Intensive Care Unit Protocol Research Articles

PERSONAL EXPERIENCE OF IMPLEMENTING THE ENHANCED RECOVERY AFTER SURGERY (ERAS) SOCIETY RECOMMENDATIONS IN NEONATAL SURGICAL PATHOLOGY

This paper presents our own experience of implementing the Enhanced Recovery After Surgery (ERAS) International Protocolin neonatal surgical pathology from 2023. The results demonstrate the effi cacy of this approach in the context of the currentsituation, which is characterized by an increased workload in neonatal departments due to the destruction of medical facilities as a consequence of the Russian Federation’s military actions.Aim. To analyze, assess and discuss the experience and details of implementing the ERAS International Protocol in neonatalsurgical pathology.Materials and methods. The objective of this study was to conduct a retrospective analysis of the experience in using the ERAS International Protocol in a Neonatal Intensive Care Unit with a neonatal mobile team from the CE «Regional Medical Center of Family Health» DRC. A retrospective analysis of the experience of implementing the ERAS International Protocol was conducted in a Neonatal Intensive Care Unit with a neonatal mobile team from the CE «Regional Medical Center of Family Health» DRC.Results. The article elucidates the principal stages of utilizing the ERAS International Protocol in the care of paediatric patients with surgical pathology in the Neonatal Intensive Care Unit with the neonatal mobile team of the CE «Regional Medical Center of Family Health» DRC. This hospital has become the second largest children’s hospital in Ukraine, off ering a comprehensive range of medical services. The infl ux of patients has considerably increased the workload on the department, necessitating an optimization of anaesthetic and surgical care provision to newborns.Conclusions. Compliance with the ERAS Protocol allows to reduce hospital length of stay in children as well as signifi cantly bring down the treatment costs of postoperative complications and is expedient for implementation.

The effect of an open-heart surgery patient care protocol on post-sternotomy pain, anxiety and quality of care: A randomized controlled trial.

Open-heart surgery patients face many problems because of post-sternotomy pain. Care protocols can eliminate pain and pain-related problems by providing holistic care. The aim of this study was to examine the effect of an open-heart surgery patient care protocol developed in the study on post-sternotomy pain, anxiety and quality of care. The study was carried out as a double-blind randomized controlled trial. The sample size was calculated. Considering some attrition, the sample size was increased by 10% for each group, and a total of 68 participants, including 34 in each group, were included in the sample. Data were collected using a 'Patient Information Form', a 'Post-Sternotomy Pain Follow-up Form', the 'Numeric Rating Scale', the 'State Anxiety Inventory' and the 'Strategic and Clinical Quality Indicators in Postoperative Pain Management Questionnaire'. The patients in the experimental group were given care in accordance with the protocol, which was developed in the study, on postoperative days 0, 1 and 2. The statistical evaluation showed a significant difference between the mean scores of the experimental (F = 7.28; p < .001) and control groups (F = 2.42; p < .05) on the pain assessment scale. It was determined that the number of analgesics used in the experimental group was statistically significantly lower than in the control group. Intra-group comparisons showed that there was a difference between the mean pre-test and post-test state anxiety scale scores of the groups (p < .001). The experimental group had higher mean scores on the Strategic and Clinical Quality Indicators in Postoperative Pain Management Questionnaire than that of the control group (p < .001). The protocol developed in the study was found to be effective in reducing pain, the use of NSAIDs and opioids, and anxiety levels and increasing the level of quality of care. The protocol was original and feasible in that it included independent nursing interventions to improve the quality of care by reducing pain and anxiety. Particularly, the use of protocols in intensive care units was nurses' strongest resource in patient care management. Thus, the protocol, which was prepared for intensive care patients who most frequently experience pain and anxiety, was promising for nurses in improving the quality of care by reducing pain and anxiety. However, it is necessary to conduct further studies involving longitudinal follow-up in samples and institutions with similar conditions.

Assessment of the Level of Awareness and Degree of Implementation of Central Line Bundles for Prevention of Central Line-associated Blood Stream Infection: A Questionnaire-based Observational Study.

The objective of this study was to assess the extent of knowledge and application of central line bundles in the intensive care unit (ICU) of a tertiary care hospital for the purpose of avoiding central line-associated bloodstream infections (CLABSI). This assessment was conducted through the use of a questionnaire. A cross-sectional study was conducted in the ICU, involving doctors and nurses. The study was observational in nature. The study employed a methodical validated questionnaire to evaluate the level of knowledge, attitude, and practice of central line bundles for the prevention of central line-associated bloodstream infections (CLABSI). The questionnaire was designed using preexisting awareness surveillance systems, infection control measures, and patient care practices that were specifically relevant to CLABSIs in the ICU. The data were analyzed utilizing SPSS. The research involved a total of 93 healthcare professionals, consisting of 67 physicians and 26 nurses. The mean knowledge score among participants was 82%, with higher scores reported in individuals who had training in central line bundles. Healthcare professionals exhibited robust compliance with hand cleanliness, antiseptic skin preparation prior to insertion, aseptic draping of the patient, utilization of utmost sterile barriers, verification of central venous catheter (CVC) tip placement using chest X-ray or fluoroscopy, and preservation of a sterile environment. The study emphasized the significance of training in enhancing understanding and adherence to central line bundling protocols in ICUs. Participants exhibited a high level of knowledge and commitment to recommended practices, indicating that this training can have a favorable effect on CLABSI rates. Singh S, Sharma A, Dhawan M, Sharma SP. Assessment of the Level of Awareness and Degree of Implementation of Central Line bundles for Prevention of Central Line-associated Blood Stream Infection: A Questionnaire-based Observational Study. Indian J Crit Care Med 2024;28(9):847-853.

Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study

BackgroundPracticing hand hygiene is a cost-effective method to decrease the occurrence of Healthcare-Associated Infections (HAIs). However, despite their simplicity, adhering to hand hygiene methods among healthcare workers (HCWs) can be highly challenging. We aim to examine the factors influencing hand hygiene compliance as perceived by HCWs working in the intensive care units (ICUs) at several major hospitals in Riyadh, Saudi Arabia.MethodThis qualitative study was conducted by adopting a content analysis to examine the interviews of HCWs who are currently working in the ICUs of various major hospitals located in the capital city of Riyadh, Saudi Arabia.ResultsWe interviewed 49 HCWs working in ICUs, with an average age of 38 and 8 years of experience. The HCWs comprised doctors (n = 12), anesthesiologists (n = 6), and nurses (n = 31). There were 34 females and 15 males among the participants. Our analysis revealed several factors that impact hand hygiene compliance, including individual, work/environment, team, task, patient, organizational, and management concerns. Several obstacles and possibilities for enhancement have been identified.ConclusionThe results of this study would enhance our comprehension of hand hygiene practices and serve as a foundation for creating future strategies and assessment methods to enhance compliance with hand hygiene protocols in ICUs.

Impact of nursing interventions on the prevention of ocular surface disorders in critical care patients: A systematic review.

Intensive care unit (ICU) patients are at an increased risk of ocular surface injuries because of various factors such as reduced tear production and impaired protective mechanisms. Despite the significance of ocular care in ICU settings, there is a lack of consensus on effective interventions, leading to inadequate prevention of ocular surface disease (OSD). This systematic review aimed to assess the effectiveness of nursing eye care in preventing OSD in ICU patients. Secondary objectives included identifying primary risk factors for ocular injuries and examining the most effective preventive methods. A systematic review following PRISMA guidelines was conducted, encompassing a literature search, article selection, quality assessment and data synthesis. Studies meeting inclusion criteria were observational studies and clinical trials, focusing on adults admitted to ICUs under sedation and receiving mechanical ventilation. Of 3545 initially identified articles, 12 studies met inclusion criteria. These studies involved a total of 1853 participants. Various interventions were assessed, including saline rinsing, lubricating drops, gel lubricants, occlusion with polyethylene dressing, passive blinking and eyelid closure with tape. Moist chamber occlusion every 6 h combined with gel lubrication emerged as the most effective method in preventing OSD. Gel lubrication along with moist chamber occlusion proved to be the most effective strategy in preventing ocular injuries in ICU patients. Conversely, the routine use of physiological saline was associated with increased severity of corneal lesions. Properly defined protocols and well-trained nursing teams are crucial for reducing ocular injuries in ICU settings. The findings underscore the importance of implementing evidence-based eye care protocols in ICUs, emphasizing the use of gel lubrication and ocular surface protection to mitigate the risk of OSD. This highlights the need for comprehensive training programmes for ICU nursing staff to ensure optimal ocular care delivery.

#2999 Renal venous congestion as a predictor of poor prognosis in patients with acute decompensated heart failure

Abstract Background and Aims Systemic venous congestion in acute decompensated heart failure (ADHF) is associated with a risk of end-organ damage and high in-hospital mortality. We aimed to assess the prevalence and severity of renal venous congestion using venous excess ultrasound (VExUS) protocol in intensive care unit (ICU) patients with ADHF, and to evaluate the association between type of intra-renal venous blood flow, incidence of acute kidney injury (AKI), and in-hospital death. Method A prospective single-center study included 99 patients who were admitted to the ICU with ADHF (mean age 71.1 ± 12.54 years, 56 (56.6%) males). Inclusion criteria: age ≥18 years, ADHF II–IV, signed informed consent. Exclusion criteria: acute coronary syndrome, severe concomitant diseases, refusal to participate in the study. Upon admission, routine clinical, laboratory and instrumental examinations, lung ultrasound using the BLUE protocol, and assessment of venous congestion using the pulse-wave dopplerography were performed. The presence of continuous blood flow was regarded as the absence of renal venous congestion, while intermittent (biphasic and monophasic blood flow) indicated venous congestion. The diagnosis of ADHF and AKI was established based on generally accepted criteria in accordance with modern international recommendations. All patients received optimal drug therapy. The end point was defined as death from cardiovascular causes during hospitalization. Statistical analysis was performed using SPSS Statistics, version 26.0. Results Upon admission, continuous renal venous blood flow was detected in 17 (17.2%) patients, intermittent in 82 (82.8%): biphasic in 47 (47.5%) and monophasic in 35 (35.3%). The patient groups were comparable in gender, age, frequency of coronary heart disease, diabetes mellitus, anemia. Atrial fibrillation was more common in case of monophasic (p &amp;lt; 0.006), and arterial hypertension in patients with continuous venous blood flow (p &amp;lt; 0.001). Patients with renal venous congestion, compared with patients without signs of congestion, had more severe heart failure: swollen neck veins: 5 (29.4%) vs 21 (45%) vs 28 (60%), p &amp;lt; 0.001; hepatomegaly 12 (72.6%) vs 40 (85.1%) vs 31 (88.6%), p &amp;lt; 0.001; edema 8 (47.3%) vs 40 (85.1%) vs 24 (68.6%), p &amp;lt; 0.001; NYHA functional class IV 8 (47.1%) vs 32 (68.1%) vs 26 (74.6%), p &amp;lt; 0.001; more B-lines on lung ultrasound, M+SD 28.82 ± 8.91 vs 34.38 ± 9.64 vs 35.37 ± 8.72, p &amp;lt; 0.001, higher NTproBNP levels, pg/l, Ме(IQR) 2100 (1800;4560) vs 3418 (2300;8434) vs 4100 (2500;9282), p &amp;lt; 0.001, and albuminuria levels mg/g, Ме(IQR) 85 (29;145) vs 127 (49;248) vs 139 (64;245), p &amp;lt; 0.001. The incidence of AKI (4 (23.5%) vs 23 (49%) vs 31 (88.6%), p &amp;lt; 0.001), and in-hospital death (0 (0) vs 11 (23.4%) vs 12 (34.3%), p &amp;lt; 0.003) was also higher in the group of patients with monophasic renal blood flow. The presence of renal venous congestion on admission was associated with an increased risk of death due to heart failure during hospitalization with RR 1.32 (95% CI: 1.16-2.64), p &amp;lt; 0.001, and RR 1.64 (95% CI: 1.48-2.83), p &amp;lt; 0.001 in patients with biphasic and monophasic renal venous blood flow respectively, and with development of AKI RR 3.29 (95% CI: 1.50-7.24), p &amp;lt; 0.003 in patients with monophasic renal venous blood flow. Conclusion In ICU patients with ADHF, the presence of renal venous congestion, assessed on admission with Doppler ultrasound of the intrarenal veins using the VEXUS protocol, is associated with a high risk of developing AKI and in-hospital death.

Prevalence and factors influencing anemia recovery after intensive care

BackgroundAnemia is associated with adverse outcomes and prolonged hospitalizations in critically ill patients. Regarding the recent adoption of restrictive transfusion protocols in intensive care unit (ICU) management, anemia remains highly prevalent even after ICU discharge. This study aimed to investigate the prevalence of anemia following ICU discharge and factors affecting recovery from anemia. MethodsIn this retrospective cohort study involving 3969 adult ICU survivors, we assessed anemia severity using the National Cancer Institute criteria at six time points: ICU admission, ICU discharge, hospital discharge, and at 3-, 6-, and 12-month post-hospital discharge. In addition, baseline characteristics, including age, sex, comorbidities, and recent iron supplementation or erythropoietin administration, were evaluated. ResultsOur findings revealed an in-hospital mortality rate of 28.6%. The median hospital and ICU stays were 20 and 5 days, respectively, with common comorbidities including hypertension, and diabetes mellitus (DM). Among the patients, the hemoglobin levels of 3967 patients were confirmed at the time of discharge from the ICU, representing 99.95% of the total. The prevalence of anemia persisted post- ICU discharge; less than 30% of patients recovered, whereas 13.6% of them experienced worsening of anemia post-ICU discharge. Factors contributing to anemia severity were female sex, DM, chronic renal failure, malignant solid tumors, and administration of iron supplements. ConclusionsThis study highlighted the need for targeted interventions to manage anemia post-ICU discharge and suggested potential factors that influence recovery from anemia.

Perspective on dysphagia screening, assessment methods, and protocols in intensive care units: an opinion article.

Perspective on dysphagia screening, assessment methods, and protocols in intensive care units: an opinion article.

Implementation of a standardized lung ultrasound protocol for respiratory distress in a neonatal intensive care unit: an observational study.

To assess the feasibility of implementing a simple point-of-care lung ultrasound (LU) evaluation and reporting protocol in a neonatal intensive care unit (NICU) and its effect on patient management. Retrospective observational study of LU examinations performed in a level III NICU. Each examination was performed according to a standardized protocol. An independent radiologist-assessed chest X-ray (CXR) was used to compare the LU diagnosis. The impact on patient management was also evaluated. A total of 206 LU studies in 158 neonates were reviewed. There was significant agreement between LU and CXR diagnoses (84.95%, 95% CI 80.07-89.83%). LU affected patient management in 87.8% of the cases (95% CI 83.33-92.28%). Implementation of a simplified, sign-based protocol for LU in the NICU is feasible. LU is not inferior to CXR studies and supports patient management as an imaging modality.

Substantiating and Adopting Lung Ultrasound Scores to Predict Surfactant Need in Preterm Neonates with Respiratory Distress Syndrome within an Institution.

Administering surfactant timely and appropriately is important to minimize lung injury but remains challenging in preterm neonates with respiratory distress syndrome. The published literature supports that lung ultrasound (LUS) score can predict surfactant need. Neonatal LUS scanning specification and parameter setting guidelines have been recently published for standardization. However, variations in scanning protocols and machine settings hinder its clinical implementation widely. This observational study aims to internally validate the suggested LUS protocol in a neonatal intensive care unit to establish a correlation between LUS scores and surfactant need as the first step of integrating LUS in the clinical practice. LUS was performed on 40 eligible preterm neonates within 3 hours after birth or before surfactant administration between May 2020 and March 2021. The neonates were between 27 and 32 weeks' gestational age, and all had respiratory distress. Neonates with known congenital anomalies were excluded. A high-frequency linear probe was used to obtain LUS images from six lung zones which were scored using a 0 to 3 system, yielding a maximum of 18 points. Treating physicians were blinded to the LUS score. Receiver operating characteristic analysis determined the optimal LUS score cut-off for predicting surfactant need. Fifteen of the 40 neonates (38%) required higher oxygen fraction and received surfactant. In our cohort, an LUS score ≥10 was identified as the optimal cut-off for predicting surfactant need, with a sensitivity of 80% and specificity of 84%. The area under the curve was 0.8 (p = 0.0003). LUS predicted surfactant need at a median of 3.5 hours earlier than traditional clinical decision (p < 0.0037). LUS is a helpful adjunct for predicting surfactant need in preterm neonates. This study describes an approach to implement the LUS protocol and score for clinical decision-making in the clinical practice. · LUS is a helpful adjunct for predicting surfactant need in preterm neonates.. · Machine setting variation and probe selection may affect LUS image and score.. · LUS score should be validated at the local unit before clinical implementation..

Body composition after implementation of an enhanced parenteral nutrition protocol in the neonatal intensive care unit: a randomised pilot trial

Background Very low birthweight (VLBW) infants are at risk for growth failure and poor neurodevelopment. Optimised parenteral nutrition may help promote optimal growth and development, but concerns that provision of enhanced nutrition may contribute to increased early adiposity and later metabolic disease remain. Aim To determine associations between provision of an early enhanced parenteral nutrition protocol or standard parenteral nutrition protocol and growth and body composition for VLBW preterm infants in the neonatal intensive care unit. Subjects This is a secondary analysis of data from a clinical trial aimed at assessing the feasibility and safety of randomising VLBW preterm infants to Standard (n = 45) or Intervention (n = 42) parenteral nutrition groups between August 2017 and June 2019. Methods We evaluated associations between weekly infant growth and body composition measurements from n = 55 infants (Standard = 29, Intervention = 26) that were clinically stable enough to have body composition measurements taken before discharge using mixed effects linear regression models. Result No statistically significant associations between nutrition group and infant growth or body composition measures were observed (p >.05). Conclusion In this pilot trial, enhanced parenteral nutrition in the first week of life was not associated with significant differences in infant growth or body composition during hospitalisation.

Red Blood Cell Transfusion Practice Pattern Before and After Implementation of a Local Restrictive Transfusion Protocol in a Neonatal Intensive Care Unit

Background A restrictive red blood cell (RBC) transfusion guideline was established in 2019 in a neonatal intensive care unit (NICU), suggesting a hemoglobin concentration threshold of 7 g/dL. Objectives (a) To determine its impact on the number of RBC transfusions and donor exposure; (b) to characterize RBC-transfusion determinants and justifications. Study Design Single-center retrospective historical control study comparing all neonates consecutively admitted to the NICU during two five-month periods: 401 patients in 2013 before and 402 patients in 2021 after restrictive guideline implementation. Possible determinants were assessed via logistic regressions and justifications via a questionnaire. Results In 2021, 9.2% of neonates received at least one RBC transfusion compared to 13.5% in 2013 ( p = .075). Adherence to protocol thresholds was 50%. Implementation of a restrictive transfusion protocol had some impact on determinants related to neonatal morbidity and illness severity and some impact on justifications being mainly based on hemoglobin value. Conclusion Our study demonstrates that the implementation of a restrictive RBC transfusion protocol tended to decrease transfusion rates and donor exposure in the NICU, but the trend was not statistically significant. Future work should focus on improving protocol adherence.

Enhancing ICU Candida spp. surveillance: a cost-effective approach focused on Candida auris detection.

Candida auris is an emerging pathogen that represents a worldwide health problem due to its global expansion, multidrug resistance, and difficult laboratory identification. Among the risk factors for colonization/infection by C. auris, a stay in an intensive care unit (ICU) stands out. This prospective multicenter study aimed to monitor the trend of the local epidemiology of Candida spp. and unveil the prevalence of C. auris. From 2020 to 2022, axillar/inguinal swabs were collected from adult patients at three points: upon admission (D1) and on the fifth (D5) and eighth (D8) days of their ICU stay. We employed culture-based screening methods combined with molecular techniques to identify Candida spp. down to the species level. Specific screening for Candida auris was conducted using a real-time PCR assay in combination with an improved selective culture medium, mannitol salt agar auris (MSAA). To validate the effectiveness of MSAA, a collection of reference C. auris strains representing the four major geographical clades was used. We enrolled 675 patients, and 355 Candida isolates were retrieved from the 988 swab samples collected. From those, 185/355 (52.1%) were identified as C. albicans and 170/355 (47.9%) as non-albicans Candida (NAC). MSAA medium showed a specificity of 94.8%, albeit C. auris was not detected in this cohort. The dynamics of Candida spp. colonization by ICU were significant at the three collection points. Upon admission, C. albicans was associated with the Beatriz Ângelo Hospital ICU (p=0.003) and C. tropicalis with the general Hospital Professor Doutor Fernando Fonseca (FFH) ICU (p=0.006). C. parapsilosis and C. lusitaniae were associated with FFH ICUs, with the general ICU at D5 (p=0.047) and surgical ICU at D8 (p=0.012). The dynamics of NAC colonization by ICU were significantly different at D1 (p=0.011), D5 (p=0.047), and D8 (p=0.012). We developed and implemented a screening protocol for C. auris while uncovering the colonization patterns of Candida in the ICU. Our findings contribute to the optimization of overall patient management, ensuring that ICU protocols are resilient and adaptive to emerging fungal threats.

Implementation of a swallow screening protocol in a tertiary adult intensive care unit: A quality improvement project

Background: Post-extubation dysphagia occurs in 3% to 62% of adults who have received invasive mechanical ventilation in an intensive care unit (ICU). A stepwise approach to identify dysphagia includes a routine swallow screening in patients who are recently extubated followed by a formal assessment by a Speech and Language Pathologist (SLP), in the event of a failed swallow screen, has been suggested. This quality improvement project aimed to implement and evaluate a new post-extubation swallow screening process. Methods: Using the Model for Improvement framework, a new process that included the Yale Swallow Protocol (YSP) was developed, implemented, and evaluated between July and December 2022 in a 20-bed tertiary ICU. All patients with at least four hours after post-extubation were included in the project. Process development included a literature review and feedback from ICU educators, nurses, physicians, SLPs, and Registered Dietitians (RD). Education was provided to critical care nurses prior to implementation. Data on patient characteristics, process indicators, and outcomes were collected between September and December 2022 to evaluate the project implementation. Descriptive statistics were used to describe the data and bivariate analyses were used to compare data between patients who passed and failed the YSP. Results: Fifty-four patients were extubated and evaluated using the new swallow screening process. Post-extubation dysphagia was diagnosed by an SLP in 30.0% of patients. Dysphagia was diagnosed in 90.0% of patients who failed compared to 8.6% of patients who passed the YSP (P&lt;0.001). Conclusion: A swallow screening process using the YSP was successfully adopted in a tertiary ICU.

Implementation of an early mobility protocol in the neuroscience ICU

Abstract &#x0D; Background: Early mobility is a safe and effective intervention to improve patient outcomes in the neuroscience intensive care unit (ICU). However, mobilization of patients in a neuroscience ICU within an academic medical center was suboptimal, with less than 36% of patients achieving their highest level of mobility.&#x0D; Aim: The purpose of the quality improvement project was to develop and implement a multidisciplinary early mobility protocol, including a safety-screening tool.&#x0D; Methods: Iterative Plan-Do-Study-Act cycles were implemented from April to August 2022. The screening tool assisted nurses in assessing the patient’s eligibility for early mobilization. A mobility section addressing patient-specific mobility screening, barriers to mobility, and a daily mobility plan was added to the provider note templates. Baseline data were collected from September to November 2021; post-implementation data were collected from April to August 2022.&#x0D; Results: There was a reduction in the mean time between admission to the first documented out of bed activity from 3.24 to 2.01 days, p=.061. The mean number of documented out of bed activities significantly increased from 6.13 to 8.35, p = .002. Hospital length of stay significantly decreased from 19.8 to 12.42 days, p=.006.&#x0D; Conclusions: Implementing an early mobility screening tool and protocol in the neuroscience ICU increased mobility for patients with neurological diagnoses. Other hospitals should consider implementing a similar process to help improve patient outcomes.

Pathogenic and Non-Pathogenic Microbial Presence in Ventilator Associated Pneumonia Patients in Intensive Care Unit and Safety Protocols Under Surveillance of Healthcare Provider: A Research Study

Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection that is associated with longer stays in intensive care units (ICUs) and under mechanical ventilation for more than 48 hours. This article explores the prevalence and impact of VAP on mortality and morbidity, emphasizing the microbial associations involved in hospital-acquired infections. Various infections, including Lung infections, surgical site infections, sepsis, and urinary tract infections, are discussed, along with their associated microorganisms. Diagnostic criteria for VAP and related infections are outlined, highlighting the importance of microbiological testing for accurate diagnosis. The underlying factors for VAP acquisition in ICU patients are identified, and prompt antibiotic initiation is emphasized as a critical first-line defense against VAP. In this study, we have populated data from 100 ICU patients, among which 45 were suffering from VAP. It was found that female patients (57.40%) were more affected than male patients (30.43%). The decreasing PaO2 level was seen to be the early sign of infection. It was found that the time of ventilation was the major factor influencing the VAP. The most common organism causing infection in our study was found to be Staphylococcus Aureus (45.1%). The prognosis of early-onset VAP was 35.55% while compared to Late-onset VAP 64.44%. When compared to VAP and Non-VAP patients there was not very huge difference with 55% and 45% respectively. The other factor was age and position. Implementation of Prevention strategies, such as protective environments and HEPA filtration systems, is proposed to reduce VAP incidence. Proper diagnosis, treatment, and prevention are crucial to combatting VAP and enhancing patient outcomes in hospital settings.

Remi-fent 1—A pragmatic randomised controlled study to evaluate the feasibility of using remifentanil or fentanyl as sedation adjuncts in mechanically ventilated patients

ObjectiveTo evaluate the feasibility of conducting a prospective randomised controlled trial (pRCT) comparing remifentanil and fentanyl as adjuncts to sedate mechanically ventilated patients. DesignSingle-center, open-labelled, pRCT with blinded analysis. SettingAustralian tertiary intensive care unit (ICU). ParticipantsConsecutive adults between June 2020 and August 2021 expected to receive invasive ventilation beyond the next day and requiring opioid infusion were included. Exclusion criteria were pregnant/lactating women, intubation >12 h, or study-drug hypersensitivity. InterventionsOpen-label fentanyl and remifentanil infusions per existing ICU protocols. OutcomesPrimary outcomes were feasibility of recruiting ≥1 patient/week and >90 % compliance, namely no other opioid infusion used during the study period. Secondary outcomes included complications, ICU-, ventilator- and hospital-free days, and mortality (ICU, hospital). Blinded intention-to-treat analysis was performed concealing the allocation group. Results208 patients were enrolled (mean 3.7 patients/week). Compliance was 80.6 %. More patients developed complications with fentanyl than remifentanil: bradycardia (n = 44 versus n = 21; p < 0.001); hypotension (n = 78 versus n = 53; p < 0.01); delirium (n = 28 versus n = 15; p = 0.001). No differences were seen in ICU (24.3 % versus 27.6 %,p = 0.60) and hospital mortalities (26.2 % versus 30.5 %; p = 0.50). Ventilator-free days were higher with remifentanil (p = 0.01). ConclusionsWe demonstrated the feasibility of enrolling patients for a pRCT comparing remifentanil and fentanyl as sedation adjuncts in mechanically ventilated patients. We failed to attain the study-opioid compliance target, likely because of patients with complex sedative/analgesic requirements. Secondary outcomes suggest that remifentanil may reduce mechanical ventilation duration and decrease the incidence of complications. An adequately powered multicentric phase 2 study is required to evaluate these results.

Barriers to Adherence of Early Mobilization Protocols in the Pediatric Intensive Care Units

AbstractChildren who survive critical illness suffer many sequelae of prolonged hospitalization. National guidelines recommend pediatric intensive care units (PICUs) employ ICU care bundles to combat acquired delirium, pain, and weakness. While the use of early mobility (EM) protocols has increased in PICUs, there remain challenges with adherence. The aim of this study is to better understand perceived barriers to EM in the PICU before and after introducing an EM protocol. We hypothesized that providers would be most concerned about the safety of EM. This pre–post-survey study was conducted at a single-center tertiary PICU. A total of 94 PICU providers were included in this study, including nurses, physicians, and therapists. Responses were collected anonymously. Survey respondents consented to participation. The initial survey was conducted prior to enacting an EM protocol to gauge knowledge and opinions surrounding EM. Based on the results, education regarding EM was performed by a multidisciplinary team. An EM protocol “Move Jr.” was initiated. Four months postinitiation, a follow-up survey was sent to the same cohort of providers to determine knowledge of the protocol, changes in opinions, as well as barriers to the implementation of EM. While providers believed that EM was beneficial for patients and were interested in implementing an EM protocol, the initial top three perceived barriers to EM were risk of inadvertent extubation, risk of inadvertent loss of central lines, and time constraints. Four months after the initiation of the EM protocol, a follow-up survey revealed that the top three perceived barriers of EM had changed to time constraints, increased workload, and level of sedation. After 4 months, the change in perceived barriers suggests greater acceptance of the safety of EM but challenges in application. Survey responses describe a desire to perform EM exercises but difficulty finding time. Understanding of the protocol also differed among providers. Greater collaboration among providers could lead to more cohesive therapy plans. There was a clear benefit in educating providers to consider EM as a priority in patient care.

Impact of the implementation of a sedation and analgesia protocol in a pediatric intensive care unit.

Introduction. Adequate sedation and analgesia is essential in the management of patients requiring mechanical ventilation (MV). The implementation of protocols and their monitoring is recommended; mixed results on adherence and impact have been reported. Objectives. To assess the impact of the implementation of a sedation and analgesia protocol on the use of benzodiazepines, opioids, and evolution in the pediatric intensive care unit (PICU) in patients requiring MV for more than 72 hours. Methods. Before-and-after, uncontrolled study in the PICU of a children’s hospital. The study was developed in 3 stages: pre-intervention for situational diagnosis (from April to September 2019), intervention,and post-intervention for implementation of a sedation and analgesia protocol, education on use, and monitoring of adherence and impact (from October 2019 to October 2021). Results. A total of 99 and 92 patients were included in the study in the pre- and post-intervention stages, respectively. Patients had a more severe condition, were younger, and had a lower weight in the preintervention period. After adjusting for severity and age, the group comparison in the post-intervention stage showed a reduction in days of continuous infusion of opioids (6 ± 5.2 versus 7.6–5.8, p = 0.018) and days of continuous infusion of benzodiazepines (3.3 ± 3.5 versus 7.6 ± 6.8, p=0.001).Nosignificantdifferences were observed in days of MV and total days of benzodiazepine use. Conclusion. The implementation of a sedation and analgesia protocol resulted in a reduction in the use of continuous infusion of drugs.

Evaluation of an Empiric Vancomycin Dosing Protocol on Goal Troughs and Acute Kidney Injury in a Neonatal Intensive Care Unit.

Review the efficacy and safety of an updated empiric vancomycin dosing protocol in a neonatal intensive care unit (NICU). Retrospective chart review including neonates with postmenstrual age (PMA) less than 40 weeks without renal dysfunction who received vancomycin per protocol at a single institution's NICU before and after implementation of an updated dosing protocol. The primary outcome is the proportion of initial therapeutic troughs. Secondary outcomes include average trough, achievement of a therapeutic trough, number of days before attainment of a therapeutic trough, and proportion of acute kidney injury (AKI) during therapy. The 2 groups were similar in gestational age, race, birth weight, PMA, and weight at time of vancomycin initiation. The post-implementation group had a higher proportion of initial therapeutic troughs (33.0% vs 55.1%) and a lower proportion of a subtherapeutic (58.7% vs 43.8%) and supratherapeutic (8.3% vs 1.1%) initial troughs (p = 0.002). The median trough was not different (9.20 vs 10.50 mg/L; p = 0.092). There was no difference in the proportions of achieving a therapeutic trough throughout therapy (69% vs 76%; p = 0.235); however, the post-implementation group achieved a therapeutic trough 1 day earlier (3 vs 2 days; p < 0.001). There was no difference in proportions of AKI developing between the pre-implementation vs post-implementation groups (10.1% vs 5.6%; p = 0.251). Implementation of an updated vancomycin dosing protocol yielded a higher percentage of initial therapeutic vancomycin troughs and patients reached the therapeutic range 1 day earlier without increasing the proportion of AKI.