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BACKGROUND: PEEP is a cornerstone treatment for children with pediatric ARDS. Unfortunately, its titration is often performed solely by evaluating oxygen saturation, which can lead to inadequate PEEP level settings and consequent adverse effects. This study aimed to assess the impact of increasing PEEP on hemodynamics, respiratory system mechanics, and oxygenation in children with ARDS. METHODS: Children receiving mechanical ventilation and on pressure-controlled volume-guaranteed mode were prospectively assessed for inclusion. PEEP was sequentially changed to 5, 12, 10, 8 cm H2O, and again to 5 cm H2O. After 10 min at each PEEP level, hemodynamic, ventilatory, and oxygenation variables were collected. RESULTS: A total of 31 subjects were included, with median age and weight of 6 months and 6.3 kg, respectively. The main reasons for pediatric ICU admission were respiratory failure caused by acute viral bronchiolitis (45%) and community-acquired pneumonia (32%). Most subjects had mild or moderate ARDS (45% and 42%, respectively), with a median (interquartile range) oxygenation index of 8.4 (5.8-12.7). Oxygen saturation improved significantly when PEEP was increased. However, although no significant changes in blood pressure were observed, the median cardiac index at PEEP of 12 cm H2O was significantly lower than that observed at any other PEEP level (P = .001). Fourteen participants (45%) experienced a reduction in cardiac index of > 10% when PEEP was increased to 12 cm H2O. Also, the estimated oxygen delivery was significantly lower, at 12 cm H2O PEEP. Finally, respiratory system compliance significantly reduced when PEEP was increased. At a PEEP of 12 cm H2O, static compliance had a median reduction of 25% in relation to the initial assessment (PEEP of 5 cm H2O). CONCLUSIONS: Although it may improve arterial oxygen saturation, inappropriately high PEEP levels may reduce cardiac output, oxygen delivery, and respiratory system compliance in pediatric subjects with ARDS with low potential for lung recruitability. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study sought to estimate the overall cumulative incidence and odds of Hospital-acquired venous thromboembolism (VTE) among critically ill children with and without exposure to invasive ventilation. In doing so, we also aimed to describe the temporal relationship between invasive ventilation and hospital-acquired VTE development. METHODS: We performed a retrospective cohort study using Virtual Pediatric Systems (VPS) data from 142 North American pediatric ICUs among children < 18 y of age from January 1, 2016-December 31, 2022. After exclusion criteria were applied, cohorts were identified by presence of invasive ventilation exposure. The primary outcome was cumulative incidence of hospital-acquired VTE, defined as limb/neck deep venous thrombosis or pulmonary embolism. Multivariate logistic regression was used to determine whether invasive ventilation was an independent risk factor for hospital-acquired VTE development. RESULTS: Of 691,118 children studied, 86,922 (12.4%) underwent invasive ventilation. The cumulative incidence of hospital-acquired VTE for those who received invasive ventilation was 1.9% and 0.12% for those who did not (P < .001). The median time to hospital-acquired VTE after endotracheal intubation was 6 (interquartile range 3-14) d. In multivariate models, invasive ventilation exposure and duration were each independently associated with development of hospital-acquired VTE (adjusted odds ratio 1.64 [95% CI 1.42-1.86], P < .001; and adjusted odds ratio 1.03 [95% CI 1.02-1.03], P < .001, respectively). CONCLUSIONS: In this multi-center retrospective review from the VPS registry, invasive ventilation exposure and duration were independent risk factors for hospital-acquired VTE among critically ill children. Children undergoing invasive ventilation represent an important target population for risk-stratified thromboprophylaxis trials. [ABSTRACT FROM AUTHOR]

Secondary pneumonia has a significant clinical impact on critically ill patients with COVID-19. Considering potential geographic variations, this study explores the clinical implications of secondary pneumonia within East Asian populations. This multicenter, retrospective cohort study enrolled critical COVID-19 patients requiring intensive care units (ICUs) admission in Taiwan from December 31, 2020, to June 1, 2022. Among the 187 critical COVID-19 patients, 80 (42.8%) developed secondary pneumonia. The primary causative pathogens were gram-negative bacilli (GNB) (76.8%). Gram-positive cocci and fungi were mainly observed during the initial two weeks of ICU stay. Notably, the incidence of pulmonary aspergillosis was 9.2% during the first week of ICU stay and all Staphylococcus aureus were susceptible to methicillin. Multi-drug resistant organisms (MDROs) were responsible for 28.3% of the cases, exhibiting significantly longer ICU stays compared to the non-MDRO group (median, 27 vs. 14 days, P < 0.001). In the multivariate analysis, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores were associated with a significantly increased risk of secondary pneumonia. In-hospital mortality was significantly higher in patients with secondary pneumonia than in those without (37.7% vs. 16.7%, P = 0.02) and survival analysis demonstrated gram-negative bacilli-related secondary pneumonia contributed to a worse prognosis. Secondary pneumonia in critical COVID-19 patients significantly raised in-hospital mortality and extended hospital and ICU stays. Moreover, the presence of GNB notably predicted an unfavorable prognosis. [ABSTRACT FROM AUTHOR]

• In the highly specialized environment of cardiac ICUs, tailored nurse-led frailty management strategies are needed. • Nurse-led frailty management in cardiac ICUs is a complex task that leverages the wuli-shili-renli (WSR) system approach, emphasizing mechanisms and regularities (Wuli), operation and management (Shili), and coordination and interaction among individuals (Renli). • Recommendations for improving nurse-led frailty management in cardiac ICUs include strengthening foundational support, implementing closed-loop management, and enhancing personnel training and coordination. Frailty is prevalent among older patients in intensive care units (ICUs) and poses significant challenges to recovery. Despite its importance, there is limited research on effective nurse-led frailty management strategies in this context. The purpose of this qualitative study was to explore nurses' perceptions of frailty management in cardiac ICUs through the lens of the Wuli-Shili-Renli (WSR) system approach. Sixteen nurses from two tertiary hospitals in Shandong province, China, participated in semi-structured interviews. Participants were selected based on their involvement in frailty training, educational background, and cardiac ICU work experience. Thematic analysis was conducted to identify key themes and sub-themes. Analysis in three categories revealed the need for foundational support, including the need for appropriate screening tools, updated evidence-based practices, and institutional support. Closed-loop management involved frailty screening, personalized program implementation, information management, and follow-up assessment. Personnel training and coordination emphasized enhancing nurses' professionalism, multidisciplinary teamwork, and cooperation from patients and their caregivers. The insights gained can inform evidence-based practices and improve the quality of care provided to frail patients in cardiac ICUs. There is a need for future research to empirically investigate these strategies. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients with a tracheostomy and difficult weaning from invasive mechanical ventilation constitute a challenging problem in critical care. An increased duration of ventilation may lead to diaphragmatic dysfunction and a noninvasive assessment of the diaphragm, such as ultrasound, attracts interest in the clinical practice. We evaluated the relationship of ultrasound-derived indices with weaning outcome and with established indices of respiratory strength and load in subjects who are tracheostomized and undergoing weaning. METHODS: This prospective study was conducted at an academic ICU in Greece. Twenty subjects with tracheostomy and difficult weaning, during a spontaneous breathing trial, underwent time synchronous diaphragmatic sonography and esophageal manometry, to assess diaphragmatic excursion and thickening fraction, esophageal and transdiaphragmatic pressures, pressure-time product of the esophageal pressure, and maximum inspiratory pressure. The primary outcome was liberation from mechanical ventilation at 48 h. The relationship of diaphragmatic ultrasound with esophageal pressure-derived indices was also evaluated. RESULTS: Weaning from invasive ventilation failed in 10 subjects. Diaphragmatic excursion exhibited a significant difference between weaning success and failure (1.34 ± 0.56 versus 0.79 ± 0.44; P = .044), a strong correlation with transdiaphragmatic pressure (r = 0.7, P = .02), and a moderate correlation with the pressure-time product of the esophageal pressure (r = 0.65, P = .02) and the maximum inspiratory pressure (r = 0.66, P = .02). Transdiaphragmatic pressure presented the highest area under the curve (0.97). However, when transdiaphragmatic pressure was compared with diaphragmatic excursion (area under the curve, 0.84) for predictive accuracy, no significant difference was found. CONCLUSIONS: Diaphragmatic excursion is a valuable tool for the assessment of diaphragmatic strength, respiratory load, and weaning prediction. [ABSTRACT FROM AUTHOR]

BACKGROUND: Recovery of walking independence in critically ill patients is required for safe discharge home. However, the pre-admission predictors affecting this outcome in this patient group are unknown. This study aimed to identify these predictors. METHODS: We included subjects who required mechanical ventilation for at least 48 h and could walk before admission. We investigated frailty, cognitive impairment, and malnutrition risk according to the pre-admission health status. Walking independence was defined as the ability to walk for at least 45 m on level ground. The primary outcome was the association between the time to event from an ICU discharge to walking independence, and pre-admission predictors were analyzed using a Fine-Gray proportional hazards regression. RESULTS: The rate of walking independence was 38.0 (100 cases/person-month; sample N = 144). In the proportional hazards regression model, adjusted for covariates, frailty (hazard ratio [HR] 0.08 [95% CI 0.01-0.67]), pre-frailty (HR 0.37 [95% CI 0.14-0.99]), cognitive impairment (HR 0.21 [95% CI 0.05-0.90]), and malnutrition risk (HR 0.20 [95% CI 0.07-0.58]) were associated with walking independence. CONCLUSIONS: Pre-admission frailty or pre-frailty, cognitive impairment, and malnutrition risk can help predict walking independence in critically ill patients who require mechanical ventilation. [ABSTRACT FROM AUTHOR]

BACKGROUND: The first aim of this study was to evaluate the capacity of electrical impedance tomography (EIT) to identify the effect of PEEP on regional ventilation distribution and the regional risk of collapse, overdistention, hypoventilation, and pendelluft in mechanically ventilated patients. The second aim was to evaluate the feasibility of EIT for estimating airway opening pressure (AOP). METHODS: The EIT signal was recorded both during baseline cyclic ventilation and slow insufflation for one breath for 9 subjects with moderate-to-severe ARDS. From these data, the AOP and volumes insufflated to lung regions with or without the risk of either collapse, overdistention, hypoventilation, or pendelluft were assessed at 3 PEEP levels (5, 10, and 15 cm H2O). PEEP levels were compared by Friedman analysis of variance and the AOP measured by EIT evaluated using an F-test and the Bland and Altman method. RESULTS: The volume for which there was no specific risk significantly decreased at the highest PEEP from 55 ± 31% tidal volume (VT) at PEEP = or 82 ± 18% VT at PEEP 10 to 10 ± 30% VT at PEEP 15 (P = .038 between PEEP 5 vs PEEP 15; P = .01 between PEEP 10 vs PEEP 15). The volume associated with overdistention significantly increased with increasing PEEP, whereas that associated with atelec-trauma significantly decreased. Pendelluft significantly decreased with increasing PEEP: VT of 8.9 ± 18.6%, 3.6 ± 7.0%, and 3.2 ± 7.1% for PEEP 5, PEEP 10, and PEEP 15, respectively. The center of ventilation tended to increase in the dependent direction with higher PEEP. The AOPs assessed by EIT and from the pressure-volume curve were in good agreement (bias 0.48 cm H2O). CONCLUSIONS: Our results suggest that EIT could aid clinicians in making personalized and reasoned choices in setting the PEEP for subjects with ARDS. [ABSTRACT FROM AUTHOR]

Objective: Health care associated infections (HAIs) are major threat to patient safety in a hospital. Inadequate hand hygiene (HH) practice plays a very important role in transmission of HAIs. Material and Methods: The present study was a prospective interventional study, divided into 3 phases: preintervention, intervention phase, and post-intervention. A total of 40 HCWs, including doctors, nurses, and cleaning staff had given consent to participate in the study. Using standard formulas HH complete adherence rate (HHCAR), HH partial adherence rate (HHPAR), and HH total adherence rate (HHTAR) were calculated. Results: HHCAR, HHPAR, and HHTAR were estimated to be 18.03%, 49.53%, 67.57% respectively. HHCAR in the pre-intervention and post-intervention phases were 2.4% and 22.37%, respectively, reflecting a significant improvement in HH compliance (푃<.001); whereas the improvement in HHPAR was found to be marginal, from 46.16% in the pre-intervention phase to 50.46% in the post-intervention phase. The HHTAR significantly improved to 72.83% in post intervention phase from 48.58 in pre-intervention phase. Conclusion: The present study demonstrated a statistically significant improvement in HH compliance following a multimodal educational intervention in the neurosurgery ICU of a tertiary care hospital. [ABSTRACT FROM AUTHOR]

Chronic respiratory failure is a common cause of ventilator dependence in the intensive care unit (ICU). The causes of chronic respiratory failure include primary disease or complications, such as ICU-acquired weakness. Traditional practice requires patients to remain immobile and bedridden; however, recent evidence suggests that early adequate exercise promotes recovery without increasing risks. In this study, we explored the efficacy of planned progressive abdominal sandbag training in promoting the successful withdrawal of patients with chronic respiratory failure from mechanical ventilation. This study was conducted between April 2019 and November 2020. Patients were recruited and divided into two groups: abdominal sandbag training group and control group (no training). The training group participated in a 3-month daily pulmonary rehabilitation program, which involved a 30-min session of progressive sandbag loading on the upper abdomen as a form of diaphragmatic resistant exercise. The pressure support level of the ventilator was adjusted to maintain a tidal volume of 8 mL/kg. To investigate the effect of abdominal sandbag training on patients with chronic respiratory failure, we compared tidal volume, shallow breathing index, maximum respiratory pressure, and diaphragm characteristics between the training and control groups. This study included 31 patients; of them, 17 (54.8 %) received abdominal sandbag training and 14 (45.2 %) did not. No significant between-group difference was found in baseline characteristics. Compared with the control group, the training group exhibited considerable improvements in ventilation-related parameters (p < 0.001): the tidal volume markedly increased (p = 0.012), rapid shallow breathing index declined (p = 0.016), and maximum respiratory pressure increased (p < 0.001) in the training group. The diaphragm motion value (p = 0.048) and diaphragm thickness (p = 0.041) were greater in the training group than in the control group. Nine patients (52.9 %) in the training group were removed from the ventilator compared with 1 (7.1 %) in the control group (p = 0.008). Abdominal sandbag training may be beneficial for patients dependent on a ventilator. The training improves the function of the diaphragm muscle, thereby increasing tidal volume and reducing the respiratory rate and rapid shallow breathing index, thus facilitating withdrawal from ventilation. This training approach may also improve the thickness and motion of the diaphragm and the rate of ventilator detachment. [ABSTRACT FROM AUTHOR]

This article reports a study designed to evaluate the effectiveness of regular oral care protocol developed specifically for adults in intensive care to prevent mucositis. Data were collected using oral mucositis assessment scale, oral cavity assessment tool, and the National Cancer Institute Common Toxicity Criteria. The results indicated that oral mucositis can be reduced through the practice of administering oral care in accordance with oral health care guidelines. Oral care implemented in line with an evidence-based oral care guide and frequent observation of patients is the most important step in preventing oral mucositis. [ABSTRACT FROM AUTHOR]

There have been few reports concerning simulation drills forthe relocation of severely ill orinjured patients treated in intensive care units (ICUs). We herein report our experience of one such simulation drill. It is a Narrative method. A simulation drill was performed on a weekday 2 weeks prior to the actual relocation. We selected 3 mock patients. The first one was a severely ill and unstable patient, the second had severe stroke, and the third had severe trauma. After the simulation, the average transportation time was 15 minutes. The simulation revealed that mock patients with a percutaneous cardiopulmonary support system and intra-aortic balloon pumping in a standard ICU bed could not be accommodated in the elevator. Furthermore, working the elevator controls resulted in wasted time while transferring the patients. As a result, the number of people, who controlled the elevator, was therefore increased during the actualrelocation. During the actual relocation, all patients were transported safely and more quickly than predicted based on the results of the simulation drill. Most physicians and paramedical staff have little experience with relocating ICUs, so a simulation drill was necessary to ensure the safe and prompt transport of patients. [ABSTRACT FROM AUTHOR]

Arterial puncture is a painful procedure performed to assess patients’ respiratory status. Pain is a stressful situation for unconscious patients as they cannot communicate their feeling verbally. To control patients’ pain and prevent the adverse effects of painkillers, nonpharmacological pain management strategies have been solicited. The aim of this study is to investigate the effect of cryoanalgesia on unconscious patients’ pain during arterial puncture. We adopted a quasi-experimental one-group research design. A sample of 86 unconscious patients in a surgical intensive care unit were recruited in this study. The intervention was applying an ice pack over the puncture site for 5 minutes before the arterial puncture procedure. Pain was assessed for 2 times; before and after application of cryoanalgesia. A statistically significant difference in participants’ pain scores between pre-tests and post-tests was noted. For the intubated ventilated participants, the mean pain score before and after applying cryoanalgesia was 5.26 versus 4.00 (P ≤ .05). For the non-intubated or intubated non-ventilated participants, the mean pain score was 6.66 versus 4.63 (P ≤ .05). Cryoanalgesia is a feasible and effective method incorporate during arterial puncture along with standard procedure elements to achieve maximum pain reduction for unconscious patients during arterial punctures. [ABSTRACT FROM AUTHOR]

Caring for patients in the intensive care unit (ICU) creates competing priorities of interventions for nurses and other health care providers. Oral care might be prioritized lower; however, its neglect may lead to sequelae such as extended time in the ICU, nosocomial diseases most notably ventilator-associated pneumonia (VAP), or oral problems. Safe patient care depends on effective and efficient oral care. The aim of this study was to lower the incidence of VAP and maintain oral health through implementing an “oral care bundle” for mechanically ventilated (MV) patients. Using a quasi-experimental design, we divided 82 adult MV patients in the ICUs of a university-based hospital in Egypt into a control group (n = 41) that received the standard of care and a bundle group (n = 41) that received an “oral care bundle.” The results of the study reported a significantly lower incidence of VAP in the intervention group (P = .015). It can be concluded that there is a significant relationship between receiving an oral care bundle and improved oral health and a reduction in the VAP rate among MV patients. This highlights the need to incorporate the oral care bundle in the daily nursing care for MV patients. [ABSTRACT FROM AUTHOR]

Pressure ulcer is considered a common and costly problem in the care of patients. Prevention and management of pressure ulcer are very important due to the high cost of treatment and the adverse consequences of pressure ulcer. This study aimed to evaluate the effect of implementing “aSSKINg” model in reducing pressure ulcer risk. This study used a before- and afterintervention quasi-experimental design. This study was performed on 60 patients who were not randomly selected and assigned in to control and study group. The data collection tool was a 3-part sheet (Braden scale, skin health assessment, and Pressure ulcer assessment). The incidence of pressure ulcer was 19 (60.0%) in the control group versus 9 (30.0%) in the study group with statistical significant differences. The most common site of pressure ulcer was coccyx (6 [31.6%]) in the control group and Heel (3 [33.3%]) in the study group. The application of “aSSKINg” model in the patients with pressure ulcers is effective in reducing the incidence and severity of pressure ulcers. [ABSTRACT FROM AUTHOR]

This article reports a comparative prospective study aimed to explore and compare nurses’ perceptions of bedside clinical handover in 3 different settings (emergency unit, ICU, and medical ward). Results revealed that the participant nurses’ perceptions varied significantly for different aspects of the handover process. Our data demonstrate department-specific variations in perceptions related to the adequacy, organization, relevance, availability of charts, use of charts for review, ease of following the information, and timeliness of the information. [ABSTRACT FROM AUTHOR]

A study was conducted to evaluate the effect of virtual education on knowledge and practice of nurses regarding administration of drugs through enteral feeding tubes (EFTs). Sixty nurses working in 4 intensive care units were enrolled. A questionnaire evaluating knowledge and practice of nurses regarding drug administration through EFTs was used. At the pre-intervention stage, all nurses responded to the questionnaire. Then an educational videoclip was provided to the intervention group. One month later, post-intervention stage, both groups answered to the questionnaire again. At the end of the study, the scores of all items in the knowledge domain including medication preparation (mean difference [MD] [95% CI]: 1.11 [0.57; 1.66]), tube flushing (MD [95% CI]: 2.15 [1.59; 2.79]),recognizing drug-drug/drug-feed interactions (MD [95% CI]: 0.57 [0.05; 1.09]), and recognizing dosage forms (MD [95% CI]: 1.51 [0.94; 2.10]) and practice domain including medication preparation (MD [95% CI]: 1.63 [1.04; 2.21]), tube flushing (MD [95% CI]: 1.19 [0.64; 1.74]), and recognizing drug-drug/drug-feed interactions [MD (95% CI): 2.16 (1.53; 2.80)] in the intervention group were significantly higherthan those in the control group (P < .05). Education of proper technics of preparation and administration of drugs through EFTs improved knowledge and practice of the participants. [ABSTRACT FROM AUTHOR]

Purpose: To investigate effectiveness of the ABCDEF bundle to manage and prevent delirium. Background: ICU delirium is a common hospital problem that 80% of critically ill patients in the ICU experience. The ABCDEF bundle is one of the tools that included in Delirium guidelines to manage critically ill patients. Research design: Pre- and post intervention a quasiexperimental design was utilized in the present study. Setting: This study was conducted in the intensive care units of Assiut University Hospital. Methods: A total of 60 mechanically ventilated patients were recruited using inclusion and exclusion criteria. The ABCDEF bundle was implemented every day for the first 7 days of ICU admission, and patient sedation and delirium status were assessed using the Confusion Assessment Method for the Intensive Care Unit (CAMICU). Sedation instrument measures were utilized in data collection. Results: Significant differences were found in the incidence of delirium: 20% in the study group versus 70% in the control group. The increased mean of days without delirium ICU stay was 4.6333 in the study group and 1.1000 in the control group, with P value = .001. Conclusion: The mechanically ventilated patients exposed to the implementation of the ABCDE bundle experienced fewer delirium signs than before the ABCDE bundle was implemented. [ABSTRACT FROM AUTHOR]

Background: Triage is pivotal in intensive care for patient safety and resource allocation. The admission algorithm has been shown to correlate with the appropriateness of ICU admission and offer decision aid when facing challenges in times of scarce critical care resources. This study aimed to explore the development of a reference tool to support triage decisions for admission to the ICU. Methods: In this retrospective observational study, the Intensive Care Triage Score (ICTS) was generated as a reference to correlate with the triage decision made by clinical judgment. ICU admission would be advised for ICTS below 6. The primary outcome was ICU admission. The secondary outcomes included ICU, hospital, 90- day, and 1-year mortality. The receiver operating characteristic curve was used to assess the performance of ICTS. Results: A total of 1664 patients were included in the analysis. There were 1204 patients (72.4%) admitted to the ICU; 680 of 738 (92%) with ICTS below 6 were admitted to the ICU. The hospital mortality of the whole cohort was 25.1%; there was a positive correlation between ICTS and hospital mortality. The area under the receiver operating characteristic curve (AUC) of ICTS in predicting hospital mortality for all patients was 0.754 (95% CI 0.728-0.780). The correlation between ICTS and hospital mortality was observed in patients admitted and not admitted to the ICU. Conclusion: Developing a scoring system as a reference tool would be useful for ICU triage. [ABSTRACT FROM AUTHOR]

Introduction: Hypoxic respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia. High-flow nasal cannula (HFNC) improved the survival rate among patients with acute hypoxic respiratory failure. Due to physiological alterations, pregnancy can exacerbate distal renal tubular acidosis (dRTA). Pregnancy complicated by hypokalemic periodic paralysis (HPP) poses significant risks due to the potential cardiac and respiratory failure related to low potassium levels. Case description: A woman, 21 years old, pregnant with her first child at 33-34 weeks gestation came with complaints of shortness of breath one day before admission. Complaints accompanied by cramps in both legs. On the second day, the respiratory rate (RR) suddenly increased to 35x/min, and oxygen saturation (SpO2) was 95% on a non-rebreathing mask (NRM) at 15 l/min. The patient was transferred to the Intensive Care Unit (ICU) with a diagnosis of primigravida at 33-34 weeks, respiratory failure, HPP, suspected dRTA, severe metabolic acidosis, sepsis, and urinary tract infection (UTI). She was given O2 via HFNC at flow 40 l/min and a fraction of inspired oxygen (FiO2) 66%. Improvement was seen on the 4th day; the patient's shortness of breath was reduced with HFNC, and the patient's motor strength improved. Conclusion: The use of HFNC showed a positive outcome and was proven to have been successful in treating hypoxic respiratory failure in pregnant women. Respiratory muscle weakness and severe metabolic acidosis caused by dRTA and HPP cannot be cleared due to the limited settings in rural areas. Furthermore, the assessment and management of HPP and dRTA are still limited in many hospitals in remote areas of Indonesia. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to determine the correlation between pentraxin-3 and procalcitonin levels with Sequential Organ Failure Assessment (SOFA) scores in septic patients. Design: This observational analysis with a cross-sectional method assessed the correlation between pentraxin-3 (PTX-3) and procalcitonin (PCT) levels and the SOFA scores of septic patients. Setting: We conducted this study in the Intensive Care Unit (ICU) of Dr. Wahidin Sudirohusodo Hospital and Medical Laboratory Center of Hasanuddin University from December 2023 to April 2024. Patients and participants: Thirty-two patients with clinical sepsis were admitted to the ICU of Dr. Wahidin Sudirohusodo Hospital. Intervention: Blood samples were collected on day 1 and day 2 of ICU care in septic patients to measure pentraxin-3 and procalcitonin levels. Measurements and results: The Wilcoxon test showed a significant difference in pentraxin-3 levels on ICU care's first and second days (p=0.036). Similarly, there was a significant difference in procalcitonin levels on the first and second days of ICU care. The Spearman correlation test found a significant correlation between procalcitonin and SOFA scores (p=0.008) with a correlation value r=0.462 on the first and second days. The resulting correlation value showed a positive correlation, which meant that the higher the procalcitonin level in septic patients, the higher the SOFA scores with moderate strength (correlation value 0.4-<0.6). The correlation of pentraxin- 3 with the Spearman test showed a positive correlation on the first day. In contrast, on the second day, there was no significant statistical value with the SOFA scores with a correlation value p=0.093 (p>0.05). Conclusion: Pentraxin-3 and procalcitonin levels correlate with SOFA scores in septic patients admitted to the ICU. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to assess the effect of mechanical ventilation based on predicted body weight (PBW) and driving pressure (DP) as directed in patients without acute respiratory distress syndrome (ARDS). Design: Experimental, single-blind design with pretest-posttest control group design to assess the effect of using PBW and DP as a guide in regulating the amount of tidal volume and airway pressure in mechanically ventilated patients without ARDS. Setting: We conducted this study in the Intensive Care Unit (ICU) at Dr. Wahidin Sudirohusodo General Hospital, Makassar, from November 2023 to March 2024. Patients and participants: Patients with respiratory failure who were admitted to the ICU of Dr. Wahidin Sudirohusodo General Hospital, Makassar. Intervention: Patients in the PBW group were given a tidal volume setting of 8 ml/kg PBW, adjusted to the lowest positive end-expiratory pressure (PEEP) with the largest lung compliance target, while the DP group did the same thing and adjusted the tidal volume regarding the driving pressure target. The oxygen partial pressure (pO2), carbon dioxide partial pressure (pCO2), oxygen partial pressure to fractional inspired oxygen ratio (P/F ratio), mechanical power, and ventilatory ratio were assessed at the first hour and 24th hour. Measurement and results: Thirty-two patients were divided into two groups, 16 patients each, recruited from November 2023 to March 2024. There was a significant difference in the P/F ratio in the DP group compared to the PBW group after 24 hours (p<0.001 vs p=0.190). Similarly, pCO2 after 24 hours significantly differed between the DP group (p=0.001) and the PBW group (p=0.658). Regarding mechanical power, the two groups had no significant difference (10.92±2.51 vs 11.68±1.21 Joules/min, p=0.284). The PBW group had a wider range of mechanical power values (range 8.4 J/min) than the DP group (range 4.6 J/min), suggesting the DP group had more consistent mechanical power magnitude. Conclusion: Mechanical ventilation guided by DP can improve oxygenation and ventilation outcomes. Even though both the PBW and DP methods resulted in similar mechanical power levels, the DP-guided approach provided more stable and predictable mechanical power values. This stability can benefit patient management in the ICU, as it suggests a reduced risk of lung injury and potentially better overall outcomes for patients receiving mechanical ventilation. [ABSTRACT FROM AUTHOR]

Background: Acute respiratory distress syndrome (ARDS) has a high mortality rate if not diagnosed and treated promptly. Several markers could increase during ARDS, such as interleukin 6 (IL-6), high mobility group box-1 (HMGB-1), and neutrophil-to-lymphocyte ratio (NLR). This study aimed to determine the correlation between these markers and the severity of ARDS. Methods: This cross-sectional study was conducted at Dr. Wahidin Sudirohusodo General Hospital from January to April 2024. The population included in this study consisted of all patients treated in the Intensive Care Unit (ICU) and divided into two groups: ARDS and non-ARDS. IL-6, HMGB-1, and NLR were measured once during treatment. The severity assessment was conducted using the Berlin criteria (mild, moderate, severe) for ARDS patients. Results: A total of 30 patients were divided equally into two groups. Mean IL-6 levels were higher in ARDS patients (21.15±3.89) than in non-ARDS (12.56±3.08) with a significant difference (p=0.000). The mean HMGB-1 levels were also higher in ARDS (26.46±30.14) than in non- ARDS (9.37±4.23), with a significant difference (p=0.040). IL-6 (p=0.000) and HMGB-1 (p=0.026) were also significantly associated with ARDS severity. Conclusion: IL-6 and HMGB-1 are related to ARDS severity. [ABSTRACT FROM AUTHOR]

The article presents a case study of unresolved pneumonia in a 43-year-old male admitted to the ICU due to an endobronchial mass obstructing the left main bronchus. Typically, patients with community-acquired pneumonia show improvement within 3-5 days; however, persistent symptoms or radiologic infiltrates indicate non-resolving pneumonia, necessitating the ruling out of alternative diagnoses such as tuberculosis or cancer, and assessment of treatment efficacy and patient compliance.

Background: Diarrhea during enteral nutrition may induce various complications and increase the nursing workload. Local Problem: The diarrhea rate in our intensive care units (ICUs) was 37.14% from May to July 2021. Nurses reported a moderate to heavy burden regarding care for those with diarrhea. Methods: A pre-post implementation design was used to evaluate the impact of evidence-based interventions for diarrhea screening and prevention. Interventions: A diarrhea risk screening tool and countermeasures were developed through an extensive literature review. Tools were integrated into the electronic health record system. Results: The rate of diarrhea decreased from 37.14% to 17.33% (P = .000). Nurse's compliance with practice standards increased for diarrhea assessment, risk factor screening, agent choice, and countermeasures provision (P < .05). Conclusions: The evidence-based tools developed for this project helped decrease the diarrhea rate in our ICUs. [ABSTRACT FROM AUTHOR]

Background: Nuisance and false alarms distract clinicians from urgent alerts, raising patient safety risks. Local Problem: High alarm rates in a pediatric progressive care unit resulted in experiencing 180-250 alarms per day or 1 alarm every 3 to 4 minutes per clinician. Methods: Through Plan-Do-Study-Act cycles, environmental, policy, and technology changes were implemented to decrease the average alarms/day/bed and percentage of time in alarm. Interventions: Alarm settings tailored to patient needs using features embedded within the patient monitoring system were implemented and monitored with the assistance of alarm champions. Results: The average number of alarms/day/bed decreased from 177.69 to 96.94 over the course of 10 years, a 45.45% reduction. The percentage of time in alarm decreased from 7.52% to 2.83%, a 62.37% reduction. Conclusions: Arming clinicians with technology to analyze real-time clinical data made alarms meaningful and actionable, decreasing false alarms without compromising patient safety. [ABSTRACT FROM AUTHOR]

Background: Cardiac disease in pregnancy is a leading, indirect cause of maternal mortality. The disease spectrum differs between high-, middle-, and low-income countries. We describe the disease spectrum and short-term in-hospital outcomes in obstetric patients with cardiac disease at an obstetric critical care unit (OCCU) in an upper middle-income country (UMIC). Methods: A single-centre, descriptive, historical cohort study was performed of all the obstetric patients with cardiac disease admitted between January 2018 and December 2019 to the Tygerberg Hospital (TBH) OCCU (n = 86) in Cape Town, South Africa (SA). We analysed groups according to the Cardiac Disease in Pregnancy (CARPREG) II and modified World Health Organization (mWHO) risk assessment tools. Results: Three main groups were identified: valvular heart diseases (50%), cardiomyopathy (22%), and congenital heart disease (21%). The majority (88%) of 34 adverse cardiac outcomes occurred with cardiomyopathy and valvular disease. CARPREG II echocardiography high-risk parameters depended on the cardiac class: cardiomyopathy and valvular disease had a higher association (p < 0.001). Cardiac interventions were performed in 30 patients before pregnancy: 17 valvular, 12 congenital, and one Takayasu's arteritis. Three interventions were performed during pregnancy and none postpartum. Peripartum OCCU interventions (ventilation and vasoactive support) were exclusively required by patients with cardiomyopathy (n = 12) and valvular disease (n = 11). Patients presenting with pulmonary oedema (p = 0.035) and needing ventilation (p = 0.027) or vasoactive support (p < 0.001) had longer OCCU stays. Conclusion: Patients admitted to the OCCU with cardiac disease in obstetrics had mainly valvular heart disease, cardiomyopathy, and congenital heart disease. Adverse cardiac outcomes were associated with cardiomyopathy and valvular disease. Although SA is classified as an UMIC, our disease spectrum was more representative of a low- to middle-income country (LMIC). Patients with previous cardiac interventions had fewer adverse cardiac outcomes and booked earlier. The length of stay was longer when patients presented with pulmonary oedema and needed ventilation and vasoactive support. [ABSTRACT FROM AUTHOR]

Background: Today, stroke has become the most common condition that people in every age group are facing. There are various reasons why a stroke can happen, whether it is a symptom or a complication. The main goal is to handle these people, especially in their early stages. Objective: The objective of this research is to study the awareness of the importance of handling skills among the staff nurses in stroke Intensive Care Units (ICU). Method: A simple random sampling technique was used to select the 93 nursing staff of Krishna Vishwa Vidyapeeth Karad based on inclusion and exclusion criteria. The study period was 6 months. The devices included a demographic questionnaire and a recognition scale for checking the proficiency of nurses in managing stroke cases. From the literature reviews, the researcher developed the entirety of the questionnaire. The analysis’s conclusion showed that the average individual age was 29 years. Their age range was 23-36 years. The male participants were 62% while females were 38%. The survey questionnaire highlighted multiple areas where nurses exhibited limited awareness. These areas encompassed understanding common patient positions, employing effective methods for patient positioning, recognising the advantages of early mobilisation and the essential role that nurses perform in facilitating optimal positioning and early mobilisation for stroke patients. The results were calculated based on the responses and then presented with the help of statistical analysis. Results: Based on the statistical analysis, it was found that there is a lack of and incomplete knowledge about the various aspects of the handling methods of a stroke patient in the ICU. Conclusion: Findings show that nurses are facing various difficulties and have little knowledge about the handling methods of stroke patients, their positioning and changing the patient’s clothes. [ABSTRACT FROM AUTHOR]

Background: While there is a growing body of knowledge specific to understanding the experiences of nurses who work in various contexts in Canada’s northern territories, there continues to be a dearth of research specific to the care of critically ill patients and their families. Purpose: The purpose of this study was to further expand our understanding of how critical care nursing is experienced in the northern context. This study explored nurses’ experiences of providing critical care in all settings from purpose-built intensive care unit to community health centres. Study design: An interpretive descriptive approach was used. Methods: Telephone interviews were conducted with nine registered nurses currently employed in various settings, and three additional telephone interviews were used from an earlier pilot study. Interviews were transcribed and thematically coded. Findings: The following themes emerged: Always the Nurse; Working in Community; Must Haves and Managing Resources; Working Together – Even if We’re Not Together; and A Paradigm Shift: Working Up North. Conclusions: This study highlights the need to consider how nursing geography impacts nursing identity and how to best support nurses who provide critical care but, appropriately, may not identify as critical care nurses due to the expansive roles and responsibilities that some assume in nursing work outside of intensive care units. It also provides a strong incentive to establish relationships with those expanding our understanding of the northern context and what is required of nurses in this context to provide optimal care to patients, families and communities when and wherever critical illness is experienced. [ABSTRACT FROM AUTHOR]

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

We would like the reader to consider the current paediatric point-of-care ultrasound (POCUS) landscape. Even in the most developed European healthcare systems, paediatric POCUS programmes and users mostly operate in silos and are un-, or at best underrepresented by major professional bodies. While international societies focus on the extent and content of POCUS investigations, guidelines and associated evidence, there is little to no established framework for education and clinical governance standards on this explosively advancing field. Borrowing from fluid dynamics, this rapid advancement generates cavitation, leaving providers and educators exposed in certain crucial areas of ongoing clinical practice covered contemporaneously, or worse, post hoc, allowing for clinical governance or medico-legal scrutiny. We give a glimpse into our prospective local POCUS clinical practice initiative and how it complements, advances and affirms our clinical decision making on a daily basis. We'll guide the reader through ward rounds, procedural applications, specialist assessments with allied health professionals, referrals, remote consultations, new patient admissions, and grand rounds. As we are in the process of building a robust, reliable and accountable clinical governance structure around our daily practice, we would also like to demonstrate the need and utility for introductory courses, ongoing educational sessions, established mentorship and regular governance meetings ensuring optimal clinical outcomes. We hope to give insights to clinical practice, deployment, recruitment, education and potential future applications like telemedicine. [ABSTRACT FROM AUTHOR]

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Prolonged bed rest is a known contributor to muscle atrophy, weakness, and deconditioning. Early active mobilization protocols aim to combat acquired weakness and loss of function in patients in the intensive care unit. Despite these benefits, mobilization of patients in the intensive care unit remains a challenge, most notably for patients with limited ability to get out of bed because of invasive devices and prolonged hospitalization. Virtual reality has gained favor for use in critical care to mitigate patients' stress, pain, and anxiety and to provide distraction and socialization. This case report demonstrates a novel application of virtual reality and the ease with which virtual reality can be used to facilitate early mobility and activity progression in the critically ill. [ABSTRACT FROM AUTHOR]

Expanded criteria donors help to increase graft availability, but provide organs with an increased risk of delayed graft function. We aimed to investigate whether donor hypothermia decreases the risk of delayed graft function compared with normothermia. We did this multicentre, randomised, controlled, parallel-arm trial at 53 intensive care units and transplant centres in France. We included expanded criteria donors in whom death was diagnosed based on neurological criteria, in compliance with French law, and the recipients of their kidney grafts. Eligible expanded criteria donors were older than 60 years or were aged 50–59 years and had at least two other risk factors (history of hypertension, creatinine >132 μmol/L, or cerebrovascular cause of death). Donors were randomly assigned to hypothermia (34–35°C) or normothermia (36·5–37·5°C). Machine perfusion was used routinely. Randomisation was done using a computer-generated, interactive, web-response system, in permuted blocks (block size six), stratified by centre. Outcome assessors were masked; investigator masking was not feasible. The primary outcome was the proportion of kidney recipients with delayed graft function, defined as renal replacement therapy within 7 days after transplantation, assessed in the modified intention-to-treat (mITT) population, which included all recipients who received at least one kidney from an expanded criteria donor, with the exception of those under guardianship. Secondary outcomes in expanded criteria donors were the number of organs recovered and transplanted, kidney function, body temperature, total volume of fluids administered, blood pressure and need for vasopressors and inotropes, and adverse events (cardiovascular events, metabolic disturbances, and coagulation disorders). Secondary outcomes in kidney recipients were duration of hospital stay, kidney graft function and vital status at day 7, day 28, 3 months, and 1 year after transplantation, and adverse events (infections, cardiovascular events, and surgical complications). Secondary outcomes were assessed in the mITT population. The trial was registered at ClinicalTrials.gov , NCT03098706. Between Nov 9, 2017, and March 3, 2021, 365 donors were randomly assigned, of whom 298 (151 [51%] male, 147 [49%] female) provided kidneys to 526 recipients (323 [61%] male, 203 [39%] female). 251 recipients in the hypothermia group and 275 recipients in the normothermia group were included in the analysis. Graft function was delayed in 40 (16%) of 251 recipients in the hypothermia group and 58 (21%) of 275 recipients in the normothermia group (odds ratio 0·71 [95% CI 0·44–1·13]; p=0·14; absolute difference –5·2% [95% CI 11·8–1·5]). Compared with donors in the normothermia group, donors in the hypothermia group had higher highest mean arterial pressure (115 mm Hg [SD 22] vs 108 mm Hg [20]; p=0·001). 1 year after transplantation, recipients in the hypothermia group had a lower mean creatinine concentration (152·4 μmol/L [SD 59·1] vs 169·7 μmol/L [51·4]; p=0·0351) and a higher mean creatinine clearance (42·3 mL/min/1·73 m2 [15·8] vs 40·5 mL/min/1·73 m2 [17·9]; p=0·0414) than those in the normothermia group. No significant differences between groups were identified for any other secondary outcomes. Hypothermia in expanded criteria donors whose organs were routinely stored using machine perfusion did not decrease the frequency of delayed kidney graft function. However, hypothermia was associated with a lower serum creatinine concentration and a higher creatinine clearance 1 year after transplantation. French Ministry of Health and French Intensive Care Society. [ABSTRACT FROM AUTHOR]

BACKGROUND: When treating acute respiratory failure, both hypoxemia and hyperoxemia should be avoided. ... should be monitored closely and O2 flows adjusted accordingly. Achieving this goal might be easier with automated O2 titration compared with manual titration of fixed-flow O2. We evaluated the feasibility of using an automated O2 titration device in subjects treated for acute hypoxemic respiratory failure in a tertiary care hospital. METHODS: Health-care workers received education and training about oxygen therapy, and were familiarized with an automated O2 titration device (FreeO2,). A coordinator was available from 8:00 AM to 5:00 PM during weekdays to provide technical assistance. The ability of the device to maintain ... within the prescribed therapeutic window was recorded. Basic clinical information was recorded. RESULTS: Subjects were enrolled from November 2020 to August 2022. We trained 508 health-care workers on the use of automated O2 titration, which was finally used on 872 occasions in 763 subjects, distributed on the respiratory, COVID-19, and thoracic surgery wards, and in the emergency department. Clinical information could be retrieved for 609 subjects (80%) who were on the system for a median (interquartile range) of 3 (2-6) d, which represented 2,567 subject-days of clinical experience with the device. In the 82 subjects (14%) for whom this information was available, the system maintained ... within the prescribed targets 89% of the time. Ninety-six subjects experienced clinical deterioration as defined by the need to be transferred to the ICU and/or requirement of high flow nasal oxygen but none of these events were judged to be related to the O2 device. CONCLUSIONS: Automated O2 titration could be successfully implemented in hospitalized subjects with hypoxemic respiratory failure from various causes. This experience should foster further improvement of the device and recommendations for an optimized utilization. [ABSTRACT FROM AUTHOR]

BACKGROUND: Mechanical ventilation is a common life-saving procedure but can lead to serious complications, including ARDS and oxygen toxicity. Nonadherence to lung-protective ventilation guidelines is common. We hypothesized that a respiratory therapist-driven mechanical ventilation bundle could increase adherence to lung-protective ventilation and decrease the incidence of pulmonary complications in the ICU. METHODS: A respiratory therapist-driven protocol was implemented on August 1, 2018, in all adult ICUs of a Midwestern academic tertiary center. The protocol targeted low tidal volume, adequate PEEP, limiting oxygen, adequate breathing frequency, and head of the bed elevation. Adherence to lung-protective guidelines and clinical outcomes were retrospectively observed in adult subjects admitted to the ICU and on ventilation for ≥ 24 h between January 2011 and December 2019. RESULTS: We included 666 subjects; 68.5% were in the pre-intervention group and 31.5% were in the post-intervention group. After adjusting for body mass index and intubation indication, a significant increase in overall adherence to lung-protective ventilation guidelines was observed in the post-intervention period (adjusted odds ratio 2.48, 95% CI 1.73-3.56). Fewer subjects were diagnosed with ARDS in the post-intervention group (adjusted odds ratio 0.22, 95% CI 0.08-0.65) than in the pre-intervention group. There was no difference in the incidence of ventilator-associated pneumonia, ventilator-free days, ICU mortality, or death within 1 month of ICU discharge. CONCLUSIONS: A respiratory therapist-driven protocol increased adherence to lung-protective mechanical ventilation guidelines in the ICU and was associated with decreased ARDS incidence. [ABSTRACT FROM AUTHOR]

Background: Emerging evidence suggests that virtual patient observation (VPO) may help promote patient safety. Purpose: The purpose of this study was to examine and describe the demographic and clinical characteristics of patients who incurred VPO. Methods: A retrospective analysis was conducted. Differences in total VPO hours between groups were examined, followed by a hierarchical regression to investigate the effect of predictor variables on VPO utilization variance. Results: A total of 286 patient charts were reviewed. Mean VPO hours were higher in patients with an intensive care unit admission history. Adjusted for gender and history of dementia/Alzheimer's/memory impairment, the prediction of total VPO hours increased with the patient's intensive care unit admission history and overall hospital length of stay. Conclusions: Examining the prevalence and variability in the pattern of VPO utilization by specific patient characteristics is essential for identifying what patients could best benefit from this technology. [ABSTRACT FROM AUTHOR]

The issue of failed weaning is a critical concern in the intensive care unit (ICU) setting. This scenario occurs when a patient experiences difficulty maintaining spontaneous breathing and ensuring a patent airway within the first 48 hours after the withdrawal of mechanical ventilation. Approximately 20% of ICU patients experience this phenomenon, which has severe repercussions on their health. It also has a substantial impact on clinical evolution and mortality, which can increase by 25% to 50%. To address this issue, we propose a medical support system that uses a convolutional neural network (CNN) to assess a patient's suitability for disconnection from a mechanical ventilator after a spontaneous breathing test (SBT). During SBT, respiratory flow and electrocardiographic activity were recorded and after processed using time-frequency analysis (TFA) techniques. Two CNN architectures were evaluated in this study: one based on ResNet50, with parameters tuned using a Bayesian optimization algorithm, and another CNN designed from scratch, with its structure also adapted using a Bayesian optimization algorithm. The WEANDB database was used to train and evaluate both models. The results showed remarkable performance, with an average accuracy 98 ± 1.8% when using CNN from scratch. This model has significant implications for the ICU because it provides a reliable tool to enhance patient care by assisting clinicians in making timely and accurate decisions regarding weaning. This can potentially reduce the adverse outcomes associated with failed weaning events. [ABSTRACT FROM AUTHOR]

Introduction: Telemedicine has shown promising results, allowing specialists to provide rapid and effective care in remote locations. However, to our knowledge, current evidence is not robust enough to prove the effectiveness of this tool. This cluster-randomized trial (CRT) aimed to evaluate the impact of telemedicine on clinical care indicators in pediatric intensive care units (PICUs). Methods: An open-label CRT was conducted in 16 PICUs within the Brazilian public health system. The trial took place from August 2022 to December 2023 and compared an intervention group, which received telemedicine support, with a control group, which received usual PICU care. The primary outcome was the PICU length of stay. The main secondary outcomes were mortality rate and ventilator-free days. Results: A total of 1393 participants were included, 657 in the control group and 736 in the intervention group. The mean PICU length of stay was 10.42 (SD, 10.71) days for the control group and 11.52 (SD, 10.80) days for the intervention group. The overall mean of ventilator-free days was 6.82 (SD, 7.71) days. Regarding mortality, 7.54% of participants died in total. No significant difference was found in the outcomes between the groups. Conclusion: Despite the potential benefits of telemedicine, its effective implementation in the Brazilian public health system faces considerable challenges, highlighting the continued importance of investigating and improving the role of telemedicine in pediatric critical care. Clinical trial registration: ClinicalTrials.gov NCT05260710 and ReBEC – RBR-7×j4wyp. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to understand the non-contact nursing experiences of clinical nurses during the COVID-19 pandemic. Methods: A qualitative research design applying thematic analysis was used. The participants were purposive sampled from three institutes: a tertiary hospital, a general hospital, and a residential treatment center in Seoul. Data were collected between December 2021 and January 2022 through individual in-depth interviews with 12 clinical nurses. The data were analyzed using Braun and Clarke's method to identify the meaning of the participants' experiences. Results: During the COVID-19 pandemic, the fields where the participants performed non-contact nursing included intensive care units and isolation wards of hospitals, a residential treatment center, and home cares. Their tasks in non-contact nursing commonly involved remote monitoring using digital devices or equipment, consultation and education. From their experiences performing tasks in these fields, the four theme clusters and nine themes were derived. The four theme clusters are as follows: (1) Confusion of nursing role; (2) Conflict due to insufficient support system; (3) Concern about the quality of nursing; (4) Reflection on the establishment of nursing professionalism. Conclusion: This study highlights the necessity for institutionalizing professional nursing areas, nursing education, and practical support by clarifying the purpose and goals of non-contact nursing and developing nursing knowledge through frameworks. [ABSTRACT FROM AUTHOR]

Purpose: This study investigated the effects of an eye care protocol (ECP) on patients in the intensive care unit (ICU). Methods: This study utilized a randomized controlled design. Participants were patients who met the inclusion criteria and were admitted to the ICU (36 in the experimental group and 38 in the control group). The experimental group received an ECP, while the control group received standard eye care, starting the day after admission, for a duration of 10 days. The ECP classifies the degree of eyelid obstruction into three stages based on the degree of exposure to the lower eyelid conjunctiva and cornea. The protocol included cleansing with normal saline gauze, administering eye drops, applying silicone and polyurethane films, and recommending consultation with an ophthalmologist if necessary. The effectiveness of ECP was assessed by analyzing tear volume, hyperemia, chemosis, and eye discharge. Data analysis was conducted using SPSS 27.0, employing the Mann-Whitney U-test and generalized estimating equations. Results: On day 5, the experimental group demonstrated a significant increase in tear volume in both eyes compared with the control group. However, no statistically significant differences were observed in the incidence of hyperemia, chemosis, and eye discharge on days 5 and 10 of the intervention. Conclusion: The application of the ECP in this study increased tear volume in ICU patients, thereby reducing discomfort caused by dry eyes. It has the potential to prevent complications such as damage to the surface of the eyeball resulting from decreased tear volume. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to probe the correlation between lung ultrasound score (LUSS) and the arterial oxygen pressure to the inspired oxygen fraction ratio (P/F ratio) in patients with respiratory failure on the first and second days of intensive care unit (ICU) care. Design: This was a prospective, analytic study of LUSS and P/F ratio values below 300 in patients under mechanical ventilation. Setting: We conducted in the ICU of Wahidin Sudirohusodo Hospital Makassar, South Sulawesi, Indonesia, in April 2024. Patients and participants: Patients with respiratory failure on mechanical ventilation. Measurement and results: All patients were examined using GE Logiq V2 ultrasonography and blood gas analysis. Of 52 patients, the mean age was 41.62±15.83 years. Most of the samples were male (61.5%), with the majority having a normal body mass index (BMI). In cases of improvement, there was a significant relationship between the LUSS and the P/F ratio of patients with respiratory failure under mechanical ventilation on the first (r=-0.851, p<0.001) and second day (r=-0.682, p<0.001). In cases of worsening LUSS (n=6), it was found that there was no significant relationship (p>0.05) between the LUSS and the P/F ratio of patients with respiratory failure on mechanical ventilation either on the first or second day. Conclusion: There was a significant correlation between LUSS and P/F ratio on the first and second day in cases of improvement in patients with respiratory failure under mechanical ventilation. [ABSTRACT FROM AUTHOR]

Introduction: For most women, pregnancy is a normoevolutive physiological state; however, this is not true in all cases, as some obstetric patients present with life-threatening complications requiring admission to the obstetric Intensive Care Unit (ICU). Our study aimed to identify the primary reasons for admission to the obstetric ICU of a tertiary care center in Sinaloa, Mexico, from January 1 to December 31, 2023. This objective is crucial for understanding and improving maternal healthcare. Our study was a retrospective, cross-sectional, and descriptive analysis of 83 patient records from the Women's Hospital of Sinaloa ICU. This unique approach provides valuable insights into the leading causes of obstetric ICU admissions. Results: The mean age was 24±7.25 years; the patients had a minimum of 1 and a maximum of 6 pregnancies; 65% had been terminated by delivery, 72.2% by cesarean section, and 14.1% by abortion. Prenatal care had not been provided in 27.7% of cases. The mean length of stay in the ICU was 3.1 days. Regarding marital status, 15.7% were single, 41.4% were married, and 43.4% were in a common-law relationship. Twenty-five point three percent had primary education, 42.2% had secondary education, 27.7% had high school, and 4.8% had professional studies. The most common diagnoses were preeclampsia with severity criteria (25.3%), obstetric hemorrhage (21.7%), hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome (9.6%), and eclampsia (7.2%). Conclusions: Our findings underscore the significance of hypertensive disorders of pregnancy and obstetric hemorrhage as the leading causes of ICU admissions in our hospital. This knowledge is crucial for improving maternal healthcare. [ABSTRACT FROM AUTHOR]

Background: Pneumonia is an infectious disease with high mortality rates despite early diagnosis and adequate treatment. Therefore, the use of biological infection parameters is expected to improve patients' clinical outcome prognostic accuracy. In this study, we proposed a combination of decreased procalcitonin (PCT) and C-reactive protein (CRP) to predict the clinical outcome of severe pneumonia. Methods: This was a prospective cohort study of severe pneumonia patients treated in the single-center Intensive Care Unit (ICU) of Dr. Soetomo General Hospital from December 2023 to February 2024. Subjects who met the inclusion and exclusion criteria were examined for PCT and CRP within the first 24 hours of admission and repeated 96 hours later (day five). Clinical outcomes, including acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), septic shock, and 30-day mortality, were observed. Results: Thirty-five patients were enrolled for this study. Five subjects did not survive until the fifth day, and 30 subjects were eligible for analysis. A decrease of PCT >50% within five days was associated with a reduction of 30-day mortality (p=0.013) and septic shock incidence (p=0.005), whereas the decrease in CRP alone did not show any significant relationship towards any clinical outcome. The combination of a decreased PCT >50% and decreased CRP within five days could increase the prognostic specificity up to 88.9% in predicting 30-day mortality. Conclusion: Decreased PCT by more than 50% within 96 hours may predict the 30-day mortality rate and septic shock incidence in patients with severe pneumonia, while combining it with a decreased CRP expression would elevate prognostic specificity for severe pneumonia. [ABSTRACT FROM AUTHOR]

The benefits of therapeutic play (TP) in pediatrics are widely reported in the literature, however its use by health professionals is still limited. The objective was to understand how professionals belonging to the BrinquEinstein group evaluate the process of systematic implementation of TP in hospital pediatric units. Exploratory study, with a qualitative approach, developed in the pediatric and intensive care units of extra-large general hospital in São Paulo. The sample consisted of 13 professionals from different categories belonging to BrinquEinstein. Data was collected through individual semi-structured and audio-recorded interviews, being analyzed based on the Inductive Thematic Analysis proposed by Braun and Clark. From the analysis of the interviews, five themes emerged: experiencing a transforming process; the benefits that strengthen the path; the facilities that encourage the walk; the barriers that challenge the process; the future prospects. For the interviewed professionals, it is essential that the use of TP becomes a routine practice in different contexts of the child´s healthcare, in which managers and institutions play a fundamental role in its implementation. [ABSTRACT FROM AUTHOR]

Background: Enteral feeding by a transpyloric tube in critically ill infants is indicated when there is a failure in gastric feeding. However, there is a wide variability regarding the insertion technique. Purpose: Toperformasystematicreviewofthemethodsforinsertingatranspyloricfeedingtubeinnewbornsandinfants. Data Sources: Nine databases, without date or language restrictions, accessed in September 2021. Study Selection: A systematic review of experimental and nonexperimental studies, according to the "Patient/problem; Intervention; Comparison; Outcome" strategy and the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. The clinical question was about the measurement and insertion techniques, as well as the success rates of properly placing a transpyloric tube in newborns and infants. Data Extraction: Two authors (N.M.Q. and J.F.S.) analyzed 6 observational descriptive prospective studies, all of them published in peer-reviewed indexed medical journals and one in the official journal of the National Association of Neonatal Nurses. Results: The success rate varied between 70% and 100%. There was an important variability in the type of tube, measurement method, and insertion techniques. It was found that the most common strategies to achieve proper positioning were glabella-calcaneal measurements, gastric air insufflation, and right lateral decubitus. Implications for Practice: A transpyloric catheter insertion protocol needs to be established in each neonatal unit, according to the literature findings. Implications for Research: Randomized controlled studies that evaluate the gastric air insufflation technique and other adjuvant measures could elucidate the knowledge gap concerning the correct positioning of transpyloric tubing in newborns and infants. [ABSTRACT FROM AUTHOR]

The optimal timing of intubation in acute hypoxaemic respiratory failure is uncertain and became a point of controversy during the COVID-19 pandemic. Invasive mechanical ventilation is a potentially life-saving intervention but carries substantial risks, including injury to the lungs and diaphragm, pneumonia, intensive care unit-acquired muscle weakness, and haemodynamic impairment. In deciding when to intubate, clinicians must balance premature exposure to the risks of ventilation with the potential harms of unassisted breathing, including disease progression and worsening multiorgan failure. Currently, the optimal timing of intubation is unclear. In this Personal View, we examine a range of parameters that could serve as triggers to initiate invasive mechanical ventilation. The utility of a parameter (eg, the ratio of arterial oxygen tension to fraction of inspired oxygen) to predict the likelihood of a patient undergoing intubation does not necessarily mean that basing the timing of intubation on that parameter will improve therapeutic outcomes. We examine options for clinical investigation to make progress on establishing the optimal timing of intubation. [ABSTRACT FROM AUTHOR]

Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes. This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned—using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age—in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov , NCT01211522 , and is complete. Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73–2.04] at 3 months and 1·12 [0·60–2·11] at 12 months) nor ziprasidone (1·07 [0·59–1·96] at 3 months and 0·94 [0·62–1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo. In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults. National Institutes of Health and the US Department of Veterans Affairs. [ABSTRACT FROM AUTHOR]

• Among patients with CRP > 125 mg/L at D4, 25% presented with anastomotic leakage and 16% with another type of infection; in 47% of cases on D6, CRP had spontaneously fallen below the threshold. • With CRP > 125 mg/L on the 4th day following colorectal surgery, it is urgent to carry out a CT-scan with opacification of the anastomosis. • A protocol expressly drawn up for management of these patients enables them to derive maximum benefit from early diagnosis and decreases length of hospital stay (fewer than 15 d for 68% of patients). • In our experimental setting, early endoscopy for the diagnosis and treatment of colorectal and colocolic fistulas did not turn out to be feasible. To evaluate the feasibility and benefit of a diagnostic and therapeutic algorithm for management of patients presenting with a high C-reactive protein (CRP) level after colorectal surgery. Prospective study including patients with CRP > 125 mg/L at the 4th postoperative day following elective colorectal surgery. The protocol involved CT-scan of which the results were to orient subsequent management: antibiotics, radiological drainage, endoscopy or surgical redo. Success (primary endpoint) consisted in the proportion of patients with total duration of hospitalization fewer than 15 d. Secondary endpoints were: applicability of the protocol in real-life conditions, number of stomas created, duration of hospitalization in an intensive care unit. One hundred and six (106) patients were included: 51 patients (48%) presented with postoperative complications, of which 21 (41%) were severe. No death occurred. Among the included patients, 68% had a hospital stay < 15 d. Major deviations from the management algorithm occurred in 38% of cases. No patients had an early endoscopy. There was no significant difference with regard to the secondary endpoints according to whether or not the protocol was strictly observed. It is necessary to define a protocol for management of patients presenting with high CRP levels after colorectal surgery, the objective being to reduce the impact of complications and to avoid excessive lengthening of hospital stay. The protocol begins with CT-scan, which is to orient subsequent management. [ABSTRACT FROM AUTHOR]

Increasing palliative care presence in the intensive care unit (ICU) improves symptom management, increases goals-of-care discussion, and reduces unnecessary procedures in ICU patients. An interdisciplinary study team developed a palliative care trigger program in a 17-bed surgical ICU (SICU). Surgical ICU patients who met 3 triggers (ICU length of stay > 10 days, repeat ICU admission, and metastatic cancer) automatically received a palliative care consult. The purpose of the current study was to survey SICU health care professionals before and after the institution of the palliative care trigger program. Overall, the palliative care trigger program was viewed positively by interdisciplinary team members with increased team communication and decreased resistance for the inclusion of palliative care in the SICU plan of care. The palliative care trigger program was successfully developed and implemented in a SICU and was accepted by the interdisciplinary team members caring for SICU patients. Team member feedback is being used to expand the palliative care trigger program to improve care for SICU patients. [ABSTRACT FROM AUTHOR]

Introduction: Critical care pharmacists as integral members of multidisciplinary teams, play a crucial role in enhancing clinical, economic, and humanistic outcomes for all critically ill patients. In this region, however, the economic impact of critical care pharmacist has not been well investigated. Objectives: The purpose of this study was to classify and estimate critical care pharmacist interventions that are associated with cost avoidance in the intensive care units. Methods: This was a single-center, prospective, observational study conducted at a 30-bed adult medical and surgical intensive care unit for over 12 months. Interventions performed by the critical care pharmacist and accepted by the multidisciplinary intensive care teams were documented weekly. Interventions were retrieved monthly to be categorized and quantified for cost estimation using a systematic framework. Total cost avoidance was calculated by aggregating the cost avoidance values for each intervention. The average rates of cost avoidance per month were computed by dividing the total cost avoidance by the number of months the critical care pharmacist provided care. For the net benefit, we subtracted the cost of the clinical pharmacist service from the total cost savings. Results: For a cohort of 239 critically ill patients, a total of 912 interventions were recommended. Forty percent of critical care pharmacist interventions were related to the optimization of antibiotics. Cost avoidances were mainly observed in adverse event prevention (n = 170; 18%), which resulted in a cost savings of $336,189.2 and individualized patient care accounted for (n = 486; 53%) and resulted in cost savings of $304,905.46 The total cost avoidance was $697,254.1 with a benefit-cost ratio of 5.7:1. Conclusion: The presence of pharmacists in the intensive care unit has resulted in significant cost avoidance, mainly in adverse event prevention and individualized patient care, with a substantial return on investment. [ABSTRACT FROM AUTHOR]