Practice In Intensive Care Unit Research Articles

A National Survey of Neonatal Nurses' Knowledge, Beliefs, and Practices of Antibiotic Stewardship.

In the neonatal intensive care unit, implementation of antibiotic stewardship programs has been challenging, especially for staff nurses. To identify neonatal nurses' knowledge and attitudes toward antibiotic stewardship programs in neonatal intensive care units. This was a descriptive survey study to assess knowledge, attitudes, and beliefs of neonatal nurses related to antibiotic stewardship. The survey consisted of 23 questions, 6 of which were open-ended. The questions evaluated perceptions of general understanding of antibiotic stewardship, administration of antibiotics, information and perspective about antibiotic use, antibiotic resistance, and availability and usage of resources and education related to antibiotics. The survey was posted online for about 3 months on the Web site of a professional organization of neonatal nurses. Of the 78 neonatal nurses who responded to the survey, 39% were very familiar with the term antibiotic stewardship . The majority of participants did not question the treating provider about the choice, route, or dose of antibiotics. The majority also agreed that more education is needed to achieve the goal of incorporating principles of antibiotic stewardship more fully into practice in the neonatal intensive care unit. Results suggest that although most nurses are familiar with the term antibiotic stewardship , they would like to have more education on the appropriate use of antibiotics. Further studies are needed to identify nurse involvement in applying the principles of antibiotic stewardship programs while working with the vulnerable population of preterm infants.

Dying in intensive care: An analysis of the perspectives of families and clinicians on end-of-life care

BackgroundDespite a growing body of research into end-of-life care (EOLC) in intensive care units (ICUs), few studies have concurrently explored the perspectives of families and clinicians. ObjectiveThe objective of this study was to identify the characteristics of high-quality EOLC in the ICU from family and clinician perspectives and by examining the care documented in medical records. MethodsA convergent mixed-methods study incorporating electronic health record audits (n = 20), structured interview surveys with families (n = 20), clinician surveys (n = 189), and focus groups (n = 10) was undertaken at a 30-bed, level 3 ICU at a metropolitan public adult teaching hospital in Australia. Descriptive statistics were calculated from quantitative data, and inductive thematic analysis was used to analyse qualitative data. ResultsOverall, families were very satisfied with EOLC and the quality of communication yet, felt that earlier, clearer communication that the patient was dying was required. Families spoke of the attentiveness, or lack thereof, by ICU clinicians and the opportunity to be present for the patient's death. The majority of ICU clinicians felt EOLC could be improved. Nurses highlighted communication challenges when family meetings were delayed. Some nurses expressed a lack of clarity of how to withdraw care, resulting in hesitancy to cease potentially inappropriate care, and to provide EOLC outside ICU practice norms. In many instances, observations, invasive monitoring, and interventions were documented after EOLC commenced. A lack of documented personal cares was also noted. ConclusionsThis study provides new insights into EOLC from the dual perspectives of families and clinicians. There is a need for institutional guidelines to support ICU clinicians’ EOLC practices and education to improve clinician confidence with communication.

337.6: Ultrasound Scanning in Lung Procurement. Protocol For Decision-Making With the Purpose of Increasing Transplant Eligible Lungs

Introduction: Despite having a similar population, Latin America performs 11x less lung transplant procedure than Europe. Improving brain death diagnosis and converting potential donors into real donors is key to improve these numbers. Ultrasonography (US) is common practice in Intensive Care Units. Available literature on its use in the management of brain death donors and lung procurement is extremely scarce. The selection and rejection of lungs for transplantation is usually done with chest X-rays, however US has shown better sensitivity and specificity for the diagnosis of pulmonary pathologies. Lung US allows to identify the reversible causes low PaO2/FiO2 ratio (PaFi), thus allowing to establish specific interventions which, if proved successful, could turn lungs into transplant-eligible lungs. Methods: Introducing a simple Protocol aiming at identifying and treating the main reversible causes of a low PaFi. Respiratory causes of a low PaFi ratio can be either parenchymal or pleural. Parenchymal causes: Pulmonary edema (either neurogenic or cardiogenic) determines the visualization of bilateral and symmetrical B lines. Fluid restriction prioritizing inotropic drugs to revert hypotension and usage of hypertonic solutions can reduce edema. Atelectasis, contusion and pneumonia can appear as patterns for unilateral B lines and/or consolidations. The presence of a static or dynamic air bronchogram can differentiate them. In atelectasis, fiberoptic bronchoscopy can revert the situation. In all other cases, a single lung transplant can be considered, which is a valid option in aged recipients when donors are scarce. Pneumothorax and pleural effusion are both pleural causes of a low PaFi. They can be easily diagnosed through an ultrasound scan, not there being a reason for rejection. Its resolution can turn these lungs into transplant eligible lungs. The pneumothorax —frequently anterior in ventilated patients in dorsal decubitus— may be overlooked in the chest x-ray. Diagnosis is made by the absence of pleural sliding and presence of a lung pint. Pleural effusion is anechoic, present quad sign and the sinusoid sign. The acquisition of skills to diagnose all these conditions does not require much reading and has a fast-learning curve (25 cases monitored). Results: This Protocol is currently used for donor decision-making and will be implemented prospectively by the lung transplant team to assess its ability to increase the number of lungs suitable for transplantation. Conclusions: US is a useful technique to identify reversible and treatable causes of a low PaFi, helping decision-making to increase the number of transplant eligible lungs.

Improving Mobility Practices of Critically Ill Children.

This quality improvement project aimed to improve mobility practices in a pediatric intensive care unit. Three interventions were implemented: a staff-developed mobility progression guideline (including patient mobility phase identification using animal images), physical therapy (PT), and occupational therapy (OT) referrals for all patients with expected hospitalizations of more than 3 days, and the use of activity goal posters. The frequency of mobility activities performed, the number of PT and OT referrals and nurses' confidence in mobilizing patients were compared before and after project implementation. Improvements occurred in the median number of daily mobility activities per patient encounter (1.5-4.0), number of PT and OT referrals (43% and 61% increase, respectively), and nurses' confidence in mobilizing patients (69% of clinical nurses agreed their confidence in mobilizing patients improved after protocol implementation). Implementation of an interprofessional mobility quality improvement project improved mobility practices in the pediatric intensive care unit.

Experiences and contextual practices of family-centered care in Ghanaian nicus: a qualitative study of families and clinicians

BackgroundFamilies, whether at home or at the hospital, should be a vital part of newborn care. However, most families are excluded from hospital care, particularly in neonatal intensive care units (NICUs). This is incompatible with the concepts of Family-Centered Care (FCC) and may compromise care continuity and family satisfaction following discharge from neonatal intensive care facilities. The purpose of this study was to examine FCC practices in Ghanaian neonatal intensive care units and provide the experiences and contextual practices of FCC from the perspectives of families and clinicians.MethodsThe study qualitatively examined the contextual practices of FCC from the perspectives of families and clinicians in neonatal intensive care units using an exploratory descriptive design. With the help of MAXQDA software, 36 transcripts were generated and their contents were analyzed.ResultsContextual practices of FCC, family experiences of FCC and clinician experiences of FCC emerged as three main categories from the data. Respect and dignity, culture and religion and a multidisciplinary approach were the contextual practices. Emotional stress, lack of information and coping strategies were all common family experiences. Support, counseling, education and financial problems have all been experienced by clinicians.ConclusionsShared decision-making, counseling and education, as well as respect/dignity amongst clinicians, managers and families using a multidisciplinary approach are the fundamental concepts of FCC approach in Ghana. Acceptance and integration of FCC approach into neonatal intensive care units may reduce the burden of care as well as improve the quality of care. Further studies are needed to map out strategies and interventions for the integration of FCC into intensive care units.

Roadmap to optimal pharmacovigilance practice in neonatal intensive care units.

Roadmap to optimal pharmacovigilance practice in neonatal intensive care units.

Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians: A Survey to Members of the Society of Critical Care Anesthesiologists.

Despite the growing contributions of critical care anesthesiologists to clinical practice, research, and administrative leadership of intensive care units (ICUs), relatively little is known about the subspecialty-specific clinical practice environment. An understanding of contemporary clinical practice is essential to recognize the opportunities and challenges facing critical care anesthesia, optimize staffing patterns, assess sustainability and satisfaction, and strategically plan for future activity, scope, and training. This study surveyed intensivists who are members of the Society of Critical Care Anesthesiologists (SOCCA) to evaluate practice patterns of critical care anesthesiologists, including compensation, types of ICUs covered, models of overnight ICU coverage, and relationships between these factors. We hypothesized that variability in compensation and practice patterns would be observed between individuals. Board-certified critical care anesthesiologists practicing in the United States were identified using the SOCCA membership distribution list and invited to take a voluntary online survey between May and June 2021. Multiple-choice questions with both single- and multiple-select options were used for answers with categorical data, and adaptive questioning was used to clarify stem-based responses. Respondents were asked to describe practice patterns at their respective institutions and provide information about their demographics, salaries, effort in ICUs, as well as other activities. A total of 490 participants were invited to take this survey, and 157 (response rate 32%) surveys were completed and analyzed. The majority of respondents were White (73%), male (69%), and younger than 50 years of age (82%). The cardiothoracic/cardiovascular ICU was the most common practice setting, with 69.5% of respondents reporting time working in this unit. Significant variability was observed in ICU practice patterns. Respondents reported spending an equal proportion of their time in clinical practice in the operating rooms and ICUs (median, 40%; interquartile range [IQR], 20%-50%), whereas a smaller proportion-primarily those who completed their training before 2009-reported administrative or research activities. Female respondents reported salaries that were $36,739 less than male respondents; however, this difference was not statistically different, and after adjusting for age and practice type, these differences were less pronounced (-$27,479.79; 95% confidence interval [CI], -$57,232.61 to $2273.03; P = .07). These survey data provide a current snapshot of anesthesiology critical care clinical practice patterns in the United States. Our findings may inform decision-making around the initiation and expansion of critical care services and optimal staffing patterns, as well as provide a basis for further work that focuses on intensivist satisfaction and burnout.

Clinical validation of a multiplex droplet digital PCR for diagnosing suspected bloodstream infections in ICU practice: a promising diagnostic tool

BackgroundDroplet digital PCR (ddPCR) has emerged as a promising tool of pathogen detection in bloodstream infections (BSIs) in critical care medicine. However, different ddPCR platforms have variable sensitivity and specificity for diverse microorganisms at various infection sites. There is still a lack of prospective clinical studies aimed at validating and interpreting the discrepant ddPCR results for diagnosing BSI in intensive care unit (ICU) practice.MethodsA prospective diagnostic study of multiplex ddPCR panels was conducted in a general ICU from May 21, 2021, to December 22, 2021. Paired blood cultures (BCs) and ddPCRs (2.5 h) were obtained synchronously to detect the 12 most common BSI pathogens and three antimicrobial resistance (AMR) genes. Firstly, ddPCR performance was compared to definite BSI. Secondly, clinical validation of ddPCR was compared to composite clinical diagnosis. Sensitivity, specificity, and positive and negative predictive values were calculated. Thirdly, the positive rate of AMR genes and related analysis was presented.ResultsA total of 438 episodes of suspected BSIs occurring in 150 critical patients were enrolled. BC and ddPCR were positive for targeted bacteria in 40 (9.1%) and 180 (41.1%) cases, respectively. There were 280 concordant and 158 discordant. In comparison with BCs, the sensitivity of ddPCR ranged from 58.8 to 86.7% with an aggregate of 72.5% in different species, with corresponding specificity ranging from 73.5 to 92.2% with an aggregate of 63.1%. Furthermore, the rate of ddPCR+/BC− results was 33.6% (147/438) with 87.1% (128 of 147) cases was associated with probable (n = 108) or possible (n = 20) BSIs. When clinically diagnosed BSI was used as true positive, the final sensitivity and specificity of ddPCR increased to 84.9% and 92.5%, respectively. In addition, 40 blaKPC, 3blaNDM, and 38 mecA genes were detected, among which 90.5% were definitely positive for blaKPC. Further, 65.8% specimens were predicted to be mecA-positive in Staphylococcus sp. according to all microbiological analysis.ConclusionsThe multiplexed ddPCR is a flexible and universal platform, which can be used as an add-on complementary to conventional BC. When combined with clinical infection evidence, ddPCR shows potential advantages for rapidly diagnosing suspected BSIs and AMR genes in ICU practice.

Early mobilization of mechanically ventilated ICU patients in Saudi Arabia: Results of an ICU-wide national survey

BackgroundImproved outcomes for patients on mechanical ventilation may be achieved with early mobilization (EM). However, it is not clear how widely this strategy is adopted into routine intensive care unit (ICU) practice in Saudi Arabia. ObjectivesThis study was conducted to describe the present practices and challenges to providing EM for mechanically ventilated patients, which may drive dissemination and implementation activities. MethodsWe approached 205 ICUs across Saudi Arabia using a validated tool to assess ICU characteristics, the practices of EM for mechanically ventilated patients, and the barriers to providing EM. ResultsWe approached 205 ICU persons in charge and achieved a 65% response rate (133 ICUs). The prevalence of EM for mechanically ventilated patients was 47% (63 ICUs). A total of 85 (64%) of the respondents reported having no previous training in EM. The absence of a written protocol was reported by 55% of the ICU practitioners in charge, 36% started EM within 2 to 5 days of critical illness, and 35% reported that performing EM for mechanically ventilated patients was totally dependent on physicians’ orders. Forty-seven percent of the ICUs that practised EM had at least one coordinator or person in charge of facilitating EM. The highest level of EM with mechanically ventilated patients was 35/63 (55%) with patients remaining in-bed and 28/63 (45%) with patient getting out of bed. A majority of the respondents (39, 64%) performed EM once daily for an interval period of more than 15 min. Previous training in EM and years of experience of the ICU person in charge were significant factors that promoted EM for mechanically ventilated ICU patients (OR: 7.6 (3.37–17.26); p < 0.001 and OR: 1.07 (1.01–1.14), p = 0.004, respectively). Existing protocols increased the odds of starting EM within 2 to 5 days of critical illness by six-fold (OR: 6.03 (1.79–20.30); p = 0.004). No written guidelines/protocols available for EM, medical instability, and limited staff were the most common hospital-, patient- and health care provider-related barriers to EM in the ICUs, respectively. ConclusionThe prevalence of EM for mechanically ventilated patients across Saudi Arabia was 47%, although only 36% of the ICU staff had previous training in EM. Targeting modifiable barriers to EM, including a lack of training, guidelines and protocols, and staffing, will help to promote EM in Saudi Arabian ICUs.

Green practice guideline program regrading waste management on nurses’ knowledge and practice in intensive care units

Background: Hospitals all over the world looking forward to become more sustainable and get rid of medical waste which resulting in environmental pollution, misallocation and increased costs for medical facilities. The study was carried out at Ain shams University Hospitals and which included surgical, medical and cardiac (ICU). A convenient sample of 60 nurses were included. Study tools: A structured self-administrated questionnaire, waste reduction and prevention checklist, and barriers of green practice regarding waste management questionnaire. Results: (91.7%) of the studied nurses have unsatisfactory level of total knowledge about green practice pre guideline program implementation while (93.3%) of them improved to satisfactory level post implementation and slightly decreased to (90%) at follow-up phase. Also, (93.3%) of the studied nurses have unsatisfactory level of total practice pre guideline program implementation while (94.6%) of them improved to satisfactory level post program implementation and slightly decreased to (93.1%) at follow-up phase. mean and standard deviation of the barriers of application of green practice regarding waste management in ICU as; administrative barriers was 1.12 ± 0.87 in the surgical ICU nurses compared to 1.45 ± 1.110 and 1.37±0.94 in the medical and cardiac ICU nurses.

Standardized concentrations for continuous infusion-results of anationwide survey in German intensive care units

HintergrundIntensivpatienten erhalten zahlreiche Arzneimittel (AM) als Dauerinfusion appliziert. In Deutschland fehlt bisher für die als Dauerinfusion applizierten AM eine einheitliche Liste mit Standardkonzentrationen.Ziel der ArbeitZiel war es, bundesweit repräsentative Informationen zu Standardkonzentrationen von als Dauerinfusion mittels Spritzenpumpe oder Infusionspumpe applizierten AM auf den Intensivstationen zu gewinnen.Material und MethodenZur Ermittlung der Akzeptanz und Präferenz für Dauerinfusionen von ausgewählten AM wurde ein Fragenkatalog in einem online- Umfragetool entwickelt und von der DIVI an die jeweils verantwortlichen Leiter*innen von 1816 Intensivstationen versendet. Die Umfrage umfasste Vorschläge zu 59 AM mit insgesamt 73 Konzentrationen. Ergänzend konnten die Teilnehmer in Freitextfeldern eigene Vorschläge zu AM und entsprechenden Konzentrationen angeben. Die Häufigkeit der Verwendung der Arzneimittel als Dauerinfusion und der präferierten Standardkonzentrationen wurde bezogen auf die Zahl der Antworten pro Arzneimittel berechnet.ErgebnisseDie Umfrage wurde von 312 (17 %) Intensivstationen beantwortet. Die Akzeptanzrate für das Prinzip der geschwindigkeitsgesteuerten Dauerinfusion in Standardkonzentrationen ist deutschlandweit sehr hoch, Die Top 10 bzw. 25 der vorgeschlagenen AM werden von über 90 % bzw. 50 % der Teilnehmer regelmäßig als Dauerinfusion eingesetzt. Für viele dieser AM konnte eine oder mehrere präferierte Konzentrationen identifiziert werden.DiskussionDie Top-37-Arzneimittel und die präferierten Konzentrationen sind als Grundlage für eine bundesweit geltende Standardliste mit Standardkonzentrationen für Dauerinfusionen (in der Regel 50 ml) geeignet. Die damit befassten Fachgesellschaften können basierend auf den Umfrageergebnissen eine bundeseinheitliche Standardliste konsentieren.

Factors influencing critical care nurses' family engagement practices: An international perspective.

Family engagement positively impacts patient and family members' experiences of care and health outcomes. While partnering with families denotes best practice in intensive care units (ICUs), its full adoption requires improvement. A better understanding of the factors that influence the implementation of family engagement practices is necessary. To investigate the factors that enable or hinder adult ICU nurse-family engagement and to explore potential international variations. Descriptive, cross-sectional survey. Nurses from 10 countries completed the 'Questionnaire on Factors that Influence Family Engagement' (QFIFE), including five open-ended questions. We performed descriptive statistics on quantitative data and content analysis for open-ended questions, and then integrated the findings according to influencing factors and geographical patterns. This was part of a larger qualitative study where 65 nurses participated from adult intensive care units. Sixty-one nurses completed the questionnaire, making a response rate of 94%. Overall, patient acuity (Md=5.0) and nurses' attitudes (Md=4.6) seemed to be the most influential facilitator, followed by nurse workflow (Md=4.0) and ICU environment (Md=3.1) (score 1-6 most influential). The open-ended question data showed a more nuanced picture of the complexity of family engagement in care around these four determinants. Adding a fifth determinant, namely Families are complex structures that respond uniquely to the ICU and patient, revealed that difficult family dynamics, miscommunication and family having difficulty in understanding the situation or health literacy, hindered family engagement. Exploring geographical variations, Africa/Middle East consistently differed from others on three of the four QFIFE subscales, showing lower median levels. Some determinants are perceived to be more influential than others, becoming barriers or enablers to nurse-family engagement in adult ICU. Research that investigates contextual determinants and which compares implementation and improvement initiatives tailored to address family engagement practices barriers and enablers are needed. Knowledge of this international study expands our understanding of enablers and barriers in family engagement that may inform family engagement practice improvement efforts around the world.

The effects of neonatal resuscitation gamification program using immersive virtual reality: A quasi-experimental study

BackgroundClinical practice in neonatal intensive care units for nursing college students has been restricted due to the COVID-19 pandemic outbreak; thus, the gamification program has emerged as an alternative learning method. Consequently, there is a need to examine the effectiveness of such alternative learning methods to enhance the response to high-risk newborn emergencies. ObjectivesTo examine the effects (neonatal resuscitation nursing knowledge, problem-solving and clinical reasoning ability, self-confidence in practical performance, degree of anxiety, and learning motivation) of a neonatal resuscitation gamification program using immersive virtual reality based on Keller's ARCS model. DesignA non-randomized controlled simulation study with a pretest-posttest design. SettingLab and lecture rooms of two universities in South Korea, from June to November 2021. ParticipantsPrelicensure nursing students. MethodsThe virtual reality group (n = 29) underwent a neonatal resuscitation gamification program using virtual reality based on Keller's ARCS model. The simulation group (n = 28) received high-fidelity neonatal resuscitation simulations and online neonatal resuscitation program lectures. The control group (n = 26) only received online neonatal resuscitation program lectures. Changes in scores among these groups were compared using analysis of variance and analysis of covariance with SPSS for Windows version 27.0. ResultsPost intervention, neonatal resuscitation knowledge [F(2) = 3.83, p = .004] and learning motivation [F(2) = 1.79, p = .025] were significantly higher in the virtual reality and simulation groups than in the control group, whereas problem-solving ability [F(2) = 2.07, p = .038] and self-confidence [F(2) = 6.53, p < .001] were significantly higher in the virtual reality group than in the simulation and control groups. Anxiety [F(2) = 16.14, p < .001] was significantly lower in the simulation group than in the virtual reality and control groups. ConclusionsThe neonatal resuscitation gamification program using immersive virtual reality was found to be effective in increasing neonatal resuscitation knowledge, problem-solving ability, self-confidence, and learning motivation of the nursing students who participated in the trial application process.

Implementation Science in Pediatric Critical Care - Sedation and Analgesia Practices as a Case Study.

Sedation and analgesia (SA) management is essential practice in the pediatric intensive care unit (PICU). Over the past decade, there has been significant interest in optimal SA management strategy, due to reports of the adverse effects of SA medications and their relationship to ICU delirium. We reviewed 13 studies examining SA practices in the PICU over the past decade for the purposes of reporting the study design, outcomes of interest, SA protocols used, strategies for implementation, and the patient-centered outcomes. We highlighted the paucity of evidence-base for these practices and also described the existing gaps in the intersection of implementation science (IS) and SA protocols in the PICU. Future studies would benefit from a focus on effective implementation strategies to introduce and sustain evidence-based SA protocols, as well as novel quasi-experimental study designs that will help determine their impact on relevant clinical outcomes, such as the occurrence of ICU delirium. Adoption of the available evidence-based practices into routine care in the PICU remains challenging. Using SA practice as an example, we illustrated the need for a structured approach to the implementation science in pediatric critical care. Key components of the successful adoption of evidence-based best practice include the assessment of the local context, both resources and barriers, followed by a context-specific strategy for implementation and a focus on sustainability and integration of the practice into the permanent workflow.

Considerations in Critical-Care and Anesthetic Management of Adult Patients Living With Fontan Circulation

The Fontan procedure is a staged palliation for various complex congenital cardiac lesions, including tricuspid atresia, pulmonary atresia, hypoplastic left heart syndrome, and double-inlet left ventricle, all of which involve a functional single-ventricle physiology. The complexity of the patients' original anatomy combined with the anatomic and physiologic consequences of the Fontan circulation creates challenges. Teens and adults living with Fontan palliation will need perioperative support for noncardiac surgery, peripartum management for labour and delivery, interventions related to their structural heart disease, electrophysiology procedures, pacemakers, cardioversions, cardiac surgery, transplantation, and advanced mechanical support. This review focuses on the anesthetic and intensive care unit (ICU) management of these patients during their perioperative journey, with an emphasis on the continuity of preintervention planning, referral pathways, and postintervention ICU management. Requests for recipes and doses of medications are frequent; however, as in normal anesthesia and ICU practice, the method of anesthesia and dosing are dependent on the presenting medical/surgical conditions and the underlying anatomy and physiologic reserve. A patient with Fontan palliation in their early 20s attending school full-time with a cavopulmonary connection is likely to have more reserve than a patient in their late 40s with an atriopulmonary Fontan at home waiting for a heart transplant. Each case will require an anesthetic and critical care plan tailored to the situation. The critical care environment is a natural extension of the anesthetic management of a patient, with complex considerations for a patient with Fontan palliation.

Clinical Course of a Case of Elizabethkingia Meningoseptica in a Critical Neonate at a Tertiary Care Hospital in Saudi Arabia

Case Report: In this paper we discuss the clinical course of a 25-week gestational age preterm neonate who suffered with multiple comorbidities atop of an E. meningoseptica infection causing meningitis and hydrocephalus. A multitude of antibiotics were administered to the child, such as vancomycin, ciprofloxacin, trimethoprim-sulfamethoxazole, and rifampicin. However, the pathogen either had prior resistance to the agents or newly developed resistance along the disease course. After many trials of antibiotics, the usage of ceftazidime/avibactam and moxifloxacin dual therapy induced clinical and microbiological eradication of the pathogen. Objective: This case report aims to discuss the multidrug approach used to treat a preterm neonates Elizabethkingia Meningoseptica infection in a Tertiary Care Hospital in Saudi Arabia. Conclusion: E. meningoseptica is an uncommon infectious agent which can cause meningitis and even sepsis that is difficult to treat due to its multidrug resistance phenotype. Continuous reviews of new case reports on successful attempts of treating E. meningoseptica are paramount to maintaining updated therapy options for newly encountered cases in day-to-day practice in the neonatal intensive care unit (NICU).

Identifying Gaps in Resuscitation Practices Across Level-IV Neonatal Intensive Care Units.

This study aimed to describe resuscitation practices in level-IV neonatal intensive care units (NICUs) and identify possible areas of improvement. This study was a cross-sectional cohort survey and conducted at the Level-IV NICUs of Children's Hospital Neonatal Consortium (CHNC). The survey was developed with consensus from resuscitation and education experts in the CHNC and pilot tested. An electronic survey was sent to individual site sponsors to determine unit demographics, resuscitation team composition, and resuscitation-related clinical practices. Of the sites surveyed, 33 of 34 sites responded. Unit average daily census ranged from less than 30 to greater than 100, with the majority (72%) of the sites between 30 and 75 patients. A designated code response team was utilized in 18% of NICUs, only 30% assigned roles before or during codes. The Neonatal Resuscitation Program (NRP) was the exclusive algorithm used during codes in 61% of NICUs, and 34% used a combination of NRP and the Pediatric Advanced Life Support (PALS). Most (81%) of the sites required neonatal attendings to maintain NRP training. A third of sites (36%) lacked protocols for high-acuity events. A code review process existed in 76% of participating NICUs, but only 9% of centers enter code data into a national database. There is variability among units regarding designated code team presence and composition, resuscitation algorithm, protocols for high-acuity events, and event review. These inconsistencies in resuscitation teams and practices provide an opportunity for standardization and, ultimately, improved resuscitation performance. Resources, education, and efforts could be directed to these areas to potentially impact future neonatal outcomes of the complex patients cared for in level-IV NICUs. · Resuscitation practice is variable in level-IV NICUs.. · Resuscitation algorithm training is not uniform. · Standardized protocols for high-acuity low-occurrence (HALO) events are lacking.

Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study.

BackgroundWe aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010–2011.MethodsAn observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs.ResultsOn the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality.ConclusionsHospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care.Registered at clinicaltrials.gov (NCT03631927).How to cite this articleDivatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018–2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093–1107.

Factors Associated With Deep Sedation Practice in Mechanically Ventilated Patients: A Post hoc Analysis of a Cross-Sectional Survey Combined With a Questionnaire for Physicians on Sedation Practices.

PurposeThe study aimed to explore factors associated with deep sedation practice in intensive care units (ICUs).Materials and MethodsA post hoc analysis was conducted for a cross–sectional survey on sedation practices in mechanically ventilated (MV) patients, combined with a questionnaire for physicians regarding their preferences for light sedation (P–pls Score) in 92 Chinese ICUs.ResultsThere were 457 and 127 eligible MV patients in the light and deep sedation groups respectively. A multivariable logistic regression analysis demonstrated that the control mode of mechanical ventilation, plasma lactate level, and the Sequential Organ Failure Assessment (SOFA) score were independent risk factors for deep sedation practice (p <0.01). Notably, the adjusted odds ratio (95% CI) of the average P–pls score in the ICU ≤ 2 for deep sedation practice was 1.861 (1.163, 2.978, p = 0.01). In addition, the areas under curves of receiver operating characteristics (AUC–ROC) of the model to predict the probability of deep sedation practice were 0.753 (0.699, 0.806) and 0.772 (0.64, 0.905) in the training set and the validation set, respectively. The 28–day mortality was increased in patients with exposure to deep sedation practice but not significantly.ConclusionBoth factors related to stressful stimuli and the ICU physicians' perception of patient tolerability in mechanical ventilation were likely associated with deep sedation practice in MV patients.

Early versus delayed enteral nutrition in mechanically ventilated patients with circulatory shock: a nested cohort analysis of an international multicenter, pragmatic clinical trial

IntroductionReal-world evidence on the timing and efficacy of enteral nutrition (EN) practices in intensive care unit (ICU) patients with circulatory shock is limited. We hypothesized early EN (EEN), as compared to delayed EN (DEN), is associated with improved clinical outcomes in mechanically ventilated (MV) patients with circulatory shock.MethodsWe analyzed a dataset from an international, multicenter, pragmatic randomized clinical trial (RCT) evaluating protein dose in ICU patients. Data were collected from ICU admission, and EEN was defined as initiating < 48 h from ICU admission and DEN > 48 h. We identified MV patients in circulatory shock to evaluate the association between the timing of EN initiation and clinical outcomes. The regression analysis model controlled for age, mNUTRIC score, APACHE II score, sepsis, and Site.ResultsWe included 626 patients, from 52 ICUs in 14 countries. Median age was 60 years [18–93], 55% had septic shock, 99% received norepinephrine alone, 91% received EN alone, and 50.3% were randomized to a usual protein dose. Forty-two percent of EEN patients had persistent organ dysfunction syndrome plus death at day 28, compared to 53% in the DEN group (p = 0.04). EEN was associated with more ICU-free days (9.3 ± 9.2 vs. 5.7 ± 7.9, p = 0.0002), more days alive and free of vasopressors (7.1 ± 3.1 vs. 6.3 ± 3.2, p = 0.007), and shorter duration of MV among survivors (9.8 ± 10.9 vs. 13.8 ± 14.5, p = 0.0002). This trend was no longer observed in the adjusted analysis. There were no differences in ICU/60-day mortality or feeding intolerance rates between groups.ConclusionIn MV patients with circulatory shock, EEN, as compared to DEN, was associated with improved clinical outcomes, but no longer when adjusting for illness severity. RCTs comparing the efficacy of EEN to DEN in MV patients with circulatory shock are warranted.