Intensive Care Unit Protocol Research Articles

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

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

Nutritional and metabolic characteristics of critically ill patients admitted for severe toxidermia

Drug-induced toxidermia is an idiosyncratic adverse skin reaction that may become life-threatening in a small portion of patients, requiring intensive care unit (ICU) admission. The treatment recommendations are extrapolated from those of major burns, while prospective data remain sparse. The objective was to observe the application of these recommendations in patients treated in a burn ICU. Retrospective cohort study including patients requiring ICU between 2006 and 2020 in a tertiary university hospital. Age >18 years. Patients were categorized as Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), or other toxidermia. severity scores, body surface area (BSA) involvement, nutritional and metabolic variables, trace element status, outcome variables. Descriptive statistics: median [IQR]. Altogether 35 patients were included (27 SJS/TEN and 8 "other"), aged 58 [48; 69] years. Skin involvement was 45% [30; 60] of body surface, 17 patients required mechanical ventilation, and length of ICU stay was 16 [6.5; 26] days. Hospital mortality was 23%. Fluid resuscitation requirements were moderate, despite intense inflammation (admission CRP (144 [89; 218] mg/L). The first 2 weeks' energy and protein intakes were below recommendations (p<0.0001), lowest with oral feeding. Indirect calorimetry showed high energy expenditure in 11 patients (30.4 [23.9; 35.5] kcal/kg) resulting in negative energy balances (mean-245 kcal/day). Copper and zinc levels were below reference range during the first week, the low copper values being a novel finding. Trace elements should be monitored. The cohort was underfed with intakes lower than our ICU protocols, partly explained by short intubation times, and mucocutaneous involvement complicating the management and placement of feeding tubes. Oral feeding was least efficient and may become an indication for supplemental parenteral nutrition in the absence of an enteral feeding tube. gov Identifier: NCT05320653.

Importance of the Pediatric Dentist in the Neonatal ICU.

Pediatric dentistry presents great challenges, especially when the professional is interested in the neonatal ICU, where the situation is more delicate and with an imminent risk of infections. The professional should act in prevention, checking, and sanitizing the baby's mouth so that there are no possible future oral health problems or even death. One of the most common causes of infections is, for example, pneumonia in the ICU due to the use of mechanical ventilation or even early diagnosis of aquiloglossia. Objective: To present a pediatric dentistry protocol in a Neonatal Intensive Care Unit and its importance, since the aim is to prevent various diseases and alterations that babies may present in the future. Methodology: The research was bibliographical research analyzing publica-tions, books, and scientific articles whose authors deal with the subject. Final considerations: The presence of a pediatric dentist in the multidisciplinary team of a maternity hospital, in addition to being a law, can improve care, preventing various illnesses that may interfere with the life of the newborn, reducing the length of stay in neonatal intensive care units and improving this baby's quality of life.

Analysis of delirium prediction in the ICU based on the hybrid SGDCS-ANFIS approach.

In recent years, intensive care unit (ICU) doctors have paid more attention to delirium. ICU patients have a high risk of delirium. Delirium can lead to serious adverse outcomes, but early diagnosis and prediction of delirium are very difficult and lack effective assessment tools. The causes of delirium are many and complex, and there is no definite prediction model. To solve this problem, this paper proposes a delirium prediction model based on a hybrid cuckoo search algorithm with stochastic gradient descent-the adaptive-network-based fuzzy inference system (SGDCS-ANFIS) approach. Thirty-five relevant indicators of 1072 ICU cases (536 delirium cases and 536 nondelirium cases) were selected to establish a delirium prediction model to judge whether patients tended to experience delirium. The experiments show that the delirium prediction model based on the hybrid SGDCS-ANFIS approach has better performance than traditional classification and prediction machine learning approaches, and the accuracy is improved to 73.02%. It can provide some reference for the prediction of delirium, promote early diagnosis, and provide knowledge for early intervention to improve the prognosis of ICU patients. Adding this delirium prediction model to the ICU protocol will potentially improve the treatment outcome, quality, and cost. Doctors can manage sudden symptoms more calmly, and patients will also benefit. By collecting the real-time data commonly used in electronic medical records of ICUs, the proposed delirium prediction model can be easily applied in hospitals. Delirium can lead to serious adverse outcomes, but early diagnosis and prediction of delirium are very difficult and lack effective assessment tools. We propose a hybrid SGDCS-ANFIS approach to establish delirium prediction model to judge whether ICU patients tend to experience delirium. It can provide some reference for the prediction of delirium, promote early diagnosis, and provide knowledge for early intervention to improve the prognosis of ICU patients. By collecting the real-time data commonly used in electronic medical records of ICUs, the proposed delirium prediction model can be easily applied in hospitals. Fig. Development flow from raw data to the building of the delirium prediction model and model comparison.

2316. Impact of Surveillance and Decolonization on Methicillin-resistant Staphylococcus aureus Infection Rates in a Neonatal Intensive Care Unit

Abstract Background Neonates colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at high risk of developing life-threatening MRSA infection. In neonatal intensive care units, surveillance for MRSA colonization and decolonization of positive infants aims to interrupt MRSA transmission and progression to infection. Methods In this retrospective study, we compared rates of MRSA infections before and after implementation of an MRSA surveillance and decolonization protocol in a 42-bed neonatal intensive care unit. Infections from Jan 2014 to Dec 2020 were reviewed. The protocol was introduced in late October 2016 and fully implemented by Feb 2017. MRSA colonization was initially assessed with cultures of three body sites and later the methodology was changed to PCR. Colonized infants were treated with topical mupirocin and 2% chlorhexidine gluconate wipes. MRSA infection was defined as any specimen from which MRSA was isolated. Multiple positive specimens from the same site were considered the same infection if within a 14-day window. Infection rates were calculated as unique infections per 1000 patient days. An interrupted time-series analysis was performed on Stata 14.2. This study was approved through the Baylor College of Medicine Institutional Review Board. Results While we continued to identify colonized infants in the unit, monthly infection rates in the post-intervention period never reached the peak rates in the pre-intervention period and clusters of infections have been eliminated (Figure 1). Prior to the intervention in Feb 2017, the rate of infection increased by 0.06 infections per 1000 patient days every month (p=0.124, CI = -0.017, 0.137). During the first month after full implementation of the intervention, the infection rate decreased by 1.522 infections per 1000 patient days (p=0.145, CI = -3.579, 0.534) followed by a monthly rate decrease of 0.066 infections per 1000 patient days (p=0.088, CI = -0.142, 0.010) (Figure 2). Conclusion We found a sustained trend towards decreased MRSA infections after implementing MRSA surveillance and decolonization. Further studies should explore adherence to decolonization, whether decolonization is enduring and what risk factors lead to recurrence of colonization. Disclosures All Authors: No reported disclosures.

HYPOTENSION PREDICTABILITY INDEX, A NEW TOOL TO PREDICT HYPOTENSION AFTER CARDIAC SURGERY

<h3>Introduction</h3> Cardiac surgery is prone to hypotensive periods due to the frequent, unpredictable shifts in fluid status and vasomotor tone. Hypotension has been shown to occur as high as 99% of the cases in the perioperative period and is clearly linked to increased morbidity (acute kidney injury, stroke, myocardial ischaemia) and possibly mortality as well. Hypotension Predictability Index (HPI) a newly developed tool which utilizes the benefits of machine learning to predict hypotension minutes before its occurrence in different surgical situations. However, there is less data available regarding the postoperative period after cardiac surgery. The aim of our study was to monitor HPI in postoperative cardiac surgical patients and validate its effectiveness in predicting hypotension in this cohort. <h3>Methods</h3> In this pilot observational study, 10 cardiac surgical patients were sequentially chosen to be equipped with a Flowtrac IQ pressure transducer (Edwards Lifesciences), which contains the HPI protocol. The Flowtrac IQ can be used as a regular pressure transducer but pairing with a Hemosphere Monitor (Edwards) allows the display and recording of the HPI and blood pressure data. The patients did not receive any additional intervention based on HPI, postoperative care was carried out as per our Intensive Care Unit's protocol. Blood pressure and HPI values from the first 12 post-operative hours were collected and analysed retrospectively. Hypotension was defined as a decrease in mean arterial pressure below 65 mmHg for at least a minute as suggested by previous studies. The data set was analysed in its entirety. The total number of hypotensive events was calculated and analysed in terms of absolute duration. HPI and blood pressure data from the preceding 5 minutes were analysed with Receiver Operating Characteristics (ROC) analysis for correlation. <h3>Results</h3> Patients mean age was 64,4±11,3 years with an Euroscore of 1,7±1,1%. 70% were male. 80% of patient underwent CABG procedure, 20% had AVR, while 1 patient had an atrial mass removal. 90% had at least one hypotensive episode in the postoperative 12 hours. An average of 8.1±11.2 hypotensive events were recorded during the observed period with a mean duration of 4.1±4.0 minutes, which resulted in an average total hypotensive length of 44.2±66,4 minutes. HPI was able to predict the occurrence of hypotension with a sensitivity of 95,1% and specificity of 92,4%. Our data suggests that a cut off value of 92 might provide the best sensitivity and specificity, which is higher than cut off of 85 suggested by the manufacturer. <h3>Conclusions</h3> Hypotension is a frequent occurrence during cardiac surgery, which can be seen in even our small randomly chosen cohort. HPI was able to predict the incidence of hypotension with a good sensitivity and specificity in the post-operative 12 hours after cardiac surgery. This suggests that HPI can be a valuable tool in preventing post-operative hypotension and its complications.

Implementation of a spontaneous awakening/spontaneous breathing trial protocol in a surgical intensive care unit: a before and after study.

Prolonged invasive mechanical ventilation (IMV) influences patient outcome in multiple ways. In this regard the early weaning from IMV is a major goal to be achieved in the treatment of ICU patients. Adopting a weaning protocol that incorporates a Spontaneous Awakening Trial (SAT) and a Spontaneous Breathing Trial (SBT) seems to be essential to reach this goal. Most studies investigating the effectiveness of SAT/SBT protocols in ICU patients' outcomes have focused mainly on medical or mixed (medical and surgical), but not on exclusively surgical patient populations. Surgical patients usually experience more complications and often undergo revision surgeries, therefore needing longer sedation periods and adequate analgo-sedation therapy. Moreover, the longer IMV times make the weaning process more arduous. Our retrospective data analysis therefore investigates the effectiveness of a SAT/SBT protocol implementation in the surgical ICU of Heidelberg University Hospital, focusing exclusively on surgical patients and their outcome related to the weaning process. The SAT/SBT protocol was adopted in Heidelberg ICU starting from 05/2019. We therefore analyzed the time period before and after the implementation between 03/2018 and 08/2020. Adult patients who required invasive ventilation for at least 48 hours were screened for study entry. Demographic data, clinical data and SOFA Score on admission, were collected to define the baseline characteristics of the two groups. Only patients with full adherence to the protocol were included. The primary outcome was defined as the successful extubation, intended as an extubation not followed by successive re-intubations until discharge from the ICU. We performed an univariate analysis to evaluate the rate of successful extubations between the two groups. In total, 199 patients were included in the analysis, 98 of which before the SAT/SBT protocol implementation (control group) and 101 after the SAT/SBT protocol implementation (intervention group). The successful extubation rate in the intervention group resulted in 82% (83/101 patients) compared to 64% (63/98 patients) in the control group (P<0.004). We conclude that even for an exclusively surgical patient population, the implementation of a SAT/SBT protocol could result in a higher rate of successful extubation.

Factors influencing the implementation of a ventilation weaning protocol in an adult intensive care unit: a qualitative multidisciplinary evaluation.

Development of protocolized care in the intensive care unit (ICU) improves patient outcomes, but presents multiple challenges. A mechanical ventilation weaning protocol (WP) was adopted in our institution but was underused. This study aimed to determine the factors that influenced the implementation of this protocol locally. We performed a qualitative descriptive study using semidirected interviews in small profession-specific focus groups. The interviews were based on a standardized guide covering the major domains found in the Consolidated Framework for Implementation Research. A total of 32 participants across four key professions were recruited. The interviews were transcribed and codified sequentially, followed by categorization and analysis. Three broad factors emerged that negatively impacted the implementation of the WP. First, the goals of the WP differed between professional groups. This difference led to significant frustration and breaches in collaboration. Second, there was a lack of a continuous quality improvement process. Third, the WP was incompatible with the routine and procedures already in place at the time of implementation. Time-of-day of WP application and patient safety concerns were specifically identified issues. Implementation of a continuous improvement process with regular and specific follow-up may help identify potential challenges and thus help ensure a more consistent use of the WP.

Implementation of a 24-hour infection diagnosis protocol in the pediatric cardiac intensive care unit (CICU).

To reduce unnecessary antibiotic exposure in a pediatric cardiac intensive care unit (CICU). Single-center, quality improvement initiative. Monthly antibiotic utilization rates were compared between 12-month baseline and 18-month intervention periods. A 25-bed pediatric CICU. Clinically stable patients undergoing infection diagnosis were included. Patients with immunodeficiency, mechanical circulatory support, open sternum, and recent culture-positive infection were excluded. The key drivers for improvement were standardizing the infection diagnosis process, order-set creation, limitation of initial antibiotic prescription to 24 hours, discouraging indiscriminate vancomycin use, and improving bedside communication and situational awareness regarding the infection diagnosis protocol. In total, 109 patients received the protocol; antibiotics were discontinued in 24 hours in 72 cases (66%). The most common reasons for continuing antibiotics beyond 24 hours were positive culture (n = 13) and provider preference (n = 13). A statistical process control analysis showed only a trend in monthly mean antibiotic utilization rate in the intervention period compared to the baseline period: 32.6% (SD, 6.1%) antibiotic utilization rate during the intervention period versus 36.6% (SD, 5.4%) during the baseline period (mean difference, 4%; 95% CI, -0.5% to -8.5%; P = .07). However, a special-cause variation represented a 26% reduction in mean monthly vancomycin use during the intervention period. In the patients who had antibiotics discontinued at 24 hours, delayed culture positivity was rare. Implementation of a protocol limiting empiric antibiotic courses to 24 hours in clinically stable, standard-risk, pediatric CICU patients with negative cultures is feasible. This practice appears safe and may reduce harm by decreasing unnecessary antibiotic exposure.

Postpartum Hypernatremia with Extrapontine Rhabdomyelinolysis: A Case Report.

Hypernatremia (serum sodium>160 meq/L) present with diverse neurological manifestations, ranging from flaccid paralysis to impaired cognition, encephalopathy, and even deep coma. Osmotic demyelination refers to changes in brain cells because of an acute change in plasma osmolality. It is further divided into two types, i.e., central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM). Patients with EPM, besides spasticity, may also present with other movement disorders such as catatonia, parkinsonism, and dystonia. We present a case of a postpartum woman bought to the emergency department by her relatives in an unconscious state. In view of poor sensorium (Glasgow coma scale < 7), she was intubated and received mechanical ventilatory support. On admission, computed tomography ofthebrain was normal, and the patient was transferred to the intensive care unit (ICU) for further management. The preliminary work-up in the ICU showed hypernatremia (serum sodium of 182 mEq/L) with hyper-osmolality (359 mOsm/kgH2O). She was managed as per the ICU protocol for hypernatremia. During her ICU stay, her sensorium improved, but she developed flaccid paralysis and was quadriplegic. Thus, a tracheostomy was performed, and she was weaned from the ventilator. After ventilator weaning, she was transferred to the ward for further rehabilitation. During rehabilitation, the patient was able to sit and takefoodorally.To date, only a few cases are reported in postpartum women with acute severe hypernatremia caused by high-grade fever and loss of body fluids leading to extra-pontine demyelination and flaccid paralysis. This case highlightsthat prompt recognition and appropriate intervention can improve the outcomes in these patients.

Existence and perceived application of pain management protocols in German neonatal intensive care units.

We explored the existence and application of standard operating procedures (SOPs) for pain management (PM) in German neonatal intensive care units (NICUs), and identified the factors associated with their application in practice. This study was part of the Safety4NICU project, a cross-sectional survey conducted from 2015 to 2016. All 224 German NICUs were invited to participate, providing written consent from the head neonatologist and head nurse. We distributed questionnaires to the head neonatologist, the head nurse, and the NICU staff (physicians and nurses). We asked the head neonatologist whether written SOPs for PM existed, and we asked the staff whether these SOPs were applied in their daily routine. We received evaluable responses from 468 physicians and 1251 nurses from 76 NICUs. Of these 76 NICUs, the head neonatologists from 54 NICUs (71.1%) reported that written SOPs for PM exist. However, only 48.5% of the physicians and 53.7% of the nurses declared that these existing SOPs were also applied. We found various predictors for the existing SOPs as being applied, depending on the profession. For physicians, clinical training was important (OR: 2.482, p ≤ 0.05), while for nurses their working experience was a decisive predictor (OR: 1.265, p ≤ 0.05). For both, a high level of perceived cooperative norms between physicians and nurses increased the probability that SOPs for PM were applied, whereas a high bed turnover rate decreased that probability. According to the responses from head neonatologists, written SOPs for PM were common in German NICUs. However, if management strategies on pain existed, this did not mean that these were directly applied in the daily routine. Clinical training of the staff, the promotion of adequate interprofessional cooperation, as well as allowing time to deal with these SOPs might be all essential measures to strengthen the application.

Healthcare-associated infections in COVID-19 ICU patients - two-centre study.

The aim of this retrospective study was to estimate the prevalence of healthcare-associated infections (HAI), microbiological data including resistance patterns and impact of HAI on patients' survival. Two-centre study on 172 patients was performed. Medical records of patients hospitalized in the two COVID-19 intensive care units (ICU) localized in Bydgoszcz between 1 October 2020 and 30 March 2021 were analysed retrospectively. Data collection included demographics, microbiological, clinical variables, and patient outcome. All infections were defined according to the HAI-Net ICU protocol of the European Centre for Disease Prevention and Control (ECDC). Detailed data concerning bloodstream infection (BSI), pneumonia (PN) and urinary tract infection (UTI) were collected. In 97 patients (56.4%), 138 HAI cases were identified. Patients with HAI statistically more often had been administered antimicrobial therapy prior to the admission to ICU (59.8% vs. 34.7%, p < 0.05), and needed catecholamines during hospitalization (93.8% vs. 70.7%, p < 0.001). The risk of HAI increased by 50% if antimicrobial therapy had been applied before the admission to ICU, and was three times higher if during the hospitalization in ICU catecholamines infusion was needed. Mortality was higher in patients diagnosed with HAI (72.2% vs. 65.3%) but the difference was not statistically significant (p = 0.34). Further investigation of co-infections in critically ill patients with COVID-19 is required in order to identify HAI risk factors, define the role of empiric antimicrobial therapy and proper prevention strategies.

Implementation of a neonatal donation protocol in the neonatal intensive care unit: A single-center experience.

Lack of specific protocols for neonatal donation contributes to the rarity of neonatal donors. In this study, we evaluate the impact of the implementation of a neonatal donation protocol in our NICU. In this single-center study, we conducted a retrospective chart review of neonatal deaths in our NICU from January 2013 to January 2022. The study was divided into two periods: before and after the implementation of a neonatal donation protocol. The referral rates of potential neonatal donors to the OPO in the two periods were compared using the chi-square test. A p value < .05 was considered statistically significant. Sixty-four infants were reviewed. Seven (10.9%) met the inclusion criteria for potential neonatal donors after DCC. The referral rate of potential neonatal donors increased from 2.5% to 16.7% after the implementation of this protocol (p = .041), and one infant (4.1%) became an effective heart-valve donor. The implementation of a local neonatal donation protocol could have contributed to increase the referral rate of potential neonatal donors in our NICU. Following the implementation of a local neonatal donation protocol, we were able to perform a heart-valve donation for the first time in our unit.

Caregiver perceptions of an early mobility and communication protocol in the pediatric ICU.

Early mobility (EM) and patient communication have known benefits for critically ill patients, but perceived barriers exist, notably related to family and caregiver concerns. Caregiver perceptions of an EM and communication therapy protocol in the pediatric intensive care unit (PICU) were assessed. Caregivers of PICU patients at a free-standing academic children's hospital completed a survey using a Likert-type agreement scale on their perceptions surrounding the safety of EM, benefits of EM and communication, and barriers to EM and communication services. Forty caregivers completed the survey. Most agreed or strongly agreed that EM helped their child get stronger (76%), improved their child's mood (57%), helped them to be involved in their child's care (86%), and improved their child's overall experience (78%). Most disagreed with statements relating to EM causing fear or pain (57%). Caregivers agreed that communication therapy improved overall ICU experience (75%). Free-text comments emphasized meaningful relationships with rehabilitation and unit staff. Caregivers perceived EM and communication interventions as enriching to their child's ICU experience and the majority did not perceive that EM caused fear or pain.

Implementation of a Pediatric Delirium Screening Program in a Pediatric Intensive Care Unit.

Knowledge of and screening for delirium are important to patient care. As bedside caregivers, nurses are in a strategic position to observe changes that may indicate delirium. To institute a delirium screening protocol in a pediatric intensive care unit using the Cornell Assessment of Pediatric Delirium. Implementation strategies included cycles of education and repeated, timed compliance and accuracy assessments. Surveys administered before and 6 months after implementation were used to identify nurses' perceptions of screening. Compliance with and accuracy of screening were measured over 3 years. During the second and third years, text messages to bedside nurses' telephones served as screening reminders. Responses on the nursing surveys before (n = 89) and after (n = 74) implementation were compared. After implementation, time to complete the assessment, medical providers, and procedures were less likely to be perceived as obstacles to screening. Nurses' confidence in delirium screening improved over time. Accuracy increased from 60% during the first year to 100% during the second and third years (P < .05). Unit-wide compliance with delirium screening was 68% in the first year, 51% in the second year, and 72% in the third year, a trend toward improvement that was statistically significant (P < .05). Although unit-wide compliance with the screening protocol decreased without regular monitoring, it subsequently improved after the institution of reminders and reeducation of nursing staff. Nursing perceptions evolved to view screening as an important component of patient care that did not disrupt daily workflow.

Effectiveness of Interventional Program on Nurses’ Practices concerning Physiotherapy Protocol at Intensive Care Units in AL-Nasiriyah City

Background: Respiratory physiotherapy is a treatment option that addresses secretory elimination and promotes airway clearance, hence reducing breathing workload, promoting lung expansion, and preventing collapse. Most respiratory disorders benefit from chest physiotherapy as an adjuvant treatment, including COPD, bronchiectasis, and cystic fibrosis, as well as neuromuscular diseases and peri-operative care, particularly in upper abdominal procedures. The goal of the study is to see how effective the intervention program was in altering the nursing staff's practices of physiotherapy protocol in intensive care unit. Methods: Pre-experimental (one group pre-test- post-test) design was carried out about physiotherapy protocol at an intensive care unit at AL-Nasiriyah Heart Center and AL-Nasiriyah General Hospital in AL-Nasiriyah city. The sample was non-probability (purposive). The data was analyzed using descriptive statistics and SPSS. Results: Statistically significant improvements (pre-test 38.9 %, post-test 84.64%) of nurses’ knowledge and practice of physiotherapy after the educational program. Conclusion: interventional program has a positive effect for increasing nurses' knowledge and practice of physical therapy protocol. The Application of physiotherapy guidelines issued by the American Association of Respiratory Care’s (AARC) and more studies should be done of the physiotherapy protocol in the intensive care unit. Keywords: Intensive Care Units/ Interventional Program/ Physiotherapy/Practice

Neurological monitoring and sedation protocols in the Liver Intensive Care Unit

Patients with liver disease often have alteration of neurological status which requires admission to an intensive care unit. Patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and rarely cirrhosis are at risk of cerebral edema. These patients require prompt assessment of neurological status including assessment of intra-cranial pressure (ICP) and monitoring metabolic parameters like arterial/venous ammonia levels, serum creatinine and serum electrolytes so that timely specific therapy for raised ICP can be instituted to prevent permanent neurological dysfunction. The overall aims of neuromonitoring and sedation protocols in a liver intensive care unit are to identify the level of multifactorial metabolic encephalopathy, individualize sedation and analgesia requirements for patients on mechanical ventilation, institute specific therapy to correct the neurological insult in ALF and ACLF, provide clear physiological data for guided therapy of drugs like muscle relaxants, antiepileptics, and cerebral edema reducing agents, and assist with overall prognostication. In this review article we will outline the clinical scenarios related to liver disease requiring intensive care and neuromonitoring, current techniques of neurological assessment, sedation protocols and point of care tests which enable the treating physician and intensivist guide therapy for raised ICP.

Implementation of a Nurse-Driven Spontaneous Awakening Trial Protocol in a Cardiac Intensive Care Unit.

In patients receiving mechanical ventilation, spontaneous awakening trials reduce morbidity and mortality when paired with spontaneous breathing trials. However, spontaneous awakening trials are not performed every day they are indicated and little is known about spontaneous awakening trial protocol use in cardiac intensive care units. Spontaneous awakening trial completion rate at the study institution was low and no trial protocol was regularly used. A preintervention-postintervention retrospective cohort study was performed in adult patients with at least 24 hours of invasive mechanical ventilation in Michigan Medicine's cardiac intensive care unit. Patients with SARS-CoV-2 infection were excluded. Data included demographics, sedation, mechanical ventilation duration, and in-hospital mortality. A nurse-driven spontaneous awakening trial protocol modified for the cardiac intensive care unit was implemented in October 2020. Compared with the preintervention cohort (n = 29, May through July 2020), the postintervention cohort (n = 27, October 2020 through February 2021) had a higher ratio of number of trials performed to number of days eligible for trial (0.91 vs 0.52; P < .01). Median continuous sedative infusion duration was shorter after intervention (2.3 vs 3.6 days; P = .02). Median mechanical ventilation duration (3.8 vs 4.7 days; P = .18) and mortality (41% vs 41%; P = .95) were similar between groups. Spontaneous awakening trial protocol implementation led to a higher trial completion rate and a shorter duration of continuous sedative infusion. Larger studies are needed to assess the impact of protocolized spontaneous awakening trials on cardiac intensive care unit patient outcomes.

Adequacy of nutritional support in critically ill patients post implementation of nutritional protocols in surgical intensive care unit of a university hospital.

To evaluate improvement in nutrition support therapy after the implementation of nutritional protocols in critically ill surgical patients. The ambidirectional study was conducted at the surgical intensive care unit of Aga Khan University Hospital, Karachi, using an evidenced-based nutritional protocol. The pre-protocol retrospective data group A comprised patient records from July to September 2018, while the post-protocol prospective data group B related to the period between October and December 2018. Both data sets involved patients of either gender aged at least 18 years who needed admission to surgical intensive care unit and were unable to take oral nutrition for >2 days and remained under intensive care for up to seven days. Data was analysed using SPSS 21. Of the 65 patients, 30(46.2%) were in group A; 21(70%) males and 9(30%) females with mean age 40±16.55 years (range: 18-80 years). The remaining 35(53.8%) were in group B; 27(77%) males and 8(23%) females with mean age 48.66±17.7 years (range: 18-86 years). Nutritional screening indicated that 16(53.3%) patients in group A and 35(100%) in group B were at the risk of developing malnutrition. Patients receiving enteral nutrition within 24 hours of admission increased from 7(23.35%) in group A to 17 (48.3%) in group B. Overall, the amount of enterally administered calories increased from mean 321057±2495 kcal (29.6%) in group A to mean 384585±2343 (92.6%) in group B. The amount of protein administered increased from mean 622.2±148.7 kcal (14.7%) in group A to mean 549±125.48 kcal (67.1%) in group B. Implementation of nutritional protocol resulted in improved delivery of nutritional support in thesurgical intensive care unit.

Designing and Implementing a Skin Care Protocol for Infants With Neonatal Abstinence Syndrome to Decrease Rates of Diaper Dermatitis.

Infants with neonatal abstinence syndrome (NAS) are at an increased risk for diaper dermatitis, which can cause skin breakdown and lead to significant pain and potential infection exposure. Skin care protocols in the neonatal intensive care unit (NICU) setting seldom specifically address the needs of this at-risk population, leading to inconsistent skin care management. The goal was to support a decrease in the rate of diaper dermatitis for infants with NAS by designing and implementing an evidence-based skin care protocol. A retrospective medical record review was used to examine outcomes of 25 infants preintervention and 8 infants postintervention. The skin care protocol was a bundle of 5 evidence-based interventions: (1) a specific diaper dermatitis assessment tool; (2) frequent diaper changes with superabsorbent diapers; (3) application of petroleum jelly and alcohol-free wipes; (4) infant bathing in pH neutral soap; and (5) application of zinc oxide barrier cream for erythema. There was an overall 80.5% decrease in diaper dermatitis from pre- to postimplementation (P ≤ .01) as noted when comparing positive cases of diaper dermatitis with negative cases from pre- to postintervention. Expanding the skin care protocol to all neonates in the NICU and nursery could aid in maintaining skin integrity and decreasing diaper dermatitis in the NICU. More research is needed following this study for the data to be generalizable to other NICUs. This study offers key takeaways including using a specific diaper dermatitis assessment tool and consistently using the bundle of interventions. https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=47.