Sample Of Intensive Care Unit Patients Research Articles

Spiritual Care in the Intensive Care Unit: Experiences of Dutch Intensive Care Unit Patients and Relatives.

To gain insight into both patients' and relatives' experiences with spiritual care (SC) in the intensive care unit (ICU). Method used was qualitative interviewing. This was a thematic, topic-centered, biographical, and narrative approach, using semistructured interviews with thematic analysis. A purposive sampling method was used to select a sample of ICU patients and ICU patients' relatives. An interview guide facilitated individual, semistructured interviews. The interview data were recorded by means of note-taking and audio-recording. Verbatim transcripts were compiled for analysis and interpretation. All 12 participants-7 ICU patients and 5 family members of 5 other ICU patients-experienced ICU admission as an existential crisis. Participants would appreciate the signaling of their spiritual needs by ICU health care professionals (HCPs) at an early stage of ICU admission and subsequent SC provision by a spiritual caregiver. They regarded the spiritual caregiver as the preferred professional to address spiritual needs, navigate during their search for meaning and understanding, and provide SC training in signaling spiritual needs to ICU HCPs. Early detection of existential crisis signals with ICU patients and relatives contributes to the mapping of spiritual and religious needs. Spiritual care training of ICU HCPs in signaling spiritual needs by ICU patients and relatives is recommended. Effective SC contributes to creating room for processing emotions, spiritual well-being, and satisfaction with integrated SC as part of daily ICU care.

Prospective Validation of Sedation Scale Scores That Identify Light Sedation: A Pilot Study.

Intensive care unit (ICU) sedation guidelines recommend targeting a light sedation level, but light sedation has no accepted definition, and inconsistent levels have been proposed. To determine Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores that best describe patients' ability to follow voice commands. This prospective, observational pilot study enrolled a convenience sample of ICU patients receiving mechanical ventilation. Pairs of trained investigators evaluated scores on the Sedation-Agitation Scale and Richmond Agitation-Sedation Scale and ability to follow commands before and up to 2 hours after sedation lightening in a blind, independent, simultaneous fashion. Positive predictive values (PPVs) and likelihood ratios (LRs) of Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores associated with light sedation (ability to follow at least 3 commands) were calculated. Ninety-six assessments (50 before and 46 after lightening of sedation) were performed in medical ICU patients. Scores best associated with ability to follow at least 3 commands were Sedation-Agitation Scale score of 4 (PPV, 0.88; 95% CI, 0.70-0.98; LR, 14.0) and Richmond Agitation-Sedation Scale score of -1 (PPV, 0.81; 95% CI, 0.61-0.93; LR, 10.7), superior to previously recommended thresholds of Sedation-Agitation Scale score of 3 (PPV, 0.62; 95% CI, 0.48-0.75; LR, 3.1) and Richmond Agitation-Sedation Scale score of -3 (PPV, 0.52; 95% CI, 0.39-0.64; LR, 2.0). The level of sedation most associated with the ability to follow commands appears higher than previously recommended. Further study is needed regarding the effects of sedation level on ICU patients' ability to follow commands and assessment of delirium, pain, and patient preferences.

Exploration of a Multi-Parameter Technology for Pain Assessment in Postoperative Patients After Cardiac Surgery in the Intensive Care Unit: The Nociception Level Index (NOL)TM.

IntroductionThe aim of this study was to explore the use of a multi-parameter technology, the Nociception Level (NOL) index (Medasense Biometrics Ltd, Ramat Gan, Israel), for pain assessment in postoperative awake patients after cardiac surgery during non-nociceptive and nociceptive procedures in the intensive care unit (ICU).Materials and MethodsA prospective cohort repeated-measures design was used. Patients were included if they were in the ICU after undergoing cardiac surgery and if they could self-report their pain. A non-invasive probe was placed on the patient’s finger for the continuous monitoring of the NOL index. Patients’ self-reports of pain and anxiety (0–10 Numeric Rating Scale or NRS), and behavioral scores with the Critical-Care Pain Observation Tool (CPOT) were obtained before and during a non-nociceptive procedure (ie, non-invasive blood pressure [NIBP] using cuff inflation), and before, during and after a nociceptive procedure (ie, chest tube removal [CTR]) for a total of five time points. Non-parametric tests were used to compare scores at different time points, and receiver operating characteristic curve analysis was performed.ResultsFifty-four patients were included in the analysis. The NOL index, pain and anxiety scores were significantly higher during CTR compared to rest and NIBP (p < 0.001). During CTR, the NOL was associated with self-reported pain intensity and unpleasantness but not with anxiety and CPOT scores. The NOL showed a modest performance in detecting pain (NRS ≥1 and ≥5) in this sample with sensitivity and specificity ranging from 61% to 85%.ConclusionThe NOL index was able to discriminate between a non-nociceptive and a nociceptive procedure and was associated with self-reported pain. Further validation testing of the NOL is necessary in a heterogeneous sample of ICU patients.

Metabolomics Pilot Study Identifies Desynchronization of 24-H Rhythms and Distinct Intra-patient Variability Patterns in Critical Illness: A Preliminary Report.

Background: Synchronized circadian rhythms play a key role in coordinating physiologic health. Desynchronized circadian rhythms may predispose individuals to disease or be indicative of underlying disease. Intensive care unit (ICU) patients likely experience desynchronized circadian rhythms due to disruptive environmental conditions in the ICU and underlying pathophysiology. This observational pilot study was undertaken to determine if 24-h rhythms are altered in ICU patients relative to healthy controls by profiling 24-h rhythms in vital signs and plasma metabolites.Methods: We monitored daily rhythms in 5 healthy controls and 5 ICU patients for 24 h. Heart rate and blood pressure were measured every 30 min, temperature was measured every hour, and blood was sampled for mass spectrometry-based plasma metabolomics every 4 h. Bedside sound levels were measured every minute. Twenty-four hours rhythms were evaluated in vitals and putatively identified plasma metabolites individually and in each group using the cosinor method.Results: ICU patient rooms were significantly louder than healthy controls' rooms and average noise levels were above EPA recommendations. Healthy controls generally had significant 24-h rhythms individually and as a group. While a few ICU patients had significant 24-h rhythms in isolated variables, no significant rhythms were identified in ICU patients as a group, except in cortisol. This indicates a lack of coherence in phases and amplitudes among ICU patients. Finally, principal component analysis of metabolic profiles showed surprising patterns in plasma sample clustering. Each ICU patient's samples were clearly discernable in individual clusters, separate from a single cluster of healthy controls.Conclusions: In this pilot study, ICU patients' 24-h rhythms show significant desynchronization compared to healthy controls. Clustering of plasma metabolic profiles suggests that metabolomics could be used to track individual patients' clinical courses longitudinally. Our results show global disordering of metabolism and the circadian system in ICU patients which should be characterized further in order to determine implications for patient care.

Heparin resistance in COVID-19 patients in the intensive care unit.

Patients with COVID-19 have a coagulopathy and high thrombotic risk. In a cohort of 69 intensive care unit (ICU) patients we investigated for evidence of heparin resistance in those that have received therapeutic anticoagulation. 15 of the patients have received therapeutic anticoagulation with either unfractionated heparin (UFH) or low molecular weight heparin (LMWH), of which full information was available on 14 patients. Heparin resistance to UFH was documented in 8/10 (80%) patients and sub-optimal peak anti-Xa following therapeutic LMWH in 5/5 (100%) patients where this was measured (some patients received both anticoagulants sequentially). Spiking plasma from 12 COVID-19 ICU patient samples demonstrated decreased in-vitro recovery of anti-Xa compared to normal pooled plasma. In conclusion, we have found evidence of heparin resistance in critically unwell COVID-19 patients. Further studies investigating this are required to determine the optimal thromboprophylaxis in COVID-19 and management of thrombotic episodes.

The Characterization of Antibiotic Resistance of Bacterial Isolates from Intensive Care Unit Patient Samples in a University Affiliated Hospital in Romania

To determine the resistance pattern of bacterial pathogens involved in infections of the patients aged between 18-64 years, admitted in a ICU from a 1518-bed university-affiliated hospital. A retrospective study of bacterial pathogens was carried out on 351 patients aged between 18-64 years admitted to the ICU, from January to December 2017. In this study there were analysed 469 samples from 351 patients (18-64 years). A total of 566 bacterial isolates were obtained, of which 120 strains of Klebsiella spp. (35.39%%), followed by Nonfermenting Gram negative bacilli, other than Pseudomonas and Acinetobacter (NFB) (75- 22.12%), Acinetobacter spp. (53 - 15.63%), Pseudomonas aeruginosa and Proteus (51 - 15.04%), and Escherichia coli (49 - 14.45%). The most common isolates were from respiratory tract (394 isolates � 69.61%). High rates of MDR were found for Pseudomonas aeruginosa (64.70%), MRSA (62.65%) and Klebsiella spp. (53.33%), while almost all of the isolated NFB strains were MDR (97.33%). There was statistic difference between the drug resistance rate of Klebsiella and E. coli strains to ceftazidime and ceftriaxone (p[0.001), cefuroxime (p[0.01) and to cefepime (p[0.01). The study revealed an alarming pattern of antibiotic resistance in the majority of ICU isolates.

Absence of Gender-Based Differences in Outcome of Patients with Hospital-Acquired Pneumonia

The objective of this analysis was to evaluate the association between gender and clinical outcomes in intensive care unit (ICU) patients with hospital-acquired pneumonia (HAP) since data thus far are controversial. Data from a convenience sample of ICU patients with HAP, including ventilator-associated and health care-associated pneumonia, were retrospectively collected from four academic institutions (Improving Medicine through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia [IMPACT-HAP] study). Outcomes included 28-day mortality, clinical failure at day 14, hospital and ICU length of stay (LOS), and duration of mechanical ventilation. We compared baseline characteristics and performed multivariate analysis to identify factors independently associated with mortality. Among 416 patients, 271 were men and 145 were women. Women were older (62.4±16.9 vs. 55.7±16.5 years, p<0.001) and more critically ill, with Acute Physiology and Chronic Health Evaluation (APACHE) II scores of 21 vs. 19 (p=0.004). Day-28 mortality was 30% for women and 24% for men (p=0.25). Increased 28-day mortality was associated with severity of illness, age, ventilator-associated pneumonia, vascular disease, and hospital LOS prior to pneumonia diagnosis. No significant differences were found in the distribution of bacteria pathogens or in clinical failure rates (36% vs. 31%) between genders. Duration in days of mechanical ventilation, ICU LOS and hospital LOS after the diagnosis of pneumonia were not significantly different between men and women. Analyzing data for women based on presumed pre- or postmenopausal status (age breakpoint of 50 years), showed an increased in ICU LOS (15 vs. 25 days; p=0.0026) and hospital LOS (22 vs. 30 days; p=0.05) for women ≤50 years. No differences were noted in 28-day mortality (24.3% vs. 13.1%; p=0.18) in women ≤50 years of age. In ICU patients with pneumonia, female gender was not associated with worse outcomes or increased resource utilization compared to male gender. Further studies are needed to evaluate menopausal status and outcomes in women with pneumonia.

Performance of cassette-based blood gas analyzers to monitor blood glucose and lactate levels in a surgical intensive care setting

With the use of a traditional blood gas analyzer (BGA) (ABL800 Radiometer) for blood glucose monitoring, tight glucose control (TGC) reduced in-hospital mortality and morbidity of surgical intensive care unit (ICU) adult and pediatric patients. Such BGAs are now superseded by cassette-based BGAs. We assessed the analytical reliability of cassette-based BGAs to monitor patient's metabolic status in an ICU setting. We evaluated recovery/linearity, imprecision/repeatability and relative accuracy vs. comparison methods for glucose [coupled hexokinase glucose-6-phosphate dehydrogenase (HK/G6PD) assay] and lactate (lactate dehydrogenase assay) in ICU patient samples with two cassette-based BGAs [RP500 (Siemens) and ABL90 (Radiometer)] and with the ABL800 BGA. Recovery of spiked glucose up to 348 mg/dL (19.3 mmol/L) was complete for all BGAs. Repeatability of ABL800 and ABL90 was comparable with the comparison method (about 1%), but higher for RP500 (about 2.4%). All BGAs were in agreement with the comparison method, with all glucose measurements falling within preset 10% criteria suggested by Karon. Recovery of spiked lactate (up to 25 mmol/L) was incomplete at all levels. Repeatability of ABL800 and ABL90 was comparable with the comparison method (about 4%), and 5.5% for RP500. All BGAs were in agreement with the comparison method, with >98% of the lactate measurements falling within 30% biological-variation-based criteria. The cassette-based BGAs quantified blood glucose and lactate levels in ICU patients within the acceptable error ranges. Cassette-based BGAs can be used for monitoring patient's metabolic status in an ICU setting.

Multidrug-Resistant Acinetobacter baumannii Causing Necrotizing Fasciitis in a Pancreas-Kidney Transplant Recipient

Multidrug-Resistant Acinetobacter baumannii Causing Necrotizing Fasciitis in a Pancreas-Kidney Transplant Recipient

Analysis of cortisol, cortisone and dexamethasone in human serum using liquid chromatography tandem mass spectrometry and assessment of cortisol: Cortisone ratios in patients with impaired kidney function

Background We developed a high sensitivity method for simultaneous measurement of cortisol, cortisone and dexamethasone. Using this method, we compared concentrations of cortisol, cortisone and their ratios in samples from intensive care unit (ICU) and non-ICU patients, and cortisol and dexamethasone concentrations in patients with Cushing's and suspected Cushing's syndrome. Methods Two hundred microliters of human serum aliquots were extracted using solid phase extraction and analyzed using liquid chromatography–tandem mass spectrometry. Primary mass transitions monitored for cortisol, cortisone and dexamethasone were m/z 363/121, 361/163 and 393/373 respectively. Results The limits of quantification for cortisol and cortisone were 0.3 μg/l (0.8 nmol/l) and for dexamethasone it was 0.5 μg/l (1.2 nmol/l). Total imprecision was < 10.9%. Median cortisol to cortisone ratio of ICU patient samples was found to be 2 times higher than non-ICU samples. 54.2% of patients after 1 mg dose of overnight dexamethasone could be categorized as consistent with Cushing's syndrome. Conclusions The method has high sensitivity and specificity. High cortisol to cortisone ratios in samples from ICU patients suggest change in activity of 11β-hydroxysteroid dehydrogenase in modulation of systemically available cortisol. Simultaneous measurement of dexamethasone and cortisol can be used to differentially diagnose diseases causing increased concentrations of cortisol.

Patients’ self‐report of procedural pain in the intensive care unit

To determine which routine nursing procedures performed on conscious intensive care unit (ICU) patients were painful and which routine procedures were not painful. Current empirical evidence supports that routine procedures are often not viewed in the context of causing pain to the critically ill patient. Given the complexity of illness and the need to prioritize care in ICU patients, clinicians may not consider routine procedures as causing pain. With patients in intensive care undergoing frequent routine procedures, greater understanding of which procedures inflict pain is warranted to improve patient care and inform and shape nursing practice. A prospective, descriptive study using a convenience sample of ICU patients was used. Sixty-one patients were asked to rate pain intensity experienced prior to and during a routine nursing procedure using a verbal numeric rating scale. The procedures observed were turning, tracheal suctioning, line removal, deep breathing and coughing exercises, simple dressings and drain removal. Results showed that certain routine procedures cause pain with significant differences observed between pre- and postprocedure pain scores for drain removal (p = 0.042), deep breathing and coughing exercises (p = 0.003), suctioning (p = 0.025), positional change (p = 0.000) and line removal (p = 0.010). A higher proportion of morphine was administered to those patients undergoing drain removal (50%), deep breathing and coughing exercises (38.5%) and turns (32.6%) but results show that <50% of patients actually received analgesia. Heart rate, systolic and diastolic blood pressure all increased slightly postprocedure but were not found to be statistically significant. Haemodynamic measures are not suitable indicators for the presence of pain. Nurses need to recognise that certain routine procedures can cause pain and should therefore plan patient care with this in mind. Nurses need to recognise of the fact that routine procedures can cause pain and to use analgesia appropriately to minimize this pain. Practice guidelines should recommend that pain relieving measures be considered as part of routine procedural instructions. Analgesic prescription and administration could be improved for this patient group.

Prevalence of Heparin Antibodies in ICU Patients (The HAICU Study).

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is an antibody-mediated prothrombotic disorder characterized by absolute or relative thrombocytopenia occurring after exposure to heparin. Although thrombocytopenia in HIT patients usually resolves after discontinuing heparin, the risk for thrombosis persists up to 3 months.PURPOSE: The HAICU study was conducted to determine the prevalence of heparin-induced antibodies and HIT on admission to the intensive care unit (ICU) and their development within a week of hospitalization.METHODS: Platelet counts and heparin-platelet factor 4 antibodies (GTI ELISA) were measured on admission and again on day 7 ± 2 or discharge on a convenience sample of ICU patients. Patients with new onset thrombocytopenia (unexplained platelet count <100 x109/L or a 50% decrease in count) or a positive ELISA had confirmatory testing for HIT antibodies using a serotonin release assay. HIT was prospectively defined as positive HIT antibodies by both assays or as HIT antibodies with new onset, unexplained thrombocytopenia.RESULTS: Over 6 months, 118 patients were enrolled from three ICUs. Subjects had an average ICU LOS of 9 +/− 11 days, hospital LOS of 20 +/− 11 days and Apache II Physiology Score of 14 +/− 7; 59% were male. HIT, as defined above, occurred in 3 (3%) patients on admission. After 7.2 ± 2 days, HIT occurred in an additional 9 patients. Overall, 12 of 118 (10%) ICU patients had HIT at or within a week of admission (Table 1). 5 had documented prior exposure to heparin within 100 days of ICU admission, and 4 received heparin during the period when HIT assays were performed. Cases were distributed throughout the ICU's, yet relatively more often in the neurotrauma and shock-trauma units than the medical unit.CONCLUSION: Heparin-induced antibodies and HIT are common in the ICU, occurring in 3% of patients on admission and 10% in the first week. Physicians need to be aware of heparin exposure and the possibility of HIT in this population.Patients Positive for Heparin Antibodies by Type of ICU and Time PointUnitNo. of PatientsPercent (%)Day of ICU AdmissionDay 7 +/− 2TOTALPercent Positive per ICU (%)NTICU5647.515611STICU393323513MICU2319.50114TOTAL118100391210

Improving health care organizational management through neural network learning.

In order to provide more ethical and objective measures of the likelihood of Intensive Care Unit (ICU) recovery, hospitals have turned increasingly to decision support system software packages, such as APACHE. However, these packages derive estimates from parametric techniques, such as Binary Logit Regression (BLR) in the APACHE case, and require the developer to specify in advance the functional relationships among variables in the model. Recent rapid advancements in computer software and hardware technology have encouraged researchers to use more computationally intensive, non-parametric techniques such as Neural Networks (NNs), which are purported to be better than parametric models in terms of prediction capabilities. The present study applies both methodologies to a sample of ICU patients and shows that the NN technique predicts mortality rates more correctly than BLR, and offers a promising non-parametric alternative to the parametric methodologies in hospital settings.

Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.

Subjective scales to assess agitation and sedation in adult intensive care unit (ICU) patients have rarely been tested for validity or reliability. We revised and prospectively tested the Sedation-Agitation Scale (SAS) for interrater reliability and compared it with the Ramsay scale and the Harris scale to test construct validity. A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised SAS, Ramsay, and Harris Scales. Multidisciplinary 34-bed ICU in a nonuniversity, academic medical center. Forty-five ICU patients (surgical and medical) were examined a total of 69 times by evaluator pairs. The mean patient age was 63.2 yrs, 36% were female, and 71% were intubated. When classified by using SAS, 45% were anxious or agitated (SAS 5 to 7), 26% were calm (SAS 4), and 29% were sedated (SAS 1 to 3). Interrater correlation was high for SAS (r2 = .83; p < .001) and the weighted kappa score for interrater agreement was 0.92 (p < .001). Of 41 assessments scored as Ramsay 1, 49% scored SAS 6, 41% were SAS 5, 5% were SAS 4, and 2% each were SAS 3 or 7. SAS was highly correlated with the Ramsay (r2 = .83; p < .001) and Harris (r2 = .86; p < .001) scales. SAS is both reliable (high interrater agreement) and valid (high correlation with the Harris and Ramsay scales) in assessing agitation and sedation in adult ICU patients. SAS provides additional information by stratifying agitation into three categories (compared with one for the Ramsay scale) without sacrificing validity or reliability.

Survival prediction in the intensive care unit: a comparison of neural networks and binary logit regression

As a component of hospital cost containment policy, the National Institutes for Health recommends that hospitals limit intensive care unit (ICU) resources to patients who have a reasonable probability of recovery. In order to provide more ethical and objective measures of the likelihood of ICU recovery, hospitals have turned increasingly to decision support software such as APACHE (acute physiology and chronic health evaluation), which derives predictions from binary logit regression (BLR), a parametric estimation technique. Rapid advancements in computer software and hardware technology have encouraged researchers to use more computationally intensive non-parametric techniques such as neural networks (NNs) whose prediction capabilities are purported to be greater than those of parametric models. The present study applies this methodology to a sample of ICU patients and shows that neural networks appear to more correctly predict survival than does BLR.