Practice In Intensive Care Unit Research Articles

Pilot Study to Investigate Enteral Feeding Practices and the Incidence of Underfeeding Among Mechanically Ventilated Critically Ill Patients at a Specialist Tertiary Care Hospital in Saudi Arabia.

Enteral nutrition (EN) is an essential therapeutic intervention. Many studies internationally have reviewed feeding practices in intensive care units (ICUs) and recorded the incidence of underfeeding in these settings, yet none were performed in the Middle East, including Saudi Arabia. The purpose of the study is to assess the adequacy of EN delivery and investigate the enteral feeding practices in the ICU at a specialized tertiary care hospital in Saudi Arabia. In this observational study, we prospectively monitored energy and protein delivery for 6 consecutive days in critically ill patients. Malnutrition was assessed by Nutrition Risk Screening (NRS-2002) scores. Underfeeding was identified by comparing the intake against the calculated requirements. Patients were categorized into early and late EN starters to investigate whether the time of EN initiation impacts the cumulative nutrition intake. This study included 43 patients. About 44% (19 of 43) of the patients were malnourished on admission to ICU, and the prevalence of underfeeding was >90%. The median cumulative intake of energy and protein was 39% and 31% of the estimated requirements, respectively. Patients who started early EN had statistically higher cumulative energy and protein intake (P-value = .00). Patients treated with inotropes received less energy and protein compared with those who did not receive inotropes (P-value = .00). Higher NRS-2002 score was associated with fewer ventilation-free hours (r = -0.369, P-value = .045). Protein underfeeding remains a significant problem in ICU settings. The time of EN initiation plays a major role in determining when the nutrition requirements will be met. Therefore, it is crucial to implement effective feeding protocols to ensure early initiation of EN when permissible.

Implementation of the Comprehensive Unit-Based Safety Program to Improve Hand Hygiene in Four NICUs in Pune, India

Background: In low- and middle-income country (LMIC) healthcare facilities, gaps in infection prevention and control (IPC) practices increase risk of healthcare-associated infections (HAIs) and mortality among hospitalized neonates. Method: In this quasi-experimental study, we implemented the Comprehensive Unit-based Safety Program (CUSP) to improve adherence to evidence-based IPC practices in neonatal intensive care units (NICUs) in 4 tertiary-care facilities in Pune, India. CUSP is a validated strategy to empower staff to improve unit-level patient safety. Baseline safety culture was measured using the Hospital Survey on Patient Safety Culture (HSOPS). Baseline IPC assessments using the Infection Control Assessment Tool (ICAT) were completed to describe existing IPC practices to identify focus areas, the first of which was hand hygiene (HH). Sites received training in CUSP methodology and formed multidisciplinary CUSP teams, which met monthly and were supported by monthly coaching calls. Staff safety assessments (SSAs) guided selection of multimodal interventions. HH compliance was measured by direct observation using trained external observers. The primary outcome was HH compliance, evaluated monthly during the implementation and maintenance phases. Secondary outcomes included CUSP meeting frequency and HH compliance by healthcare worker (HCW) role. Result: In March 2018, 144 HCWs and administrators participated in CUSP training. Site meetings occurred monthly. During the implementation phase (June 2018–January 2019), HH monitoring commenced, sites formed their teams, completed the SSA, and selected interventions to improve HH based on the WHO’s IPC multimodal improvement strategy: (1) system change; (2) training and education; (3) monitoring and feedback; (4) reminders and communication; and (5) a culture of safety (Fig. 1). During the maintenance phase (February–September 2019), HH was monitored monthly and sites adapted interventions as needed. HH compliance improved from 58% to 70% at participant sites from implementation to maintenance phases (Fig. 2), with an odds ratio (OR) of 1.66 (95% CI, 1.50–1.84; P < .001). HH compliance improved across all HCW roles: (1) physician compliance improved from 55% to 67% (OR, 1.69; 95% CI, 1.42–2.01; P < .001); (2) nurse compliance from 61% to 73% (OR, 1.68; 95% CI, 1.46–1.93; P < .001); and (3) other HCW compliance from 52% to 62% (OR, 1.48; 95% CI, 1.10–1.99; P = .010). Conclusion: CUSP was successfully adapted by 4 diverse tertiary-care NICUs in Pune, India, and it resulted in increased HH compliance at all sites. This multimodal strategy is a promising framework for LMIC healthcare facilities to sustainably address IPC gaps and reduce HAI and mortality in neonates.Funding: NoneDisclosures: Aaron Milstone, Johns Hopkins University, BD (consulting)

Assessment of Neonatal Intensive Care Unit Practices and Preterm Newborn Gut Microbiota and 2-Year Neurodevelopmental Outcomes

In very preterm newborns, gut microbiota is highly variable with major dysbiosis. Its association with short-term health is widely studied, but the association with long-term outcomes remains unknown. To investigate in preterm newborns the associations among practice strategies in neonatal intensive care units (NICUs), gut microbiota, and outcomes at 2 years. EPIFLORE is a prospective observational cohort study that includes a stool sample collection during the fourth week after birth. Preterm newborns of less than 32 weeks of gestational age (GA) born in 2011 were included from 24 NICUs as part of the French nationwide population-based cohort, EPIPAGE 2. Data were collected from May 2011 to December 2011 and analyzed from September 2016 to December 2018. Eight NICU strategies concerning sedation, ventilation, skin-to-skin practice, antibiotherapy, ductus arteriosus, and breastfeeding were assessed. A NICU was considered favorable to a practice if the percentage of that practice in the NICU was more than the expected percentage. Gut microbiota was analyzed by 16S ribosomal RNA gene sequencing and characterized by a clustering-based method. The 2-year outcome was defined by death or neurodevelopmental delay using a Global Ages and Stages questionnaire score. Of 577 newborns included in the study, the mean (SD) GA was 28.3 (2.0) weeks, and 303 (52.5%) were male. Collected gut microbiota was grouped into 5 discrete clusters. A sixth cluster included nonamplifiable samples owing to low bacterial load. Cluster 4 (driven by Enterococcus [n = 63]), cluster 5 (driven by Staphylococcus [n = 52]), and cluster 6 (n = 93) were significantly associated with lower mean (SD) GA (26.7 [1.8] weeks and 26.8 [1.9] weeks, respectively) and cluster 3 (driven by Escherichia/Shigella [n = 61]) with higher mean (SD) GA (29.4 [1.6] weeks; P = .001). Cluster 3 was considered the reference. After adjustment for confounders, no assisted ventilation at day 1 was associated with a decreased risk of belonging to cluster 5 or cluster 6 (adjusted odds ratio [AOR], 0.21 [95% CI, 0.06-0.78] and 0.19 [95% CI, 0.06-0.62], respectively) when sedation (AOR, 10.55 [95% CI, 2.28-48.87] and 4.62 [1.32-16.18], respectively) and low volume of enteral nutrition (AOR, 10.48 [95% CI, 2.48-44.29] and 7.28 [95% CI, 2.03-26.18], respectively) was associated with an increased risk. Skin-to-skin practice was associated with a decreased risk of being in cluster 5 (AOR, 0.14 [95% CI, 0.04-0.48]). Moreover, clusters 4, 5, 6 were significantly associated with 2-year nonoptimal outcome (AOR, 6.17 [95% CI, 1.46-26.0]; AOR, 4.53 [95% CI, 1.02-20.1]; and AOR, 5.42 [95% CI, 1.36-21.6], respectively). Gut microbiota of very preterm newborns at week 4 is associated with NICU practices and 2-year outcomes. Microbiota could be a noninvasive biomarker of immaturity.

Sedation and Analgesia Practices in Pediatric Intensive Care Units: A Survey of 27 Centers from Turkey.

The management and monitoring of sedoanalgesia are important measures in improving the efficacy of procedures and mechanical ventilation, as well as reducing adverse effects and preventing withdrawal syndrome, and delirium in pediatric intensive care units (PICUs). As there is an ongoing need to clarify the best approach to sedoanalgesia in PICUs, we aimed to analyze the current approaches in sedation, analgesia, withdrawal, and delirium practices among PICUs in Turkey. Twenty-seven PICUs completed the survey. Only 9 (33.3%) and 13 (48.1%) centers had a written protocol for analgesia and sedation, respectively. Paracetamol and a combination of midazolam and fentanyl were preferred in 51.8 and 40% of the PICUs for postoperative periods, respectively, and 81.4% of the units preferred ketamine for short-term interventions. For prolonged sedation in mechanically ventilated children, a combination of benzodiazepines and opiates were the most preferred first-line agents with a very high percentage of 81.4%, whereas ketamine and dexmedetomidine accounted for 62.9 and 18.5%, respectively, as second-line options. Although sedative and analgesic agent preferences were comparable with the relevant literature, we should focus on developing a standardized, evidence-based algorithm for sedation and analgesic drugs.

Nurses' communication with mechanically ventilated patients in the intensive care unit: Umbrella review.

To conduct a review summarizing evidence concerning communication with mechanically ventilated patients in the intensive care unit (ICU). ICU patients undergoing mechanical ventilation are unable to communicate verbally, causing many negative emotions. Due to changes in sedation practice, a growing number of patients are conscious and experience communication difficulties. The umbrella review method guided by the Joanna Briggs Institute was applied. A systematic search was done in the Cochrane Library, the Joanna Briggs Institute database, Cinahl, Pubmed, PsycINFO and Scopus between January -April 2019. Search terms were 'nurse-patient communication', 'mechanical ventilation', 'intensive care', and 'reviews as publication type'. Literature from 2009-2019 was included. Following recommendations by the Joanna Briggs Institute, a quality appraisal, data extraction, and synthesis were done. Seven research syntheses were included. There were two main themes and six subthemes: (1) Characterization of the nurse-patient communication: (a) Patients' communication; (b) Nurses' communication; (2) Nursing interventions that facilitate communication: (a) Communication assessment and documentation; (b) Communication methods and approaches; (c) Education and training of nurses; and (d) Augmentative and alternative communication. Nurse-patient communication was characterized by an unequal power relationship with a common experience - frustration. Four key interventions were identified and an integration of these may be key to designing and implementing future ICU communication packages. Nurse-patient communication is characterized by an unequal power relationship with one joint experience - frustration. Four key interventions should be integrated when designing and implementing communication packages in the ICU. Findings are transferable to ICU practices where patients are conscious and experience communication difficulties.

Perioperative nutrition in extremely preterm infants undergoing surgery for patent ductus arteriosus

Summary Background and aims Patent ductus arteriosus is a common neonatal morbidity affecting more than half of infants born extremely preterm. Suboptimal nutrition in extremely preterm infants in general has been demonstrated in recent studies. The aim of this study was to describe perioperative nutritional practices in Swedish neonatal intensive care units caring for extremely preterm infants undergoing surgery for patent ductus arteriosus. Methods Daily enteral and parenteral nutritional intakes during the perioperative week starting three days prior and ending three days after surgery were retrospectively evaluated in five University hospitals caring for infants born Results In total, 132 infants and data from 912 perioperative days were included. Mean daily energy intakes during the perioperative week (range 78–105 kcal/kg/day) varied significantly between hospitals, with the lowest intakes on the day of surgery (range 54–87 kcal/kg/day). Mean daily protein intakes during the perioperative week did not vary (range 2.3–2.6 g/kg/day) but did differ on the day of surgery (range 1.5–2.4 g/kg/day). Median parenteral (range 33–99 mL/kg/day) and enteral (range 34–123 mL/kg/day) fluid intakes during the perioperative week, as well as median parenteral contents of energy and protein, varied significantly between hospitals. Conclusions Current recommended nutritional goals for extremely preterm infants were not met in the studied neonatal intensive care units. Suboptimal nutrition may have implications for short and long-term outcomes. Improved adherence to nutritional guidelines is warranted for these patients.

Effectiveness of a Daily Rounding Checklist on Processes of Care and Outcomes in Diverse Pediatric Intensive Care Units Across the World.

Implementation of checklists has been shown to be effective in improving patient safety. This study aims to evaluate the effectiveness of implementation of a checklist for daily care processes into clinical practice of pediatric intensive care units (PICUs) with limited resources. Prospective before-after study in eight PICUs from China, Congo, Croatia, Fiji, and India after implementation of a daily checklist into the ICU rounds. Seven hundred and thirty-five patients from eight centers were enrolled between 2015 and 2017. Baseline stage had 292 patients and post-implementation 443. The ICU length of stay post-implementation decreased significantly [9.4 (4-15.5) vs. 7.3 (3.4-13.4) days, p = 0.01], with a nominal improvement in the hospital length of stay [15.4 (8.4-25) vs. 12.6 (7.5-24.4) days, p = 0.055]. The hospital mortality and ICU mortality between baseline group and post-implementation group did not show a significant difference, 14.4% vs. 11.3%; p = 0.22 for each. There was a variable impact of checklist implementation on adherence to various processes of care recommendations. A decreased exposure in days was noticed for; mechanical ventilation from 42.6% to 33.8%, p < 0.01; central line from 31.3% to 25.3%, p < 0.01; and urinary catheter from 30.6% to 24.4%, p < 0.01. Although there was an increased utilization of antimicrobials (89.9-93.2%, p < 0.01). Checklists for the treatment of acute illness and injury in the PICU setting marginally impacted the outcome and processes of care. The intervention led to increasing adherence with guidelines in multiple ICU processes and led to decreased length of stay.

Interactions Between Intensive Care and Palliative Care Are Influenced by Training, Professionals' Perceptions and Institutional Barriers.

Background: There is growing interest in the use of a Palliative care approach in Intensive care. However, it tends to remain inconsistent, infrequent or non-existent, as does its acceptance by intensive care physicians. This study sought to explore the perceptions, level of knowledge, perceived barriers, and practices of physicians regarding palliative care practices (PC) in Intensive Care Units (ICU). Methods: Descriptive-correlational study. Participating physicians working in ICU in Colombia (n = 101) completed an ad hoc questionnaire that included subscales of perceptions, knowledge, perceived barriers, and PC practices in ICU. A Structural Equation Model (PLS-SEM) was used to examine the reciprocal relationships between the measured variables and those that could predict interaction practices between the 2 specialties. Results: First, results from the measurement model to examine the validity and reliability of the latent variables found (PC training, favorable perceptions about PC, institutional barriers, and ICU-PC interaction practices) and their indicators were obtained. Second, the structural model found that, a greater number of hours of PC training, a favorable perception of PC and a lower perception of institutional barriers are related to greater interaction between PC and ICU, particularly when emotional or family problems are detected. Conclusions: PC-ICU interactions are influenced by training, a positive perception of PC and less perceived institutional barriers. An integrated ICU-PC model that strengthens the PC training of those who work in ICU and provides clearer guidelines for interaction practices, may help overcome perceived barriers and improve the perception of the potential impact of PC.

The pharmacist’s role in implementation of the ABCDEF bundle into clinical practice

To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.

Nursing Students' Experiences of Clinical Practices in Emergency and Intensive Care Units.

Clinical practices are key environments for skill acquisition during the education of nursing students, where it is important to encourage reflective learning. This study sought to explore the experience of final year nursing students during their clinical placement in emergency and intensive care units and to identify whether differences exist between female and male students. Using qualitative methodology, a documentary analysis of 28 reflective learning journals was carried out at a public university in Northern Spain. Four themes were identified: “an intense emotional experience”, “the importance of attitudes over and above techniques”, “identifying with nurses who dominate their environment and are close to the patient in complex and dehumanized units” and “how to improve care in critically ill patients and how to support their families”. The female students displayed a more emotional and reflective experience, with a strong focus on patient care, whereas male students identified more with individual aspects of learning and the organization and quality of the units. Both male and female students experienced intense emotions, improved their learning in complex environments and acquired attitudes linked to the humanization of care. However, the experience of these clinical rotations was different between female and male students.

Urinary Metabolomic Profile of Preterm Infants Receiving Human Milk with Either Bovine or Donkey Milk-Based Fortifiers.

Fortification of human milk (HM) for preterm and very low-birth weight (VLBW) infants is a standard practice in most neonatal intensive care units. The optimal fortification strategy and the most suitable protein source for achieving better tolerance and growth rates for fortified infants are still being investigated. In a previous clinical trial, preterm and VLBW infants receiving supplementation of HM with experimental donkey milk-based fortifiers (D-HMF) showed decreased signs of feeding intolerance, including feeding interruptions, bilious gastric residuals and vomiting, with respect to infants receiving bovine milk-based fortifiers (B-HMF). In the present ancillary study, the urinary metabolome of infants fed B-HMF (n = 27) and D-HMF (n = 27) for 21 days was analyzed by 1H NMR spectroscopy at the beginning (T0) and at the end (T1) of the observation period. Results showed that most temporal changes in the metabolic responses were common in the two groups, providing indications of postnatal adaptation. The significantly higher excretion of galactose in D-HMF and of carnitine, choline, lysine and leucine in B-HMF at T1 were likely due to different formulations. In conclusion, isocaloric and isoproteic HM fortification may result in different metabolic patterns, as a consequence of the different quality of the nutrients provided by the fortifiers.

Novel approaches to facilitate the implementation of guidelines in the ICU.

The effective implementation of evidence-based recommendations in routine intensive care unit (ICU) practice is challenging. Barriers related to the proposed recommendations, local contexts and processes can make the adoption of evidence-based practices difficult, contributing to healthcare inefficiency and worse patient and family outcomes. This review discusses the common barriers to guideline implementation in critical care settings, explores how implementation science provides an important framework for guiding implementation interventions, and discusses some specific and proven implementation strategies to improve adherence to evidence-based practices in the ICU.

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Approach of the Clinicians Practicing in Intensive Care Units to Brain Death Diagnosis and Training Expectations in Turkey: A Web-Based Survey

BackgroundFor health professionals, recognizing and diagnosing brain death is vital for the development of organ transplantation. However, cadaveric organ donation rates remain insufficient, and this problem has become one of the most serious obstacles in the treatment of end-organ failure. ObjectivesThis study examines the attitude and knowledge level of clinicians who practice in intensive care units (ICUs) concerning the determination of brain death and describes the hindrances in diagnosing brain death. Materials and MethodsA survey study was designed with 26 questions, including questions regarding the determination of characteristics of respondents’ trainings, practicing preferences, and their knowledge and approach toward brain death diagnosis. Clinicians practicing in ICUs in Turkey were invited to the survey. ResultsA total of 244 surveys were fully completed. Physicians working at the university hospitals or university-affiliated hospitals answered the basic knowledge questions about brain death more accurately (P < .001). Also, physicians employed in university or university-affiliated hospitals feel more capable in diagnosing brain death (P = .002) and are more willing to receive education on the brain death issue (P < .001). ConclusionThere is a gap separating the practices suggested in guidelines and the daily practice of ICU clinicians working in state hospitals or private institutions. Academic organizations producing and leading the education curricula may assist in informing ICU clinicians who should be trained.

The current practice regarding neuro-prognostication for comatose children after cardiac arrest differs between and within European PICUs: A survey.

To describe current practices in European Paediatric Intensive Care Units (PICUs) regarding neuro-prognostication in comatose children after cardiac arrest (CA). An anonymous online survey was conducted among members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) and the European Paediatric Neurology Society (EPNS) throughout January and February 2019. The survey consisted of 49 questions divided into 4 sections: general information, cardiac arrest, neuro-prognostication and follow-up. The survey was sent to 1310 EPNS and 611 ESPNIC members. Of the 108 respondents, 71 (66%) (23 countries, 45 PICUs) completed the "neuro-prognostication" section. Eight PICUs (20%) had a local neuro-prognostication guideline. The 3 methods considered as most useful were neurological examination (92%), magnetic resonance imaging (MRI) (82%) and continuous electroencephalography (cEEG) (45%). In 50% a Pediatric Cerebral Performance Category (PCPC) score≥4 was considered as poor neurological outcome. In 63% timing of determining neurological prognosis was based on the individual patient. Once decided that neurological prognosis was futile, 55% indicated that withdrawing life-sustaining therapy (WLST) was (one of) the options, whereas 44% continued PICU treatment (with or without restrictions). In 28 PICUs (68%) CA-survivors were scheduled for follow-up visits. Local guidelines for neuro-prognostication in comatose children after CA are uncommon. Methods to assess neurological outcome were mainly neurological examination, MRI and cEEG. Consequences of poor outcome differed between respondents. Inaccuracies in neuro-prognostication can result in premature WLST, thereby biasing outcome research and creating a self-fulfilling cycle. Further research is needed to develop scientifically based international guidelines for neuro-prognostication in comatose children after CA.

Survey of practices in relation to chronic pulmonary hypertension in neonates in the Canadian Neonatal Network and the National Institute of Child Health and Human Development Neonatal Research Network.

Current knowledge gaps pertaining to diagnosis and management of neonatal chronic pulmonary hypertension (cPH) may result in significant variability in clinical practice. The objective of the study is to understand cPH management practices in neonatal intensive care units affiliated with the Canadian Neonatal Network (CNN) and National Institute of Child Health and Human Development Neonatal Research Network (NRN). A 32-question survey seeking practice details for cPH evaluation, diagnostic criteria, conservative measures, pharmacotherapeutics, and follow-up was e-mailed to a designated physician at each center. Responses were described as frequency (percentage) and compared between CNN and NRN, where appropriate. Overall response rate was 67% (CNN 20/28 (71%), NRN 9/15 (60%)). While 8 (28%) centers had standardized management protocols, 17 (59%) routinely evaluate high-risk patients; moderate-severe chronic lung disease being the commonest indication. While interventricular septal flattening on echocardiography was the commonest listed diagnostic criterion, several adjunctive indices were also identified. Asymptomatic neonates with cPH were managed expectantly (routine care) in 50% of sites, and using various conservative measures in others. Pulmonary vasodilators were prescribed for symptomatic cases, with 60% of sites using them early (86% reporting any use). Seventy-five percent of sites use inhaled nitric oxide and sildenafil citrate as first- and second-line agents, respectively. Use of standard protocols, cardiac catheterization, and conservative measures for asymptomatic cases was more common in NRN units (p < 0.05). While there is relative homogeneity in patient identification and diagnostic criteria used for neonatal cPH, significant interunit inconsistencies still exists in routine evaluation, use of additional investigations, management of asymptomatic cases, frequency and type of conservative measures, and choice of pulmonary vasodilators.

Surveillance Practice for Sonographic Detection of Intracranial Abnormalities in Premature Neonates: A Snapshot of Current Neonatal Cranial Ultrasound Practice in Australia

There are no publications reporting on scan duration and Doppler use during neonatal cranial ultrasound scans. We investigated current practice of neonatal cranial ultrasound at four large tertiary neonatal intensive care units in Australia. Cranial scans were prospectively recorded between March 2015 and November 2016. Variables, including total number of scans, scan duration and frequency and duration of colour and spectral Doppler mode, were extracted. A total of 196 scans formed the final cohort. The median (range) number of scans for each neonate was 1 (1–12). The median (range) overall total scan duration was 309 (119–801) s. Colour mode with or without spectral Doppler mode was used in approximately half of the cohort (106/196, 54%). Our findings comport with our hypotheses. Operators performing neonatal cranial scans in Australia have low overall scan durations. Although the use of Doppler mode during neonatal cranial scans is not standard practice in all neonatal intensive care units, it is used widely irrespective of the degree of prematurity or the presence of brain pathology. Further efforts are required to incorporate recommendations on scan duration and the routine use of Doppler mode during neonatal cranial scans. This is especially imperative given that the most vulnerable neonates with the greater neural tissue sensitivity are likely to be scanned more often.

Mechanical Ventilation, Sedation and Neuromonitoring of Patients with Aneurysmal Subarachnoid Hemorrhage in Germany: Results of a Nationwide Survey.

ObjectiveCurrent evidence-based guidelines for the management of aneurysmal subarachnoid hemorrhage (aSAH) focus primarily on timing, modality and technique of aneurysm occlusion, and on prevention and treatment of delayed cerebral ischemia. Significant aspects of management in the intensive care unit (ICU) during the later course of aSAH such as ventilation and sedation (VST) remain unaddressed. aSAH patients present unique challenges not accounted for in general ICU recommendations and guidelines, which is why we attempted to further characterize ICU practices in aSAH patients in Germany.MethodsWe conducted a nationwide survey on ICU practices in aSAH in Germany. Secondarily, we assessed the existence of and compliance with current guidelines regarding ICU practices. The questionnaire was designed in interdisciplinary fashion and distributed online through the kwiksurvey® platform (Bristol, UK).ResultsA total of 50 responses were received, accounting for a response rate of 49%. Twenty-one were university hospitals (UH), 23 high-volume centers (HVC), 6 low-volume centers (LVC). Half of the participating centers do not take into consideration WFNS at presentation to indicate ventilation. While 42% of centers rely on the P/F ratio to indicate ventilation, 62% of them have a cutoff value of < 200, and 38% of < 100. While most UH and HVC used propofol for the first phase of sedation (95%), LVC employed benzodiazepines (100%). Sedation deepening was done with ketamine in UH (75%) and HVC (60%), whereas LVC used predominantly clonidine (100%).ConclusionsOur study clearly demonstrates that attitudes and practices pertaining to ICU management in aSAH are enormously heterogeneous, reflecting the lack of good quality evidence and differing interpretations thereof.Electronic supplementary materialThe online version of this article (10.1007/s12028-020-01029-8) contains supplementary material, which is available to authorized users.

Mobilization practices in critically ill children: a European point prevalence study (EU PARK-PICU)

BackgroundEarly mobilization of adults receiving intensive care improves health outcomes, yet little is known about mobilization practices in paediatric intensive care units (PICUs). We aimed to determine the prevalence of and factors associated with physical rehabilitation in PICUs across Europe.MethodsA 2-day, cross-sectional, multicentre point prevalence study was conducted in May and November 2018. The primary outcome was the prevalence of physical therapy (PT)- or occupational therapy (OT)-provided mobility. Clinical data and data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥72 h.ResultsData of 456 children admitted to one of 38 participating PICUs from 15 European countries were collected (456 patient days); 70% were under 3 years of age. The point prevalence of PT- and/or OT-provided mobility activities was 39% (179/456) (95% CI 34.7–43.9%) during the patient days, with significant differences between European regions. Nurses were involved in 72% (924/1283) of the mobility events; in the remaining 28%, PT/OT, physicians, family members, or other professionals were involved. Of the factors studied, family presence was most strongly positively associated with out-of-bed mobilization (aOR 7.83, 95% CI 3.09–19.79). Invasive mechanical ventilation with an endotracheal tube was negatively associated with out-of-bed mobility (aOR 0.28, 95% CI 0.12–0.68). Patients were completely immobile on 25% (115/456) of patient days. Barriers to mobilization were reported on 38% of patient days. The most common reported patient-related barriers were cardiovascular instability (n = 47, 10%), oversedation (n = 39, 9%), and medical contraindication (n = 37, 8%). Potential safety events occurred in 6% of all documented mobilization events.ConclusionTherapists are infrequently consulted for mobilization of critically ill children in European PICUs. This study highlights the need for a systematic and interdisciplinary mobilization approach for critically ill children.Graphical abstract

Protective Ventilation Measures Improve Outcomes During Major Vascular Surgery

Despite strong evidence from intensive care unit practices demonstrating benefits of improved ventilation management, with low tidal volume and high positive end-expiratory pressure (PEEP), no consensus exists for protective ventilation use intraoperatively.