Search

Under a Creative Commons license: Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Clinical practice is a moment of stress for nursing students with impact in academic outcomes. Neonatal Intensive Care Units (NICU) are a specific and multifaceted context that offer complex experiences to nursing students. A descriptive, cross-sectional, and observational study, with a qualitative approach was outlined that aimed to describe and categorize the experiences of nursing students in NICU. Semi structured interviews were used for data collection and content analysis for data analysis. Among eligible students (those that had performed clinical practice in NICU and agreed to participate) a purposive sample of 6 students was selected. Data analysis allowed the identification of five categories: clinical practice evolution, expectations about clinical practice, challenges faced in clinical practice, feelings for the babies and their parents, and comparing with the adult nursing clinical practice. The findings of this study indicate that nursing students experienced a wide range of feelings and experiences. info:eu-repo/semantics/acceptedVersion

Delirium is a marker of acute brain insufficiency and a harbinger of poor outcomes and increased healthcare costs. Despite success preventing delirium by nonpharmacologic measures, the incidence in the postcardiac surgical ICU population remains high. Dexmedetomidine, a selective alpha-2 agonist, is a plausible preventive agent with sedative, anxiolytic, analgesic, sympatholytic and anti-inflammatory properties, and is the subject of very active study in cardiac surgery populations.Recent trials, including DEXACET (2019), DECADE (2020), LOWDEXDEL (2021), and DIRECT (2022) individually, failed to show a benefit for dexmedetomidine and highlighted associated risks. Meta-analyses have offered conflicting results, highlighting the complexity of delirium, and likely interaction of multiple etiological pathways; those that concluded benefit often were driven by trials at high risk of bias. Meta-analyses excluding biased trials currently suggest no benefit for dexmedetomidine over control in unselected cardiac surgical populations.Although using dexmedetomidine to prevent delirium in unselected cardiac surgical patients is not supported by current evidence, there remains hope that it may offer benefits in highly selected populations, and further trials are ongoing.

There are four conditions caused by Kaposi sarcoma herpesvirus (KSHV): Kaposi sarcoma, KSHV-associated multicentric Castleman disease (MCD), primary effusion lymphoma (PEL), and KSHV inflammatory cytokine syndrome (KICS). These KSHV-associated disorders (KADs) often occur in people with HIV and can lead to multiorgan dysfunction requiring admission to the ICU. However, little is known about patient outcomes in this setting.A retrospective study of patients with KADs admitted to the ICU between 2010 and 2021 was conducted, examining KAD admission diagnoses, HIV characteristics, selected cytokine profiles, and ICU interventions. Primary outcomes were 60-day and median overall survival from ICU admission to death from any cause.Forty-seven patients (all but one with HIV coinfection) were included. At ICU admission, 44 patients (94%) were on antiretroviral therapy with a median CD4 + count of 88 cells/μl and HIV viral load of 23 copies/ml. The most common presentation was respiratory failure alone (19%) or with hypotension (17%). Twenty-two (47%) patients had presumed KICS (with or without Kaposi sarcoma) at admission and an additional KAD was diagnosed in 36% of these patients. IL-6 levels did not vary across KAD subtype. Twenty (43%) patients received KAD-directed therapy in the ICU. Sixty-day survival was 70% and median overall survival was 9 months.The majority of patients with HIV and KADs admitted to the ICU had well controlled HIV. Additional KAD were diagnosed during ICU admission in a proportion of patients who presented with presumed KICS. Critical illness did not preclude a subset of patients from receiving KAD-directed therapy in the ICU.

Objective: Right-to-left ventricle diameter ratio (dRV/dLV) on CT pulmonary angiography (CTPA) is a predictor of outcomes in non-operated chronic thromboembolic pulmonary hypertension (CTEPH) patients. The purpose of this study is to evaluate the performance of a novel machine learning (ML) algorithm for dRV/dLV measurement in operated CTEPH patients and its association with post-operative outcomes. Methods: This retrospective study reviewed consecutive CTEPH patients who underwent pulmonary endarterectomy between 2013 and 2017. ML calculated dRV/dLV on pre-operative CTPA and compared with manual measures. Associations of dRV/dLV with patient characteristics and post-operative outcomes were evaluated including intensive care (ICU) and hospital length of stay (LOS) using multivariable linear regression analysis. Prolonged LOS was defined as greater than median. Results: ML segmented the ventricles in 99/125 (79%) patients. The most common cause of failure was misidentification of the moderator band as the interventricular septum (7.9%). Mean dRV/dLV by ML was 1.4 ± 0.4 and strongly correlated with manual measures (r = 0.9–0.96 p < 0.0001). dRV/dLV was moderately correlated with measures of pulmonary hypertension on right heart catheterization and RV dilatation on echocardiogram (r = 0.5–0.6, p < 0.0001). dRV/dLV ≥ 1.2 was associated with proximal Jamieson type disease (p = 0.032), longer cardiopulmonary bypass (p = 0.037), aortic cross-clamp (p = 0.022) and circulatory arrest (p < 0.001) at surgery and dRV/dLV ≥ 1.6 with post-operative ECMO (p = 0.006). dRV/dLV was independently associated with prolonged ICU LOS (OR = 3.79, 95% CI 1.1–13.06, p = 0.035). Conclusion: dRV/dLV was associated with CTEPH severity and independently associated with prolonged ICU LOS. This CT parameter may therefore assist in perioperative planning. Further refinement of the ML algorithm or CTPA technique is required to avoid errors in ventricular segmentation. Advances in knowledge: Automated right-to-left ventricle ratio measurement by machine learning is feasible and is independently associated with outcome after pulmonary endarterectomy.

Background: Infection is a frequent and serious complication after combat-related trauma. The Sequential Organ Failure Assessment (SOFA) score has been shown to have predictive value for outcomes, including sepsis and mortality, among various populations. We evaluated the prognostic ability of SOFA score in a combat-related trauma population. Methods: Combat casualties (2009–2014) admitted to Landstuhl Regional Medical Center (LRMC; Germany) intensive care unit (ICU) within 4 days post-injury followed by transition to ICUs in military hospitals in the United States were included. Multivariate logistic regression was used to determine predictive effect of selected variables and receiver operating characteristic (ROC) curve analysis was used to evaluate overall accuracy of SOFA score for infection prediction. Results: Of the 748 patients who met inclusion criteria, 436 (58%) were diagnosed with an infection (32% bloodstream, 63% skin and soft tissue, and 40% pulmonary) and were predominantly young (median 24 years) males. Penetrating trauma accounted for 95% and 86% of injuries among those with and without infections, respectively (p

Among critically ill patients, acutely depressed level of consciousness is associated with mortality, but its relationship to long-term outcomes such as disability and physical function is unknown. We investigated the relationship of level of consciousness during hospitalization with long-term disability and physical function in ICU survivors.Multi-center observational cohort study.Medical or surgical ICUs at five U.S. centers.Adult survivors of respiratory failure or shock.None.Depressed level of consciousness during hospitalization was defined using the Richmond Agitation Sedation Scale (RASS) score (including all negative scores) by calculating the area under the curve using linear interpolation. Sedative-associated level of consciousness was similarly defined for all hospital days that sedation was received. We measured disability in basic activities of daily living (BADLs), instrumental activities of daily living (IADLs), discharge destination, and self-reported physical function. In separate models, we evaluated associations between these measures of level of consciousness and outcomes using multivariable regression, adjusted for age, sex, race, body mass index, education level, comorbidities, baseline frailty, baseline IADLs and BADLs, hospital type (civilian vs veteran), modified mean daily Sequential Organ Failure Assessment score, duration of severe sepsis, duration of mechanical ventilation, and hospital length of stay. Of the 1,040 patients enrolled in the ICU, 781 survived to hospital discharge. We assessed outcomes in 624 patients at 3 months and 527 patients at 12 months. After adjusting for covariates, there was no association between depressed level of consciousness (total or sedation-associated) with BADLs or IADLs at either 3- or 12-month follow-up. There was also no association with self-reported physical function at 3 or 12 months or with discharge destination.Depressed level of consciousness, as defined by the RASS, was not associated with disability or self-reported physical function. Future studies should investigate additional modifiable in-hospital risk factors for disability and poor physical function following critical illness.

To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA).Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial.Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497).Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021.None.Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621).In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.

Anemia is common in critically ill patients and may be exacerbated through phlebotomy-associated iatrogenic blood loss. Differences in phlebotomy practice across patient demographic characteristics, clinical features, and practice environments are unclear. This investigation provides a comprehensive description of contemporary phlebotomy practices for critically ill adults.This is an observational cohort study of adults ≥18 years of age requiring intensive care unit (ICU) admission between January 1, 2019, and December 31, 2019, at a large academic medical center. Descriptive statistics were utilized to summarize all phlebotomy episodes throughout hospitalization, with each phlebotomy episode defined by unique peripheral venous, central venous, or arterial accesses for laboratory draws, exclusive of finger sticks. Secondarily, financial costs of phlebotomy and the relationships between phlebotomy practices, hemoglobin concentrations, and red blood cell (RBC) transfusions were evaluated.A total of 6194 patients were included: 59% were men with a median (interquartile range) age of 66 (54-76) years and median ICU and hospital durations of 2.1 (1.4-3.9) and 7.1 (4.3-11.8) days, respectively. The median number of unique laboratory draws was 41 (18-88) throughout hospitalization, with a median volume of 232 (121-442) mL, corresponding to 5.2 (2.6-8.8) draws and 29 (19-43) mL per day. Waste (ie, discard) volume was responsible for 10.8% of total phlebotomy volume. Surgical patients had a higher number of phlebotomy episodes and greater total phlebotomy volumes compared to nonsurgical patients. Phlebotomy practices differed across ICU types, with the greatest frequency of laboratory draws in the cardiac surgical ICU and the greatest daily phlebotomy volume in the medical ICU. Across hospitalization, ICU environments had the greatest frequency and volumes of laboratory draws, with the least intensive phlebotomy practice observed in the general hospital wards. Patients in the highest quartile of cumulative blood drawn experienced the longest hospitalizations, lowest nadir hemoglobin concentrations, and greatest RBC transfusion utilization. Differences in phlebotomy practice were limited across patient age, gender, and race. Hemoglobin concentrations declined during hospitalization, congruent with intensity of phlebotomy practice. Each 100 mL of phlebotomy volume during hospitalization was associated with a 1.15 (95% confidence interval [CI], 1.14-1.17; P.001) multiplicative increase in RBC units transfused in adjusted analyses. Estimated annual phlebotomy costs exceeded $15 million (approximately $2500 per patient admission).Phlebotomy continues to be a major source of blood loss in hospitalized patients with critical illness, and more intensive phlebotomy practices are associated with lower hemoglobin concentrations and greater transfusion utilization.

Vasopressor-induced ischemia of the hand, while relatively rare, is a severe complication in critically ill intensive care unit (ICU) patients requiring high concentrations of sympathomimetic pressors and often results in digit necrosis and amputation. Currently, there are no widely accepted approaches for treating this cause of peripheral digital ischemia. Case reports have demonstrated that reducing the concentration of vasopressors that patients are given may reverse the progression of ischemic events prior to necrosis. While this approach is at odds with the principle of “life over limb,” it demonstrates that digit necrosis can be reversed, resulting in improved outcomes. Here, we present a therapeutic strategy for treating digital limb ischemia in the septic ICU patient without the need to lower systemic vasopressor dose by using locally injected botulinum toxin A into ischemic hands.

The Post Intensive Care Syndrome (PICS) has been described in intensive care (ICU) survivors, being present in 50% of patients surviving 12 months, with well-defined risk factors. Severely burned patients combine many of these risk factors, but the prevalence of PICS has not yet been documented in burns. The study aimed to answer this question and identify associations of PICS with clinical characteristics. Cross-sectional descriptive study of major burn survivors admitted to the burn ICU between 2013 and 2019. Main inclusion criteria: major burns>20 %BSA and ICU admission. The PICS components were assessed using three questionnaires: 1) Physical with Burn Specific Health Scale-Brief (BSHS-B); 2) Cognitive health with MacNair Cognitive Difficulties Self-Rating Scale (CDS); 3) Mental health with the Hospital Anxiety and Depression Scale (HADS) questionnaire. PICS was considered present if at least one component out of three was abnormal. Data as mean±SD. Among the 288 patients admitted during the period, 132 met the inclusion criteria: 53 patients were finally enrolled. They were aged 44 ± 18 years at the time of injury and burned 24 ± 20 BSA % and stayed 25 ± 44 days in the ICU. PICS was identified in 35 patients (66 %): more than one component was altered in 21 patients (60 %). Principal risk factors were more than 3 general anesthetics, prolonged mechanical ventilation (>4 days), ICU stay (>8 days), and hospital stay (>25 days) CONCLUSION: PICS occurred in 66 % of major burns with two or three components affected simultaneously in 60 %, i.e. more frequently than in general ICU patients.

Injury is the leading cause of death in children over the age of one in Canada, and remains the most common cause of death in Quebec pediatric patients. Indigenous communities are 3-4 times more likely to be affected by injuries than the national average. In Quebec, health centres can range from 30 to 1000 km away from the closest level I trauma center.Descriptive analysis and multiple logistic regression were performed for severely injured pediatric trauma patients received at the Montreal Children's Hospital (MCH) over a ten-year period. Outcomes were compared between regional groups in Quebec using forward sortation areas.Two hundred and forty four pediatric patients presented to the MCH with major trauma between 2006 and 2016. Of those, 42% of patients resided in Montreal, 42% off-island, and 16% in Northern Quebec. Admission to the Intensive Care Unit (ICU) was required for 60% of off-island patients and 58% of Northern residents. The median length of hospital stay (LOS) was 5 days for off-island and 15 days for Northern patients. Most patients (78% off-island vs. 76% Northern Quebec) were discharged home. The overall mortality was 5%. In multiple regression analysis, residence in Northern Quebec was associated with increased incidence of longer than median length of stay compared to off-island patients (OR 2.78, 95%CI (1.12-7.29)) after adjusting for injury severity, operative intervention, age, and sex.ICU admission rate was similar among Northern and off-island populations. Patients from Northern Quebec appeared to have longer-than-median hospital length of stay. In-hospital mortality was infrequent and limited to on-island and off-island populations. A further exploration of this data is required to identify the "trauma deserts" and advocate for children involved in trauma in all areas of Quebec.

Gastrointestinal (GI) emergencies and disorders are among the most common reasons to be admitted to an intensive care unit (ICU). In addition, critically ill patients admitted to the ICU for non-GI-related diseases are frequently at risk of developing GI complications during their hospitalization. This article details the epidemiology/etiology, clinical presentation, diagnostic assessment, and management of the following GI emergencies: upper and lower GI bleed, acute pancreatitis, and ascending cholangitis.

Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.

We attempted to determine the predictive ability of the first-day Sequential Organ Failure Assessment (SOFA) score in the cardiac intensive care unit, as well as a new score combining the anion gap (AG) with the SOFA score (SOFA-AG).Information was obtained from the Medical Information Mart for Intensive Care III (MIMIC III 1.4) database. We plotted the relationship between the maximum first-day AG and 90-day mortality after admission to the care unit. Patients were divided into five groups based on the hazard ratio (HR) and assigned scores of 0, 1, 2, 3, or 4 points. We compared the area under the curve (AUC) for the receiver-operating characteristic curve of the SOFA and that of the SOFA-AG.A total of 1316 patients were identified and divided into the following five groups: AG 8 to16 mmol/L; AG 16 to17 mmol/L; AG 17 to19 mmol/L; AG 19 to21 mmol/L; and AG ≥ 21 mmol/L. The SOFA-AG score had a greater AUC than the SOFA score at 7 days (0.770 vs. 0.711; P 0.001), 14 days (0.751 vs. 0.692; P 0.001), 28 days (0.741 vs. 0.684; P 0.001), and 90 days (0.727 vs. 0.667; P 0.001).The SOFA score showed moderate predictive value only for 7-day mortality after admission to the cardiac intensive care unit, but the SOFA-AG score had improved predictive ability for up to 90 days after admission.

The majority of hip fracture patients in the United States are older adult patients with multiple comorbidities. Aortic stenosis (AS) in older adult patients with traumatic hip fracture is not uncommon. This study investigated the association between AS and postoperative mortality and serious complications.In this retrospective cohort study, a chart review was performed of patients with AS who underwent hip fracture surgical repair between January 2011 and December 2019 within one health system. A control group of hip fracture patients without AS was identified and matched based on body mass index, age, sex, date of surgery and Charlson Comorbidity Index. The primary outcome of interest was 90-day mortality; secondary outcomes included 30-day postoperative complications, intensive care unit admission (ICU), and hospital length of stay.In total, 146 hip fracture patients with AS and 146 without AS were identified. In the AS group, there was an increased odds of 90-day mortality (odds ratio 2.64, 95% confidence interval 1.32-5.28,The presence of AS was independently associated with an increase in 90-day mortality and postoperative ICU stay in patients undergoing surgical repair of a hip fracture.

The incidence of acute kidney injury (AKI) is high in critically ill patients with rhabdomyolysis. Limited evidence was proved of the association between serum phosphate levels at intensive care unit (ICU) admission and the subsequent risk of AKI. Our study aims to assess if serum phosphate levels at admission were independently associated with AKI risk in these patients.This study extracted and analyzed data from Medical Information Mart for Intensive Care-Ⅲ (MIMIC-Ⅲ, version1.4). Rhabdomyolysis was defined as a peak creatine kinase (CK) level higher than 1000 U/L. Serum phosphate was measured within the first day into the ICU and was categorized to 4 groups (2.6, 2.6-3.4, 3.5-4.5,4.5mg/dl). AKI was defined according to the Kidney Disease Improving Global Outcome (KDIGO) guidelines. Adjusted smoothing spline plots and multivariable logistic regressions were carried out to explode the association between serum phosphate and risk of AKI. Subgroup analyse was applied to verify the consistency of the association.Three hundred and twenty-one patients (68% male) diagnosed as rhabdomyolysis were eligible for this analysis. AKI occurred in 204 (64%) patients of total. Incidence of AKI with admission serum phosphate groups2.6, 2.6-3.4, 3.5-4.5 and4.5mg/dl were 53%, 57%, 68% and 76%, respectively. Smoothing spline curve showed that there was a positive curve between the elevated phosphate values and increasing risk of AKI, and there was no threshold saturation effect. In multivariable logistic regression, OR was 1.2 (95%CI 1.0-1.5, P=0.035, P trend=0.041) after adjusting confounders. Subgroup analyses proved the consistency of the relationship in these patients, possibly, except in the strata of potassium.In rhabdomyolysis patients admitted to ICU, serum phosphate levels at admission were independently associated with an increased risk of AKI. As phosphate levels rise, the risk of AKI increased.

Diseases of the peripheral nervous system create an additional diagnostic conundrum within the intensive care setting. Causes are vast, presentations are myriad, and symptoms are often ill-defined or misidentified. Care benefits from a multidisciplinary approach including a neuromuscular specialist, rehabilitation services, and a specialty pharmacist in addition to the neurocritical care team. In general, survivors achieve a good functional recovery relative to their preintensive care unit baseline.

Impaired physical function is a common complication in intensive care unit (ICU) patients. However, specific upper limb (UL) function is still poorly studied in this population. To evaluate UL function at discharge and after a 6-month follow-up of individuals hospitalized in the ICU.This was a longitudinal prospective 6-month multicentre cohort study with forty-six individuals hospitalized in the ICU undergoing mechanical ventilation for ≥ 48 h (ICU Group) and forty-six healthy individuals matched by sex, age, and socioeconomic status (control Group). The primary outcomes were measurements of UL disability using the Jebsen-Taylor Hand Function Test (JTT) and the Nine Hole Peg Test (NHPT). Secondary outcomes were physical function (Barthel index), muscle strength (Medical Research Council scale and hand grip strength), and quality of life (EuroQol-5 Dimension). All measurements were assessed after ICU discharge and at a 6-month follow-up.The JTT performance time in the ICU group after discharge was worse than that in the control group [121 s (86-165) vs. 54 s (49-61), median (IQR), p0,001] and was reduced after 6 months [62 s (54-81), p0,01]. The NHPT performance time at discharge in the ICU group was worse than that in the controls [39 s (33-59) vs. 21 s (20-23), p0,001] and was reduced after 6 months of follow-up [24 s (21-27), p0,01]. Physical function, muscle strength and quality of life were reduced after ICU discharge.Individuals hospitalized in the ICU presented with reduced UL function at discharge and at the 6-month follow-up.

Human gestation and birthing result in many deviations from usual physiology that are nonetheless normal to be seen. However, on occasion, certain complications in the obstetric patient can be life-threatening to both mother and fetus. Timely recognition of these disorders and allocation of the appropriate resources are especially important. These conditions often require an intensive care unit admission for closer monitoring and supportive care. They can affect an array of physiological systems and can lead to significant morbidity. Such complications are discussed in greater detail in this article.

We investigated the predictive values of the expanded Simplified Acute Physiology Score (SAPS) II and Acute Physiologic Score and Chronic Health Evaluation (APACHE) II score in predicting in-hospital mortality in coronary care unit (CCU) patients.In this study, expanded SAPS II and APACHE II scores were calculated in the CCU of a single-center tertiary hospital. Patients admitted to CCU with any cardivascular indication were included in the study. Both scores were calculated according to previously determined criteria. Calibration and discrimination abilities of the scores in predicting in-hospital mortality were tested with Hosmer-Lemeshow goodness-of-fit C chi-square and receiver operating characteristics (ROC) curve analyses.A total of 871 patients were included in the analysis. The goodness-of-fit C chi-square test showed that both scores have a good performance in predicting survivors and nonsurvivors in CCU. Expanded SAPS II score has a sensitivity of 80% and a specificity of 91.8% with the cut-off value of 5.55, while APACHE II has a sensitivity of 75.9% and a specificity of 87.4% with the cut-off value of 16.5 in predicting mortality.Expanded SAPS II and APACHE II scores have good ability to predict in-hospital mortality in CCU patients. Therefore, they can be used as a tool to predict short-term mortality in cardiovascular emergencies.

Continuous prediction surveillance modeling is an emerging tool giving dynamic insight into conditions with potential mitigation of adverse events (AEs) and failure to rescue. The Epic electronic medical record contains a Deterioration Index (DI) algorithm that generates a prediction score every 15 min using objective data. Previous validation studies show rapid increases in DI score (≥14) predict a worse prognosis. The aim of this study was to demonstrate the utility of DI scores in the trauma intensive care unit (ICU) population.A prospective, single-center study of trauma ICU patients in a Level 1 trauma center was conducted during a 3-mo period. Charts were reviewed every 24 h for minimum and maximum DI score, largest score change (Δ), and AE. Patients were grouped as low risk (ΔDI14) or high risk (ΔDI ≥14).A total of 224 patients were evaluated. High-risk patients were more likely to experience AEs (69.0% versus 47.6%, P = 0.002). No patients with DI scores30 were readmitted to the ICU after being stepped down to the floor. Patients that were readmitted and subsequently died all had DI scores of ≥60 when first stepped down from the ICU.This study demonstrates DI scores predict decompensation risk in the surgical ICU population, which may otherwise go unnoticed in real time. This can identify patients at risk of AE when transferred to the floor. Using the DI model could alert providers to increase surveillance in high-risk patients to mitigate unplanned returns to the ICU and failure to rescue.

The aim of this study was to assess the differences in effectiveness between nurse educator-led and clinical coach-led intensive care unit (ICU) training programs for new graduate nurses.New graduate ICU nurses require substantial clinical training, which is often provided by peers serving as clinical coaches who have not been formally trained for an educator role. Our medical center successfully transitioned from a nurse educator-led to clinical coach-led model for initial ICU education after formally training the clinical coaches.Nurses enrolled in nurse educator-led (n = 114) or clinical coach-led (n = 166) ICU clinical training programs were compared on program pass rate, satisfaction, preparedness, turnover, and competence.There were no statistically significant differences between the groups on any of the identified measures of program effectiveness.Both educator-led and clinical coach-led models, with appropriate training, effectively prepared ICU nurses in this setting. Implementing a clinical coaching model for ICU training of new graduate nurses could assuage common resource issues, such as a shortage of nurse educators, as well as address the increasing demand for well-trained ICU nurses.

Clinicians must individualize pharmacotherapy for patients with acute neurological injury based on multiple factors, including age, comorbidities, and chronic medication use. Many pharmacokinetic and pharmacodynamic properties are altered during acute illness, particularly absorption, distribution, metabolism, and elimination, which may result in loss of drug effect or toxicity. This article provides clinicians with general pharmacologic knowledge of the following drug regimens commonly prescribed to neurocritically ill adults: sedatives, analgesics, osmotherapy, antiseizure medications, antishivering agents, vasoactive agents, and antithrombotic reversal agents.

The COVID-19 pandemic has placed a great deal of strain on healthcare providers across the world. There has been no research into the experiences of health care providers in Turkey caring for hospitalized patients with COVID-19 in the ICU.To explain the experiences of health care providers who provide services to patients with Covid-19 in an intensive care unit.This study used a phenomenological approach to recruit 15 participants (10 nurses and 5 physicians). The data was gathered through semi-structured in-depth interviews conducted face-to-face.The four primary themes that came up in the results were COVID-19: the unidentified enemy, front-line struggle, psychological struggle, and invasion of social life.During the epidemic, health care providers encountered several psychological, physical, social, and professional difficulties. All health care personnel must receive information and skills training on what to do in crisis and risk circumstances such as infectious disease, decision-making, anxiety management, and problem-solving during pandemics.

Background Delirium is a severe complication in critical care patients. Accurate prediction could facilitate determination of which patients are at risk. In the past decade, several delirium prediction models have been developed. Objectives To compare the prognostic accuracy of the PRE-DELIRIC, E-PRE-DELIRIC, and Lanzhou models, and to investigate the difference in prognostic accuracy of the PRE-DELIRIC model between patients receiving and patients not receiving mechanical ventilation. Methods This retrospective study involved adult patients admitted to the intensive care unit during a 2-year period. Delirium was assessed by using the Confusion Assessment Method for the Intensive Care Unit or any administered dose of haloperidol or quetiapine. Model discrimination was assessed by calculating the area under the receiver operating characteristic curve (AUC); values were compared using the DeLong test. Results The study enrolled 1353 patients. The AUC values were calculated as 0.716 (95% CI, 0.688–0.745), 0.681 (95% CI, 0.650–0.712), and 0.660 (95% CI, 0.629–0.691) for the PRE-DELIRIC, E-PRE-DELIRIC, and Lanzhou models, respectively. The difference in model discrimination was statistically significant for comparison of the PRE-DELIRIC with the E-PRE-DELIRIC (AUC difference, 0.035; P = .02) and Lanzhou models (AUC difference, 0.056; P < .001). In the PRE-DELIRIC model, the AUC was 0.711 (95% CI, 0.680–0.743) for patients receiving mechanical ventilation and 0.664 (95% CI, 0.586–0.742) for those not receiving it (difference, 0.047; P = .27). Conclusion Statistically significant differences in prognostic accuracy were found between delirium prediction models. The PRE-DELIRIC model was the best-performing model and can be used in patients receiving or not receiving mechanical ventilation.

Neurological emergencies carry significant morbidity and mortality, and it is necessary to have a multidisciplinary approach involving the emergency physician, the neurologist, the intensivist, and the critical care nursing staff. These disorders can be broadly divided into noninfectious and infectious etiologies. In this article, we review a few of the neurological emergencies that present to the neurological intensive unit, with emphasis on convulsive status epileptics, myasthenia gravis, Guillain-Barré syndrome, meningitis, encephalitis, and brain abscess.

Background Detailed data on intensive care unit (ICU) occupancy in Japan are lacking. Using a nationwide inpatient database in Japan, we aimed to assess ICU bed occupancy to guide critical care utilization planning. Methods We identified all ICU patients admitted from January 1, 2015 to December 31, 2018 to ICU-equipped hospitals participating in the Japanese Diagnosis Procedure Combination inpatient database. We assessed the trends in daily occupancy by counting the total number of occupied ICU beds on a given day divided by the total number of licensed ICU beds in the participating hospitals. We also assessed ICU occupancy for patients with mechanical ventilation, patients with extracorporeal membrane oxygenation, and patients without life-supportive therapies. Results Over the 4 study years, 1,379,618 ICU patients were admitted to 495 hospitals equipped with 5,341 ICU beds, accounting for 75% of all ICU beds in Japan. Mean ICU occupancy on any given day was 60%, with a range of 45.0% to 72.5%. Mean ICU occupancy did not change over the 4 years. Mean ICU occupancy was about 9% higher on weekdays than on weekends and about 5% higher in the coldest season than in the warmest season. For patients with mechanical ventilation, patients with extracorporeal membrane oxygenation, and patients without life-supportive therapies, mean ICU occupancy was 24%, 0.5%, and 30%, respectively. Conclusion Only one-fourth of ICU beds were occupied by mechanically ventilated patients, suggesting that the critical care system in Japan has substantial surge capacity under normal temporal variation to care for critically ill patients.

The aim of this study was to assess the association between race and ethnicity and admission to intermediate (IMCUs) or intensive care units (ICUs) among hospitalized patients.Using Florida hospital discharge data from the Agency for Healthcare Research and Quality-sponsored State Inpatient Database in 2017, we assessed the relationship between race (White, Black, Other) and Hispanic ethnicity and IMCU or ICU admission. Demographic covariates included age, sex, quartile of household income for patient ZIP code, insurance status, and patient residence. An adjusted model assessed the association between race and ethnicity and IMCU or ICU admission using log binomial regression with generalized estimating equations after controlling for demographic characteristics and the Elixhauser Comorbidity Index.After controlling for demographics and comorbidities, the prevalence of IMCU or ICU admission was higher among non-Hispanic Blacks (adjusted prevalence ratio [aPR] 1.04; 95% confidence interval [CI] 1.02-1.05) and non-Hispanic patients of other races (aPR 1.03; 95% CI 1.01-1.04) compared with non-Hispanic Whites. The prevalence of IMCU or ICU use was lower among Hispanic Whites (aPR 0.98; 95% CI 0.86-1.00) and Hispanics of other races (aPR 0.96; 95% CI 0.95-0.98) compared with non-Hispanic Whites after controlling for other demographic characteristics and comorbidities.Among hospitalized patients, racial minorities are slightly more likely to use higher levels of care, whereas Hispanic patients are generally slightly less likely than non-Hispanic White patients to use higher levels of care. Further evaluation is needed to identify reasons for disparate IMCU or ICU admission.

Critically ill patients with COVID-19 are at high nutrition risk. This study aimed to describe the nutrition support practices in a single centre critical care unit during the initial surge of the COVID-19 pandemic. Practices were explored from ICU admission to post-ICU follow-up clinic and patients who received veno-venous extra-corporeal membrane oxygenation (VV-ECMO) were compared to those who did not.This retrospective observational study included COVID-19 positive, adult ICU patients who were mechanically ventilated for ≥72 h. Data were collected from ICU admission until the time of post-ICU clinic. For in-ICU data, results are compared between patients who did and did not receive VV-ECMO.252 patients were included (VV-ECMO n = 58). Adequate energy and protein was delivered in 193 (76.6%) patients during their ICU admission with no differences between those who did and did not receive VV-ECMO (44 (75.9%) vs. 149 (76.8%)). Parenteral nutrition only being required in 12 (4.8%) patients. Following stepdown to the ward 77 (70%) patients required ongoing enteral nutrition support, and 74 (66.7%) required a texture modified diet or were NBM. Following hospital discharge, nearly a third of ICU survivors (28.4%) were referred for dietetic input. The most common referral reason was loss of weight. Breathlessness and fatigue were the most commonly reported nutrition impact symptoms experienced following hospital discharge.Results show it is possible to reach nutritional adequacy for most patients and that neither VV-ECMO nor proning were barriers to nutritional adequacy. Nutritional issues for patients who were critically ill with COVID-19 persist following stepdown to ward level and into the community and strategies to manage this require further investigation.

Background & aims Dysphagia can be a consequence of prolonged hospitalization in intensive care units (ICUs) due to severe SARS-CoV-2 pneumonia. This study aims at Identifying the risk factors for dysphagia in ICU patients with COVID-19 pneumonia requiring invasive mechanical ventilation, and at determining the frequency of postextubation dysphagia in this population. Methods Observational, descriptive, retrospective, cohort study of SARS-CoV-2 pneumonia patients admitted into the ICUs from March to May 2020. The Modified Viscosity Volume Swallowing Test (mV-VST) was used to screening for dysphagia during the first 48 h of extubation in patients requiring mechanical ventilation. Descriptive statistics, univariate and multivariate analyses were conducted. A logistic regression was applied to construct a predictive model of dysphagia. Results A total of 232 patients were admitted into the ICUs (age [median 60.5 years (95% CI: 58.5 to 61.9)]; male [74.1% (95% CI: 68.1 to 79.4)]; APACHE II score [median 17.7 (95% CI: 13.3 to 23.2)]; length of mechanical ventilation [median 14 days (95% CI: 11 to 16)]; prone position [79% (95% CI: 72.1 to 84.6)]; respiratory infection [34.5% (95% CI: 28.6 to 40.9)], renal failure [38.5% (95% CI: 30 to 50)])). 72% (167) of patients required intubation; 65.9% (110) survived; and in 84.5% (93) the mV-VST was performed. Postextubation dysphagia was diagnosed in 26.9% (25) of patients. APACHE II, prone position, length of ICU and hospital stay, length of mechanical ventilation, tracheostomy, respiratory infection and kidney failure developed during admission were significantly associated (p

While acute empyema is a critical infectious disease showing a high mortality rate, there are no prognostic tools to evaluate the disease severity and prognosis for patients. We conducted a retrospective cohort to determine whether quick Sequential Organ Failure Assessment (qSOFA) and SOFA score can predict the disease severity and prognosis of acute empyema. A total of 53 patients were enrolled in the study. The mean age was 69 years and 41 patients (77%) were male. Twenty-two patients (42%) had multiple underlying diseases with the Charlson comorbidity index ≥3. The-30 days, and in-hospital deaths were 7 (13%) and 10 (19%), respectively. The area under the ROC curve of SOFA score and CCI for 30-day and in-hospital deaths were 0.814 (p = 0.073) and 0.752 (p = 0.082), 0.848 (p = 0.07) and 0.762 (p = 0.011), respectively. Univariate analysis showed that qSOFA ≥2 and SOFA score ≥2, isolation of potentially drug-resistant (PDR) pathogen, high CCI (≥3), performance status of 2-4, surgical intervention, and anaerobic bacteria involvement were prognostic factors. Of these, multivariate logistic regression analysis showed that qSOFA ≥2 and SOFA score ≥2 (p = 0.011), isolation of PDR pathogen (p = 0.005), and high CCI (≥3) (p = 0.015) were independently poor prognostic factors. We concluded that qSOFA and SOFA scores could predict the disease severity and prognosis in acute empyema. Additionally, isolation of PDR pathogens and high CCI could be poor prognostic factors for patients.

To assess the level of implementation of medication safety practices in Intensive Care Units (ICUs) and to identify opportunities for improvement.A descriptive multicenter study was carried out.Intensive Care Units.A total of 40 ICUs voluntarily completed the "Medication use-system safety self-assessment for Intensive Care Units" between March and September 2020. The survey comprised 147 items for evaluation grouped into 10 key elements.Calculation was made of the mean scores and mean percentages based on the maximum possible values for the overall survey, for the key elements and for each individual item for evaluation.The mean score of the overall questionnaire among the participating ICUs was 436.8 (49.2% of the maximum possible score). No differences were found according to functional dependence, size of the hospital or type of ICU. The key elements referred to the incorporation of clinical pharmacists in these units, as well as the competence and training of the professionals in safety practices yielded the lowest values (31.2% and 33.2%, respectively). Three other key elements related to accessibility to information about patients and medicines; to the standardization, storage and distribution of medicines; and to the quality and risk management programs, yielded percentages below 50%.Numerous effective safety medication practices have been identified with a low level of implementation in ICUs. This situation must be addressed in order to reduce medication errors in critically ill patients.

To investigate the pandemic's impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, 'PUI'). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies.

Summary Background & aims Sarcopenia, a loss of muscle mass, quality and function, which is particularly evident in respiratory muscles, has been associated with many clinical adverse outcomes. In this study, we aimed at evaluating the role of reduced muscle mass and quality in predicting ventilation weaning, complications, length of intensive care unit (ICU) and of hospital stay and mortality in patients admitted to ICU for SARS-CoV-2-related pneumonia. Methods This was an observational study based on a review of medical records of all adult patients admitted to the ICU of a tertiary hospital in Milan and intubated for SARS-CoV-2-related pneumonia during the first wave of the COVID-19 pandemic. Muscle mass and quality measurement were retrieved from routine thoracic CT scans, when sections passing through the first, second or third lumbar vertebra were available. Results A total of 81 patients were enrolled. Muscle mass was associated with successful extubation (OR 1.02, 95% C.I. 1.00–1.03, p = 0.017), shorter ICU stay (OR 0.97, 95% C.I. 0.95–0.99, p = 0.03) and decreased hospital mortality (HR 0.98, 95% C.I. 0.96–0.99, p = 0.02). Muscle density was associated with successful extubation (OR 1.07, 95% C.I. 1.01–1.14; p = 0.02) and had an inverse association with the number of complications in ICU (Β −0.07, 95% C.I. −0.13 - −0.002, p = 0.03), length of hospitalization (Β −1.36, 95% C.I. −2.21 - −0.51, p = 0.002) and in-hospital mortality (HR 0.88, 95% C.I. 0.78–0.99, p = 0.046). Conclusions Leveraging routine CT imaging to measure muscle mass and quality might constitute a simple, inexpensive and powerful tool to predict survival and disease course in patients with COVID-19. Preserving muscle mass during hospitalisation might have an adjuvant role in facilitating remission from COVID-19.

Summary Background & aims COVID-19 patients present a high hospitalization rate with a high mortality risk for those requiring intensive care. When these patients have other comorbid conditions and older age, the risk for severe disease and poor outcomes after ICU admission are increased. The present work aims to describe the preliminary results of the ongoing NUTRICOVID study about the nutritional and functional status and the quality of life of adult COVID-19 survivors after ICU discharge, emphasizing the in-hospital and discharge situation of this population. Methods A multicenter, ambispective, observational cohort study was conducted in 16 public hospitals of the Community of Madrid with COVID-19 survivors who were admitted to the ICU during the first outbreak. Preliminary results of this study include data retrospectively collected. Malnutrition and sarcopenia were screened at discharge using MUST and SARC-F; the use of healthcare resources was measured as the length of hospital stay and requirement of respiratory support and tracheostomy during hospitalization; other study variables were the need for medical nutritional treatment; and patients’ functional status (Barthel index) and health-related quality of life (EQ-5D-5L). Results A total of 176 patients were included in this preliminary analysis. Most patients were male and older than 60 years, who suffered an average (SD) weight loss of 16.6% (8.3%) during the hospital stay, with a median length of stay of 53 (27–89.5) days and a median ICU stay of 24.5 (11–43.5) days. At discharge, 83.5% and 86.9% of the patients were at risk of malnutrition and sarcopenia, respectively, but only 38% were prescribed medical nutrition therapy. In addition, more than 70% of patients had significant impairment of their mobility and to conduct their usual activities at hospital discharge. Conclusions This preliminary analysis evidences the high nutritional and functional impairment of COVID-19 survivors at hospital discharge and highlights the need for guidelines and systematic protocols, together with appropriate rehabilitation programs, to optimize the nutritional management of these patients after discharge.

Effective treatment of pneumonia requires timely administration of appropriate antimicrobials but standard diagnostic tests take around 48 h to generate results. Highly accurate, rapid molecular tests have been developed for identifying organisms in lower respiratory tract samples, however their impact on antibiotic use is unknown. The aim of this study was to assess the impact of syndromic molecular point-of-care testing compared to conventional diagnostic testing, on antibiotic use.In this pragmatic, randomised controlled trial, we enrolled critically ill adults with pneumonia. Patients were assigned (1:1) to molecular testing of samples at the point-of-care or routine clinical care. The primary outcome was the proportion of patients who received results-directed antimicrobial therapy.200 patients were randomly assigned to point-of-care testing (n = 100) or the control group (n = 100). 85 patients had community acquired pneumonia (42 in the mPOCT group and 43 in the control group), 69 hospital acquired pneumonia (30 in mPOCT and 39 in control) and 46 ventilator associated pneumonia (28 in mPOCT and 18 in control). The median [IQR] time to results was 1.7 [1.6-1.9] hours for point-of-care testing and 66.7 [56.7-88.5] hours for standard diagnostics (difference of -65.0 h, 95%CI -68.0 to -62.0; p 0.0001). 71 (71%) patients in the point-of-care testing arm had pathogens detected compared to 51 (51%) in the control arm (difference of 20%, 95%CI 7 to 33; p = 0.004). 80 (80%) of patients in the point-of-care group received results-directed therapy, compared with 29 (29%) of 99 in the control group (difference of 51%, 95%CI 39-63; p 0.0001). Time to results-directed therapy was 2.3 [1.8-7.2] hours in the mPOCT group and 46.1 [23.0-51.5] hours in the control group (difference of -43.8 h, 95% CI -48.9 to -38.6; p 0.0001). 42 (42%) patients in mPOCT group had antibiotics de-escalated compared with 8 (8%) of 98 in the control group (difference of 34%, 95%CI 23-45; p 0.0001). Time to de-escalation was 4.8 [2.4-13.0] hours in the mPOCT group compared with 46.5 [26.3-48.6] hours in the control group (difference of -41.4 h, 95%CI -53 to -29.7; p 0.0001). There was no major difference in antibiotic duration or in clinical or safety outcomes between the two groups.Use of molecular point-of-care testing in patients with pneumonia returned results more rapidly and identified more pathogens than conventional testing. This was associated with improvements in appropriate antimicrobial use and appeared safe.

Infection of the lower respiratory tract is a potentially severe or life-threatening illness. Taking the right steps to recognize, identify, and treat pneumonia is critical to improving patient outcomes. An awareness of the diversity of potential infectious causes, the local endemic flora and resistance patterns, as well as testing strategies to differentiate causes of pneumonia is essential to providing the best patient outcomes. Understanding surveillance definitions allow intensivists to become partners in reducing hospital-associated infections and improving quality of care.

Immunologically mediated diseases can lead to severe courses that have to be treated in an intensive care unit. The use of extracorporeal organ support systems (ventilation, ECMO) is common. A therapeutic principle for these diseases is the removal of disease-causing antibodies. This can be done nonspecifically by plasmapheresis or specifically by immune adsorption. While most intensive care units have the facilities for plasmapheresis (membrane plasma filtration), immunoadsorption is much less common. Over a period of 10 years, the numbers of immunoadsorption and plasmapheresis treatments performed in a single center intensive care unit are shown according to their indication (IA: 18 Pts, 58 treatments. PA: 54 Pts, 148 treatments). A case study of a patient with granulomatosis with polyangiitis shows the successful treatment with immunoadsorption. The advantages of immunoadsorption in patients with complex coagulation disorders and a critical clinical picture in terms of SIRS and ARDS are shown.

Although blood test is a routine in major burns, its relationship with burn size and intensive care unit length of stay (ICULOS) remains undetermined. We investigated the feasibility of using these tests as a reference for definite diagnosis of major burn size, burn size20% of the total body surface area (TBSA), and their relationships with ICULOS.Data of routine laboratory blood tests within 24 h after burns (n = 73) were collected retrospectively. Correlation tests and regression analyses were performed.Burns ≥20 TBSA had higher incidences of leucocytosis, hypoalbuminaemia, elevated haemoglobin (Hb), and elevated haematocrit (Hct). Burn size was correlated negatively with albumin but positively with Hb, Hct, and white blood cell (WBC) count. For each unit increase in blood urea nitrogen (BUN)/creatinine (Cr), there was an increase of 1.2 days of ICULOS in females, while in males, there was a 6.7 day increase for every unit increase in Hb and a 3.1 day increase for each unit increase in BUN. A female model including Hb and WBC was derived, discriminating burns ≥20 TBSA with sensitivity and specificity 0.94 and 1.0 respectively, and area under the receiver operating characteristic curve (AUROC) 0.96 (95% CI 0.91-1.00). The male model had sensitivity 0.96, specificity 1.0, and AUROC 0.96 (95% CI 0.89-1.00).Admission Hb and WBC could be used as a reference for definite diagnosis of major burn size, especially in borderline cases. BUN/Cr in females, and Hb and BUN in males, were related to ICULOS.

PURPOSE: High-dose methotrexate (HDMTX; > 500 mg/m2) is an important component of lymphoma therapy. Serum MTX monitoring at 48 hours is the standard approach to identify those at increased risk of developing MTX toxicity. Our aim was to characterize the incidence of complications and their association with MTX levels. METHODS: A retrospective review of our institutional electronic medical record was conducted to identify patients with lymphoma who received HDMTX between January 1, 2002, and December 31, 2018. We characterized the incidence of acute kidney injury (AKI), intensive care unit (ICU) admission, length of hospital stay (LOS), and 30-day mortality across 48-hour MTX levels. To establish an association between 48-hour MTX levels and the complications listed, we performed chi-square analysis for dichotomous variables and Kruskal-Wallis for nonparametric data. Receiver operator characteristic curve analysis was performed to identify the MTX level where AKI grade ≥ 2 was more likely. Multivariate logistic regression analysis was performed to identify risk factors for this MTX level. RESULTS: We identified 642 patients with 2,804 cycles of HDMTX. The incidence of AKI was 19.1% with AKI grade ≥ 2 making up 21% of cases. Rates of AKI, ICU admission, and 30-day mortality are associated with elevated 48-hour MTX levels. There was a significant increase in median LOS with elevated MTX levels ( P < .001). Receiver operator characteristic curve analysis for AKI grade ≥ 2 demonstrated a 48-hour MTX level threshold of 1.28 μmol/L. Multivariate logistic regression analysis revealed age, male sex, elevated body surface area, higher MTX dose, monotherapy, and first cycle as independent factors. CONCLUSION: Elevated MTX levels are associated with a significant increased rate of AKI, ICU admission, prolonged LOS, and 30-day mortality. Elevated 48-hour MTX levels, particularly > 1.28 μmol/L, should alert clinicians for complications and to initiate measures to reduce MTX levels.

Postoperative infection and sepsis in the surgical intensive care unit (SICU) are common problems, and can be the reason for SICU admission or can be acquired during the SICU stay. Both diagnosis and management of infection and sepsis in the SICU can be complex, related to the surgical procedures performed, patient comorbidities, and resistant pathogens. The need for "source control" of postoperative infections can pose specific challenges and significant complexity in patient management. Postoperative infections in the SICU are associated with increased morbidity, mortality, and resource utilization, and therefore a strong focus on infection preventive strategies is warranted.

Background & aims Severe COVID-19 infection is characterized by an inflammatory response and lung injury that can evolve into an acute respiratory distress syndrome that needs support treatment in intensive care unit. Nutritional treatment is an important component of the management of critically ill patients and should be started in the first 48 h of ICU admission to avoid malnutrition. This study describes the characteristics of the patients treated in a tertiary hospital in Madrid during the months of March–May 2020 (first wave), the medical nutrition treatment employed and its influence in the clinical outcome of these patients. Methods This is a retrospective study including COVID-19 patients admitted in ICU that needed medical nutrition treatment (MNT). Collected variables included sex, age, BMI, underlying diseases, time from hospitalisation to ICU admission, type of respiratory support (invasive mechanical ventilation (IMV) or high flow nasal cannula (HFNC) or non-invasive ventilation (non-IMV)), caloric and protein requirements (25 kcal/kg adjusted body weight (ABW), 1.3 g/kg ABW/day), MNT type (enteral nutrition (EN), parenteral nutrition (PN), mixed EN + PN), total calories (including propofol) and proteins administered, percentage of caloric and protein goal in ICU day 4th and 7th, metabolic complications, acute kidney failure (AKF), length of stay (LOS) and mortality. Data are expressed as mean ± SD, median (IQR) or frequencies. Statistical analysis was performed with the IBM SPSS Statistics for Windows, Version 25.0. p

Assessment of the raw parameters derived from bioelectrical impedance analysis (BIA) has gained emphasis in critically ill patients. The phase angle (PhA) reflects the integrity of the cell membrane, and bioelectrical impedance vector analysis (BIVA) is indicative of patients' hydration status. The aim of this study was to investigate whether these parameters are associated with clinical outcomes in the intensive care unit (ICU) setting.We conducted a systematic review with meta-analysis. We searched PubMed, Embase, Scopus and Web of Science for all published observational studies without language restrictions up to April 2022. Two reviewers independently performed study selection and data extraction. We judged the risk of bias by the Newcastle-Ottawa Scale and the certainty of evidence by the GRADE approach. Mortality was the primary outcome. Secondary outcomes included ICU length of stay, hospital length of stay, duration of mechanical ventilation, nutritional risk, and malnutrition. A meta-analysis with a random-effect model was performed to combine data on R version 3.6.2.Twenty-seven studies were included in the systematic review (4872 participants). Pooled analysis revealed that patients with low PhA had a higher risk of death (14 studies; RR = 1.82, 95% CI 1.46 to 2.26; IThis meta-analysis revealed, with limited evidence, that low PhA was associated with higher mortality and ICU length of stay, while overhydration identified by BIVA was not a predictor of death in critically ill patients.

Background Pulse oximetry is commonly used in critical care settings to monitor oxygenation status and assist with decision-making regarding oxygen therapy. Although it is imperative that nurses follow manufacturer guidelines, off-label use is common and could affect patient safety. Objective To increase staff members’ knowledge and reduce the frequency of off-label pulse oximeter placement in the critical care setting. Methods A preintervention audit was completed to assess the frequency of off-label use, and a preintervention survey was given to staff. Health care staff in the critical care units received an educational intervention. A postintervention survey for health care staff and a postintervention audit were completed to assess outcomes. With the support of hospital management, 90 ear probes were purchased for critical care settings to address supply barriers to the use of appropriate pulse oximetry sensors. Results In the preintervention audit (508 observations), a finger probe was used off label on the ear in 77 patients (15.2%). In the postintervention audit (365 observations), a finger probe was used on the ear in only 3 patients (0.8%). Conclusion Providing a brief educational session and making ear pulse oximeter probes readily available in the critical care setting increased compliance with manufacturer guidelines and helped ensure safe pulse oximetry monitoring.

To determine measurement properties of the Activity Measure for Post-Acute Care Inpatient Mobility Short Form (6-clicks) and Functional Status Score for the Intensive Care Unit (FSS-ICU).Retrospective analysis of scores from a cohort of patients over 24 months. Outcome measures were administered to patients referred to physical therapy on admission and discharge.Tertiary care hospital in the United Arab Emirates.2793 adults referred to physical therapy; 62% were male, with a median age of 58 (interquartile range=44-70) and the median length of stay was 14 days (interquartile range=8-28).Not applicable.Instruments' clinical measurement properties: (1) responsiveness as per mean change and effect size; (2) floor and ceiling effects; and (3) minimal important difference. Results were analyzed for the whole group as well as 3 subgroups: patients with stroke as primary diagnosis (n = 644), discharged from heart and vascular floors (n = 642), and discharged from medical floors (n = 554).The mean change and effect size (Cohen's d) for the 6-clicks were +8.3 (±8.6) and 0.97, and for the FSS-ICU they were +6.8 (±7.8) and 0.87, respectively. 6-Clicks had a floor effect on admission among patients with stroke (16.9%) and patients discharged from medical floors (19.3%), as well as a ceiling effect on discharge (25.5% in the whole group). The FSS-ICU had a ceiling effect on discharge (23.2% in whole group). The estimated minimal important difference for the 6-clicks was 4.3, and for the FSS-ICU it was 3.9.Both instruments demonstrate good responsiveness in adults hospitalized in the United Arab Emirates. The FSS-ICU exhibited several advantages in performance that suggest greater clinical utility than the 6-clicks. Minimal important differences were generated, which has not been previously reported for the 6-clicks.