Multidisciplinary Intensive Care Unit Research Articles

Symptoms of anxiety, depression, and post-traumatic stress disorder 6 weeks and 6 months after ICU: Six out of 10 survivors affected.

Mental health conditions such as depression, anxiety and post-traumatic stress disorder (PTSD) are being increasingly recognised as common adverse outcomes for critical illness survivors. These conditions can have lasting consequences on their wellbeing, ability to return to their pre-illness level of functioning and health-related quality of life. There is a paucity of South African data in terms of the psychological aspects of the post-intensive care unit (ICU) syndrome. To identify and characterise patients who suffered from significant symptoms of mental health disease and poor mental health- related quality of life after ICU admission and who may benefit from appropriate referral, further investigation and medical intervention. Critically ill patients in a multidisciplinary tertiary ICU were prospectively enrolled upon ICU discharge. Survivors were screened for anxiety, depression and post-traumatic stress syndrome at 6 weeks and 6 months after hospital discharge. The Hospital Anxiety and Depression Score (HADS) and the Impact Of Events Scale - Revised (IES-R) were used as screening tools. The mental component summary score (MCS) of the RAND short form-36 was used to determine the effect of psychological symptoms on health-related quality of life (HRQOL). The median age of the 107 ICU survivors was 42 years, and half of them were admitted for complications of COVID-19. Six out of every 10 ICU survivors experienced significant symptoms of anxiety, depression and/or PTSD at follow-up. At the 6-month study visit, 4 out of every 10 patients were experiencing significant psychological symptoms. Those affected had a significantly lower mental HRQOL when compared with those who were unaffected. More than half of those affected had co-occurrence of psychological symptoms. Significant symptoms of anxiety were common, with 5 out of every 10 participants experiencing significant symptoms at either, or both, of the study visits. More than 3 out of 10 of affected patients' symptoms only occurred after the 6-week visit. Associations for significant psychological symptoms comprised female sex, younger age, a diagnosis of trauma and frightening memories of the ICU admission. The burden of mental health disease in ICU survivors is substantial, affecting their HRQOL. Six out of 10 patients experienced symptoms of anxiety, depression and PTSD, and more than half of those affected experienced co-occurrence of the conditions. A third of those affected developed these symptoms only beyond 6 weeks after hospital discharge. A potentially modifiable association with psychological symptoms was frightening memories of the ICU stay.

Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study.

While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians. Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.

Assessment of the use of antibiotics based on the WHO access, watch, and reserve index in a multidisciplinary intensive care unit of a medical college in Eastern India

Assessment of the use of antibiotics based on the WHO access, watch, and reserve index in a multidisciplinary intensive care unit of a medical college in Eastern India

Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

BackgroundThere is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources.MethodsA three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as ‘critical’ by more than 50% of steering committee members. These interventions and experts’ comments were summarized as final considerations for best practice.ResultsAt the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 ‘critical’ best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept.ConclusionsThis Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

Promoting Patient Safety: Exploring Device-Associated Healthcare Infections and Antimicrobial Susceptibility Pattern in a Multidisciplinary Intensive Care Units.

Device-associated healthcare infections are among the prevailing threats to patient safety worldwide. They constitute the third most common adverse event during healthcare delivery, resulting in heightened morbidity, mortality, and healthcare costs. Patients in intensive care units (ICUs) are at increased risk for device-associated healthcare infections. Focused active surveillance is a crucial measure for assessing the prevalence of healthcare-associated infections and controlling the transmission of pathogens, ultimately contributing to the establishment of quality outcome indicators.This study aimed to investigate and establish the baseline rates of healthcare-associated infections associated with medical devices in adult multidisciplinary ICUs within a tertiary care institute. This hospital-based prospective observational study was conducted in two adult ICUs of atertiary care institute in Central India over nine months. Targeted active surveillance for three device-associated health care infections namely central line-associated bloodstream infection(CLABSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated event (VAE)was conducted as per the Center for Disease Control (CDC)/National Healthcare Safety Network (NHSN) 2016 surveillance definitions and criteria. Pathogens associated with device-associated healthcare infections were identified and their antimicrobial susceptibility profile was studied. During the study period, a total of 5,773 patientdays were investigated. Of1,270patients, 28 episodes of device-associated healthcare infectionswere detected in 26 patients, this suggests a collective occurrence of five device-associated healthcare infections for every 1,000 patient days in the ICUs. The device utilization ratios of the central line, mechanical ventilator, and urinary catheters were 0.33, 0.27, and 0.68, respectively. VAE, CLABSI, and CAUTI rates were 8.92, 5.68, and 0.76 per 1,000 device days, respectively. The most common pathogenisolated from device-associated healthcare infections wasKlebsiella pneumoniae (39%) followed by Acinetobacter baumanii (22%). The majority (82.3%) of pathogens were multidrug resistant. The death rate among device-associated healthcare infections was 69.2% with a crude excess mortality rate of 37.7%. The study sheds light on the proportion, types of device-associated healthcare infections, and underlying etiological agents associated with these infections in our institute's ICUs, thereby facilitating a better understanding of the healthcare-associated infection landscape within our facility. Moreover, the susceptibility patternof pathogens associated with these infections offers crucial information for guiding the selection of appropriate antimicrobial therapies and infection control measures.

Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness

Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited. To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes. The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021. The A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months. The main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes. This study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], -0.6 [0.5] vs -0.9 [0.5]; difference, 0.3 [95% CI, -1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], -2.0 [1.0] vs 0.9 [1.0] visits per person; difference, -1.1 [95% CI, -3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs -2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs -1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs -0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed. The A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization. ClinicalTrials.gov Identifier: NCT03224858.

Biological age is superior to chronological age in predicting hospital mortality of the critically ill.

Biological age is increasingly recognized as being more accurate than chronological age in determining chronic health outcomes. This study assessed whether biological age, assessed on intensive care unit (ICU) admission, can predict hospital mortality. This retrospective cohort study, conducted in a tertiary multidisciplinary ICU in Western Australia, used the Levine PhenoAge model to estimate each patient's biological age (also called PhenoAge). Each patient's PhenoAge was calibrated to generate a regression residual which was equivalent to biological age unexplained by chronological age in the local context. PhenoAgeAccel was a dichotomized measure of the residuals, and its presence suggested that one was biologically older than the corresponding chronological age. Of the 2950 critically ill adult patients analyzed, 291 died (9.9%) before hospital discharge. Both PhenoAge and its residuals (after regressing on chronological age) had a significantly better ability to differentiate between hospital survivors and non-survivors than chronological age (area under the receiver-operating-characteristic curve 0.648 and 0.654 vs. 0.547 respectively). Being phenotypically older than one's chronological age was associated with an increased risk of mortality (PhenoAgeAccel hazard ratio [HR] 1.997, 95% confidence interval [CI] 1.568-2.542; p = 0.001) in a dose-related fashion and did not reach a plateau until at least a 20-year gap. This adverse association remained significant (adjusted HR 1.386, 95% CI 1.077-1.784; p = 0.011) after adjusted for severity of acute illness and comorbidities. PhenoAgeAccel was more prevalent among those with pre-existing chronic cardiovascular disease, end-stage renal failure, cirrhosis, immune disease, diabetes mellitus, or those treated with immunosuppressive therapy. Being phenotypically older than one's chronological age was more common among those with comorbidities, and this was associated with an increased risk of mortality in a dose-related fashion in the critically ill that was not fully explained by comorbidities and severity of acute illness.

Association of CPR simulation program characteristics with simulated and actual performance during paediatric in-hospital cardiac arrest

AimTo evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest. MethodsThis is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016–March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status. ResultsOverall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites. ConclusionsPoint-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.

Pattern of Patients in Intensive Care Unit in a Tertiary Care Hospital in Lumbini Province Nepal

BACKGROUND Intensive care is a crucial component of hospital care, reserved for patients with potentially recoverable conditions who can benefit from invasive treatment. However, in developing countries like Nepal, resources and availability of intensive care become hurdles in delivering healthcare. This study presents the pattern of admission and outcome of patients' management in a general intensive care unit (ICU) of this tertiary care center in Lumbini Province, Nepal. 
 METHODS A cross sectional study conducted in the Department of Internal Medicine, Bheri Hospital between July 2021 to June 2022. A total of 792 patient’s details were obtained from the record section. Demographic data, diagnosis, duration of stay in ICU, managing units, and outcome were collected and analyzed with Statistical Package for the Social Sciences 20.
 RESULTS A total of 729 patients were admitted in the study period; 57.82% were male and 42.18% were female. Majority 60% of admissions were from Department of Medicine followed by Cardiology 24% and Surgery 10%. Pneumonia and Chronic Obstructive Pulmonary Disease 18.30% followed by Myocardial Infraction 14.52%, Acute abdomen 10.22% and sepsis 9.84% were the most common morbidity. Mean duration of ICU stay was 3.5. days. Discharge rate was 69.82% and the mortality rate was 17.80 %. 
 CONCLUSION The most common patients admitted in the ICU of Bheri hospital were mostly Medical cases. Surgical and obstetric cases were lesser in number. The outcomes were comparable with other multidisciplinary ICU of similar settings.

Clinical features and outcomes of patients with myasthenia gravis admitted to an intensive care unit: A 20-year retrospective study.

There are limited data on the clinical characteristics and outcomes of patients with myasthenia gravis (MG) admitted to the intensive care unit (ICU) at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). The aim was to study the clinical characteristics and outcomes of patients with MG admitted to the CMJAH over two decades. A retrospective study was undertaken of patients with MG admitted to the multidisciplinary ICU of CMJAH over a 20-year period, from 1998 to 2017. Demographic data, clinical features, management and outcomes of patients were assessed and reviewed from the case records. Thirty-four patients with MG were admitted to the ICU during this period: 24 female and 10 male. The mean age ± SD was 37.4 ± 13.0 years, with a range of 16 - 66 years. Four patients were human immunodeficiency virus (HIV)-positive. The mean length of stay (LOS) in ICU was 10.6 ± 20.1 days, ranging from 1 to 115 days. Two patients were diagnosed with MG in the ICU after failure to wean from the ventilator. Overall, 22 patients were intubated and ventilated on admission. Morbidities included self-extubation, aspiration pneumonia and iatrogenic pneumothorax. History of thymectomy was present in 12 patients. The treatments received for MG included pyridostigmine (73.5%), corticosteroids (55.9%), azathioprine (35.3%), plasmapheresis (26.5%) and intravenous immunoglobulin (8.8%). The overall mortality in the ICU was 5.9%. MG is a serious disorder with considerable morbidity and mortality. It is, however, a potentially manageable disease, provided that appropriate ICU resources are available. This study provides further insight into the characteristics and outcomes of myasthenia gravis patients in ICU, within a South African context.

Expansion of around the clock critical care and emergency medicine clinical pharmacy services at a large urban academic medical center

AbstractThe impact of a pharmacist as a dedicated member of multidisciplinary intensive care unit (ICU) and emergency department (ED) teams has repeatedly been described in the literature for over 20 years. A 2020 position paper published by the Society of Critical Care Medicine and the American College of Clinical Pharmacy recommended the optimal practice model include critical care pharmacists providing direct patient care 24 h a day, 7 days a week. The objective of this paper is to describe the expansion and evolution of clinical pharmacy services provided in the ICU and ED at a large academic health center, beginning in 2015 and accelerated in the face of a global pandemic. This was made possible through a combination of creating new positions and reallocating existing positions to substantially increase ICU and ED clinical pharmacy coverage. Over a 7 year period, the emergency medicine and critical care clinical pharmacy team expanded from six full time equivalent (FTE) employees in 2015 to 16 FTEs in early 2022. This allowed for reduced pharmacist to patient ratios, the expansion of clinical pharmacy services from primarily weekday hours to a 24 h per day coverage model, 7 days a week, and to better support clinical pharmacy specialists providing these services. Rapid expansion of around the clock clinical pharmacy services was only possible through collaboration between clinical and operations pharmacy managers and feedback from members of the multidisciplinary team.

Clinical Practice Guidelines for Management of Pain, Agitation, Delirium, Immobility, and Sleep Disturbance in the Intensive Care Unit: The ABCDEF Bundle.

It is crucial to prevent and manage intensive care unit (ICU) distress caused by a pentad of pain, agitation, delirium, immobility, and sleep disturbance (PADIS) to optimize immediate and longterm recovery and outcomes of critically ill patients. This clinical practice guideline provides an update on the prevention, management, and liberation of PADIS in adult ICU patients using an integrated, evidence-based, multidisciplinary ICU protocol: the ABCDEF bundle. ABCDEF bundle incorporates assessment, prevention, and management of pain; both spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT); choice of sedation and analgesia; delirium: assessment, prevention and management, and early mobility and exercise; family involvement and empowerment (ABCDEF) together as a PADIS care bundle. This is a multidimensional ICU liberation bundle which is a patient-oriented, holistic team approach to the management of critically ill patients aimed at reducing ICU distress and immediate and long-lasting consequences of PADIS.

Factors that may threaten or protect the wellbeing of staff working in paediatric intensive care environments

ObjectiveThis study explored the risk and protective factors for wellbeing from the perspectives of multidisciplinary paediatric intensive care unit staff. DesignUsing a qualitative, descriptive study design we purposively recruited a sample of nurses, physicians, and allied health professionals to participate in semi-structured interviews which explored staff perceptions of risk and protective factors relating to their daily paediatric intensive care roles. Data was analysed using thematic analysis. SettingFour paediatric intensive care units in Australia. FindingsTwenty staff were recruited. Braun and Clarke’s thematic analysis approach identified perceived risks for wellbeing included a lack of preparation for the role, and clinical situations that contributed to psychological distress, including perceived worst shift, moral distress, non-accidental injuries, and isolation. Themes perceived as protective to wellbeing included: finding the work stimulating and meaningful, belonging to the team, and using humour. ConclusionStaff perceptions of wellbeing in the paediatric intensive care unit suggested that risk factors often co-existed simultaneously with protective factors. These results are not consistent with the notion that wellbeing as a phenomenon can be considered on a risk-protection continuum. Strategies that enhance this work as meaningful and stimulating, promote a sense of belonging to the team, and support the use of humour, may assist health professionals to achieve a balance between risk and protective factors for wellbeing. Implications for clinical practiceEducation and training on end-of-life care, and how to have difficult conversations and manage the consistent psychological distress of intensive care work, is essential at orientation and requires regular formal interventions.Experiencing the work as stimulating highlights the need for advanced scope of practice work. Opportunities for individual and team reflection about the meaning and purpose of their work, and ensuring staff feel valued and experience a sense of belonging to the team, are critical to the intensive care context.

Identification of an optimal threshold to define oliguria in critically ill patients: an observational study

BackgroundThe relevance of current consensus threshold to define oliguria has been challenged by small observational studies. We aimed to determine the optimal threshold to define oliguria in critically-ill patients.MethodsCohort study including adult patients admitted within a multi-disciplinary intensive care unit between January 1st 2010 and June 15th 2020. Patients on chronic dialysis or who declined consent were excluded. We extracted hourly urinary output (UO) measurements along with patient’s characteristics from electronic medical records and 90-day mortality from the Swiss national death registry. We randomly split our data into a training (80%) and a validation (20%) set. In the training set, we developed multivariable models to assess the relationship between 90-day mortality and the minimum average UO calculated over time windows of 3, 6, 12 and 24 h. Optimal thresholds were determined by visually identifying cut-off values for the minimum average UO below which predicted mortality increased substantially. We tested models’ discrimination and calibration on the entire validation set as well as on a subset of patients with oliguria according to proposed thresholds.ResultsAmong the 15,500 patients included in this analysis (training set: 12,440, validation set: 3110), 73.0% (95% CI [72.3–73.8]) presented an episode of oliguria as defined by consensus criteria (UO < 0.5 ml/kg/h for 6 h). Our models had excellent (AUC > 85% for all time windows) discrimination and calibration. The relationship between minimum average UO and predicted 90-day mortality was nonlinear with an inflexion point at 0.2 ml/kg/h for 3 and 6 h windows and 0.3 ml/kg/h for 12 and 24 h windows. Considering a threshold of < 0.2 ml/kg/h over 6 h, the proportion of patients with an episode of oliguria decreased substantially to 24.7% (95% CI [24.0–25.4]). Contrary to consensus definition, this threshold identified a population with a higher predicted 90-day mortality.ConclusionsThe widely used cut-off for oliguria of 0.5 ml/kg/h over 6 h may be too conservative. A cut-off of 0.2 ml/kg/h over 3 or 6 h is supported by the data and should be considered in further definitions of oliguria.

Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE): Trial of Fentanyl versus Fentanyl + Dexmedetomidine for Maintenance of Sedation

Abstract Objectives This article observes the mean daily dose of fentanyl required for adequate sedation in critically ill, mechanically ventilated children randomized to receive dexmedetomidine or placebo. Methods We conducted Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multicenter, double-blind, randomized, placebo-controlled, dose-escalating trial. We enrolled children aged 35 weeks postmenstrual to 17 years (inclusive) admitted across 13 pediatric multidisciplinary and cardiac intensive care units. Adequate sedation was based on a State Behavioral Score and Richmond Agitation-Sedation Scale of –1 or lower. Only the first two dexmedetomidine dosing cohorts opened for enrollment, due to early trial closure during the coronavirus 2019 pandemic. Thirty children were randomized over 13 months and included in the analyses. Results Demographic and baseline characteristics were not different between dexmedetomidine and placebo cohorts. Similarly, mean daily fentanyl use was not different, using an unadjusted mixed regression model that considered treatment, time, and a treatment-by-time interaction. Adverse events and safety events of special interest were not different between cohorts. Conclusion The DOSE trial revealed that dexmedetomidine added to fentanyl does not impact safety and may not spare fentanyl use in critically ill children, although the trial did not meet its recruitment goals, due to early closure during the coronavirus 2019 pandemic. More rigorous inpatient pediatric trials like DOSE that study critically ill, mechanically ventilated children are needed. Despite the many obstacles faced, the DOSE trial presents challenges from which the greater research community can learn and use to optimize future therapeutic trials in children.

A qualitative study of how team characteristics and leadership are associated with information sharing in multidisciplinary intensive care units

BackgroundBetter information sharing in intensive care units has been associated with lower risk-adjusted mortality. This study explored how team characteristics and leadership are associated with information sharing in 4 intensive care units in a single large urban, academic medical center. MethodsA qualitative study was conducted to understand how team characteristics and leadership are associated with information sharing. Qualitative data were conducted through ethnographic observations. One postdoctoral research fellow and one PhD qualitative researcher conducted nonparticipant observations of a Medical, Surgical, Neurological, and Cardiothoracic intensive care unit morning and afternoon rounds, as well as nurse and resident handoffs from May to September 2021. Field notes of observations were thematically analyzed using deductive reasoning anchored to the Edmondson Team Learning Model. This study included nurses, physicians (ie, intensivists, surgeons, fellows, and residents), medical students, pharmacists, respiratory therapists, dieticians, physical therapists, physician assistants, and nurse practitioners. ResultsWe conducted 50 person-hours of observations involving 148 providers. Three themes emerged from the qualitative analysis: (1) team leaders used variable leadership techniques to involve team members in discussions for information sharing related to patient care, (2) predefined tasks for team members allowed them to prepare for effective information sharing during intensive care unit rounds, and (3) a psychologically safe environment allowed team members to participate in discussions for information sharing related to patient care. ConclusionInclusive team leadership is foundational in creating a psychologically safe environment for effective information sharing.

Outcomes of patients with haematological malignancies and febrile neutropenia at the Universitas Academic Hospital multidisciplinary intensive care unit, Free State Province, South Africa.

Mortality rates in patients with haematological malignancies who required intensive care unit (ICU) admission have in the past been high. More recently, however, improved outcomes for critically ill haematological patients have been reported. To determine outcomes, average length of ICU stay, and factors associated with mortality in patients with haematological malignancies and neutropenic fever in the multidisciplinary ICU (MICU) at Universitas Academic Hospital (UAH), Bloemfontein, Free State Province, South Africa. We conducted a retrospective review of medical and laboratory records of all patients admitted to the UAH MICU with haematological malignancies and febrile neutropenia between 2010 and 2019. A total of 182 patients with haematological malignancies were admitted to the MICU between 1 January 2010 and 31 December 2019, of whom 51 (28.0%) fulfilled the inclusion criteria for the study. The median age was 33 years, and 29 patients (56.9%) were female. Most patients had either acute myeloid leukaemia (n=22; 43.1%) or acute lymphocytic leukaemia (n=16; 31.4%), while B-cell lymphoma (n=12; 23.5%) and multiple myeloma (n=1; 2%) were less frequent. The median length of stay in the ICU was 3 days. ICU mortality was 76.5% and hospital mortality 82.4%. Factors associated with mortality included septic shock, vasoactive agent use and mechanical ventilation. Patients with haematological malignancies and febrile neutropenia in the UAH MICU have high ICU and hospital mortality rates. More needs to be done with regard to timeous management of patients with haematological malignancies and septic shock in our setting to improve survival. This is the first study to report on ICU mortality of adult patients with haematological malignancies and neutropenic sepsis in a tertiary hospital ICU in the Free State. These patients had a high mortality rate. What the study adds. Our study shows that septic shock, vasoactive agent use and mechanical ventilation were associated with increased ICU mortality.Implications of the findings. Strict adherence to infection prevention and control measures in haematology wards is required. Early recognition and treatment of sepsis before it progresses to septic shock is important. ICUs must be designed so that isolation cubicles are readily available to prevent cross-infection of patients.

Down-Regulation of the Mineralocorticoid Receptor (MR) and Up-Regulation of Hydroxysteroid 11-Beta Dehydrogenase Type 2 (HSD11B2) Isoenzyme in Critically Ill Patients.

Objective: The mineralocorticoid receptor (MR) has two ligands, aldosterone and cortisol. Hydroxysteroid 11-beta dehydrogenase (HSD11B) isoenzymes regulate which ligand will bind to MR. In this study we aimed to evaluate the expression of the MR and the HSD11B isozymes in peripheral polymorphonuclear cells (PMNs) in critical illness for a 13-day period.Design: Prospective studySetting: One multi-disciplinary intensive care unit (ICU)Participants: Forty-two critically ill patientsMethods: Messenger RNA (mRNA) expression of MR, HSD11B1, and HSD11B2, aldosterone levels, and plasma renin activity (PRA) were measured in 42 patients on ICU admission and on days 4, 8, and 13. Twenty-five age and sex-matched healthy subjects were used as controls.Results: Compared to healthy controls, MR expression in critically ill patients was lower during the entire study period. HSD11B1 expression was also lower, while HSD11B2 expression was higher. In patients, PRA, aldosterone, the aldosterone:renin ratio, and cortisol remained unaltered during the study period.Conclusion: Our results suggest that, in our cohort of critically ill patients, local endogenous cortisol availability is diminished, pointing towards glucocorticoid resistance. Aldosterone probably occupies the MR, raising the possibility that PMNs might be useful to study to gain insights into MR functionality during pathological states.

Measuring Performance on the ABCDEF Bundle During Interprofessional Rounds via a Nurse-Based Assessment Tool

Nurse-led rounding checklists are a common strategy for facilitating evidence-based practice in the intensive care unit (ICU). To streamline checklist workflow, some ICUs have the nurse or another individual listen to the conversation and customize the checklist for each patient. Such customizations assume that individuals can reliably assess whether checklist items have been addressed. To evaluate whether 1 critical care nurse can reliably assess checklist items on rounds. Two nurses performed in-person observation of multidisciplinary ICU rounds. Using a standardized paper-based assessment tool, each nurse indicated whether 17 items related to the ABCDEF bundle were discussed during rounds. For each item, generalizability coefficients were used as a measure of reliability, with a single-rater value of 0.70 or greater considered sufficient to support its assessment by 1 nurse. The nurse observers assessed 118 patient discussions across 15 observation days. For 11 of 17 items (65%), the generalizability coefficient for a single rater met or exceeded the 0.70 threshold. The generalizability coefficients (95% CIs) of a single rater for key items were as follows: pain, 0.86 (0.74-0.97); delirium score, 0.74 (0.64-0.83); agitation score, 0.72 (0.33-1.00); spontaneous awakening trial, 0.67 (0.49-0.83); spontaneous breathing trial, 0.80 (0.70-0.89); mobility, 0.79 (0.69-0.87); and family (future/past) engagement, 0.82 (0.73-0.90). Using a paper-based assessment tool, a single trained critical care nurse can reliably assess the discussion of elements of the ABCDEF bundle during multidisciplinary rounds.

INCIDENCE, INDICATION AND OUTCOME OF EMERGENCY PERIPARTUM HYSTERECTOMIES IN A TERTIARY CARE HOSPITAL

BACKGROUND: Emergency peripartum hysterectomy is the life-saving procedure to control a life-threatening haemorrhage performed at the moment or within 24 hrs of delivery (caesarean or vaginal). It is linked to a substantial percentage of maternal morbidity and mortality.AIM:To estimate the incidence,indication,and outcome of emergency peripartum hysterectomy over a 1-year period in a tertiary care hospital and the leading cause of the increased no of hysterectomies in the defined time interval. MATERIAL AND METHODS: This is a prospective study done in SMGS HOSPITAL, JAMMU, a tertiary care hospital. This study included all women who underwent emergency peripartum hysterectomy over a span of 1 year (August 1,2021,to July 31,2022).Detailed review including previous obstetric history, details of index pregnancy, an indication of peripartum hysterectomy, outcome, and infant morbidity was taken into account. RESULTS: During the course of the research, there were 33 women who had undergone peripartum hysterectomy. The incidence rate was 1.8 cases per 1000 births. The predominant indications were placenta accreta (69%),Atonic PPH (Postpartum haemorrhage) (18%),and uterine rupture (9%).Emergency peripartum hysterectomies were more prevalent after caesarean section (73%) than vaginal births (27%).Previous caesarean,multiparity,any past uterine surgeries, and older age were risk factors. 48% of women needed intensive care postoperatively.The common maternal complications were bladder injury (intraop) (12%), febrile morbidity (18%), disseminated intravascular coagulation (DIC) (8%),acute kidney injury (AKI) (9%),and wound infection (10%).There were 2 maternal deaths (6%) following emergency peripartum hysterectomy. The patient's condition was taken into consideration while deciding whether a complete or partial hysterectomy would be best.CONCLUSIONS: Abnormal placentation,placenta accreta, has surpassed uterine atony as the leading cause of emergency hysterectomy during the perinatal period in recent years. The primary reason for this is the growing popularity of caesarean sections. Peripartum hysterectomies for diagnosed cases of placenta accreta with antenatal anticipation of the risk factors,a multidisciplinary approach and ICU backup had better outcomes with less morbidity.An important factor influencing the maternal outcome was the timing of the decision to perform a peripartum hysterectomy which is neither too early nor too late