Patients In Critical Care Units Research Articles

Family caregivers’ expectations and needs in Critical Care Units

Introduction: Patient admission into the critical care unit is usually an unpleasant and unexpected life experience for the family members, and unusual for family members to cope with stress and anxiety during their hospital stay. 
 Purpose: This study aimed to explore the expectations and needs of family members of the patients in critical care units at two tertiary care hospitals in Islamabad.
 Methodology: An exploratory descriptive design was used to address the study questions. Using purposive sampling, 14 family members were individually interviewed through a semi- structured interview guide. A conventional content analysis method was used to analyze the data through which categories and sub-categories were identified.
 Findings: The data analysis revealed three roles of the family members, which included assistance in physical care, facilitator in the provision of treatment and the decision maker. The participants expressed that their needs for information and assurance were being met to some extent; however, their need for support and comfort were not. Although the physical facilities for meeting the comfort were available in private hospital, it did not match the family members’ expectations.
 Conclusion: This study revealed that despite some similarities in the role and needs, the expectations and satisfaction of the family members is linked to their awareness of the healthcare system as well as the cost of the obtained services. The suggestions of the family members are implementable to improve their experiences and satisfaction in critical care units, which can enable them to perform their roles better.

193 Balancing Education and Practice: A Reflection from A Simulation Educator During The COVID-19 Pandemic

I consider myself privileged to divide my work time between my roles as a clinical simulation educator and as an intensive care nurse in a large teaching hospital. I find that working alternate weeks in educational and clinical roles can be challenging because both demand complementary but different skills. However, I am thrilled to have the opportunity to continue caring for patients alongside supporting and learning with colleagues. Balancing these roles during a pandemic presented me with new challenges and rewards, and reflection on these experiences has given me some fascinating insights. As the COVID-19 pandemic progressed and the number of patients requiring admission to the Critical Care Unit increased, the units were expanded and staff were redeployed from other areas to provide support. These ‘surge’ staff required rapidly developed simulation-based training to allow them to work in this unfamiliar environment within a restricted scope of practice. Being involved with delivering this training as well as working with surge staff in Critical Care afforded me a deeper understanding of the surge role and the unique challenges it presented. Once surge training was completed and I returned to delivering our standard simulation-based education courses, my experiences of working clinically continued to enrich my teaching because I felt somewhat familiar with some of the challenges our learners were facing as the pandemic continued. Over the last year, I have felt conflicted at times; when working clinically during the peak of the pandemic, there was very little time to facilitate learning at the bedside, and during my educator weeks I relished the opportunity to support and teach but felt guilty for spending time away from colleagues and patients in Critical Care Unit. However, continuing with both roles better equipped me to answer questions and to provide support during surge training, particularly for those staff who had not yet spent time on the units. When assisting with other courses as a faculty member, I was able to deeply empathize with participants who encountered situations that I had become familiar with in practice – for example, communicating with others when wearing full personal protective equipment – which helped me to validate and normalize some of the experiences shared during debrief discussions. Through continuing to reflect on my time spent working in these environments during the pandemic so far, I hope to present my learning and recommendations for optimizing practice under challenging circumstances.

Impact of a National Multicentric Strategy to Support Kidney Transplant Patients During the COVID-19 Pandemic in Latin America: FUTAC Team Creation and Activities.

Impact of a National Multicentric Strategy to Support Kidney Transplant Patients During the COVID-19 Pandemic in Latin America: FUTAC Team Creation and Activities.

COVID-19 PANDEMIC EXPERIENCE IN THE UNITED KINGDOM – A NATIONAL SURVEY ABOUT CARDIAC CASES, WORK PATTERNS OF CARDIAC ANAESTHETISTS AND SUPPORT

IntroductionThe COVID-19 pandemic started in Hubei Province, China in 2019 with the first confirmed cases in the UK in January 2020. On May 21st 2020, there were 158,488 confirmed cases in England and Wales with 33,081 deaths in SARS-CoV-2 positive patients (1). From March 2020 onwards, emergency cardiac operations were prioritised and individual work patterns adjusted. The skill set of cardiac anaesthetists, often including an expertise in critical care medicine, extracorporeal membrane oxygenation and echocardiography, was useful for the multidisciplinary medical care of COVID-19 patients in critical care units. The aim of this survey was to assess individual cardiac anaesthetic experiences during the first wave of the COVID-19 pandemic in the UK.MethodsWe conducted a survey, supported by the Association for Cardiothoracic Anaesthesia and Critical Care (ACTACC). A 16-question survey related to the first UK COVID-19 surge in April and May 2020 was sent to the membership of ACTACC in 36 cardiac centres in July 2020. Data was collected and collated using the web-based survey platform “Survey Monkey” (Palo Alto, CA).ResultsThere were 80 completed responses, indicating a response rate of about 20%. The majority of anaesthetists continued cardiac anaesthesia with emergency cases (53%) and urgent cases (65%) only at their centres. Every 5th cardiac anaesthetist (22%) was re-deployed to a different unit in their hospital or to a different hospital. The clinical work pattern changed at least moderately for the majority of cardiac anaesthetists (86%). The majority of anaesthetists (90%) felt appropriately supported when they stepped outside of their usual clinical role during the pandemic and 95% felt that their existing skillset was appropriately used. The workload increased in a majority of cardiac anaesthetists (53%), but it also decreased for some (35%). Non-resident on-calls increased for about 1/3 (36%) of respondents and resident on-calls increased for 50% of cardiac anaesthetists. A majority of anaesthetists (85%) wore PPE during their clinical work and 95% felt that the supply of PPE was adequate. The most useful source of information during the pandemic was peer discussion, chosen by more than half of cardiac anaesthetists (54%).DiscussionThe results of this national survey for cardiac anaesthetists during the first COVID-19 wave in the UK demonstrate that work patterns for cardiac anaesthetists changed dramatically. These changes may have an effect on psychological wellbeing of cardiac anaesthetists (2). However, the majority of anaesthetists felt well supported in their clinical work. Peer discussions scored high as useful sources of information, suggesting that professional networks are crucial to both, personal wellbeing and good patient care. One limitation of this survey is a low response rate, with potentially more extreme experiences in the non-responder group, emphasising the importance of support measures and the challenge of gauging that they are effective.We conclude, that with subsequent COVID-19 peaks, there is a continued need to address potential effects of major changes of work patterns by cardiac anaesthetists on burnout, psychological wellbeing and resilience.

Introducing the WCN consciousness scale: A comprehensive tool to assess consciousness in the critical care setting

Different specialties use different neurologic terminology, scales and flowsheets when it comes to the assessment of unconscious patients in critical care units, and no agreement identifies slight decreases in the degree or content of consciousness. Mild decrements in consciousness without full deterioration can be assessed with a simple clinical examination to assess nuanced domains of consciousness more accurately than AVPU, JCS, GCS, FOUR, RASS, CAM-ICU or NIHSS.

Spleno-aortic radiodensity ratio – A distinctive imaging feature to predict short-term outcome in critical care unit

IntroductionTo investigate the value of contrast-enhanced CT findings - splenic and aortic radiodensities and their ratios (spleno-aortic ratio) - in predicting the prognosis of critical care unit patients (CCU). MethodsOne hundred thirteen continuous CCU patients with an acute deterioration (Group A: 37 women, age: 67.2 ± 14.0 years) were included in the retrospective study. Radiodensities of the spleen and aorta were evaluated by two radiologists separately. The spleno-aortic ratio was calculated. Matthews correlation coefficient (MCC) was used in conjunction with receiver operating characteristic analysis (ROC) to assess if and which parameter was most suitable for short-term mortality prediction. The intra-class correlation coefficient assessed consensus across readers. To validate the results for the best predictor, a second cohort was evaluated (Group B: 354 CT scans). ResultsThe portal venous spleno-aortic ratio was best suited to predict 72-hour mortality (AUC = 0.91). A threshold ratio ≤0.53 predicted short-term mortality with a high sensitivity (80.95%) and specificity (96.74%, MCC = 0.79). The post-test probability was 85%, assuming a pre-test probability of 18.6% (72-hour mortality rate). ICCs of HU measurements in the aorta, spleen, and its ratios showed high interrater agreement (ICC: 0.92–0.99). In a control cohort, a threshold ratio ≤0.53 predicted CCU patientś outcome satisfactorily (SENS = 83.93%, SPEC = 97.65%, PPV = 87.00%, NPV = 97.00%). ConclusionsThe portal venous spleno-aortic ratio serves as a distinctive imaging feature to predict short-term mortality. For CCU patients with a cut-off portal venous spleno-aortic ratio ≤0.53, the risk of dying within three days after CT scan is approximately twenty times higher.

Diabetes Related Morbidity. Causes of Diabetes Related Hospital Admissions: A Cross Sectional Study

Diabetic patients have a high morbidity and mortality related directly or indirectly to their hyperglycemia. The increase in prevalence of diabetes combined with the aforementioned fact puts an increasing burden on the healthcare system and its budget. Strategies to estimate global and local diabetes complications might offer insights to better allocate budget and resources in the future. Method: This is a cross sectional study performed in a teaching hospital from December 2020- to January 2021. Hospitalized patients in medical and critical care units are collected to estimate the incidence of diabetes related morbidity. Two hundred and twenty patients were admitted in this period, two thirds of the admissions were classified as diabetes related. Conclusion: Diabetes carries a higher burden in our cohort compared to global rates and strategies to minimize their complications is urgent and necessary.

Association between sleep disturbance and physiological parameters of critically ill patients

Background Adequate sleep quality is required for maintaining the mental and physical health for patients in critical care units (CCUs). Aim: This study aimed to evaluate the association between sleep disturbance and physiological parameters in critically ill patients. Study design and Methods: A descriptive exploratory study was conducted on purposive sample of 100 critically ill patients in a mixed critical care unit at Assiut University Main Hospital, Egypt. The sleep quality and quantity of each previous night were assessed by using ST Mary’s Hospital Sleep questionnaires which was completed every day in the morning between 7 AM and 9 AM for four consecutive days (the 1st day of admission to CCU concerning the first night of sleep in the CCU and 3 consecutive days). Pulse, respiration, and mean arterial blood pressure were evaluated every two hours daily for four days. Results: The majority of the study sample (98%) complaining from moderated sleep disturbance, which is positively correlated with physiological parameters (heart rate, mean arterial blood pressure and respiration). Conclusion: Poor sleep quality causes significant changes in heart rate, mean arterial blood pressure and respiration among patients in CCUs. Recommendations: These findings suggest the need to educate nurses in critical care units on how to assess sleep and to take measures to maintain adequate sleep and then added these to routine care of patients in CCUs

The effect of cardiac rhythm on artificial intelligence-enabled ECG evaluation of left ventricular ejection fraction prediction in cardiac intensive care unit patients

The presence of left ventricular systolic dysfunction (LVSD) alters clinical management and prognosis in most acute and chronic cardiovascular conditions. While transthoracic echocardiography (TTE) remains the most common diagnostic tool to screen for LVSD, it is operator-dependent, time-consuming, effort-intensive, and relatively expensive. Recent work has demonstrated the ability of an artificial intelligence-augment ECG (AI-ECG) model to accurately predict LVSD in critical intensive care unit (CICU) patients. We demonstrate that the AI-ECG algorithm can maintain its performance in these patients with and without AF despite their clinical differences. An AI-ECG algorithm can serve as a non-invasive, inexpensive, and rapid screening tool for early detection of LVSD in resource-limited settings, and potentially expedite clinical decision making and guideline-directed therapies in the acute care setting.

Evaluation of COVID-19 Patients in The Pediatric Critical Care Unit

Objective: Few cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported in children compared with the total number of cases in the general population. No pediatric studies (or cases) have evaluated extracorporeal techniques in severe coronavirus disease 2019 (COVID-19) patients. In this article, we aimed to describe the clinical features, treatments, and outcomes of four children with COVID‐19 who were treated with therapeutic plasma exchange (TPE) and continuous renal replacement therapy (CRRT) in our pediatric intensive care unit (PICU). Materials and Methods: The children with COVID 19 pneumonia admitted to the PICUs from March 23, and May 6, 2020 were collected. Demographic data and reason for hospitalization were recorded. Vital and laboratory findings were examined in children with extracorporeal treatments. Results: Noninvasive mechanical ventilation, antiviral and antibacterial therapy, supportive antioxidant treatments were administered for 11 children. Respiratory failure and vital signs were more serious in four patients than in other patients. Therefore, we performed extracorporeal support treatments, TPE and CRRT. The patients showed a rapid clinical response to these treatments. Conclusion: TPE and CRRT can use for severe COVID-19 infection receiving other supportive and medical treatments in children.

The Effect of Cognitive-Behavioral Therapy (CBT) on Anxiety Reduction in Critical Care Unit (CCU) Patients During Hospitalization

Patients admitted to Critical Care Units (CCU) face multiple stressors, and these stressors cause anxiety in patients. Anxiety increases heart function in heart patients. High levels of anxiety in cardiac patients increase in association with hospital complications. The purpose of this study was to determine the effect of Cognitive-Behavioral Therapy (CBT) on reducing the anxiety of patients in CCU during their hospitalization. The study design was quasi-experimental (pre-test and post-test). This study was performed on patients in CCU of Shahid Mostafa Khomeini hospital in 2019; for this purpose, 30 patients in CCU were randomly divided into intervention (n=15) and control (n=15) groups. Before the intervention, the demographic variables questionnaire and DASS-21 anxiety questionnaire were completed by both groups. Then, the intervention group received CBT for eight sessions according to the average number of hospital days (eight days) by the therapist (researcher). The control group did not receive any intervention. After the intervention, the demographic variables questionnaire and DASS-21 questionnaire were completed by the intervention and control groups again. Data analysis was done by SPSS-21 software and descriptive tests, ANOVA, and independent and pairwise t-test. There was no significant difference between the two groups in the mean score of anxiety before treatment, but the mean score of anxiety significantly decreased after treatment in the intervention group (9.63±2.773) compared to the control group (13.23±2.115; p<0.001). CBT can reduce the level of anxiety in patients admitted to CCU, and this method can be used as a simple and low-cost complementary non-pharmacological practice in these patients.

A systematic review of the effects of nicotine replacement therapy on agitation among nicotine-dependent psychiatric inpatients

AimsThis systematic review aims to evaluate the effect of nicotine replacement therapies (NRTs) on measures of agitation amongst nicotine-dependent adult psychiatric inpatients.BackgroundSince the introduction of the smoke-free policy for all psychiatric facilities, a psychiatric admission is likely to upset a nicotine-dependent individual's normal routine of nicotine consumption. In addition to the physiological effects of nicotine withdrawal (NW), the interpersonal dynamic which nurse-led guardianship of nicotine products constructs presents stressors to the nicotine dependent patient.Several systematic reviews evaluating changes in objective measures of agitation amongst smoking patients in medical critical care units have found varied results, with some demonstrating worsening agitation with NRT use. We therefore believe that there is sufficient equipoise in the use of NRT to prompt a review of studies amongst psychiatric inpatients.MethodThis review identified English language studies through developed search strategies in PubMed/MEDLINE, EMBASE, PyschINFO, PSYCHLit, Cochrane databases, and Google scholar. The bibliographies of notable papers were explored. Hand searches of five major psychiatric journals were conducted. Peer reviewed studies of any study design were included if they reported primary data of adult psychiatric inpatients. Studies were extracted from 1990 – present, this was felt appropriate as nicotine replacement patches became available in 1992.Search strategies were informed by MeSH search terms and included multiple conceptions of “agitation”, including variations on; agitation, irritability, and arousal to capture the concept from broad academic constructions. The quality of studies was assessed with the Newcastle-Ottawa and Cochrane Collaboration tools.This review follows PRISMA guidelines, and an application for PROSPERO registration has been submitted pending acceptance.ResultTwo studies were identified which matched inclusion criteria. A double-blinded randomised placebo-controlled trial of 40 nicotine-dependent inpatients from Allen et al. reported a significant 23% reduction in Agitated Behaviour Scores at 24 hours following NRT administration on admission compared to their matched placebo controls. Yet a retrospective cross-sectional analysis from Okoli using scores for NW identified more severe withdrawal symptoms including “restlessness” and “anger/irritability” than nicotine-dependent patients not provided with NRT.ConclusionDespite considerable commentary within literature there is presently only one study providing moderate evidence of a positive benefit to measures of agitated behaviour from the use of NRT amongst nicotine-dependent psychiatric inpatients. There is currently very low evidence whether NRT improves or exacerbates the agitation associated with NW amongst nicotine-dependent psychiatric inpatients.

Hepatic portal vein gas detected by point of care ultrasound.

IntroductionPortal venous gas is a rare finding in adults and is typically associated with underlying intestinal ischemia. Portal venous gas can be detected by a bedside point of care ultrasound (POCUS) examination in adult patients in critical care units (CCU). Findings include echogenic bubbles flowing centrifugally throughout the portal venous system.Case presentationWe present the case of a 73-year-old female with advanced ischemic cardiomyopathy and cardiorenal syndrome who was managed in the CCU. She developed vague abdominal pain and respiratory depression requiring intubation and dialysis during her course of treatment in the CCU. Her findings were consistent with portal venous gas upon POCUS, prompting computed tomography of her abdomen and surgical consultation. She was ultimately found to have nonobstructive mesenteric ischemia.Clinical discussionPVG is an ominous radiological sign and reflects intestinal ischemia in up to 72% of cases. Acute mesenteric ischemia of the small bowel could be due to occlusive or nonocclusive obstruction of the arterial blood supply or obstruction of venous outflow. Nonocclusive obstruction accounts for 5% to 15% of patients with acute mesenteric ischemia.ConclusionWith the increasing use of POCUS, critical care physicians should be aware of findings consistent with portal venous gas as a bedside tool for directing the treating physician toward an ominous diagnosis in patients with shock.

Design and Modelling of a Continuum Robot for Distal Lung Sampling in Mechanically Ventilated Patients in Critical Care.

In this paper, we design and develop a novel robotic bronchoscope for sampling of the distal lung in mechanically-ventilated (MV) patients in critical care units. Despite the high cost and attributable morbidity and mortality of MV patients with pneumonia which approaches 40%, sampling of the distal lung in MV patients suffering from range of lung diseases such as Covid-19 is not standardised, lacks reproducibility and requires expert operators. We propose a robotic bronchoscope that enables repeatable sampling and guidance to distal lung pathologies by overcoming significant challenges that are encountered whilst performing bronchoscopy in MV patients, namely, limited dexterity, large size of the bronchoscope obstructing ventilation, and poor anatomical registration. We have developed a robotic bronchoscope with 7 Degrees of Freedom (DoFs), an outer diameter of 4.5 mm and inner working channel of 2 mm. The prototype is a push/pull actuated continuum robot capable of dexterous manipulation inside the lung and visualisation/sampling of the distal airways. A prototype of the robot is engineered and a mechanics-based model of the robotic bronchoscope is developed. Furthermore, we develop a novel numerical solver that improves the computational efficiency of the model and facilitates the deployment of the robot. Experiments are performed to verify the design and evaluate accuracy and computational cost of the model. Results demonstrate that the model can predict the shape of the robot in <0.011s with a mean error of 1.76 cm, enabling the future deployment of a robotic bronchoscope in MV patients.

Distribution of High-Sensitivity Troponin Taken Without Conventional Clinical Indications in Critical Care Patients and Its Association With Mortality.

To describe the distribution of high-sensitivity troponin in a consecutive cohort of patients in critical care units, regardless of clinical indication, and its association with clinical outcomes. Prospective observational study. Single-center teaching hospital. Consecutive patients admitted to two adult critical care units (general critical care unit and neuroscience critical care unit) over a 6-month period. All patients had high-sensitivity troponin tests performed at admission and tracked throughout their critical care stay, regardless of whether the supervising team felt there was a clinical indication. The results were not revealed to patients or clinicians unless clinically requested. There were 1,033 patients in the study cohort (general critical care unit 750 and neuroscience critical care unit 283). The median high-sensitivity troponin was 21 ng/L (interquartile range, 7-86 ng/L), with 560 patients (54.2%) above the upper limit of normal as defined by the manufacturer. Admission high-sensitivity troponin concentrations above the upper limit of normal in general critical care unit and neuroscience critical care unit were associated with increasing age, comorbidity, markers of illness severity, and the need for organ support. On adjusted analysis, the high-sensitivity troponin concentration remained an independent predictor of critical care mortality in general critical care unit and neuroscience critical care unit. High-sensitivity troponin elevation, taken outside the context of conventional clinical indications, was common in the critically ill. Such elevations were associated with increasing age, comorbidity, illness severity, and the need for organ support. Admission high-sensitivity troponin concentration is an independent predictor of critical care mortality and as such may represent a novel prognostic biomarker at admission.

The distribution of microorganisms and antibiotic resistance profile in pulmonary critical care unit patients: A single-centre study

The patients in the intensive care unit have a higher risk of infections because of the poor general condition of these patients and the frequent application of invasive procedures with longer hospitalization length. Also, this group of patients tend to have resistant infections due to empirically widespread and uncontrolled use of broad-spectrum antibiotics. Hence, data are needed to determine appropriate empirical antibiotic therapy in intensive care patients. In this study, it was aimed to assess the distribution of microorganisms and antibiotic resistance profile from the samples taken from the patients in the intensive care unit. Patients who were hospitalized in Ankara University Faculty of Medicine Chest Diseases Intensive Care Unit for more than 24 hours between December 2016 and December 2017 were included in our study. Demographic characteristics, comorbid diseases, clinical findings, results of sputum, tracheal aspirate, blood, urine, gaita and pus culture samples and antibiotic susceptibility test results were recorded prospectively. A total of 287 patients, 150 males and 137 females, were included in the study. The mean age of all patients was 69.96 ± 14.4 years. Two hundred twenty-three positive cultures were detected in 1053 samples taken from 287 patients. Gram-negative bacilli constituted 55.1% of the 223 positive cultures. The most common microorganisms were Acinetobacter (16.6%), Staphylococcus (14.8%) and Klebsiella (10.8%). Colistin resistance was found to be 8.3% in the Acinetobacter strains and resistance rates of 97-100% were observed to other antibiotic groups. Thirty-three staphylococcus were isolated, 17 were S. aureus and 16 were coagulase-negative Staphylococcus. While 29.4% of S. aureus were resistant to methicillin (MRSA), vancomycin resistance was not detected. Meanwhile, the MRSA ratio was 62.5%, there was no vancomycin resistance among the coagulase-negative Staphylococcus. Klebsiella was the third most common microorganism and beta-lactamase producing Klebsiella strain was 62.5%. Gentamycin was found to be the most susceptible antibiotic in Klebsiella strains with a resistance rate of 20.8%. Pseudomonas aeruginosa constituted 9.4% of the cultures. While the resistance to colistin was not detected, resistance to piperacillin/tazobactam 42.8%, tobramycin, imipenem and meropenem 50% and ceftazidime 61.9%. The duration of hospitalization in patients with Acinetobacter isolated (23 [10-34] days vs 12.5 [5-24] days, p= 0.011) and the mortality rate (62.5% vs 37.5%, p= 0.008) were significantly higher than those who were not Acinetobacter isolated. In conclusion, gram-negative bacilli constitute the majority of the patients in intensive care unit. Acinetobacter, the most common microorganism, has a high resistance rate and has been associated with prolonged hospitalization and mortality.

Reducing the Incidence of Medical Device-Related Pressure Injuries From Use of CPAP/BiPAP Masks: A Quality Improvement Project.

The purpose of this work was to reduce the number of hospital-acquired pressure injuries on the nasal bridge resulting from the use of continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) therapy. Patients with medical device-related pressure injuries (MDRPI) receiving continuous/intermittent CPAP/BiPAP in a 12-bed critical care unit in a Magnet-designated, 182-bed community hospital in the mid-Atlantic region of the United States. An interprofessional team collaborated to assess factors contributing to an increase in MDRPI development in critical care unit patients using CPAP/BiPAP. Patient dependency on the high-pressurized oxygen results in nurse reluctance to remove the mask and consequently, conduct a partial or incomplete skin assessment. The project consisted of conducting a literature search on MDRPI, developing a standard work process for skin assessment and documentation in the medical record, using skin protection under the mask, and evaluating whether a different model of mask would minimize pressure on the nasal bridge. Through active collaboration, the interprofessional team implemented standard work processes, completed product evaluation of masks, and monitored key process indicators related to documentation of daily and every 4-hour skin assessments, implementation of a thin foam dressing under the CPAP/BiPAP mask for any nonblanchable or blanchable erythema, and escalation to the certified wound, ostomy, and continence nurse. In 2016, the unit identified 4 CPAP/BiPAP mask-related MDRPIs. By December 2017, only 1 stage 1 injury was identified and it resolved quickly after appropriate assessment and prompt interventions. This showed a 75% reduction in actual injuries with a zero escalation to stage 2 or greater injuries. An interprofessional team approach to CPAP/BiPAP-related MDRPI improved patient outcomes in critical care unit patients.

Torpor versus interbout arousal: what is more important for protein metabolism and regeneration?

Hibernation is used by specie as diverse as ground squirrels, snakes and bats to cope with reduced food availability and lowered temperatures and is a unique model for studying the molecular mechanisms of plasticity in striated muscles. Important questions in modern muscle biology are why some skeletal muscles atrophy and other muscles such as the diaphragm and the heart hypertrophy during hibernation, and why, despite the atrophy, skeletal muscle strength and fatigue resistance are maintained after arousal. The molecular mechanisms responsible are of interest both from a fundamental biological viewpoint and as a potential therapy for patients in critical care units. In this issue of Experimental Physiology, Yan et al. (2021) shed light on the distinctive features of the molecular mechanisms involved in the development of the hypertrophic response in the diaphragm and the atrophic response in the gastrocnemius muscle in hibernating Daurian ground squirrels. In particular, the authors showed that a decrease in protein synthesis, an increase in protein degradation and a decrease in muscle regeneration potential contributed to the atrophy of the gastrocnemius muscles during torpor, while an increase in protein synthesis, a decrease in protein degradation and an increase in muscle regeneration potential contributed to diaphragm muscle hypertrophy. In discussing these new and interesting results, it can be assumed, however, that a significant contribution to the formation of hypertrophic or atrophic muscle phenotype could have been made by changes in anabolic and catabolic processes occurring in interbout arousals, as indicated by the results of recent studies (Chang et al., 2020; Popova et al., 2020 ). Further research is needed to show how important interbout arousals are in the regulation of protein turnover and regeneration in different striated muscles in hibernating animals. Understanding these and other molecular mechanisms is important for choosing strategies and methods for treatment of skeletal muscle pathologies and diseases of the cardiovascular system, as well as for avoiding injurious interventions in cases of energy deficits in critical illness (Stanzani et al., 2020). None declared.

Nurse Educator-Led an Educational Intervention on Critical Care Nurses’ Knowledge Regarding Endotracheal Suctioning

Background: Studies placed a great emphasis on implementing in-service educational intervention fornurses in order to improve their knowledge regarding critical nursing procedures. Therefore, critical-carenurses need to be more knowledgeable and competent in providing patient care. Hence, the researcher(nurse educator) developed structured educational program that mainly focused on endotracheal suctioningbased on evidence-based recommended practice guidelines. Endotracheal suctioning is vitally importantnursing procedure in terms of maintaining airway patency and preventing complications. Objectives:to evaluate the effectiveness of endotracheal suctioning educational program on critical-care nurses’knowledge. Methodology: a quantitative, quasi-experimental one group pre-test and post-test design wasused. Convenience sample of 87 critical-care nurses are recruited from three hospitals at AL-Najaf ALAshraf City. The study conducted over the period of time that started on December 10, 2019 and ended onJanuary 22, 2020. Results: most of the participants had inadequate to moderate knowledge at pre-test. Whileafter implementing the educational intervention, the participants gained more knowledge and statisticalfindings indicated that all nurses have adequate knowledge regarding endotracheal suctioning. Conclusion:Endotracheal suctioning is a widely performed technique for mechanically ventilated patients in critical careunits. Nurses must be competent and well educated to perform this procedure in order to prevent patientpotential complications and achieve best outcomes. Educational intervention that led by nurse educator hasa positive influence on nurses’ knowledge. Recommendations: the researchers are highly recommendedimplementing ongoing educational program by using recent clinically recommended evidence that focuseson areas where knowledge expansion can be achieved to staff nurse. In Iraq, creating postgraduate degreefocusing on nursing education is a cornerstone to engage in the health care team and articulate new scientificapproach by using researches in the clinical setting and apply research findings in clinical practice.

Healthcare resource utilisation and predictors for critical care unit admissions after primary bariatric surgery in an Australian public hospital setting: an exploratory study using a mixed-methods approach.

Objectives The aim of this exploratory study was to investigate resource use and predictors associated with critical care unit (CCU) admission after primary bariatric surgery within the Tasmanian public healthcare system. Methods Patients undergoing primary bariatric surgery in the Tasmanian Health Service (THS) public hospital system between 7 July 2013 and 30 June 2019 were eligible for inclusion in this study. The THS provides two levels of CCU support, an intensive care unit (ICU) and a high dependency unit (HDU). A mixed-methods approach was performed to examine the resource use and predictors associated with overall CCU admission, as well as levels of HDU and ICU admission. Results There were 254 patients in the study. Of these, 44 (17.3%) required 54 postoperative CCU admissions, with 43% requiring HDU support and 57% requiring more resource-demanding ICU support. Overall, CCU patients were more likely to have higher preoperative body mass index and multimorbidity and to undergo sleeve gastrectomy or gastric bypass. Patients undergoing gastric banding were more likely to require HDU rather than ICU support. Total hospital stays and median healthcare costs were higher for CCU (particularly ICU) patients than non-CCU patients. Conclusions Bariatric surgery patients often have significant comorbidities. This study demonstrates that patients with higher levels of morbidity are more likely to require critical care postoperatively. Because this is elective surgery, being able to identify patients who are at increased risk is important to plan either the availability of critical care or even interventions to improve patients' preoperative risk. Further work is required to refine the pre-existing conditions that contribute most to the requirement for critical care management (particularly in the ICU setting) in the perioperative period. What is known about the topic? Few studies (both Australian and international) have investigated the use of CCUs after bariatric surgery. Those that report CCU admission rates are disparate across the contemporaneous literature, reflecting the different healthcare systems and their associated incentives. In Australia, the incidence and utilisation of CCUs (consisting of HDUs and ICUs) after bariatric surgery have only been reported using Western Australian administrative data. What does the paper add? CCU patients were more likely to have a higher preoperative body mass index and multimorbidity and to undergo a sleeve gastrectomy or gastric bypass procedure. Just over half (57%) of these patients were managed in the ICU. Sleeve gastrectomy patients had a higher incidence of peri- and postoperative complications that resulted in an unplanned ICU admission. Hospital length of stay and aggregated costs were higher for CCU (particularly ICU) patients. What are the implications for practitioners? The association of increased CCU (particularly ICU) use with multimorbidity and peri- and postoperative complications could enable earlier recognition of patients that are more likely to require CCU and ICU support, therefore allowing improved planning when faced with increasing rates of bariatric surgery. We suggest streamlined clinical guidelines that anticipate CCU support for people with severe and morbid obesity who undergo bariatric surgery should be considered from a national perspective.