Medical-surgical Intensive Care Unit Research Articles

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 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect 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 and a composite outcome of 30-day readmission or mortality. Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (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 with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay 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 pressure ulcers preventive measures among critically ill patients at a tertiary teaching hospital, Tanzania

ObjectivesTo explore nurse’s perceptions on barriers for Implementing Pressure 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.

Validation of the nutritrauma concept for the detection of potential harmful effects of medical nutritional treatment in critically ill patients in real life.

Introduction: medical nutritional treatment (MNT) can be complex and may be associated with potential metabolic complications, which has been recently described as nutritrauma. Objective: the aim of our work is to describe whether the application of the nutritrauma concept in real life is feasible and useful to detect the metabolic complications associated with the prescription of MNT. Material and methods: in this descriptive, prospective study at a single center we enrolled 30 consecutive critically ill patients in a 14-bed medical-surgical intensive care unit. The nutritrauma strategy implementation was based in four "M" steps: Metabolic screening, MNT prescription, biochemical Monitoring, and nutritional Management. Results: we analyzed 28 patients (mean age, 69.7 ± 11.3 years; APACHE II, 18.1 ± 8.1; SOFA, 7.5 ± 3.7; Nutric Score, modified, 4.3 ± 2.01, and mean BMI, 27.2 ± 3.8). The main cause of admission was sepsis (46.4 %). Length of ICU stay was 20.6 ± 15.1 days; 39.3 % of subjects died during their ICU stay. Enteral nutrition (82.1 %) was more frequent than parenteral nutrition (17.9 %). During nutritional monitoring, 54 specific laboratory determinations were made. Hyperglycemia was the most frequent metabolic alteration (83.3 % of measurements). Electrolyte disturbances included hypocalcemia (50 %), hypophosphatemia (29.6 %) and hypokalemia (27.8 %). The most frequent lipid profile abnormalities were hypocholesterolemia (64.8 %) and hypertriglyceridemia (27.8 %). Furthermore, nutritional prescription was modified for 53.6 % of patients: increased protein dosage (25 %), increased calorie dosage (21.4 %) and change to organ-specific diet (17.8 %). Conclusions: in conclusion, the application of the nutritrauma approach facilitates detection of metabolic complications and an evaluation of the appropriate prescription of MNT.

External Validation of the ICU-Venous Thromboembolism Risk Assessment Model in Adult Critically Ill Patients.

Currently, no universally accepted standardized VTE risk assessment model (RAM) is specifically designed for critically ill patients. Although the ICU-venous thromboembolism (ICU-VTE) RAM was initially developed in 2020, it lacks prospective external validation. To evaluate the predictive performance of the ICU-VTE RAM in terms of VTE occurrence in mixed medical-surgical ICU patients. We prospectively enrolled adult patients in the ICU. The ICU-VTE score and Caprini or Padua score were calculated at admission, and the incidence of in-hospital VTE was investigated. The performance of the ICU-VTE RAM was evaluated and compared with that of Caprini or Padua RAM using the receiver operating curve. We included 269 patients (median age: 70 years; 62.5% male). Eighty-three (30.9%) patients experienced inpatient VTE. The AUC of the ICU-VTE RAM was 0.743 (95% CI, 0.682-0.804, P < 0.001) for mixed medical-surgical ICU patients. Comparatively, the performance of the ICU-VTE RAM was superior to that of the Pauda RAM (AUC: 0.727 vs 0.583, P < 0.001) in critically ill medical patients and the Caprini RAM (AUC: 0.774 vs 0.617, P = 0.128) in critically ill surgical patients, although the latter comparison was not statistically significant. The ICU-VTE RAM may be a practical and valuable tool for identifying and stratifying VTE risk in mixed medical-surgical critically ill patients, aiding in managing and preventing VTE complications.

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.

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.

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.

2794. Assessing the impact of inappropriate antibiotic therapy on mortality among intensive care unit patients

Abstract Background This study evaluates the potential association between inappropriate antibiotic therapy and adverse clinical outcomes in infected patients admitted to ICUs. Methods We analyzed data from infected patients admitted to a medical-surgical Intensive Care Unit (ICU) in Belo Horizonte, a city with a population of three million in Brazil. The data was collected between January 2020 and June 2021, and included patients with healthcare-associated and community-acquired infections. In order to determine the appropriateness of antibiotic therapy, cultures and susceptibility reports were utilized. Empiric antimicrobial therapy was classified as inappropriate if the isolated strain was resistant to all empirically administered antimicrobials, while it was considered adequate if the isolated strain was susceptible to at least one of the antimicrobials used empirically. Results A total of 470 patients who received antimicrobials in the ICU were included in the analysis, all of whom had a positive culture. Among them, 65 patients experienced a FAILURE of the antimicrobial regimen, resulting in an overall failure rate of 14%. The monthly rate of inappropriate antibiotic therapy showed significant heterogeneity during the study period, ranging from 100% success in March 2021 to a failure rate of 33% in June 2021 (Fig 1). The failure rate of antimicrobial regimen was found to be significantly higher in cases where the infection was caused by multidrug-resistant (MR) strains compared to multisensitive (MS) strains, as shown in Table 1. Failure of the antimicrobial regimen was a significant risk factor for patient death, regardless of whether the infection was caused by MS or MR strains (Tables 1 and Fig 2). Patients who died tended to receive more antimicrobials compared to those who were discharged, with an average of three antimicrobials prescribed for patients who progressed to death, while discharged patients received an average of two drugs. Conclusion Inappropriate antibiotic therapy in ICU patients is associated with increased mortality risk, regardless of the type of infection. Timely and appropriate antimicrobial therapy is crucial in the management of ICU infections to improve clinical outcomes. Disclosures All Authors: No reported disclosures

Adapting co-design methodology to a virtual environment: co-designing a communication intervention for adult patients in critical care.

Research co-design is recommended to reduce misalignment between researcher and end-user needs and priorities for healthcare innovation. Engagement of intensive care unit patients, clinicians, and other stakeholders in co-design has historically relied upon face-to-face meetings. Here, we report on our co-design processes for the development of a bundled intensive care unit patient communication intervention that used exclusively virtual meeting methods in response to COVID-19 pandemic social distancing restrictions. We conducted a series of virtual co-design sessions with a committee of stakeholder participants recruited from a medical-surgical intensive care unit of a community teaching hospital in Toronto, Canada. Published recommendations for co-design methods were used with exclusively virtual adaptations to improve ease of stakeholder participation as well as the quality and consistency of co-design project set-up, facilitation, and evaluation. Virtual adaptations included the use of email for distributing information, videos, and electronic evaluations as well as the use of a videoconferencing platform for synchronous meetings. We used a flexible meeting plan including asynchronous virtual methods to reduce attendance barriers for time-constrained participants. Co-design participants included a patient and a family member (n = 2) and professionally diverse healthcare providers (n = 9), plus a facilitator. Overall, participants were engaged and reported a positive experience with the virtually adapted co-design process. Reported benefits included incorporation of diverse viewpoints in the communication intervention design and implementation plan. Challenges related to lack of hands-on time during development of the co-designed intervention and participant availability to meet regularly albeit virtually. This report describes the methods, benefits, and challenges of adapting in-person co-design methods to a virtual environment to produce a bundled communication intervention for use in the adult intensive care unit during the COVID-19 pandemic. Adapting recommended co-design methods to a virtual environment can provide further opportunities for stakeholder participation in intervention design.

Use of Lung Ultrasound in the New Definitions of Acute Respiratory Distress Syndrome Increases the Occurrence Rate of Acute Respiratory Distress Syndrome.

To assess the effect of incorporating bilateral abnormalities as detected by lung ultrasound (LUS) in the Kigali modification and the New Global definition of acute respiratory distress syndrome (ARDS) on the occurrence rate of ARDS. Post hoc analysis of a previously published prospective cohort study. An academic mixed medical-surgical ICU. The original study included critically ill adults with any opacity on chest radiography in whom subsequent LUS was performed. Patients with ARDS according to the Berlin definition, COVID-19 patients and patients with major thorax trauma were excluded. None. LUS was performed within 24 hours of chest radiography and the presence of unilateral and bilateral abnormalities on LUS and chest radiograph (opacities) was scored. Subsequently, the Kigali modification and the New Global definition of ARDS were applied by two independent researchers on the patients with newly found bilateral opacities. Of 120 patients, 116 were included in this post hoc analysis. Thirty-three patients had bilateral opacities on LUS and unilateral opacities on chest radiograph. Fourteen of these patients had ARDS according to the Kigali modification and 12 had ARDS according to the New Global definition. The detected LUS patterns were significantly different between patients with and without ARDS ( p = 0.004). An A-profile with a positive PosteroLateral Alveolar and/or Pleural Syndrome was most prevalent in patients without ARDS, whereas heterogeneous and mixed A, B, and C patterns were most prevalent in patients with ARDS. The addition of bilateral abnormalities as detected by LUS to the Kigali modification and the New Global definition increases the occurrence rate of the ARDS. The nomenclature for LUS needs to be better defined as LUS patterns differ between patients with and without ARDS. Incorporating well-defined LUS criteria can increase specificity and sensitivity of new ARDS definitions.

Natural language processing diagnosed behavioural disturbance phenotypes in the intensive care unit: characteristics, prevalence, trajectory, treatment, and outcomes

BackgroundNatural language processing (NLP) may help evaluate the characteristics, prevalence, trajectory, treatment, and outcomes of behavioural disturbance phenotypes in critically ill patients.MethodsWe obtained electronic clinical notes, demographic information, outcomes, and treatment data from three medical-surgical ICUs. Using NLP, we screened for behavioural disturbance phenotypes based on words suggestive of an agitated state, a non-agitated state, or a combination of both.ResultsWe studied 2931 patients. Of these, 225 (7.7%) were NLP-Dx-BD positive for the agitated phenotype, 544 (18.6%) for the non-agitated phenotype and 667 (22.7%) for the combined phenotype. Patients with these phenotypes carried multiple clinical baseline differences. On time-dependent multivariable analysis to compensate for immortal time bias and after adjustment for key outcome predictors, agitated phenotype patients were more likely to receive antipsychotic medications (odds ratio [OR] 1.84, 1.35–2.51, p < 0.001) compared to non-agitated phenotype patients but not compared to combined phenotype patients (OR 1.27, 0.86–1.89, p = 0.229). Moreover, agitated phenotype patients were more likely to die than other phenotypes patients (OR 1.57, 1.10–2.25, p = 0.012 vs non-agitated phenotype; OR 4.61, 2.14–9.90, p < 0.001 vs. combined phenotype). This association was strongest in patients receiving mechanical ventilation when compared with the combined phenotype (OR 7.03, 2.07–23.79, p = 0.002). A similar increased risk was also seen for patients with the non-agitated phenotype compared with the combined phenotype (OR 6.10, 1.80–20.64, p = 0.004).ConclusionsNLP-Dx-BD screening enabled identification of three behavioural disturbance phenotypes with different characteristics, prevalence, trajectory, treatment, and outcome. Such phenotype identification appears relevant to prognostication and trial design.Graphical abstract

Early detection of ocular lesions in critically ill children: Testing an ocular assessment scale.

There is scarcity of data on the incidence and factors associated with the occurrence of ocular lesions in critically ill children. The objective was to test the applicability and utility of an ocular assessment scale and to identify risk factors of ocular lesions. Prospective observational study. A tertiary care medical-surgical Paediatric Intensive Care Unit. 194 children without previous ocular disease who stayed in the Paediatric Intensive Care Unit for more than 48 h. An ocular lesions risk scale was designed including risk factors lagophthalmos, eye dryness, conjunctival hyperemia, slow blinking, intubation, sedation, relaxation, face mask and hemodynamic instability. Patients were classified as high-, medium-, and low-risk patients. Corneal lesions were examined by fluorescein staining according to their risk and were confirmed by an ophthalmologist. 76 patients were examined with fluorescein staining. Thirty-two ocular lesions were detected by nursing staff, 26 confirmed by the ophthalmologist. 53.6% of the high-risk patients developed a corneal lesion. Univariate analysis revealed an association between ocular damage and all factors included in the scale, except for face mask. In the multivariate analysis, ocular lesions were associated with lagophthalmos, hyperemia, invasive mechanical ventilation and inotropic support. The scale was useful to detect corneal lesions in critically ill children. The identification of risk factors will enable the development of measures to reduce the incidence of ocular lesions. A new, non-validated scale allowed staff to detect eye injuries, study this problem and improve future prevention.