Use In Intensive Care Unit Research Articles

Clinical trial protocol for continuous glucose monitoring in critical care at Hospital Clinic of Barcelona (CGM-UCI23).

Hyperglycaemia is common in intensive care units (ICUs), with a prevalence of up to 86.2%, increasing mortality. Technology has evolved towards continuous glucose monitoring (CGM), and its use in ICUs began especially during the coronavirus pandemic (COVID-19). Various studies have evaluated the reliability of CGM, indicating that it is safe for use in critically ill patients. The aim of this study was to compare the use of CGM with point-of-care glucose (POC-G) testing in ICU. Specific objectives include evaluating the glycaemic control, the frequency of POC-G measurements, the incidence of hyperglycaemia, hypoglycaemia and morbidity and mortality at 90 days. An experimental, controlled and randomized clinical trial with a single-blind design will be conducted at Hospital Clinic of Barcelona (HCB). A sample size of 376 participants will be recruited and randomly assigned to two groups: an experimental group, where glycaemic management will be based on CGM; and a control group, where glucose will be managed through POC-G testing, with a blinded CGM. The primary variable considered will be time in range (TIR), with secondary outcomes including, time above range (TAR), time below range (TBR), number of POC-G measurements, incidence of hyperglycaemia and hypoglycaemia, and mortality. Hypothesis testing will use the Kolmogorov-Smirnov test to assess data normality, with appropriate statistical tests applied, considering a p-value <.05. The results obtained will help us understand the impact of CGM on critically ill patients. CGM could potentially reduce the workload of nurses and improve the efficiency of decision-making by the ICU team, enabling early identification and treatment of glucose complications, thereby enhancing safety. Patient safety, a reduction in patient fingerstick and a decreased care burden are the criteria that add value to this research.

Predicting Fungemia in the ICU: Unveiling the Value of Weekly Fungal Surveillance and Yeast Colonisation Monitoring.

Fungemia remains a major threat in intensive care units (ICUs), with high mortality rates despite advances in diagnostics and treatment. Colonisation by yeasts is an independent risk factor for fungemia; however, its predictive utility requires further research. In this 8-year study, we analysed 38,017 samples from 3206 patients and 171 fungemia episodes as part of a weekly fungal surveillance programme. We evaluated species-specific colonisation patterns, the predictive value of the Colonisation Index (CI) and Corrected Colonisation Index (CCI), and candidemia risks associated with different yeast species and anatomical site colonisation. Our results showed that C. auris, N. glabratus, and C. parapsilosis colonisation increased with longer hospital stays (0.8% to 11.55%, 8.13% to 16.8%, and 1.93% to 5.14%, respectively). The CI and CCI had low discriminatory power (AUROC 67% and 66%). Colonisation by any yeast genera demonstrated high sensitivity (98.32%) and negative predictive value (NPV) (95.90%) but low specificity and positive predictive value (PPV) (23.90% and 6.64%). Tracheal and urine cultures had the highest PPV (15.64% and 12.91%), while inguinal cultures had the highest NPV (98.60%). C. auris (12.32%) and C. parapsilosis (5.5%) were associated with a higher fungemia risk (log-rank < 0.001). These findings support the use of weekly surveillance to better stratify the fungemia risk and optimise antifungal use in ICUs.

Trends in use of intensive care during hospitalizations at the end-of-life among older adults with advanced cancer.

High-intensity end-of-life (EOL) care, marked by admission to intensive care units (ICUs) or in-hospital death, can be costly and burdensome. Recent trends in use of ICUs, life-sustaining treatments (LSTs), and noninvasive ventilation (NIV) during EOL hospitalizations among older adults with advanced cancer and patterns of in-hospital death are unknown. We used SEER-Medicare data (2003-2017) to identify beneficiaries with advanced solid cancer (summary stage 7) who died within 3 years of diagnosis. We identified EOL hospitalizations (within 30 days of death), classifying them by increasing intensity of care into: (1) without ICU; (2) with ICU but without LST (invasive mechanical ventilation, tracheostomy, gastrostomy, acute dialysis) or NIV; (3) with ICU and NIV but without LST; and (4) with ICU and LST use. We constructed a multinomial regression model to evaluate trends in risk-adjusted hospitalization, overall and across hospitalization categories, adjusting for sociodemographics, cancer characteristics, comorbidities, and frailty. We evaluated trends in in-hospital death across categories. Of 226,263 Medicare beneficiaries with advanced cancer, 138,305 (61.1%) were hospitalized at EOL [Age, Mean (SD):77.9(7.1) years; 45.5% female]. Overall, EOL hospitalizations remained high throughout, from 78.1% (95% CI: 77.4, 78.7) in 2004 to 75.5% (95% CI: 74.5, 76.2) in 2017. Hospitalizations without ICU use decreased from 49.3% (95% CI: 48.5, 50.2) to 35.0% (95% CI: 34.2, 35.9) while hospitalizations with more intensive care increased, from 23.7% (95% CI: 23.0, 24.4) to 28.7% (95% CI: 27.9, 29.5) for ICU without LST or NIV, 0.8% (95% CI: 0.6, 0.9) to 3.8% (95% CI: 3.4, 4.1) for ICU with NIV but without LST, and 4.3% (95% CI: 4.0, 4.7) to 8.0% (95% CI: 7.5, 8.5) for ICU with LST use. Among those who experienced in-hospital death, the proportion receiving ICU care increased from 46.5% to 65.0%. Among older adults with advanced cancer, EOL hospitalization rates remained stable from 2004-2017. However, intensity of care during EOL hospitalizations increased as evidenced by increasing use of ICUs, LSTs, and NIV.

The Use of Pulmonary Artery Catheters and Echocardiography in the Cardiac Surgery Setting: A Nationwide Italian Survey

Wide variations exist in the use of pulmonary artery catheters (PACs) and echocardiography in the field of cardiac surgery. A national survey promoted by the Italian Association of Cardio-Thoracic Anesthesiologists and Intensive Care was conducted. The study occurred in Italian cardiac surgery centers (n = 71). Anesthesiologists-intensivists were enrolled. Anonymous questionnaires were used to investigate the use of PACs and echocardiography in the operating room (OR) and intensive care unit (ICU). A total of 257 respondents (32.2% response rate) from 59 centers (83.1% response rate) participated. Use of PACs seems less common in ORs (median insertion in 20% [5-70] of patients), with slightly higher use in ICUs; in about half of cases, it was the continuous cardiac output monitoring system of choice. Almost two-thirds of respondents recently inserted at least one PAC within a few hours of ICU admission, despite its need being largely preoperatively predictable. Protocols regulating PAC insertion were reported by 25.3% and 28% of respondents (OR and ICU, respectively). Transesophageal echocardiography (TEE) was performed intraoperatively in >75% of patients by 86.4% of respondents; only 23.7% stated that intraoperative TEE relied on anesthesiologists. Tissue Doppler and/or 3D imaging were widely available (87.4% and 82%, respectively), but only 37.8% and 24.3% of respondents self-declared skills in these modalities, respectively; 77.1% of respondents had no echocardiography certification, nor were pursuing certification (various reasons); 40.9% had not attended recent echocardiography courses. Lower PAC use was associated with university hospitals (OR: p = 0.014, ICU: p = 0.032) and with lower interventions/year (OR: p = 0.023). Higher independence in performing TEE was reported in university hospitals (OR: p < 0.001; ICU: p = 0.006), centers with higher interventions/year (OR: p = 0.019), and by respondents with less experience in cardiology (ICU: p = 0.046). Variability in the use of PACs and echocardiography was found. Protocols regulating the use of PACs seem infrequent. University centers use PACs less and have greater skills in TEE. Training and certifications in echocardiography should be encouraged.

Novo dispositivo intraoral para prevenção de lesões bucais em pacientes intubados

Oral injuries in patients in Intensive Care Units (ICU) are recurrent, especially during endotracheal intubation, as the presence of the tube added to the teeth in the oral cavity can cause injuries to the tongue and other soft tissues. Ideally, tube stabilization devices should be easy to handle by the hospital staff, should always be available for use in ICUs, in addition to being low cost. The aim of this study was to develop a device for endotracheal tube stabilization and injury prevention in patients. 3D technical drawings were prepared, and the final version of the device was prototyped in polylactic acid and positioned in the patient. When compared to mouthguards described in the literature, it was found that the developed device provided stability for the tube, provided separation of the teeth from the adjacent soft tissues, and prevented the intubated patient from biting the tube, thus contributing to the prevention of traumatic injuries. It was concluded that the device has characteristics that allow stabilization of the endotracheal tube and the prevention of oral lesions in ICU patients, and can be used by hospital nursing staff.

1792. Different Patterns of Antibiotic Use in Different Administrative Categories: An Overview of 10 years (2009/2018) of a Statewide Surveillance Program in Sao Paulo, Brazil

Abstract Background To describe intensive care unit (ICU) antibiotic use in different administrative categories based on data reported to the Nosocomial Surveillance System of the State Health Department (SHD) in the State of Sao Paulo. Methods This ecological study describes at an aggregated level the antibiotic use in adult ICU reported to São Paulo SHD, from 2009 to 2018. ICUs were categorized by hospital administrative category (private, public, and philanthropic). Public hospitals were subdivided into two administrative sub-categories as Social Health Organization (SHO), which administration is private but public funded, or direct public administration (DPA). Resistance phenotype incidence and antibiotic use correlation was calculated for meticilin-resistant Staphylococcus aureus (MRSA) and glycopeptide use, third generation cephalosporin (3GC)-resistant Enterobacterales and carbapenem use, carbapenem-resistant gram-negative bacilli (CR-GNB) and polymyxins use. Results The average number of hospitals reporting annual data on antibiotic use was 386. A total of 17.490.966 patient-days were included. Total antibiotic use in ICUs increased from 588.16 in 2009 to 943.12 DDD/1000pd in 2018 (p&amp;lt; 0,01). The DDD (defined daily dose) of antibiotic was higher in public hospitals (mean 889.11 DDD/1000pd), than in the private hospitals (mean 849.07 DDD/1000pd) and in the philanthropic hospitals (mean 48 785.12 DDD/1000pd) (p&amp;lt; 0.05). Positive correlations were detected between glycopeptide use and MRSA incidence, polymyxins use and CR-GNB incidence. A weak negative correlation between carbapenems use and 3GC-resistante Enterobacterales incidence were found. Figure I:Antimicrobial use by therapeutic class between 2009 and 2018 in DDD / 1000 patient-daysTable I:Antibiotic use by therapeutic class by administrative type in DDD/1000 patients-dayTable II:Antibiotic use in public hospital by subgroup between 2009 and 2018 in DDD/1000 patients-day Conclusion We found higher use of antibiotics in public hospitals than in private and philanthropic. Differences in antibiotic use were observed among SHO e DPA public hospitals. These data provide important information for formulating hypotheses and public health strategies to improve antimicrobial prescription. Disclosures All Authors: No reported disclosures.

Avaliação do uso da estimulação elétrica neuromuscular em pacientes críticos: conhecimento dos fisioterapeutas e barreiras à implementação

ABSTRACT Transcutaneous neuromuscular electrical stimulation (NMES) is considered an important tool to prevent muscle mass and strength loss in patients admitted to intensive care units (ICU). This study aimed to evaluate physical therapists’ profile and knowledge of NMES and identify the main barriers to its use in ICUs. This observational cross-sectional study was conducted via a structured questionnaire created by the authors. It consisted of 12 objective questions to analyze physical therapists’ knowledge of NMES use in critically ill patients. Physical therapists were invited to participate in this study during an international symposium on NMES. In total, 56 physical therapists, with a mean age of 33.5±7.2 years and working an average of 9.7±7 years after graduation, completed the survey. Overall, 34 respondents worked in ICUs, of which only four (12%) reported regular NMES use in their ICUs. We found a low average of correct answers to our questionnaire (25%; 3/12). The main barriers reported to using NMES in ICUs were lack of knowledge (28; 50%) and equipment (24; 43%). The number of correct answers expert and non-expert physical therapists was not statistically significant (p=0.68). Thus, we observed participants’ poor knowledge of NMES use in critically ill patients. Respondents showed that NMES has been underused in their ICUs. Lack of knowledge and equipment seems to be the main barriers for the use of NMES in ICUs.

Üçüncü Basamak Bir Yoğun Bakım Ünitesinde Bir Yıl Içinde Ölen Hastaların Klinik Özellikleri

Aim: The aim of this study was to find out the clinical characteristics of patients who died within a year in the intensive care unit (ICU) and to find out the association of ICU admission albumin, lactate levels and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores of these patients who died with ICU length of stay.Material and Method: The files of patients who died in the ICU (n:350) between January 2018 and December 2018 were examined retrospectively. The patients’ demographic data and their clinical characteristics, ICU admission types (surgery or medical medicine), the units they were admitted in, reasons for admission, comorbidities, admission albumin and lactate levels, APACHE II scores and ICU length of stay were recorded. The association of patients’ clinical characteristics with ICU length of stay and laboratory values was evaluated. Result: The patients’ mean age was 72.68±12.98 years, mean APACHE II score was 27.0±10.0, mean albumin value was 3.1±0.7 g/dL and mean lactate value was 4.1±3.3 mmol/L. It was found that albumin value was lower in patients admitted to ICU with mechanical ventilator (MV) need (p&amp;lt;0.001), and lactate value and APACHE II score were significantly higher in patients with post-cardiopulmonary resuscitation (p&amp;lt;0.001). Mean ICU length of stay was 28.24 ± 37.53 days. A weak positive correlation (r =0.172, p=0.001) was found between the patients’ length of stay and albumin, and a weak negative correlation was found with the lactat (r = 0.121, p=0.023) and APACHE II scores (r = 0.151, p=0.001). A weak negative correlation was found between the patients’ albumin and lactate (r =0.152, p=0.004), and APACHE II score (r =0.179, p=0.001), as well as a moderate positive correlation between lactate and APACHE II score.Conclusion: Significant association was found between hypoalbuminemia, hyperlactatemia and high APACHE II scores and ICU length of stay in patients who died in ICU. More comprehensive studies are needed to show the effects of this association on effective use of ICUs.

Development of the Japanese version of the Intensive Care Unit Trigger Tool to detect adverse events in critically ill patients.

AimThe Intensive Care Unit Trigger Tool (ICUTT) was developed to detect adverse events (AEs) in intensive care unit (ICU) patients. The purpose of this study was to determine the validity and reliability of the Japanese version of the ICUTT (ICUTT‐J).MethodsThe translation of ICUTT was carried out based on the guideline for translation of instruments. Subsequently, two review teams independently reviewed 50 patients' medical records using the ICUTT‐J, and agreement regarding the presence and number of AEs was evaluated to ensure reliability.ResultsThe ICUTT‐J was submitted to the authors of the original ICUTT, who confirmed it as being equivalent to the original version. The item‐content validity index and scale‐content validity index were 1.00 and 1.00, respectively. Interrater reliability showed moderate agreement of κ = 0.52 in terms of the presence of AEs and linear weighting of κ = 0.49 (95% confidence interval, 0.28, 0.71) in terms of the number of AEs.ConclusionThis study's findings suggest that the ICUTT‐J is valid and moderately reliable for use in ICUs.

Nurses' behaviours towards physical restraint use in the ICU: A descriptive qualitative study.

The study aims to explore and describe nurses' behaviours towards physical restraint (PR) use in intensive care units (ICUs) and identify key characteristics of these experiences. Patients within the ICU are always vulnerable, which requires a thoughtful deliberation when employing PR in ethically laden situations. Considering that the qualitative study on nurses' behaviours towards PR use in ICUs is limited, a deep understanding of how nurses reason and restrict patients is necessary before developing a minimizing programme in hospitals. A descriptive qualitative study was conducted in this paper. Data were collected by 24 semistructured, in-depth and individual interviews about PR, where 24 nurses were drawn from six ICUs of four hospital settings from a comprehensive tertiary care hospital in Qingdao. The QSR NVivo 11.0 software program was used to manage the interview data, and data analysis was guided by the Qualitative Analysis Guide of Leuven. The checklist of Consolidated Criteria for Reporting Qualitative Studies was followed as a guideline in reporting the study. Regarding PR, nurses' behaviours start with a hazard perception, followed by hesitation about whether to restrict the patient. They would usually decide to apply PR when they think that no other choice to control the situation is available. Then, they would reflect on and rationalize their behaviours. Nurses, intensivists, patients and their families participate in and affect this process directly or indirectly. Nurses' behaviours towards PR use comprise a series of complex processes centred on safety. Nurses' decision making should be performed with the participation of intensivists, patients and family caregivers.

Inapropriate use of antibiotics effective against gram positive microorganisms despite restrictive antibiotic policies in ICUs: a prospective observational study

BackgroundGram-positive spectrum antibiotics such as vancomycin, teicoplanin, daptomycin, and linezolid are frequently used in empirical treatment combinations in critically ill patients. Such inappropriate and unnecessary widespread use, leads to sub-optimal utilisation. However they are covered by the antibiotics restriction programme. This prospective observational study, evaluates gram-positive anti-bacterial utilisations in intensive care units (ICUs) with various evaluation criteria, to determine the frequency of inappropriate usage and the intervention targets required to ensure optimum use.MethodsThis clinical study was conducted prospectively between 01.10.2018 and 01.10.2019 in the medical and surgical ICUs of Gazi University Faculty of Medicine Hospital, Turkey. The total bed capacity was 55. Patients older than 18 years and who were prescribed gram-positive spectrum antibiotics (vancomycin, teicoplanin, linezolid, and daptomycin) were included. Patients under this age or immunosuppressed patients (neutropenic,- HIV-infected patients with hematologic or solid organ malignancies) were not included in the study. During the study period, 200 treatments were evaluated in 169 patients. The demographic and clinical features of the patients were recorded. Besides observations by the clinical staff, the treatments were recorded and evaluated by two infectious diseases specialists and two clinical pharmacists at 24-h intervals from the first day to the last day of treatment.SPSS software for Windows, (version 17, IBM, Armonk, NY) was used to analyse the data. Categorical variables were presented as number and percentage, and non-categorical variables were presented as mean ± standard deviation.ResultsIt was found that inappropriate gram-positive antibiotic use in ICUs was as high as 83% in terms of non-compliance with the selected quality parameters. Multivariate analysis was performed to evaluate the factors associated with inappropriate antibiotic use, increased creatinine levels were found to increase the risk of such use.ConclusionsIn spite of the restricted antibiotics programme, inappropriate antibiotic use in ICUs is quite common. Thus, it is necessary to establish local guidelines in collaboration with different disciplines for the determination and follow-up of de-escalation of such use and optimal treatment doses.

Length of stay, mortality, and readmissions among Medicare cancer patients treated with glucarpidase and conventional care: a retrospective study.

PurposeGlucarpidase (Voraxaze) is used to treat methotrexate (Mtx) toxicity in patients with delayed Mtx clearance due to impaired renal function. We examine hospital length of stay (LOS), mortality, and readmission rates for Medicare cancer patients with delayed clearance of Mtx treated with glucarpidase.MethodsUsing 2010–2017 Medicare claims data, we identified glucarpidase patients as those hospitalized with indications of select lymphomas or leukemia, inpatient chemotherapy, and glucarpidase treatment. We assessed outcomes of glucarpidase patients relative to those experienced by patients treated for presumed Mtx toxicity using other therapies. These nonglucarpidase patients were identified with a diagnosis of primary central nervous system lymphoma, indications of cancer-chemotherapy toxicity, and acute kidney injury during hospitalization (not present on admission), and were divided into two groups: treated with dialysis (dialysis+) and treated with or without dialysis (dialysis+/−). Inverse-probability treatment weighting using propensity scores was used to adjust for differences between groups.ResultsPatients treated with glucarpidase (n=30) had an average LOS of 14.7 days. They had inpatient, 30-day, and 90-day mortality rates of 3.3%, 13.3%, and 16.7%, respectively, and a 90-day all-cause unplanned readmission rate of 24.1%. The dialysis+ and dialysis+/− groups, respectively, had higher average LOS (40.2, 21.9), higher inpatient mortality (50.6%, 20.8%), and higher 90-day mortality (58.6%, 37.6%). No statistically significant differences in 30-day mortality or 90-day readmission rates were detected between the glucarpidase group and either of the nonglucarpidase groups. Unobservable differences in patient severity may impact the interpretation of our findings.ConclusionMedicare cancer patients with presumed Mtx toxicity receiving conventional treatment experience long hospitalizations, high intensive-care unit use and high mortality. Glucarpidase patients had lower LOS, inpatient mortality, and 90-day mortality than the non-glucarpidase patients.

Daily skin antisepsis and hygiene in the critically ill patient.

Hygiene and skin care of patients admitted to the Intensive Care Unit (ICU) are part of basic care. For some years there has been evidence of skin colonization by multiresistant gramnegative and grampositive pathogens. The increase in nosocomial infections due to multiresistant microorganisms has led to evaluation of the role of the use of antiseptics, mainly chlorhexidine, as a strategy for reducing the number of such infections. This article reviews the current situation of this strategy, as well as the positioning of the authors in relation to the spreading of its use in ICUs. This article is part of a supplement entitled "Antisepsis in the critical patient", which is sponsored by Becton Dickinson.

Acute antiepileptic drug use in intensive care units.

In intensive care units (ICUs), antiepileptic drugs (AEDs) are used for manifold indications. This is the first study to assess the prevalence of acute AED use in ICUs and to identify associated clinical variables. All patients in seven adult ICUs of a German university hospital in 2016 were retrospectively evaluated. Data were extracted from the computerized critical care information system and manually reviewed. Acute AED treatments were defined as initiated during ICU treatment or ≤ 6h before ICU admission, excluding benzodiazepines and sedatives. Among 2335 patients evaluated, 8.8% received acutely started AEDs: 5.1% due to epileptic seizures, mostly acute symptomatic, and 3.7% for other indications like pain, post-hypoxic myoclonus, and singultus. Following multivariable analyses, acute AED use was independently associated with intracranial reasons for ICU admission and long durations of ICU stay, but not with increased disease severity scores or mortality. Levetiracetam was the substance most frequently used to treat epileptic seizures (88%) as was pregabalin for other conditions (49%). Among surviving patients, acute AEDs were continued beyond ICU discharge in 86% if seizure-related and in 78% if not seizure-related, even if there was no evident need for long-term AED treatment. One out of eleven ICU patients receives acute AEDs, in almost half of cases for non-seizure indications. Acute AED use is a marker for intracranial ICU indications and prolonged ICU treatments. Usually, newer-generation AEDs are employed with favourable pharmacokinetic and safety profiles. However, whenever possible, acutely started AED should be discontinued before discharge from ICU.

Investigating influencing factors of physical restraint use in China intensive care units: A prospective, cross-sectional, observational study

ObjectiveIn this study, we characterised the use of physical restraints in three intensive care units (ICUs) in a general hospital in Nantong, China. Additionally, we explored risk factors potentially related to physical restraint use. BackgroundDespite their numerous harmful effects, physical restraints are frequently used in ICUs worldwide. Few studies have investigated the factors that contribute to physical restraint use in Chinese hospitals. MethodsWe conducted a prospective, cross-sectional, observational study of 312 patients in three ICUs at a general hospital in China. The quantitative data were collected during a 5-month period using a physical restraint observation form and patient records. The data obtained were analysed using descriptive statistics. The independent risk factors for physical restraint use were assessed using a logistic regression model. ResultsOf the 312 patients in the three ICUs, 191 (61.2%) were restrained, and physical restraints were used more than once for 46 (24.1%) patients during their ICU stay. The median length of physical restrain use was 20 shifts (interquartile range = 10–36 shifts). Physical restraints were applied in 6664 of 12374 (53.9%) nurse shifts. The most common time at which physical restraints were applied was the beginning of the evening shift. According to the forward stepwise logistic regression analysis, delirium (P < 0.001), mechanical ventilation (P < 0.001), and age (P < 0.001) were independent risk factors for physical restraint use. The use of analgesics (P = 0.001) exerted an independent protective effect against physical restraint use. ConclusionsThe overall prevalence of physical restraint use in Chinese ICUs was higher than that reported in previous investigations. The patients' nursing notes lacked complete physical restraint records, reflecting a need for standard guidelines and policies for physical restraint use in hospital ICUs in China. In addition, in this study, we explored the risk factors related to physical restraint use and found that age, delirium, mechanical ventilation, and analgesic use are associated with physical restraint use.

Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: study protocol for a randomised controlled trial

BackgroundVentilator-associated respiratory infection (VARI) comprises ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). Although their diagnostic criteria vary, together these are the most common hospital-acquired infections in intensive care units (ICUs) worldwide, responsible for a large proportion of antibiotic use within ICUs. Evidence-based strategies for the prevention of VARI in resource-limited settings are lacking. Preventing the leakage of oropharyngeal secretions into the lung using continuous endotracheal cuff pressure control is a promising strategy. The aim of this study is to investigate the efficacy of automated, continuous endotracheal cuff pressure control in preventing the development of VARI and reducing antibiotic use in ICUs in Vietnam.Methods/designThis is an open-label randomised controlled multicentre trial. We will enrol 600 adult patients intubated for ≤ 24 h at the time of enrolment. Eligible patients will be stratified according to admission diagnosis (180 tetanus, 420 non-tetanus) and site and will be randomised in a 1:1 ratio to receive either (1) automated, continuous control of endotracheal cuff pressure or (2) intermittent measurement and control of endotracheal cuff pressure using a manual cuff pressure meter. The primary outcome is the occurrence of VARI, defined as either VAP or VAT during the ICU admission up to a maximum of 90 days after randomisation. Patients in both groups who are at risk for VARI will receive a standardised battery of investigations if their treating physician feels a new infection has occurred, the results of which will be used by an endpoint review committee, blinded to the allocated arm and independent of patient care, to determine the primary outcome. All enrolled patients will be followed for mortality and endotracheal tube cuff-related complications at 28 days and 90 days after randomisation. Other secondary outcomes include antibiotic use; days ventilated, in ICU and in hospital; inpatient mortality; costs of antibiotics in ICU; duration of ICU stay; and duration of hospital stay.DiscussionThis study will provide high-quality evidence concerning the use of continuous endotracheal cuff pressure control as a method to reduce VARI, antibiotic use and hospitalisation costs and to shorten stay.Trial registrationClinicalTrials.gov, NCT02966392. Registered on November 9, 2016. Protocol version: 2.0; issue date March 3, 2017.

Evaluation of vancomycin therapy in the adult ICUs of a teaching hospital in southern Iran.

BackgroundVancomycin resistance in intensive care units (ICUs) accounts for significant morbidity and excess costs. The objective of the present study was to determine the appropriateness of vancomycin use in the various ICUs of Nemazee Hospital, Shiraz, Iran.MethodsThis prospective study was performed on 95 critically ill patients (48 males and 47 females) who were treated with vancomycin for at least 3 subsequent doses in 6 ICUs during 12 months. Required demographic, clinical, and paraclinical data were collected by a pharmacist. Fifteen indexes were considered for evaluation of vancomycin use.ResultsVentilator-associated hospital-acquired pneumonia (22.6%), sepsis (22.1%) and CNS infection (12.6%) were found to be the most important indications for vancomycin prescription. Vancomycin was prescribed empirically in 81% of patients. None of the patients received loading dose, and most of the patients received fixed dose. The rate of prolonged empiric antibiotic therapy was 68.5% in patients who received vancomycin. The mean score of vancomycin use in the ICUs of Nemazee Hospital was 7.1±0.6 out of 15, implying that the rate of vancomycin use was in accordance with the guideline proposed by the Department of Clinical Pharmacy of Nemazee Hospital based on Infectious Diseases Society of America by 47.3%.ConclusionBased on our results, the weakness in using vancomycin was related to not administering loading dose, the practice of prescribing fixed-dose vancomycin and prolonged duration of empiric therapy. Efforts to improve the pattern of vancomycin prescription and utilization in these ICUs should be undertaken.

A nationwide survey of intravenous antimicrobial use in intensive care units in Japan

Although most patients in the intensive care unit (ICU) receive antibiotics, little is known about patterns of antibiotic use in ICUs in Japan. The objective of this study was to evaluate the pattern of antibiotic use in ICUs. A nationwide one-day cross-sectional surveillance of antibiotic use in the ICU was conducted three times between January 2011 and December 2011. All patients aged at least16 years were included. Data from 52 ICUs and 1148 patients were reviewed. There were 1028 prescriptions for intravenous antibiotics. Of 1148 patients, 834 (73%) received at least one intravenous antibiotic, and 575 had at least one known site of infection. Respiratory and intra-abdominal infections were the two most common types. Of 1028 prescriptions, 331 (34%) were for surgical or medical prophylaxis. Excluding prophylaxis, carbapenems were the most commonly prescribed agent. Infectious disease consultations, pre- and post-prescription antimicrobial stewardship, and ICU-dedicated antibiograms were available in 44%, 52%, 77%, and 21% of the ICUs, respectively. In logistic regression analysis adjusting for patient characteristics, treatment in a university hospital (adjusted odds ratio, 1.72; 95% CI, 1.05–2.84; P = 0.033) and an open ICU (adjusted odds ratio, 2.30; 95% CI, 1.02–5.17; P = 0.044) were significantly associated with greater likelihood of carbapenem use. An increase in the number of closed ICUs and more intensive care specialists may reduce carbapenem use in Japanese ICUs. Large-scale epidemiological studies of antimicrobial resistance in the ICU are needed.

Adherence to Inhaled Medications and its Effect on Healthcare Utilization and Costs Among High-Grade Chronic Obstructive Pulmonary Disease Patients.

Adherence to inhaled medication regimens affects chronic obstructive pulmonary disease (COPD) prognosis and quality of life, and reduces the use of healthcare services, resulting in cost savings. To examine the effects of adherence to inhaled medication regimens on healthcare utilization and costs in high-grade COPD patients. We performed an observational retrospective cohort study using a longitudinal data set from the Korean Health Insurance Review and Assessment Service (2008-2013) containing healthcare services' information for 50 million beneficiaries. The study population was high-grade COPD patients. "Adherent" was defined as a patient attaining a medication possession ratio (MPR)≥80%. We estimated the effects of adherence on the use of intensive care units (ICUs) and emergency rooms (ERs) using a multivariate logistic regression, and estimated the effects on costs (all-cause and COPD-related) using a generalized linear model, with adjustment for patient sociodemographic characteristics, health status, and comorbidities. Of 9086 high-grade COPD patients, adherence declined from 34.7 to 22.3% over 4years. Adherence was inversely associated with use of ICUs and costs, and this association got stronger as the adherence period lengthened. Over the 4-year period, the adherent group had a lower likelihood of using ICUs [odds ratio (OR)=0.74, 95% confidence interval (CI) 0.60-0.91] than the non-adherent group. Similarly, the adherent group had a 10.4% lower all-cause cost (p<0.001) and an 11.7% lower COPD-related cost (p<0.0001) versus the non-adherent group. Adherence reduces healthcare utilization and costs, so adherence is not only clinically effective but also economically efficient. However, less than one-quarter of this population remained adherent over the 4-year period, suggesting that strategies are needed to improve adherence.

Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review.

Care of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan(®), AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel(®), Roche) and lorazepam (Ativan(®), Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor(®), Orion Corporation) and clonidine (Catapres(®), Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents. To conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs. We searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014. Evidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls(®), Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second reviewer cross-checked all the data extracted. Random-effects meta-analyses were used for data synthesis. Eighteen RCTs (2489 adult patients) were included. One trial at unclear risk of bias compared dexmedetomidine with clonidine and found that target sedation was achieved in a higher number of patients treated with dexmedetomidine with lesser need for additional sedation. The remaining 17 trials compared dexmedetomidine with propofol or benzodiazepines (midazolam or lorazepam). Trials varied considerably with regard to clinical population, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded outcome assessors. Compared with propofol or benzodiazepines (midazolam or lorazepam), dexmedetomidine had no significant effects on mortality [risk ratio (RR) 1.03, 95% confidence interval (CI) 0.85 to 1.24, I (2) = 0%; p = 0.78]. Length of ICU stay (mean difference -1.26 days, 95% CI -1.96 to -0.55 days, I (2) = 31%; p = 0.0004) and time to extubation (mean difference -1.85 days, 95% CI -2.61 to -1.09 days, I (2) = 0%; p < 0.00001) were significantly shorter among patients who received dexmedetomidine. No difference in time to target sedation range was observed between sedative interventions (I (2) = 0%; p = 0.14). Dexmedetomidine was associated with a higher risk of bradycardia (RR 1.88, 95% CI 1.28 to 2.77, I (2) = 46%; p = 0.001). Trials varied considerably with regard to participants, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded assessors. Evidence on the use of clonidine in ICUs is very limited. Dexmedetomidine may be effective in reducing ICU length of stay and time to extubation in critically ill ICU patients. Risk of bradycardia but not of overall mortality is higher among patients treated with dexmedetomidine. Well-designed RCTs are needed to assess the use of clonidine in ICUs and identify subgroups of patients that are more likely to benefit from the use of dexmedetomidine. This study is registered as PROSPERO CRD42014014101. The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.