symptoms at 3- and 12-month follow-up using Post-Traumatic Stress Syndrome-14 for post-traumatic stress disorder; Depression, Anxiety Stress Scales-21 for depression, anxiety, and stress. Secondary outcomes: HRQOL, using EuroQol-5D-5L questionnaire. ResultsOf the 133 ICU survivors, 54/116 (47 %) had at least one clinically significant psychological symptom (i.e., post-traumatic stress disorder, anxiety, depression, stress) at follow-up. Clinically significant scores for psychological symptoms were observed in 26 (39 %) versus 16 (32 %) at 3-months [odds ratio 1.4, 95 % confidence interval (0.66–3.13), p = 0.38]; 23 (37 %) versus 10 (31 %) at 12-months [odds ratio 1.3, 95 % confidence interval (0.53–3.31), p = 0.57] of intubated versus non-intubated survivors, respectively. Usual activities and mobility were the most commonly affected HRQOL dimension, with >30 % at 3 versus months and >20 % at 12-months of overall survivors reporting ≥ moderate problems. There was no difference between the groups in any of the EQ5D dimensions. ConclusionsNearly one-in-two (47 %) of the intubated and non-intubated ICU survivors reported clinically significant psychological symptoms at 3 and 12-month follow-ups. Overall, more than 30 % at 3-months and over 20 % at 12-months of the survivors in both groups had moderate or worse problems with their usual activities and mobility. The presence of psychological symptoms and HRQOL impairments was similar between the groups.

Relationship Between Pain and Delirium in Critically Ill Adults.

Although opioids are frequently used to treat pain, and are an important risk for ICU delirium, the association between ICU pain itself and delirium remains unclear. We sought to evaluate the relationship between ICU pain and delirium. Prospective cohort study. A 32-bed academic medical-surgical ICU. Critically ill adults (n = 4,064) admitted greater than or equal to 24 hours without a condition hampering delirium assessment. None. Daily mental status was classified as arousable without delirium, delirium, or unarousable. Pain was assessed six times daily in arousable patients using a 0-10 Numeric Rating Scale (NRS) or the Critical Care Pain Observation Tool (CPOT); daily peak pain score was categorized as no (NRS = 0/CPOT = 0), mild (NRS = 1-3/CPOT = 1-2), moderate (NRS = 4-6/CPOT = 3-4), or severe (NRS = 7-10/CPOT = 5-8) pain. To address missingness, a Multiple Imputation by Chained Equations approach that used available daily pain severity and 19 pain predictors was used to generate 25 complete datasets. Using a first-order Markov model with a multinomial logistic regression analysis, that controlled for 11 baseline/daily delirium risk factors and considered the competing risks of unarousability and ICU discharge/death, the association between peak daily pain and next-day delirium in each complete dataset was evaluated. Among 14,013 ICU days (contributed by 4,064 adults), delirium occurred on 2,749 (19.6%). After pain severity imputation on 1,818 ICU days, mild, moderate, and severe pain were detected on 2,712 (34.1%), 1,682 (21.1%), and 894 (11.2%) of the no-delirium days, respectively, and 992 (36.1%), 513 (18.6%), and 27 (10.1%) of delirium days (p = 0.01). The presence of any pain (mild, moderate, or severe) was not associated with a transition from awake without delirium to delirium (aOR 0.96; 95% CI, 0.76-1.21). This association was similar when days with only mild, moderate, or severe pain were considered. All results were stable after controlling for daily opioid dose. After controlling for multiple delirium risk factors, including daily opioid use, pain may not be a risk factor for delirium in the ICU. Future prospective research is required.