Medical-surgical Intensive Care Unit Research Articles

Lung- and Diaphragm-Protective Ventilation by Titrating Inspiratory Support to Diaphragm Effort: A Randomized Clinical Trial.

Lung- and diaphragm-protective ventilation is a novel concept that aims to limit the detrimental effects of mechanical ventilation on the diaphragm while remaining within limits of lung-protective ventilation. The premise is that low breathing effort under mechanical ventilation causes diaphragm atrophy, whereas excessive breathing effort induces diaphragm and lung injury. In a proof-of-concept study, we aimed to assess whether titration of inspiratory support based on diaphragm effort increases the time that patients have effort in a predefined "diaphragm-protective" range, without compromising lung-protective ventilation. Randomized clinical trial. Mixed medical-surgical ICU in a tertiary academic hospital in the Netherlands. Patients (n = 40) with respiratory failure ventilated in a partially-supported mode. In the intervention group, inspiratory support was titrated hourly to obtain transdiaphragmatic pressure swings in the predefined "diaphragm-protective" range (3-12 cm H2O). The control group received standard-of-care. Transdiaphragmatic pressure, transpulmonary pressure, and tidal volume were monitored continuously for 24 hours in both groups. In the intervention group, more breaths were within "diaphragm-protective" range compared with the control group (median 81%; interquartile range [64-86%] vs 35% [16-60%], respectively; p < 0.001). Dynamic transpulmonary pressures (20.5 ± 7.1 vs 18.5 ± 7.0 cm H2O; p = 0.321) and tidal volumes (7.56 ± 1.47 vs 7.54 ± 1.22 mL/kg; p = 0.961) were not different in the intervention and control group, respectively. Titration of inspiratory support based on patient breathing effort greatly increased the time that patients had diaphragm effort in the predefined "diaphragm-protective" range without compromising tidal volumes and transpulmonary pressures. This study provides a strong rationale for further studies powered on patient-centered outcomes.

Assessment of 5-year outcomes of life satisfaction in survivors after rehabilitation programs: a multicenter clinical trial

Using a rehabilitation program for the survivors of acute respiratory distress syndrome (ARDS) could be one of the important and fundamental steps to improve the pulmonary function and health-related quality of life (HRQoL) of patients. This study was carried out to evaluate the effect of two rehabilitation techniques (Family-Based Empowerment Model (FECM)/Continuing Care Model (CCM), or both of them) on pulmonary function, and HRQoL in ARDS survivors. From December 2009 to June 2016, ARDS survivors from mixed medical-surgical ICUs at four academic teaching hospitals in Tehran, Iran, were randomly assigned to one of three intervention groups (A, B, or C) or a control group (D). Pre- and post-interventions, pulmonary functions and HRQoL status of patients in all groups were collected 48 times via clinical measurements and various questionnaires during 5 years of follow-up. Significantly improvement was seen in the intervention groups compared to the control group, and the greatest benefit was observed in patients who received mixed of FCEM and CCM rehabilitation techniques. Co-administration of FCEM and CCM can improve pulmonary function as well as the life satisfaction of ARDS survivors. As a result, the execution of the empowerment model by nurses is recommended for ARDS survivors and the participation of their families at the same time.Trial registration: NCT02787720 (ClinicalTrial.gov, 24/05/2016).

Prior Carriage Predicts Intensive Care Unit Infections Caused by Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae.

ABSTRACT.Intensive care unit–acquired infection (ICU-AI) and extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-PE) carriage are a major concern worldwide. Our objective was to investigate the impact of ESBL-PE carriage on ICU-AI. Our study was prospective, observational, and noninterventional. It was conducted over a 5-year period (Jan 2013–Dec 2017) in the medical-surgical intensive care unit of the Cayenne General Hospital (French Amazonia). During the study period, 1,340 patients were included, 271 (20.2%) developed ICU-AI, and 16.2% of these were caused by ESBL-PE. The main sites of ICU-AI were ventilator-associated pneumonia (35.8%) and primary bloodstream infection (29.8%). The main responsible microorganisms were Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae (ESBL-P in 35.8% of isolates), and Enterobacter cloacae (ESBL-P in 29.8% of isolates). Prior ESBL-PE carriage was diagnosed in 27.6% of patients with ICU-AI. In multivariable analysis, the sole factor associated with ESBL-PE as the responsible organism of ICU-AI was ESBL-PE carriage before ICU-AI (P < 0.001; odds ratio: 7.9 95% CI: 3.4-18.9). ESBL-PE carriers (74 patients) developed ICU-AI which was caused by ESBL-PE in 32 cases (43.2%). This proportion of patients carrying ESBL-PE who developed ICU-AI to the same microorganism was 51.2% in ESBL-P K. pneumoniae, 5.6% in ESBL-P Escherichia coli, and 40% in ESBL-P Enterobacter spp. NPV of ESBL-PE carriage to predict ICU-AI caused by ESBL-PE was above 94% and PPV was above 43%. Carriage of ESBL-P K pneumoniae and Enterobacter spp. is a strong predictor of ICU-AI caused by these two microorganisms.

Health Care Professionals’ Perceptions of the Role of the Clinical Pharmacist and Expanded Pharmacist Coverage in Critical Care

During the first wave of the COVID-19 pandemic, coverage by critical care pharmacists (CCPs) was expanded in 2 medical-surgical intensive care units at the Queen Elizabeth II Health Sciences Centre, in Halifax, Nova Scotia, from 8 hours per day, 5 days per week, excluding holidays, to 8 hours per day, 7 days per week, including holidays. To describe health care professionals' opinions about and perceived impacts of the expanded CCP coverage on patient care, as well as their opinions about the role of the CCP as a member of the critical care team. An electronic 22-item survey was distributed to critical care health care professionals to capture opinions and perceived impacts of expanded CCP coverage. The perceived importance of 25 evidence-informed CCP activities was assessed using a 5-point Likert scale. Thirty-eight complete responses were included (15% response rate, based on distribution of the survey to 249 health care professionals). Most respondents agreed or strongly agreed with the following statements: CCPs are integral members of the critical care team (34/38 [89%]), CCPs play an important role in improving patient outcomes (34/38 [89%]), the presence of CCPs on the unit and on patient care rounds allows other health care professionals to concentrate on their own professional responsibilities (33/38 [87%]), and the expanded CCP coverage improved patient care (29/35 [83%]). Respondents most frequently categorized 23 of the 25 CCP activities as very important. Expanded CCP coverage was perceived to have a positive effect on both patient care and members of the critical care team. Most CCP activities were perceived as very important. Given the findings of this quality project, novel staffing models are being explored to optimize CCP coverage.

Risk factors, time to onset and recurrence of delirium in a mixed medical-surgical ICU population: A secondary analysis using Cox and CHAID decision tree modeling.

A retrospective secondary analysis of 4,200 patients was collected from two academic medical centers. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in all patients. Univariate and multivariate Cox models, logistic regression analysis, and Chi-square Automatic Interaction Detector (CHAID) decision tree modeling were used to explore delirium risk factors. Increased delirium risk was associated with exposed only to artificial light (AL) hazard ratio (HR) 1.84 (95 % CI: 1.66-2.044, P<0.001), physical restraint application 1.11 (95 % CI: 1.001-1.226, P=0.049), and high nursing care requirements (>8 hours per 8-hour shift) 1.18 (95 % CI: 1.048-1.338, P=0.007). Delirium incidence was inversely associated with greater family engagement 0.092 (95 % CI: 0.014-0.596, P=0.012), low staff burnout and anticipated turnover scores 0.093 (95 % CI: 0.014-0.600, P=0.013), non-ICU length-of-stay (LOS)<15 days 0.725 (95 % CI: 0.655-0.804, P<0.001), and ICU LOS ≤15 days 0.509 (95 % CI: 0.456-0.567, P<0.001). CHAID modeling indicated that AL exposure and age <65 years were associated with a high risk of delirium incidence, whereas SOFA score ≤11, APACHE IV score >15 and natural light (NL) exposure were associated with moderate risk, and female sex was associated with low risk. More rapid time to delirium onset correlated with baseline sleep disturbance (P=0.049), high nursing care requirements (P=0.019), and prolonged ICU and non-ICU hospital LOS (P<0.001). Delirium recurrence correlated with age >65 years (HR 2.198; 95 % CI: 1.101-4.388, P=0.026) and high nursing care requirements (HR 1.978, 95 % CI: 1.096-3.569), with CHAID modeling identifying AL exposure (P<0.001) and age >65 years (P=0.032) as predictive variables. Development of ICU delirium correlated with application of physical restraints, high nursing care requirements, prolonged ICU and non-ICU LOS, exposure exclusively to AL (rather than natural), less family engagement, and greater staff burnout and anticipated turnover scores. ICU delirium occurred more rapidly in patients with baseline sleep disturbance, and recurrence correlated with the presence of delirium on ICU admission, exclusive AL exposure, and high nursing care requirements.

A qualitative study of medical-surgical intensive care unit nurses' experiences in caring for critical patients.

To describe the meaning attributed to nurses' clinical experience in a medical-surgical intensive care unit in Northern Cyprus. The qualitative study was conducted in two medical-surgical intensive care units at a university hospital. Data were collected through in-depth interviews with 17 nurses. Giorgi's descriptive phenomenological approach was used to analyze nurses' experiences. The consolidated criteria for reporting a qualitative research checklist were followed in this study. The data analysis led to the extraction of the 5 themes and 19 subthemes. The themes identified for the study were competence, the emotional universe, stress resources, the meaning of nursing care, and profoundly affecting events. The study results show that the nurses expressed that having gained much experience in intensive care units and working there has contributed significantly to their professional development. It was indicated that the nurses had meaningful, caring experiences in intensive care units, which were perceived, however, as stressful experiences as well. The study has important implications for nurses, faculty members, and administrators to gain positive care experiences in terms of intensive care units.

Development, Implementation, and Evaluation of an Early Mobility Protocol in a Regional Level II Trauma Center.

The purpose of this project was to develop and evaluate a collaborative nursing/therapist protocol for early mobility in a medical-surgical intensive care unit (MICU) in a regional level II trauma center. Data for patients in the MICU were compared for the periods August 3, 2015-August 2, 2016, and August 3, 2014-August 2, 2015. Semistructured interviews were conducted with 10 nurses and 1 therapist. Average MICU length of stay decreased from 3.81 to 3.50 days (P = .057). Mean time in mobility chairs did not change (0.12 days vs 0.11 days, P = .389). Mean number of days to first documented level 2-5 activity decreased significantly, from 1.81 to 1.51 days (P = .036). The percentage of hospitalizations with any documented level 3 or 4 activity increased significantly (from 3.8% to 7.4% and from 61.5% to 66.7%, P = .003 and P = .031, respectively). Barriers/challenges to implementation included having enough people to assist, space, documentation, having to coax the physician to place order for upright mobility, availability of therapists for later stages of protocol, patient variability, fear of patient falls, availability of therapy chairs, staff changes, time, and patient refusal. A multidisciplinary approach to protocol development for early mobility in an intensive care unit was successfully implemented at a regional level II trauma center.

Assessment of venous thromboembolism prophylaxis practice in medical-surgical adult ICU: A cross sectional study

BackgroundVenous thromboembolism (VTE) is a condition in which blood clots develop in the deep veins, especially in the lower limb veins. Intensive care unit (ICU) patients have a greater risk of thrombotic events due to additional risk factors such as immobilization, mechanical ventilation, and central catheters. In medical-surgical critically ill patients, the occurrence of symptomatic or asymptomatic DVT without thromboprophylaxis is 13–31%. ObjectiveTo assess the practice of venous thromboembolism prophylaxis in medical-surgical adult ICU. MethodsAll consecutive critically ill patients in ICU from January 10, 2021, to Jun 9, 2021, were included in the study. Data were collected using reviewing the patient chart and interviewing the responsible body in ICU including the residents and nurses. The same patient was not included twice within the same cycle, or in the second cycle, if he/she was still in the ICU at the time of the second cycle excluded by observing previous patient ID. The data was processed and analyzed by using SPSS version 20 and Microsoft Excel 2010. ResultA total of 90 surgical-medical ICU patients were observed. All of the patients in the sample were receiving some form of VTE prophylaxis (100%), but none of them (0%) had the risk stratification documented in the chart. Conclusionand recommendations: It's critical to emphasize the importance of VTE risk stratification documentation in patients' charts. We recommend that the ICU staffs to follow a specific protocol for VTE risk stratification and prophylaxis dosing based on well-known guidelines and recommendations and that once that protocol is implemented, an awareness and education campaign be applied.

Clinico-demographic and Outcome Predictors in Solid Tumor Patients with Unplanned Intensive Care Unit Admissions: An Observational Study.

ObjectivesCritically ill solid organ malignancy patients admitted to intensive care unit (ICU) as unplanned medical admissions behave differently from other subsets of cancer patients (hematolymphoid malignancies and cancer patients admitted for postoperative care). These patients if appropriately selected may benefit from the ICU care. There is paucity of data on critically ill unplanned admissions of solid organ malignancies from South Asia. We analyzed data of patients with solid tumors with unplanned admissions to the ICU to determine the clinical, epidemiological characteristics, and predictors of hospital mortality in an Indian ICU.Materials and methodsThis prospective, observational study was done in our 14-bedded mixed medical–surgical ICU from July 2014 to November 2015. We included all consecutive adult unplanned admissions with solid organ malignancies having ICU stay of >24 hours. Surgical admissions, hematolymphoid malignancies, advanced malignancy with no treatment options, and those cured of cancer >5 years were excluded.ResultsTwo hundred and thirty-five consecutive patients were included in this cohort. ICU and hospital mortalities were 36.6 and 40%, respectively. On multivariate analysis, cancer status [odds ratio (OR): 3.204; 95% confidence interval (CI): 1.271–8.078], invasive mechanical ventilation (OR: 5.940; 95% CI: 2.632–13.408), and sequential organ failure assessment (SOFA) score on the day of ICU admission (OR: 1.199; 95% CI: 1.042–1.379) were independent predictors of hospital mortality.ConclusionAcute respiratory failure and septic shock are the common reasons of unplanned ICU admission for patients with solid organ malignancies. With good patient selection, more than half of such patients are likely to be discharged alive from the hospital.How to cite this articleSiddiqui SS, Narkhede AM, Chaudhari HK, Ravisankar NP, Dhundi U, Sarode S, et al. Clinico-demographic and Outcome Predictors in Solid Tumor Patients with Unplanned Intensive Care Unit Admissions: An Observational Study. Indian J Crit Care Med 2021;25(12):1421–1426.

778. Prediction of Bloodstream Infection Events and Infections of the Lower Respiratory Tract in ICU Patients: Expected and Unexpected Infections

BackgroundBloodstream infection (BSI) - Central and Non-Central Line Associated - and infections of the lower respiratory tract (RESP) - pneumonia and non pneumonia lower respiratory infections - are some of the main causes of unexpected death in Intensive Care Units (ICUs). Although the leading causes of these infections are already known, risk prediction models can be used to identify unexpected cases. This study aims to investigate whether or not it is possible to build multivariate models to predict BSI and RESP events.MethodsUnivariate and multivariate analysis using multiple logistic regression models were built to predict BSI and RESP events. ROC curve analysis was used to validate each model. Independent variables: 29 quantitative parameters and 131 categorical variables. BSI and RESP were identified using Brazilian Health Regulatory Agency protocols with data collected between January and November 2020 from a medical-surgical ICU in a Brazilian Hospital. Definitions: if an infection is 5% or less likely to occur according to the model used and it eventually occurs, it will be classified as “unexpected”, or else, if an infection is 10% or less likely to occur, it will be classified as “probably unexpected”. Otherwise, infections will be classified as “expected”. Patients with a 30% or more risk for BSI or RESP will be classified as “high risk”.ResultsA total of 1,171 patients were accessed: 70 patients with BSI (95% confidence interval [CI], 3.1%-5%), 66 patients with RESP (95% CI, 2.9%-4.7%), 235 deaths (95% CI, 11.8%-14.9%). Of the 160 potential risk factors evaluated, logistic models for BSI and RESP identified respectively five and seven predictors (Tables 1 and 2, and Figure 1). Patients admitted to the ICU with Covid-19 had a three fold BSI risk and five times more RESP risk than patients without this diagnosis. Table 1. Independent predictors of Infections of the Lower Respiratory Tract in ICU: results of multivariate analysis performed using a logistic regression model. Table 2. Independent predictors of Bloodstream Infection Events in ICU (Central Line-Associated BSI + Non-central Line Associated BSI): results of multivariate analysis performed using a logistic regression model. Figure 1. Receiver operating characteristic (ROC) curve for the fitted models: area under the ROC Curves were higher than 0.85 for both models. ConclusionThe built models make possible the identification of the expected infections and the unexpected ones. Three main course of actions can be taken using these models and associated data: (1) Before the occurrence of BSI and RESP: to place high risk patients under more rigorous infection surveillance. (2) After the occurrence of BSI or RESP: to investigate “unexpected” infections. (3) At discharge: to identify high risk patients with no infections for further studies.Disclosures All Authors: No reported disclosures

Participación de la familia en el cuidado del paciente crítico: un estudio exploratorio

ObjectivesTo determine the level of readiness of the healthcare team regarding family participation in the care of the critically ill adult and their relationship with the individual characteristics of the participants in a medical-surgical intensive care unit (ICU) in Santiago de Chile. MethodA cross-sectional correlational study using a quantitative method and including a focus group to explore the perception of healthcare staff of family participation in the care of the critically ill patient. ResultsThe level of readiness of the healthcare team for family participation in the care of the critically ill patient is medium, at 13.81 out of a total 20. The greater the readiness, the lower the age (r=−.215; P=.019), the higher the rating of previous experience working with families (r=.304; P=.006), and the higher the perception of being comfortable with different activities in the care of the critical patient (r=.495: P<.001). The participants also state that the work environment of the unit, the patient's condition, the relatives’ characteristics, personal judgement, and the preparedness of relatives affect their readiness. ConclusionsThe results contribute towards determining the healthcare team's level of readiness in a setting where the subject of the study has not been implemented. The readiness of the healthcare team is medium, and is related to individual characteristics of the healthcare staff, and to organizational and family aspects. Therefore, strategies are required to address these aspects that might increase readiness.

Healthcare utilization and mortality outcomes in patients with pre-existing psychiatric disorders after intensive care unit discharge: A population-based retrospective cohort study

Pre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU. We retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014-June 2016) with ICU length stay ≥24h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR). We included 10,598 patients. 37.6% (n=3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29-1.71), hospital readmission (RR 1.49, 95%CI 1.34-1.66), ICU readmission (RR 2.64, 95%CI 1.55-4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00-1.71) six-months post-ICU discharge. Critically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay.

Modifiable risk factors of ventilator-associated pneumonia in non-intensive care unit versus intensive care unit.

Ventilator-associated pneumonia patients are treated in non-intensive care units because of a shortage of intensive care unit beds in Thailand. Our objective was to assess whether the type of unit and medications prescribed to the patient were associated with ventilator‑associated pneumonia and multidrug resistant ventilator‑associated pneumonia. A matched case-control study nested in a prospective cohort of mechanical ventilation adult patients in a medical-surgical intensive care unit and five non-intensive care units from March 1 through October 31, 2013. The controls were randomly selected 1:1 with cases and matched based on duration and start date of mechanical ventilation. 248 ventilator-associated pneumonia and control patients were analyzed. The most common bacteria were multidrug resistant Acinetobacter baumannii (82.4%). Compared with patients in the intensive care unit, those in the neurosurgical/surgical non-intensive care units were at higher risk (p = 0.278). Proton pump inhibitor was a risk factor (p = 0.011), but antibiotic was a protective factor (p = 0.054). Broad spectrum antibiotic was a risk factor (p < 0.001) for multidrug resistant ventilator-associated pneumonia. Post-surgical and neurosurgical patients treated in non-intensive care unit settings were at the highest risk of ventilator-associated pneumonia. Our findings suggest that alternative using proton pump inhibitors should be considered based on the risk-benefit of using this medication. In addition, careful stewardship of antibiotic use should be warranted to prevent multidrug resistant ventilator-associated pneumonia.

Nephrotoxicity of continuous amphotericin B in critically ill patients with abdominal sepsis: a retrospective analysis with propensity score matching.

Continuous infusion of conventional amphotericin B (CCAB) is used in ICUs for pre-emptive treatment of invasive fungal infections. Amphotericin B has previously been associated with nephrotoxicity. To investigate if CCAB with therapeutic drug monitoring (TDM) results in renal impairment over time in critically ill patients with abdominal sepsis. The study was conducted at mixed medical-surgical ICUs of two large teaching hospitals in the Netherlands. Consecutive patients who were treated on the ICUs between 2006 and 2019 for abdominal sepsis, with or without CCAB, were included. CCAB dosing was guided by TDM. Serum creatinine concentrations and renal failure scores of patients with CCAB treatment were compared with those without CCAB treatment. Excluded were: (i) patients treated with CCAB for less than 72 h; and (ii) patients with renal replacement therapy. A total of 319 patients were included (185 treated with CCAB and 134 controls). A multiple linear regression model showed that the serum creatinine concentration was independent of CCAB treatment (β = -0.023; 95% CI = -12.2 to 7.2; P = 0.615). Propensity score matching resulted in 134 pairs of CCAB-treated and non-treated patients. Again, the analysis of these pairs showed that the cumulative CCAB dose was not associated with serum creatinine concentration during intensive care treatment (β = 0.299; 95% CI = -0.38 to 0.98; P = 0.388). CCAB with TDM did not result in renal impairment over time in critically ill patients with abdominal sepsis.

Chlorhexidine Gluconate Bathing Program to Reduce Health Care-Associated Infections in Both Critically Ill and Non-Critically Ill Patients.

Critical care nurses take care of patients with complicated, comorbid, and compromised conditions. These patients are at risk for health care-associated infections, which affect patients' lives and health care systems in various ways. To gauge the impact of routinely bathing patients with 4% chlorhexidine gluconate solution on the incidence of health care-associated infections in a medical-surgical intensive care unit and a postoperative telemetry unit; to outline the framework for a hospital-wide presurgical chlorhexidine gluconate bathing program and share the results. A standard bathing protocol using a 4% chlorhexidine gluconate solution was developed. The protocol included time studies, training, monitoring, and surveillance of health care-associated infections. Consistent patient bathing with 4% chlorhexidine gluconate was associated with a 52% reduction in health care-associated infections in a medical-surgical intensive care unit. The same program in a postoperative telemetry unit yielded a 45% reduction in health care-associated infections. A comprehensive daily 4% chlorhexidine gluconate bathing program can be implemented with standardized protocols and detailed instructions and can significantly reduce the incidence of health care-associated infections in intensive care unit and non-intensive care unit hospital settings.

TOWARDS UNIVERSAL BASIC FLUENCY: A PILOT CURRICULUM IN CRITICAL CARE ULTRASOUND

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Critical care ultrasound (CCUS) continues to revolutionize how critically ill patients are cared for. CCUS refers to focused ultrasound performed by a treating practitioner to help detect and/or monitor life-threatening illnesses and to improve the safety of life-saving procedures. Although most critical care medicine (CCM) practitioners should have, at least, basic fluency in CCUS, academic institutions may find themselves ill-equipped to deliver comprehensive CCUS education to CCM trainees and practitioners. Challenges include a paucity of skilled faculty and lack of a standardized curriculum. In this study, we implement and evaluate a novel CCUS curriculum to resolve such concerns. METHODS: This is a pilot prospective study of implementation and evaluation of a longitudinal CCUS curriculum for CCM attendings, trainees, and nurse practitioners working across five medical-surgical intensive care units in Edmonton, Alberta (Canada). The curriculum was comprised of a custom online flipped-classroom learning environment, a one-day workshop, eight two-hour expert-led hands-on sessions, an image interpretation session, and longitudinal image/report-archiving with feedback. We used Kirkpatrick's Model of Evaluation to examine for pre/post-changes in perception (survey, Likert-scale 1-5), evidence of learning (30 question MCQ / psychomotor skill assessment), and behaviour change (survey). RESULTS: Fourteen CCM practitioners participated in the curriculum (7 attendings, 3 trainees, 4 nurse practitioners). The curriculum was halted at the end of the third month because of the COVID-19 pandemic. Participants reported increases in overall perceived performance and interpretation in CCUS (p=0.001) with a moderate effect size (Cohen's d=0.63). A comparison of mean exam scores (±SD) pre- and post-curriculum were 69% (± 15%) and 78% (± 11%) with a large effect size (p=0.007, d=0.86). Psychomotor skill assessment with a standardized entrustment scale demonstrated large effect sizes across all modalities (cardiac, lung, thoracic, abdominal, vascular) with effect sizes between 0.95 and 1.28. Thirteen of the fourteen participants reported an increase use of CCUS across all modalities. While participant feedback was overwhelmingly positive, some participants wanted a longer curriculum and others reported difficulty completing CCUS exam reports while caring for the critically ill. CONCLUSIONS: A longitudinal curriculum in CCUS delivered across five medical-surgical intensive care units resulted in increases in knowledge and skill with strong effect sizes. Feedback from participants emphasized the need to lengthen the curriculum, improve workflow for CCUS exam reporting, and further increase access to direct bedside mentorship. CLINICAL IMPLICATIONS: This curriculum provides a strong foundation for local CCUS education, a path to universal basic fluency, and a template with potential for national expansion. DISCLOSURES: No relevant relationships by Aws Alherbish, source=Web Response No relevant relationships by Brian Buchanan, source=Web Response No relevant relationships by Vijay Daniels, source=Web Response No relevant relationships by Jean Deschamps, source=Web Response no disclosure on file for Sean McAleer

Safety and efficacy of peripheral versus centrally administered vasopressor infusion: A single-centre retrospective observational study

BackgroundShock affects one-third of patients admitted to intensive care and is associated with increased mortality. Vasopressor medications are used to maintain blood pressure in shock. Central venous catheters are associated with serious complications and pose logistical difficulties for insertion. Delivery of vasopressors via peripheral intravenous cannula may be a safe alternative. MethodsThis is a retrospective cohort study comparing safety profile and outcomes of vasopressor delivery via peripheral and central routes in critically ill patients over a 12-month period in a mixed medical-surgical intensive care unit. Demographics, clinical characteristics, treatments, and safety outcome data were extracted from medical records. Patients were classified into three groups: vasopressor infusions via peripheral intravenous cannula, combined peripheral intravenous cannula followed by central venous catheter, and central venous catheter only. Groups were compared using the Kruskal–Wallis test for continuous variables and Fisher's exact test for categorical variables. The impact of duration of vasopressor infusion on complication rates was assessed using logistic regression. ResultsWe identified 212 patients who received vasopressor infusion, 39 received via peripheral only (Group 1), 155 via peripheral followed by central (Group 2), and 18 via central only (Group 3). There were some baseline differences between groups. Group 1 had the lowest median Acute Physiology and Chronic Health Evaluation III score (64, interquartile range = 44–77), and Group 3, the highest (86, interquartile range = 57–101). Duration of vasopressor infusion was shortest in Group 1 and longer in Groups 2 and 3. There were no major complications; however, minor complications such as leakage, extravasation, and erythema occurred in 41% of Group 1 and 28% of Group 2 patients. Duration of peripheral vasopressor infusion was not associated with an increased risk of complications. ConclusionsAdministration of vasopressor infusions for short duration in critically ill patients via a peripheral venous cannula may be feasible, with low rates of complications, and offers a safe alternative to central venous access.

Human Factors Analysis of Latent Safety Threats in a Pediatric Critical Care Unit.

To identify unique latent safety threats spanning routine pediatric critical care activities and categorize them according to their underlying work system factors (i.e., "environment, organization, person, task, tools/technology") and associated clinician behavior (i.e., "legal": expected compliance with or "illegal-normal": deviation from and "illegal-illegal": disregard for standard policies and protocols). A prospective observational study with contextual inquiry of clinical activities over a 5-month period. Two PICUs (i.e., medical-surgical ICU and cardiac ICU) in an urban free-standing quaternary children's hospital. Attending physicians and trainees, nurse practitioners, registered nurses, respiratory therapists, dieticians, pharmacists, and patient services assistants were observed. None. Conducted 188 hours of observations to prospectively identify unique latent safety threats. Qualitative observational notes were analyzed by human factors experts using a modified framework analysis methodology to summarize latent safety threats and categorize them based on associated clinical activity, predominant work system factor, and clinician behavior. Two hundred twenty-six unique latent safety threats were observed. The latent safety threats were categorized into 13 clinical activities and attributed to work system factors as follows: "organization" (n = 83; 37%), "task" (n = 52; 23%), "tools/technology" (n = 40; 18%), "person" (n = 32; 14%), and "environment" (n = 19; 8%). Twenty-three percent of latent safety threats were identified when staff complied with policies and protocols (i.e., "legal" behavior) and 77% when staff deviated from policies and protocols (i.e., "illegal-normal" behavior). There was no "illegal-illegal" behavior observed. Latent safety threats span various pediatric critical care activities and are attributable to many underlying work system factors. Latent safety threats are present both when staff comply with and deviate from policies and protocols, suggesting that simply reinforcing compliance with existing policies and protocols, the common default intervention imposed by healthcare organizations, will be insufficient to mitigate safety threats. Rather, interventions must be designed to address the underlying work system threats. This human factors informed framework analysis of observational data is a useful approach to identifying and understanding latent safety threats and can be used in other clinical work systems.

Exploring Ketamine Analgosedation Use and Its Effect on Incident Delirium in Critically Ill Adults.

OBJECTIVES:Ketamine is increasingly being used for analgosedation, but its effect on delirium remains unclear. We compared delirium risk variables and ketamine analgosedation use between adults who developed incident delirium and those who did not, evaluated whether ketamine analgosedation increases delirium risk, and compared ICU delirium characteristics, treatments, and outcomes between ketamine and nonketamine patients with delirium.DESIGN:Secondary, subgroup analysis of a cohort study.SETTING:Single, 36-bed mixed medical-surgical ICU in the Netherlands from July 2016 to February 2020.PATIENTS:Consecutive adults were included. Patients admitted after elective surgery, not expected to survive greater than or equal to 48 hours, admitted with delirium, or where delirium occurred prior to ketamine use were excluded.INTERVENTION:None.MEASUREMENTS AND MAIN RESULTS:Trained ICU nurses evaluated patients without coma (Richmond Agitation Sedation Scale. –4/–5) every 8 hours with the Confusion Assessment Method ICU; a delirium day was defined by greater than or equal to1 + Confusion Assessment Method ICU and/or scheduled antipsychotic use. Among 11 variables compared between the delirium and nondelirium groups (Baseline: age, Charlson Comorbidity score, cognitive impairment, admission type, and Acute Physiology and Chronic Health Evaluation-IV score, daily ICU [until delirium occurrence or discharge]: Sequential Organ Failure Assessment score, coma, benzodiazepine, opioid, and ketamine use) and total ICU days, 7 (age, Charlson score, Sequential Organ Failure Assessment score, coma, benzodiazepine, opioid, and ketamine use) were significantly different and were entered, along with delirium occurrence, in a logistic regression model. A total of 332 of 925 of patients (36%) developed delirium. Ketamine use was greater in patients with delirium (54 [16%] vs 4 [0.7%]; p < 0.01). Ketamine use (adjusted odds ratio, 5.60; 95% CI, 1.09–29.15), age (adjusted odds ratio, 1.03; 95% CI, 1.01–1.06), coma (adjusted odds ratio, 2.10; 95% CI, 1.15–3.78), opioid use (adjusted odds ratio, 171.17; 95% CI, 66.45–553.68), and benzodiazepine use (adjusted odds ratio, 34.07; 95% CI, 8.12–235.34) were each independently and significantly associated with increased delirium. Delirium duration, motoric subtype, delirium treatments, and outcomes were not different between the ketamine and nonketamine groups.CONCLUSIONS:Ketamine analgosedation may contribute to increased ICU delirium. The characteristics of ketamine and nonketamine delirium are similar. Further prospective research is required to evaluate the magnitude of risk for delirium with ketamine use.

Prevalence, Risk Factors, and Outcomes of Platelet Transfusion Refractoriness in Critically Ill Patients: A Retrospective Cohort Study

Background Refractoriness to platelet transfusion is an understudied phenomenon in critically ill patients. Our objective was to evaluate the prevalence, risk factors, and clinical outcomes of platelet refractoriness among patients in a tertiary-care intensive care unit (ICU). Methods A retrospective cohort study included all patients (age >14 years) who were admitted to a tertiary-care medical-surgical ICU between 2011 and 2016 and received ≥2 platelet transfusions during their ICU stay. We calculated platelet increment (PI) and corrected count increment (CCI). Results A total of 267 patients were enrolled in the study, collectively receiving 1357 transfusions with a median of 4.0 (interquartile range: 2.0, 6.0) transfusions per patient. The median pretransfusion platelet count was 31000.0 × 106/L (interquartile range: 16000.0, 50000.0). The median PI was 6000 × 106/L. The prevalence of platelet transfusion refractoriness was 54.8% based on PI < 10000 × 106/L and 57.0% based on CCI <5000. Patients admitted under hepatology/liver transplant had the highest rates of platelet refractoriness (69.6%), while those under general surgery had the lowest rate (43.2%). Younger age, nontrauma admission, and larger spleen size were associated with platelet refractoriness. Finally, refractoriness was associated with increased length of stay in the ICU (p = 0.02), but not with mortality. Conclusions Platelet transfusion refractoriness was highly (>50%) prevalent in ICU patients. However, it was not associated with increased mortality.