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Objective: This review aims to assess the incorporation of patient and family input into intensive care unit (ICU) design processes. It aims to highlight the importance of prioritising patient and family perspectives in ICU design to improve patient experiences and clinical outcomes., Background: Traditionally, ICU design has focused on clinical efficiency at the expense of patient-centered needs, leading to heavily sedated patients and neglected holistic care delivery. While architects historically dominated design decisions, there's no recognition of the necessity to integrate patient and family perspectives. However, such efforts remain rare despite professional guidelines advocating for multi-professional team involvement., Methods: This review summarises the published literature on built ICUs that have incorporated patient and family input into the design process. It evaluates methodologies used and measures patient-centric outcomes to identify successful examples and areas for improvement in future initiatives., Results: The limited published literature identifies only three projects successfully integrating patient and family input into ICU design. Additionally, one project was identified in a search of the gray literature. However, these projects often lack rigorous evaluation of patient-centric outcomes, with initiatives involving patients and families remaining uncommon. The review underscores the need for more comprehensive evaluation and greater emphasis on patient and family involvement in ICU design., Conclusion: This review emphasizes the significance of integrating patient perspectives into ICU design to enhance outcomes and improve experiences. While progress has been made in recognizing their importance, more efforts are needed to prioritize patient and family involvement for creating conducive environments for healing and recovery., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Animal-assisted interventions (AAI) can provide psychological support to critical care patients during their intensive care unit (ICU) admission. However, there are currently no data on AAI services across UK ICUs. The current study therefore aims to (i) determine how many ICUs in the UK offer services, (ii) characterise available services and (iii) explore and review local documentation for service oversight., Methods: A service evaluation comprising two parts; a national survey of UK ICU's, analysed using descriptive statistics, and review of local service oversight documents, analysed using a framework approach., Results: Responses from 74 sites (/242, 30.6%) were included in survey analysis. AAI services were present at 32 sites (/74, 43.2%), of which 30 offered animal-assisted activity services alone and 2 offered both animal-assisted activity and animal-assisted therapy services. Animal-assisted activity services were typically delivered on a weekly basis, lasting 30-60 min and with dogs the sole animal employed. Concern over infection prevention and control was the most common barrier to service provision, as well as a lack of supporting evidence. Sixteen sites provided 27 oversight documents for analysis, that highlighted unique and shared responsibilities between critical care staff and animal therapy handlers, including aspects of administration, welfare and infection control., Conclusion: From a small sample, AAI services were available in less than half of ICUs. Empirical value of interventions is countered by current lack of definitive evidence of effectiveness, which should be addressed before wider implementation of AAI services and the associated resource requirements, is undertaken., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Bronwen Connolly is a Director of Research, Intensive Care Society. Kate Tantam is Deputy Chair, National Rehabilitation Collaborative, Intensive Care Society and co-author, Intensive Care Society Guidance for Animal-Assisted Intervention in a Critical Care Setting. This study was conducted independently of these roles., (© The Intensive Care Society 2024.)

Background: Aspirin is frequently utilized for antiplatelet therapy in children with congenital heart disease (CHD). Patients who are unresponsive to aspirin, as measured by aspirin reaction units (ARU), are at higher risk for thrombotic events. It is undetermined if dose modification of aspirin results in adequate responsiveness in these patients. This study evaluates the prevalence and risk factors for aspirin nonresponsiveness and the results of dose escalation in this population., Methods: This is a retrospective review of patients cared for in the cardiac care unit at a quaternary care academic congenital heart center who received aspirin and had responsiveness evaluated between January 2018 and January 2023. Patient demographics and clinical characteristics were extracted from the medical record. Descriptive, parametric, and nonparametric univariate analysis were employed., Results: A total of 142 patients (69 [49%] female, 45 [32%]Non-Hispanic White, and 63 [44%] Hispanic]) were identified. Median age at first aspirin responsiveness assessment was 54 [interquartile range, IQR: 23.3-411.5] days with a median weight of 5.2 [IQR: 3.64-9.29] kg. Of these, 32/142 (22.5%) were nonresponsive on their initial testing. Of these patients, 23/32 (72%) had follow-up testing with 19/23 (83%) subsequently becoming therapeutic. This was achieved with an increased dose in 12/19 (63%) patients and increased duration of therapy in 7/19 (37%) patients. Seventeen of 142 (12%) patients experienced a thrombotic event, 13/17 (77%) of which were therapeutic on initial responsiveness assessment., Conclusions: It is common for CHD patients to be aspirin nonresponsive with initial weight-based dosing. If aspirin is used in this population, it is necessary to evaluate ARUs on all patients as underdosing is not uncommon with current weight-based dosing methods., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The aim of this study was to investigate the relationship between mortality awareness and spiritual care competence among nurses working in intensive care and palliative care units. This cross-sectional, descriptive and correlational study included a sample of 163 nurses who had worked for at least one month in intensive care and palliative care units in two hospitals. Data were collected between 02/01/2024 and 28/06/2024. The mean total score of the nurses on the Multidimensional Mortality Awareness Scale was 122.59 ± 15.59 and the Spiritual Care Competence Scale was 105.85 ± 11.90. A positive significant relationship was found between mortality awareness and spiritual care competence ( p < .05). It was observed that as the mortality awareness of ICU and palliative care nurses increased, their spiritual care competence also increased., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The aim of this study was to investigate the development of fatigue and mental illness between 3 and 12 months after critical COVID-19 and explore risk factors for long-lasting symptoms. Study Design and Methods: A prospective, multicenter COVID-19 study in southern Sweden, including adult patients (≥18 years) with rtPCR-confirmed COVID-19 requiring intensive care. Survivors were invited to a follow-up at 3 and 12 months, where patient-reported symptoms were assessed using the Modified Fatigue Impact Scale (MFIS), the Hospital Anxiety and Depression Scale (HADS) and the Posttraumatic Stress Disorder Checklist version 5 (PCL-5). The development between 3 and 12 months was described by changes in relation to statistical significance and suggested values for a minimally important difference (MID). Potential risk factors for long-lasting symptoms were analyzed by multivariable logistic regression. Results: At the 3-month follow-up, 262 survivors (87%) participated, 215 (72%) returned at 12 months. Fatigue was reported by 50% versus 40%, with a significant improvement at 12 months (MFIS; median 38 vs. 33, P  < .001, MID ≥4). There were no significant differences in symptoms of mental illness between 3 and 12 months, with anxiety present in 33% versus 28%, depression in 30% versus 22%, and posttraumatic stress disorder in 17% versus 13%. A worse functional outcome and less sleep compared to before COVID-19 were risk factors for fatigue and mental illness at 12 months. Conclusions: Fatigue improved between 3 and 12 months but was still common. Symptoms of mental illness remained unchanged with anxiety being the most reported. A worse functional outcome and less sleep compared to before COVID-19 were identified as risk factors for reporting long-lasting symptoms., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The study aimed to examine the relationship between compassion fatigue and moral sensitivity of intensive care nurses. Method: Permission was obtained from the ethics committee, institution, and nurses prior to the study. The population of the study consisted of all nurses working in a university hospital, and the sample consisted of 144 intensive care nurses who agreed to participate in the study. The data were collected through the Questionnaire, the Compassion Fatigue Scale, and the Moral Sensitivity Scale. The total score of the compassion fatigue scale ranges between 24 and 120, and a high score indicates a "high level of compassion". The total score of the moral sensitivity scale, on the other hand, varies between 30-210, and as the score increases, moral sensitivity decreases. The obtained data were evaluated with Student t, One-Way Anova, Kruskal Wallis, Mann Whitney U, and correlation analysis. Results: It was found that 55.6% of the nurses had a bachelor's degree, 44.4% had been working in the intensive care unit for 4-6 years, 39.6% had professional ethical dilemmas, and 44.6% of those who had ethical dilemmas could not solve this problem. Compassion fatigue and moral sensitivity scale mean scores were found to be 83.3 ± 6.7 and 125.4 ± 7.2, respectively, and there was a positive correlation between compassion fatigue and moral sensitivity mean scores ( p < 0.05). Conclusion: The mean score of the compassion fatigue and moral sensitivity scale of intensive care nurses was at a "moderate" level, and there was a positive correlation between the nurses' moral sensitivity scale and compassion fatigue scale scores. In line with these results, it can be suggested that the compassion fatigue and moral sensitivities of nurses especially those working in intensive care be evaluated in terms of resolving the ethical dilemmas they may experience in patient care, and these nurses be supported on these matters., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The impact of methylene blue (MB) on critical patient outcomes, including overall mortality, hemodynamic stability, and organ function has been inconsistently described across studies. This study aims to evaluate the efficacy of MB therapy in adult patients with septic shock in the intensive care unit (ICU)., Methods: The systematic search of PubMed/MEDLINE, EMBASE and Cochrane Library databases up to February 2024 included randomized controlled trials and prospective observational studies involving adult septic shock patients who received intravenous MB therapy. The primary outcome was all-cause mortality, with secondary outcomes on hemodynamics and ICU length of stay., Results: Fifteen studies (5 randomized, 10 non-randomized) involving a total of 441 patients, met the inclusion criteria. The meta-analysis showed statistically significant reduction in mortality rates among septic shock patients treated with MB (mortality rate 0.52; 95% CI 0.38 to 0.66; P  < .001). In a sub-analysis of only randomized trials, the results remained statistically significant (risk ratio 0.66; 95% CI 0.47 to 0.94; P  = .023). A significant increase in mean arterial pressure post-infusion was observed in three studies. Two studies showed no substantial difference in heart rate and two studies showed no difference in cardiac index following MB administration. Only one study showed a reduction in the length of ICU stay with MB use, while another observed a decrease in overall hospital length of stay., Conclusions: The review and meta-analysis suggest that MB may be associated with a significant reduction in mortality in septic shock patients though findings are limited by sample size and heterogeneity. Further robust studies are needed to validate these results., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Necrotizing enterocolitis (NEC) is a complication that can affect infants with congenital heart disease (CHD). The objective of this study is to determine whether breast milk, which is associated with decreased incidence of NEC in preterm infants, is protective in infants with CHD. Methods: Retrospective case-control study of infants ≥ 33 weeks gestational age with CHD who underwent cardiac surgery during their admission to the Infant Cardiac Unit from 2008 to 2017. Cases were defined as infants with modified Bell's stage ≥ II NEC. Controls were matched by date of birth, gestational age, and pre- or postcardiac surgery feed initiation. Results: A total of 926 infants with gestational age ≥ 33 weeks and CHD were admitted; 18 cases of NEC were identified and compared with 84 controls. Breast milk intake was higher in controls, but this difference was not statistically significant. Single ventricle (SV) physiology was identified as an independent risk factor for NEC by multivariable analysis. Analysis of infants with SV physiology demonstrated that median age at time of surgery was 9 days (interquartile range [IQR], 7-12) in NEC cases and 5 days (IQR, 4-9) in controls ( P  = .02). Conclusions: While this study is inconclusive with regard to feeding composition and risk of NEC in infants with CHD, the trend toward greater intake of breast milk in the control group suggests that breast milk may be protective for these infants. Infants with SV physiology are at high risk for NEC. Earlier time to stage I palliation may be a modifiable risk factor for NEC., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This research was conducted as a descriptive study in order to examine the effects of the moral problems experienced by nurses working in intensive care clinics on their end of life care behaviors. The data were collected using the Moral Distress Scale and Caring Behaviors Inventory. It was found that 74.5% of the nurses were women and their mean age was 32.60 ± 6.6 years. The frequency of moral distress in the nurses was 44.27 ± 16.25 and total score was 111.02 ± 63.85. There were significant differences in the scores of the concept the use of futile treatment by nurses, the decision not to begin life-support treatment being made only by physicians, and moral distress and discomfort felt by pediatric intensive care nurses ( p < .05). A statistically significant relationship was found between total scores of discomfort on moral distress and assurance, knowledge and skills, connectedness, and being respectful on the end of life care behaviors ( p < .05)., Competing Interests: Declaration of Conflicting InterestsThe authors declare that they have no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: Infiltration and extravasation are common complications during peripheral intravenous infusion in the neonatal intensive care unit, and diagnosis is usually clinical, by inspection and palpation. Delay in diagnosis due to poor surveillance or misinterpretation of clinical signs may carry serious damage to the tissues of the neonate. Recently, a novel technology based on optical detection of infiltration has become available., Methods: We have studied two groups of term and preterm infants receiving non-vesicant intravenous infusions by the peripheral route (24G short peripheral cannulas), and we evaluated the incidence of infiltration. In the first group, we have compared the clinical detection of infiltration versus the detection obtained by a novel optical device, blinding the alarms of the device. In the second group, the comparison was carried out without blinding the alarms., Results: Of the neonates included in this study, 60% were female, 86% had a gestational age <37 weeks (34 ± 2.5 weeks) and a mean birth weight of 2.08 ± 0.4 g. Total recorded monitoring time was 1318 h and average monitoring time for each short peripheral cannula was 26.4 h. The incidence of infiltration was 80%, most of them having a Millam score <2. The novel device showed an overall sensitivity of 88.9% in detecting infiltration. Specificity was 84.4%, as evaluated assuming as standard the clinical diagnosis. Interestingly, in cases of documented infiltration, the event was diagnosed by the optical device approximately 6 h before the clinical diagnosis., Conclusions: Continuous monitoring of the insertion site, as automatically ensured by this novel optical device, may play a complementary role in early detection of infiltration, even if the percentage of false positives and false negatives suggests that periodic clinical assessment by expert nurses cannot be omitted., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The risk of arteriovenous (AV) access failure is associated with hemodynamic factors, clinical factors, or technical issues. Although several studies have shown the detrimental effects of AV access on heart function, few studies have assessed whether heart function affects AV access patency. We investigated the impact of cardiac function on AV access patency. Additionally, we evaluated the influence of heart failure (HF) on the prognosis of patients on dialysis., Methods: Patients who underwent dialysis and had echocardiographic reports between 2011 and 2013 were retrospectively included. Left ventricular ejection fraction (LVEF) was used to measure cardiac function. Data on demographics, clinical features, and technical factors associated with AV access surgery were collected. Univariate and multivariate analyses were performed to evaluate the risk factors for AV access patency loss and the prognosis of patients on dialysis., Results: During the study period, 395 patients initiated on dialysis underwent echocardiography. In multivariate analysis, older age (hazard ratio (HR) 1.02 (1-1.03), p  = 0.028), smoking (HR 2.05 (1.19-3.53), p  = 0.01), lower LVEF (HR 0.98 (0.97-1), p  = 0.015), and graft use (HR 2.29 (1.47-3.58), p  = 0.001) were significant risk factors for primary patency loss. Regarding secondary patency loss, lower LVEF (HR 0.98 (0.96-1), p  = 0.035) was the sole risk factor. In multivariate analysis, risk factors for cardiac events (acute coronary syndrome and aggravation of HF) in patients on dialysis were age (HR 1.06 (1.04-1.09), p  = 0.001), diabetes (HR 2.46 (1.31-4.63), p  = 0.005), pre-existing coronary artery disease (HR 2.84 (1.57-5.14), p  = 0.001), and HF (HR 1.93 (1.05-3.56), p  = 0.036)., Conclusion: Decreased cardiac function adversely affects the primary and secondary patency of AV access, but its impact is limited. Additionally, HF is associated with future cardiac events in dialysis patients. However, HF is not independently associated with patient survival., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Patients with congenital heart disease (CHD) are increasingly surviving to adulthood. Given their age- and condition-specific needs, the optimal postoperative setting for these patients is not yet determined. This study aims to evaluate the utility of an adult-specific order set in improving clinical outcomes for these patients in a pediatric cardiovascular intensive care unit (ICU). Methods: Adults with CHD (ACHD) admitted to the cardiovascular ICU following cardiac surgery at a pediatric tertiary care center were identified for a retrospective cohort study. Health care delivery metrics and clinical outcomes of participants who received the adult-specific order set were compared with control patients admitted prior to the intervention. Categorical outcomes were compared using the χ 2 test of independence or Fisher exact test, and continuous outcomes were assessed using the t test. Results: A total of 130 ACHD patients received the intervention, with no significant differences observed in clinical outcomes when compared with 89 controls. While there was additionally no reduction in hospital-related mortality (2.3% vs 7.8%, RR 0.3; P  = .1), clinician ordering behaviors were better aligned with best-practices following the intervention. Among patients with moderate or greater anatomic complexity, a post hoc analysis demonstrated reduced in-hospital mortality from those who received the adult order set. Conclusions: The implementation of an adult-specific order set in a pediatric care setting did not improve clinical outcomes for all ACHD patients. Patients with moderate and greater anatomic complexity did see a mortality benefit, suggestive that targeted electronic tools may most benefit those who have the highest risk., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Mechanical ventilation is a common and often lifesaving intervention that is utilised in intensive care. However, the practices can vary between centres. Through this national survey we aim to gain more information about different strategies adopted across the UK., Methods: All adult intensive care units in the UK were approached to participate. The questionnaire was developed with an electronic survey engine and conducted between 09/11/2023 and 01/04/2024 (Survey Monkey ® ). The survey included questions on ventilator modes, settings, protocols/pathways, rescue strategies, immediate post-extubation period and follow-up., Results: There were 196 responses from 104 hospitals. The most widely adopted start-up ventilation mode was pressure-regulated volume-controlled mode. For acute hypoxaemic respiratory failure (AHRF), most of respondents reported full (39.8%) or partial compliance (58.1%) with the ARDSnet protocol, with PEEP settings being the commonest deviation. Prone positioning (99.0%), followed by recruitment manoeuvres (91.3%) were commonly used rescue measures during AHRF. APRV (55.7%), inhaled (51.3%) and systemic pulmonary vasodilators (44.1%) were also commonly used. Conservative oxygen targets (SaO 2 of 88%-92%) were commonly adopted (70.6%). As a care bundle, intermittent ETT cuff pressure monitoring was more common (65.5%) than continuous cuff pressure monitoring (20.0%). Propofol and alfentanil were the most common initial sedative and analgesia (99.5% and 56.9%) respectively. Routine volatile anaesthetic use was rare., Conclusions: Our survey has shown significant variation of practice in common but crucial elements of management of patients receiving mechanical ventilation. We hope the results in our survey highlight potential future areas of research., Collaborators: South-coast Peri-operative Audit and Research Collaborative (SPARC)Severn Trainee Anaesthetic and Critical Care Research group (STAR)Collaborative research in Anaesthesia in the Northeast (CRANE)., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Intensive Care Society 2024.)

Background: Physician's clinical inputs and informed bystander opinions are essential for successful intensive care unit (ICU) patient outcomes. There is insufficient data regarding the impact of shared decision-making on treatment outcomes and family satisfaction in Indian ICU settings. We aimed to determine the effect of shared decision-making factors on family satisfaction with ICU services. Patients and Methods: Family bystanders of 336 ICU patients with a stay >72 hours were conveniently surveyed across 13 months prospectively using Family Satisfaction in the Intensive Care Unit 24 Revised (FS-ICU 24R) questionnaire. We analyzed the responses to determine shared decision-making factors impacting family satisfaction. Results: Univariate analysis of ten variables of FS-ICU 24R questionnaire decision-making subscale revealed that consistency of information (OR 8.71, P < 0.001), honesty of information (OR 7.04, P < 0.001), and frequency of communication with doctors (OR 6.25, P < 0.001) were associated with highest odds of family involvement and satisfaction. Multivariable logistic regression showed that consistency of information (adjusted OR 3.85, P < 0.001) and frequent doctor communication (adjusted OR 2.22, P = 0.02) were independent predictors associated with family satisfaction. The number of decision-makers ( P = 0.463) or family's prior ICU experience ( P = 0.430) was not associated with family satisfaction. Conclusion: A consistent and honest effort to cater to the family's information needs and frequent physician-bystander interaction is essential for family's satisfaction with ICU services. This even outweighs other decision-making factors such as number of decision-makers and their prior ICU experience. Incorporating shared decision-making in counseling should be a continuing practice. Trial registry name: Clinical Trials Registry - India. Registration number: CTRI/2022/09/045571., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Extubation failure and its associated complications are not uncommon after pediatric cardiac surgery, especially in neonates and young infants. We aimed to identify the frequency, etiologies, and clinical characteristics associated with extubation failure after cardiac surgery in neonates and young infants. Methods: We conducted a single center prospective observational study of patients ≤180 days undergoing cardiac surgery between June 2022 and May 2023 with at least one extubation attempt. Patients who failed extubation, defined as reintubation within 72 h of first extubation attempt, were compared with patients extubated successfully using χ 2 , Fisher exact, or Wilcoxon rank-sum tests as appropriate. Results: We prospectively enrolled 132 patients who met inclusion criteria, of which 11 (8.3%) failed extubation. Median time to reintubation was 25.5 h (range 0.4-55.8). Extubation failures occurring within 12 h (n = 4) were attributed to upper airway obstruction or apnea, whereas extubation failures occurring between 12 and 72 h (n = 7) were more likely to be due to intrinsic lung disease or cardiac dysfunction. Underlying genetic anomalies, greater weight relative to baseline at extubation, or receiving positive end expiratory pressure (PEEP) > 5 cmH 2 O at extubation were significantly associated with extubation failure. Conclusions: In this study of neonates and young infants recovering from cardiac surgery, etiologies of early versus later extubation failure involved different pathophysiology. We also identified weight relative to baseline and PEEP at extubation as possible modifiable targets for future investigations of extubation failure in this patient population., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Despite the progress made in recent decades on the phenomenon of futility in adult intensive care, recognizing it during clinical care practice remains a complex and sensitive process, during which questions are often raised for which concrete answers are difficult to find. Aims: To analyze the frequency with which futile nursing interventions are implemented in critically ill patients admitted to adult intensive care in specific situations and how often futile autonomous and interdependent nursing interventions are implemented in the same population, as perceived by adult intensive care nurses. Research design: Cross-sectional, quantitative, and descriptive study, which employed a questionnaire constructed specifically for this research to assess the perception of therapeutic futility in nursing in adult intensive care. Following an evaluation of the psychometric properties, the questionnaire was made available in an electronic format on the EUSurvey platform between August and October 2024. The data was analyzed between November 2023 and March 2024 using the statistical software packages SPSS and R. Participants and research context: A simple random sample of nurses working in level II and level III intensive care units in Portugal. Ethical considerations: Research ethical approvals were obtained, and the participants provided informed consent. Findings/results: Four hundred and fourteen valid questionnaires were obtained. The results allow the identification of thirty-three statistically significant associations, the inference of intervals for the mean and median for the perception of futility of nursing interventions with a 95% confidence interval, and enable the hierarchization of nursing interventions implemented in critically ill patients admitted to adult intensive care units according to the nurses' perception of their futility. Conclusion: There is a balance in nurses' perception of the futility of their interventions in the specific situations analyzed. There is statistically significant evidence that interdependent nursing interventions are, in general, more frequently perceived as futile when compared to autonomous nursing interventions., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: High-risk acute pulmonary embolism (PE) is associated with significant mortality and may require emergency endotracheal intubation and mechanical ventilation. Intubation and ventilation are thought to exacerbate cardiorespiratory instability. Our purpose was to conduct a systematic literature review to identify studies investigating peri-intubation events in acute PE., Methods: A systematic search of Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library was performed. Results were screened by two independent observers. Studies reporting on intubation and positive pressure ventilation in acute PE patients were included. The primary outcome was adverse events during the peri-intubation period. Data was synthesized and an assessment of risk of bias was conducted. The review was registered on PROSPERO (CRD42023444483)., Results: 4100 unique articles were screened. Three retrospective studies comprising 104 patients with acute PE met criteria and were included. Peri-intubation, hemodynamic collapse was observed in 19%-28% of cases. Patients with hemodynamic collapse exhibited higher rates of echocardiographic RV dysfunction., Conclusions: Peri-intubation adverse events are common in patients with acute PE. Current evidence is limited and highlights the need for further research to optimize management of respiratory failure in acute PE and patient selection for intubation to improve patient outcomes., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Kabrhel reports grants (paid to his institution) from Grifols and Diagnostica Stago. Dr Kabrhel reports consulting for BMS/Pfizer, Siemens Healthineers, and Abbot. Dr Kabrhel own stock in Insera Therapeutics. The remaining authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Arterial catheterisation is a common procedure used to manage critically ill patients. The radial artery, both for its favourable anatomical position and the presence of ulnar collateral circulation, is the most used. While there is a consensus for a catheter/vein ratio of ⩽33% for venous catheterisation, there are no strong indications for arterial catheterisation. Some authors have hypothesised that a catheter/artery ratio of less than 45% is advisable. This study aimed to explore the relationship between residual flow in the Radial Artery, the catheter/artery ratio, and ulnar compensation., Methods: This retrospective observational study included patients with radial artery catheters in general wards and intensive care units of a tertiary hospital in Italy. Residual flow in the radial artery was calculated by measuring the Peak Systolic Velocity and diameter of the artery at the midpoint of the arm. The reverse Barbeau test was used to assess the residual perfusion. The sample was stratified and analysed to the catheter/artery ratio being greater or less than 33% and 45% and to the score obtained during the reverse Barbeau test., Results: The data obtained showed a significant statistical correlation between residual flow, catheter/artery ratio, and the reverse Barbeau test ( p  < 0.0001 and p  = 0.0074 respectively). Almost 80% of the sample had a catheter with an exit site less than 4 cm from the wrist crease., Conclusion: Adhering to the current guidelines, especially using ultrasound to ensure a catheter/artery ratio of at least 45%, can help maintain preserved perfusion through the cannulated radial artery. Ulnar compensation appears to be crucial for maintaining good tissue perfusion and should always be evaluated before catheterisation. Therefore, further studies are warranted., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The purpose of the study was to illuminate the experience of caring touch in intensive care from the perspectives of patients, next-of-kin, and healthcare professionals. Design and Method: This study was explorative, and data were collected through qualitative observations ( n  = 9) with subsequent interviews ( n  = 27) at two general intensive care units. An inductive approach was embraced to be open-minded to the participants' experiences. Findings: The results are presented in one generic category-caring touch creates presence-which generated five subcategories: to touch and be touched with respect, touch as guidance and communication, touch causes suffering, touch creates compassion, and touch creates security. Conclusion: When the ability to communicate with words is lost, it is body language that reveals what a person is trying to express. Nurses create a way of being present with the patients by touching them, to communicate I am here for you. Caring touch is a tool to show compassion and respect and to protect the integrity of the lived body. The caring touch is soothing and comforting for the patient and next-of-kin and creates security. It also helps to awaken the motivation to get healthy, which is needed in an environment that is foreign.

Objective: To examine first attempt success and overall success of real-time ultrasound guided peripheral arterial cannulation in infants., Study Design: Retrospective review of 477 ultrasound guided peripheral arterial cannulations in infants less than 1 year of age. Procedural and patient characteristics were evaluated to better understand factors related to procedural success., Results: Ultrasound guided peripheral arterial cannulation had a first attempt success rate of 65% and an overall success rate of 86%. Success rates significantly differed by arterial location ( p  < 0.001). First attempt success and overall success were highest in the radial artery (72%, 91%) and lowest in the posterior tibial artery (44%, 71%). Success was more likely with greater age and greater weight ( p  = 0.006, p  = 0.002)., Conclusion: Success rates are high when using a real-time ultrasound-guided technique for peripheral arterial cannulation in infants. An infant's weight and selected artery are strong predictors of success when performing peripheral arterial cannulation. The use of procedural ultrasound may reduce unnecessary attempts and minimize procedure-related harm., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Despite widespread use of combination antiretroviral therapy, people with HIV (PWH) continue to have an increased risk of admission to and mortality in the intensive care unit (ICU). Mortality risk after hospital discharge is not well described. Using retrospective data on adult PWH (≥18 years) admitted to ICU from 2000-2019 in an HIV-referral centre, we describe trends in 1-year mortality after ICU admission., Methods: One-year mortality was calculated from index ICU admission to date of death; with follow-up right-censored at day 365 for people remaining alive at 1 year, or day 7 after ICU discharge if lost-to-follow-up after hospital discharge. Cox regression was used to describe the association with calendar year before and after adjustment for patient characteristics (age, sex, Acute Physiology and Chronic Health Evaluation II [APACHE II] score, CD4+ T-cell count, and recent HIV diagnosis) at ICU admission. Analyses were additionally restricted to those discharged alive from ICU using a left-truncated design, with further adjustment for respiratory failure at ICU admission in these analyses., Results: Two hundred and twenty-one PWH were admitted to ICU (72% male, median [interquartile range] age 45 [38-53] years) of whom 108 died within 1-year (cumulative 1-year survival: 50%). Overall, the hazard of 1-year mortality was decreased by 10% per year (crude hazard ratio (HR): 0.90 (95% confidence interval: 0.87-0.93)); the association was reduced to 7% per year (adjusted HR: 0.93 (0.89-0.98)) after adjustment. Conclusions were similar among the subset of 136 patients discharged alive (unadjusted: 0.91 (0.84-0.98); adjusted 0.92 (0.84, 1.02))., Conclusions: Between 2000 and 2019, 1-year mortality after ICU admission declined at this ICU. Our findings highlight the need for multi-centre studies and the importance of continued engagement in care after hospital discharge among PWH., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To explore the experiences of clinical and non-clinical staff in an intensive care unit regarding the perceived benefits and drawbacks of using in situ simulation as a training tool., Methods: A descriptive phenomenological qualitative study was conducted among clinical and nonclinical ICU personnel. Simulations and interviews were conducted until data saturation was achieved. The interviews were recorded, transcribed verbatim for analysis, and interpreted using the Colaizzi method., Results: Ten participant interviews generated data saturation. ISS was found to be feasible and beneficial in the ICU, facilitating experiential and emotion-based learning in real-world environments. Eight result categories were identified: simulation benefits, simulation benefits in real conditions, scenario authenticity, interference with usual work, ISS sessions, high-fidelity generating affective bonding, ISS as knowledge reinforcement, and recommendations for improvement. The fundamental structure revealed that ISS is perceived as an authentic and emotionally impactful team simulation modality that promotes experiential learning, reflection, and care improvement opportunities within the complex sociotechnical system of the ICU., Conclusions: All interviewees considered ISS to be a feasible simulation tool that should be implemented in the ICU to improve knowledge and skills, thereby enhancing teamwork., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Central venous access devices are essential for the management of critically ill patients, but they are potentially associated with many complications, which may occur during or after insertion. Many evidence-based documents-consensus and guidelines-suggest practical recommendations for reducing catheter-related complications, but they have some limitations. Some documents are not focused on critically ill patients; other documents address only some special strategies, such as the use of ultrasound; other documents are biased by obsolete concepts, inappropriate terminology, and lack of considerations for new technologies and new methods. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to offer an updated compendium of the main strategies-old and new-that should be adopted for minimizing catheter-related complications in the adult critically ill patient. The project has been planned as a consensus, rather than a guideline, since many issues in this field are relatively recent, and few high-quality randomized clinical studies are currently available, particularly in the area of indications and choice of the device. Panelists were chosen between the Italian vascular access experts who had published papers on peer-reviewed journals about this topic in the last few years. The consensus process was carried out according to the RAND/University of California at Los Angeles (UCLA) Appropriateness Methodology, a modification of the Delphi method, that is, a structured process for collecting knowledge from groups of experts through a series of questionnaires. The final document has been structured as statements which answer to four major sets of questions regarding central venous access in the critically ill: (1) before insertion (seven questions), (2) during insertion (eight questions), (3) after insertion (three questions), and (4) at removal (three questions)., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Few randomized controlled trials have evaluated the use of ketamine vs opiate-based analgosedation. Methods: A retrospective cohort analysis of 169 mechanically ventilated patients admitted to the medical intensive care unit (MICU) at an academic medical center was conducted to evaluate efficacy of ketamine vs opiate-based analgosedation by comparing the percentage of time within target sedation range. The primary outcome was percentage of time within target sedation range (RASS -1 to +1) within first 72 hours of primary sedation initiation. Secondary outcomes including percentage of time under-sedated, over-sedated, and in coma; use of concomitant analgesic, sedative, and antipsychotic agents; presence of delirium; percentage of CPOT scores at goal; and hemodynamic effects were also evaluated. Results: After weighting, the mean percentage of time at RASS goal for ketamine patients was 43.0% compared to 41.4% for opiate-based sedation patients. Ketamine was not significantly non-inferior to opiate-based sedation for the mean percentage of time at RASS goal ( P = .11). The median percentage of CPOT scores at goal was 13.3% higher in the ketamine group ( P = .042). Patients in the ketamine group received significantly less additional sedative agents than the patients in the opiate-based sedation group. Conclusion: A similar percent of time at RASS goal was found for the ketamine analgosedation group compared to the opiate-based sedation group, although this did not reach statistical signicance for non-inferiority due to lack of statistical power. This study found a higher percentage of CPOT scores within goal with less additional sedative agents required compared to an opiate-based sedation regimen., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Levels of care deemed as inappropriate generate moral distress among nurses and other intensive care professionals. Inappropriate levels of care and related moral distress are frequently broached as individual and psychological phenomena, reduced to how individuals feel and think about specific cases. However, this tends to obscure the complex context in which these situations occur, and on which healthcare professionals can act. There is thus a need for a more contextual and team-level lens on inappropriate levels of care., Research Objective: This study aims to explore and understand the issue of inappropriate levels of care in an intensive care unit (ICU) through a contextual and team-level lens., Research Design: Semi-structured interviews were conducted with nurses, respiratory therapists, and intensivists. Thematic analysis focused on understanding the causes and consequences of inappropriate levels of care, as well as potential avenues for improvement. This study is part of a 5-phase participatory living lab project on inappropriate levels of care conducted in the ICU of a Montreal (Quebec, Canada) hospital. This paper relates the initial phases of the project, focusing on understanding the issue, with reported events spanning from June 2022 to May 2023., Ethical Considerations: Ethics approval was sought and granted by the Research Ethics Board of the CIUSSS de l'Est-de-l'Île-de-Montréal., Findings/discussion: Five broad themes intrinsically related to the phenomenon of inappropriate levels of care were explored with and by participants: (1) the process of determining levels of care, (2) the distinction between appropriate and inappropriate levels of care, (3) causes of inappropriate levels of care, (4) consequences of inappropriate levels of care and (5) potential avenues for improvement., Conclusion: This research provides a comprehensive understanding of inappropriate levels of care in the ICU and emphasizes the relevance of team-level explorations of complex ethical issues., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Although thrombolytic therapy is the standard treatment for massive pulmonary thromboembolism (PTE), it is often ineffective in patients with circulatory collapse. Surgical embolectomy is another treatment option, but whether it is absolutely necessary is controversial. We sought to evaluate the outcomes of patients with massive PTE treated with intensive critical care including extracorporeal membrane oxygenation (ECMO) without thrombolytic therapy or surgical embolectomy., Methods: We analyzed 39 patients who were treated for massive PTE from January 2011 to June 2019. Massive PTE was treated with anticoagulation and hemodynamic support at an intensive care unit. ECMO was applied in patients with circulatory collapse. The computed tomography (CT) obstruction index and the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) were measured using serial CT angiography to confirm changes in pulmonary emboli and RV strain., Results: Twenty-one patients were in cardiogenic shock, and 15 of them needed cardiopulmonary resuscitation (CPR). Fifteen patients were treated with ECMO and nine of them were weaned successfully. The overall in-hospital mortality was 23% (9/39). On the follow-up CT scan after 6 months, residual PTE was observed in 10 patients and their median CT obstruction index was 6.25 % (range 2.5-35). The initial mean RV/LV ratio was 1.8 ± 0.47 and the value measured at follow-up CT decreased to less than 1 (0.9 ± 0.1)., Conclusions: Intensive critical care with heparin alone and timely ECMO support without thrombolytic therapy could be an effective treatment option in patients with acute massive PTE., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Intensive care nurses frequently encounter ethical issues with potentially severe consequences for nurses, patients, and next of kin. Therefore, ethical issues in intensive care units (ICU) should be recognized and managed., Research Objectives: To analyze ethical issues reported by intensive care nurses and how reported issues were managed within the organization using register data from the HaiPro critical incident reporting system (CIRS), and to explore the suitability of this system for reporting and managing ethical issues., Research Design: This was a retrospective descriptive register study. CIRS reports on ethical issues in adult ICUs ( n = 12) in one hospital district in Finland over 25 months (2019-2021) were analyzed through inductive content analysis and descriptive quantification. The CIRS's suitability for reporting and managing ethical issues was evaluated through a strengths, weaknesses, opportunities, and threats (SWOT) analysis., Ethical Considerations: The study was approved by the University Ethics Committee, and permission to conduct the research was granted before data collection within the organization., Results: CIRS reports on ethical issues ( n = 35) made by nurses were found in seven of the 12 ICUs. The CIRS managers of these units managed these reports. The ethical issues described by the nurses were divided into four main categories: nature, situational information, consequences, and contributing factors. Management of reported ethical issues was divided into three main categories: preventive actions proposed by nurses, proposals for actions by CIRS managers, and actions taken by CIRS managers., Conclusions: Systematic register data broadly describe ethical issues and their management, indicating that the CIRS could be suitable for reporting and managing ethical issues, thereby enabling the monitoring and development of ethical quality at the unit and organizational levels., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Sleep deprivation is reported in 80% of patients in the intensive care unit (ICU) and is associated with delirium. Guidelines recommend implementing a sleep-promoting protocol in critically ill patients which may increase the quantity and quality of sleep and may decrease delirium. Our objective was to implement a pharmacist-led interdisciplinary sleep-promoting protocol and analyze its impact on delirium in ICU patients receiving mechanical ventilation (MV). Methods: The study involved pre-implementation education, protocol development, and post-implementation analysis. ICU pharmacists completed prospective patient chart reviews to reduce exposure to deliriogenic medications and assess the need for a pharmacologic sleep aid. The primary outcome was the incidence of delirium and delirium-free days. Secondary outcomes included ICU length of stay (LOS), incidence of MV, and pharmacist medication interventions. Results: Post-protocol patients (n = 185) had a higher incidence of delirium compared to pre-protocol patients (n = 237) (51.3% vs 39.0%; P = .01). Post-protocol patients had a higher average APACHE III score ( P = <.001). Delirium-free days were not significantly different between groups ( P = .97). Difference in ICU LOS was not significant ( P = .80). More patients received MV post-protocol implementation (55.7% vs 36.1%; P < .001). Pharmacists documented a total of 113 medication interventions. Conclusion and Relevance: A pharmacist-led, ICU sleep-promoting protocol was successfully implemented but did not reduce the incidence of delirium or the administration of insomnia agents. Post-protocol patients had higher disease severity and were more likely to receive MV. Incidence of delirium was consistent with the national reported prevalence of ICU delirium. ICU pharmacists on all shifts had an active role in optimizing sleep., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In Swedish intensive care units, nine percent of patients do not survive despite receiving advanced life-sustaining treatments. As these patients transition to end-of-life care, ethical considerations may become paramount., Aim: To explore the ethical challenges that critical care nurses encounter when caring for patients at the end of life in an intensive care context., Research Design: The study used a qualitative approach with an interpretive descriptive design., Research Context and Participants: Twenty critical care nurses from eight intensive care units in an urban region in Sweden were interviewed, predominately women with a median age of fifty-one years., Ethical Considerations: This study was approved by The Swedish Ethics Review Authority., Findings: Critical care nurses described encountering ethical challenges when life-sustaining treatments persisted to patients with minimal survival prospects and when administering pain-relieving medications that could inadvertently hasten patients' deaths. Challenges also arose when patients expressed a desire to withdraw life-sustaining treatments despite the possibility of recovery, or when family members wanted to shield patients from information about a poor prognosis; these wishes occasionally conflicted with healthcare guidelines. The critical care nurses also encountered ethical challenges when caring for potential organ donors, highlighting the balance between organ preservation and maintaining patient dignity., Conclusion: Critical care nurses encountered ethical challenges when caring for patients at the end of life. They described issues ranging from life-sustaining treatments and administration of pain-relief, to patient preferences and organ donation considerations. Addressing these ethical challenges is essential for delivering compassionate person-centered care, and supporting family members during end-of-life care in an intensive care context., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Clinical empathy is an essential part of healthcare, and patient-centered care models require clinical empathy to be established. Despite this, little is known about its measurement in the neonatal scenario., Research Aim: To measure clinical empathy in health professionals who work with medium and high-risk neonates and build a construct of this empathy., Research Design: Single-center survey study., Participants and Research Context: The Jefferson Scale of Empathy for Health Professionals questionnaire was applied to health professionals who work in an intensive care unit and a medium-risk unit, in Brazil. Analysis was done using descriptive statistics and a factor analysis model, to build the construct of empathy. Overall empathy was calculated, and the domains' punctuations were analyzed and compared to the maximum punctuation possible. The study followed the STROBE checklist., Ethical Considerations: This study was approved by the Research Ethics Committee of the institution. All participants signed the informed consent form. Participants' confidentiality and anonymity were protected., Findings: Median empathy was 117 (IQR 113-124). The domain of Walking in the Patient's Shoes had lower scores and represented 77.6% of the maximum punctuation possible. The factor analysis included three factors named Understanding, Experiences, and Treatment, and Emotional Relationships, explaining 64.3% of the overall variance. The domain Walking in the Patient's Shoes was not included in the model., Conclusions: In this scenario, clinical empathy should improve. There is a need to improve the domain of Walking in the Patient's Shoes, in this case, the neonate, and provide more empathic care to them., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical device, yet despite best efforts by end-users, PIVCs experience unacceptably high early failure rates. We aimed to design a new PIVC that reduces the early failure rate of in-dwelling PIVCs and we conducted preliminary tests to assess its efficacy and safety in a porcine model of intravenous access., Methods: We used computer-aided design and simulation to create a PIVC with a ramped tip geometry, which directs the infused fluid away from the vein wall; we called the design the FloRamp™. We created FloRamp prototypes (test device) and tested them against a market-leading device (BD Insyte™; control device) in a highly-controlled setting with five insertion sites per device in four pigs. We measured resistance to infusion and visual infusion phlebitis (VIP) every 6 h and terminated the experiment at 48 h. Veins were harvested for histology and seven pathological markers were assessed., Results: Computer simulations showed that the optimum FloRamp tip reduced maximum endothelial shear stress by 60%, from 12.7 Pa to 5.1 Pa, compared to a typical PIVC tip and improved the infusion dynamics of saline in the blood stream. In the animal study, we found that 2/5 of the control devices were occluded after 24 h, whereas all test devices remained patent and functional. The FloRamp created less resistance to infusion (0.73 ± 0.81 vs 0.47 ± 0.50, p  = 0.06) and lower VIP scores (0.60 ± 0.93 vs 0.31 ± 0.70, p  = 0.09) than the control device, although neither findings were significantly different. Histopathology revealed that 5/7 of the assessed markers were lower in veins with the FloRamp., Conclusions: Herein we report preliminary assessment of a novel PIVC design, which could be advantageous in clinical settings through decreased device occlusion and reduced early failure rates., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: BJD, LJK and CS are named inventors on a patent describing the ramped tip design (WO/2020/237286). The study was funded by Flomatrix Pty Ltd of which CS is an employee and in which both BJD and CS hold equity. SK reports monies received by her employer QUT on her behalf from for educational consultancies with BD Medical and ITL Biomedical unrelated to this study. The remaining authors have no conflicts to report.

Introduction: Venovenous extracorporeal membrane oxygenation (V-V ECMO) is recommended for the support of patients with severe COVID-19 associated severe respiratory failure (SRF). We report the characteristics and outcome of COVID-19 patients supported with V-V ECMO in a Hungarian centre., Methods: We retrospectively collected data on all patients admitted with proven SARS CoV-2 infection who received V-V ECMO support between March 2021 and May 2022., Results: Eighteen patients were placed on ECMO during this period, (5 women, age (mean ± SD) 44 ± 10 years, APACHE II score (median (interquartile range)) 12 (10-14.5)). Before ECMO support, they had been hospitalised for 6 (4-11) days. Fifteen patients received noninvasive ventilation for 4 (2-8) days, two patients had high flow nasal oxygen therapy, for one day each. They had already been intubated for 2.5 (1-6) days. Prone position was applied in 15 cases. On the day before ECMO initiation the Lung Injury Score was 3.25 (3-3.26), the PaO 2 /FiO 2 ratio was 71 ± 19 mmHg. The duration of V-V ECMO support was 26 ± 20 days, and the longest run lasted 70 days. Patients were mechanically ventilated for 34 ± 23 days. The intensive care unit (ICU) and the hospital length of stay were 40 ± 28 days and 45 ± 31 days, respectively. Eleven patients were successfully weaned from ECMO. The ICU survival rate was 56%, the in-hospital survival was 50%. All patients who were discharged from hospital reported a good health-related quality of life Rankin score (0-2) at the 5-16 months follow-up., Conclusions: During the last three waves of the COVID-19 pandemic, we achieved a 56% ICU and a 50% hospital survival rate at our low volume centre., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Backgrounds: Intensive care nurses' attitudes towards the elderly and their emotional readiness before giving care can have an impact on the quality of care., Aims: The objective of this study was to investigate intensive care nurses' compassion and patience levels and their attitude towards elderly people., Methods: 'Data Gathering Form', the 'Compassion Competence Scale', the 'Patience Scale and the University of California at Los Angeles Geriatrics Attitude (UCLA-GA) were used., Results: A total of 212 intensive care nurses participated in the study. It was found that nurses whose time working in the intensive care unit and total professional experience were 6 years or more and those who were married and had children had higher levels of both compassion and patience. In addition, patience levels were significantly higher in nurses aged 29 or more. It was found that the nurses' sociodemographic and professional characteristics did not affect their UCLA-Geriatrics Attitudes total score., Conclusion: It was found in the study that there was a significant positive correlation between the nurses' compassion and patience levels and their attitudes toward elderly people., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

A 36-year-old female with sickle cell disease presented with sickle cell pain crisis. After failure to establish peripheral venous access, an internal jugular central venous catheter (CVC) was placed. Confirmation of internal jugular cannulation was performed with bedside ultrasound. A confirmatory chest X-ray revealed an unusual position of the catheter, taking a course inferiorly, making a loop and remaining on the left side of the mediastinum. A lateral view was done and revealed that the catheter passed inferiorly through the internal jugular vein then posteriorly and inferiorly giving the looped appearance. This is better delineated on a sagittal view CT scan showing the tip of the catheter terminating in the accessory hemiazygos vein. This unusual course is due to a variant of the accessory hemiazygos vein which is connected to the left superior intercostal vein. This creates a lower resistance pathway for the CVC which passes from the internal jugular vein, down the left superior intercostal vein (instead of the left brachiocephalic vein) and into the accessory hemiazygos vein. Discussion: The correct tip placement of an internal jugular CVC terminates in the superior vena cava just above the cardiac silhouette. In 1%-2% of individuals, a connection between the accessory hemiazygos and the left superior intercostal vein is present. Rare cases are discovered incidentally during CVC placement. The diameter of the accessory hemiazygos vein is less than half of that of the superior vena cava. The catheter should not be used as central venous access and removal is recommended. Malpositioning of central catheters is unpredictable but can be easily avoided by using intraprocedural methods to confirm tip position. Such modalities include intracavitary ECG or ultrasound with agitated saline injection as described in the SIC (Safe Insertion of Centrally Inserted Central Catheters) protocol., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To demonstrate that the augmented reality-assisted puncture technique improves the efficacy of ultrasound-guided puncture to get central venous access (CVA), allows the image to be obtained without limitations, freeing the hands and keeping the gaze continuously on the working field, which contributes to improving the safety of the procedure., Material and Methods: A gelatin mould with a latex surface and a chicken breast with silicone tubes inside were used to simulate vascular punctures. Images were obtained by an ultrasound scanner and post-processed with a specific software. A hologram was obtained and projected onto the previously delimited surface to be punctured. The variables related to image acquisition, the characteristics of the structure to be cannulated and the percentage of successes in the first attempt were analysed. Six operators were involved, using different ultrasound scanners. Efficiency was examined after the application of technical improvements in the process., Results: Seventy-six punctures were performed, guided by two different ultrasound scanners, divided into two groups: 37 with 33 successes (sigma = 3.52 with a process efficiency of 97.98%) and after technical improvements, 39 with 38 successes (sigma = 4.07 with a process efficiency of 99.4%). There are no significant differences among the operators (X2 p  = 0.47) and between the ultrasound scanners (X2 p  = 0.56)., Conclusions: The augmented reality ultrasound-assisted CVA technique may be the next step in standardising the process of cannulation of vascular structures. This technique provides greater accuracy, greater comfort by freeing the hands and keeping the gaze on the working field, better ultrasound image quality, and eliminates variability between operators and sonographers., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Compassion is defined as the sadness felt by a living thing or a person due to a negative situation. Compassion fatigue describes emotional, physical, social and spiritual exhaustion or a decrease in these feelings. The concept of compassion, which is at the center of nursing, may be related to compassion fatigue in nurses., Objective: The aims of the study were to determine the level of compassion fatigue and compassion among intensive care nurses and to examine the relationship between them., Methods: This study was conducted through descriptive research and cross-sectional survey. The population of the research consisted of intensive care nurses from two hospitals in Turkey. Since the universe is accessible, the sample selection method was not used ( n = 182). Demographic data form, Compassion Fatigue sub-dimension of the Professional Quality of Life Scale and Compassion Scale were used in the study., Results: The mean score of the nurses' compassion fatigue was 15.86 ± 7.22, and compassion was 72.21 ± 7.28. There was a moderate negative relationship between compassion and compassion fatigue ( r  = -.405). It was determined that the nurses' compassion was at a moderate level and their compassion fatigue was at a low level., Conclusion: It can be assumed that ICU nurses' compassion is at a medium level and their compassion fatigue is at a low level. It was established that as the compassion level of the nurses increased, the level of compassion fatigue decreased. Developing a sense of compassion in nurses working in intensive care units can reduce compassion fatigue., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Autism is a lifelong neurodevelopmental condition. Autistic people face challenges as patients in the intensive care unit (ICU) and as providers of healthcare in the ICU. This article describes the experience of autistic people using a neurodiversity-affirming approach. Using the 'Autistic SPACE' framework, the needs of autistic people are described in terms of sensory needs, need for predictability, need for autistic acceptance, communication differences and how to approach them, and the benefits of a person-centred empathy-based approach to autistic people. The approach to autistic patients is described in terms of reasonable adjustments within a framework of positive risk taking. For supervisors and managers of autistic healthcare professionals, autism-friendly adjustments to training and working practice, with rationales, are suggested., Competing Interests: The author declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author is autistic and is the ICU lead of Autistic Doctors International, a not-for-profit peer support and advocacy network., (© The Intensive Care Society 2024.)

Background: Effectively identifying deteriorated patients is vital to the development and validation of automated systems designed to predict clinical deterioration. Existing outcome measures used for this purpose have significant limitations. Published criteria for admission to high acuity inpatient areas may represent markers of patient deterioration and could inform the development of alternate outcome measures., Objectives: In this scoping review, we aimed to characterise published criteria for admission of adult inpatients to high acuity inpatient areas including intensive care units. A secondary aim was to identify variables that are extractable from electronic health records (EHRs)., Data Sources: Electronic databases PubMed and ProQuest EBook Central were searched to identify papers published from 1999 to date of search. We included publications which described prescriptive criteria for admission of adult inpatients to a clinical area with a higher level of care than a general hospital ward., Charting Methods: Data was extracted from each publication using a standardised data-charting form. Admission criteria characteristics were summarised and cross-tabulated for each criterion by population group., Results: Five domains were identified: diagnosis-based criteria, clinical parameter criteria, organ-support criteria, organ-monitoring criteria and patient baseline criteria. Six clinical parameter-based criteria and five needs-based criteria were frequently proposed and represent variables extractable from EHRs. Thresholds for objective clinical parameter criteria varied across publications, and by disease subgroup, and universal cut-offs for criteria could not be elucidated., Conclusions: This study identified multiple criteria which may represent markers of deterioration. Many of the criteria are extractable from the EHR, making them potential candidates for future automated systems. Variability in admission criteria and associated thresholds across the literature suggests clinical deterioration is a heterogeneous phenomenon which may resist being defined as a single entity via a consensus-driven process., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Intensive Care Society 2024.)

Background: Catheter-related bloodstream infection is a well-known, severe complication of central venous catheter insertion. Studies that have evaluated the coronavirus disease 2019 pandemic's influence on the incidence of catheter-related bloodstream infection in intensive care units are limited. Therefore, we conducted a retrospective study on catheter-related bloodstream infection in coronavirus disease 2019 intensive care unit with previously documented low incidence rates to evaluate the pandemic's impact., Objectives: To evaluate the impact of the coronavirus disease 2019 pandemic on catheter-related bloodstream infection incidence in the intensive care unit., Methods: All central venous catheter-inserted patients aged ⩾18 years admitted to the intensive care unit with coronavirus disease 2019 pneumonia were included. The primary outcome was the incidence of catheter-related bloodstream infection, and the secondary outcome was the detection of catheter-related bloodstream infection-causative microorganisms., Results: During the pandemic's first year, 124 patients were admitted, and 203 central venous catheters were inserted. Two patients developed catheter-related bloodstream infection. The incidence of catheter-related bloodstream infection was 0.79/1000 catheter days. The microorganisms responsible for catheter-related bloodstream infection were Staphylococcus epidermidis and Escherichia coli., Conclusion: This study revealed a low incidence of catheter-related bloodstream infection in the coronavirus disease 2019-intensive care unit, thus suggesting that coronavirus disease 2019 is not a risk factor for catheter-related bloodstream infection and indicating the high resilience of well-established routines aimed at catheter-related bloodstream infection prevention., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: In the United Kingdom, around 184,000 adults are admitted to an intensive care unit (ICU) each year with over 30% receiving mechanical ventilation. Oxygen is the commonest therapeutic intervention provided to these patients but it is unclear how much oxygen should be administered for the best clinical outcomes., Methods: The UK-ROX trial will evaluate the clinical and cost-effectiveness of conservative oxygen therapy (the minimum oxygen concentration required to maintain an oxygen saturation of 90% ± 2%) versus usual oxygen therapy in critically ill adults receiving supplemental oxygen when invasively mechanically ventilated in ICUs in England, Wales and Northern Ireland. The trial will recruit 16,500 patients from approximately 100 UK adult ICUs. Using a deferred consent model, enrolled participants will be randomly allocated (1:1) to conservative or usual oxygen therapy until ICU discharge or 90 days after randomisation., Objectives: The primary clinical outcome is all cause mortality at 90 days following randomisation., Discussion: The UK-ROX trial has received ethical approval from the South Central - Oxford C Research Ethics Committee (Reference: 20/SC/0423) and the Confidentiality Advisory Group (Reference: 22/CAG/0154). The trial commenced in May 2021 and, at the time of publication, 95 sites had opened to recruitment., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Intensive Care Society 2024.)

Objective: The purpose of this study was to investigate the prevalence of depression, anxiety disorder, hopelessness, and suicide among first-degree relatives of patients hospitalised in medical and anaesthesia intensive care units at an academic medical centre., Methods: In this case-control study conducted in Türkiye, 32 first-degree relatives of 32 patients hospitalised for 14 days or more in intensive care units and 32 healthy volunteers were included for assessment. The Beck Depression Scale (BDS), Beck Anxiety Scale (BAS), Beck Hopelessness Scale (BHS), and Suicide Probability Scale (SPS) were administered to participants. Results: The mean age of patients' relatives was 42.1 ± 11.6 years and that of the controls was 43.0 ± 11.3 years. The median scores for the BDS, BHS, and SPS were significantly higher among the relatives of the patients than among controls ( P = .008, P = .013, and P = .001, respectively). Based on cutoff scores for the BDS and BAS, depression was observed in 56.3% of the relatives of the patients and anxiety disorder was observed in 46.9%. In the group comprising patients' relatives, the median score for the BDS was significantly higher among female participants than among male participants ( P = .038)., Conclusions: First-degree relatives of patients hospitalised in intensive care units have a higher prevalence of depression, hopelessness, and suicidality. Female relatives are more depressed than male. Ensuring psychiatric evaluation of the relatives of patients hospitalised in intensive care units in Türkiye is important., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: This study aims (1) to understand the needs and challenges of the current intensive care unit (ICU) environments in supporting patient well-being from the perspective of healthcare professionals (HCPs) and (2) to explore the new potential of ICU environments enabled by technology., Background: Evidence-based design has yielded how the design of environments can advocate for patient well-being, and digital technology offers new possibilities for indoor environments. However, the role of technology in facilitating ICU patient well-being has been unexplored., Method: This study was conducted in two phases. First, a mixed-method study was conducted with ICU HCPs from four Dutch hospitals. The study investigated the current environmental support for care activities, as well as the factors that positively and negatively contribute to patient experience. Next, a co-creation session was held involving HCPs and health technology experts to explore opportunities for technology to support ICU patient well-being., Results: The mixed-method study revealed nine negative and eight positive patient experience factors. HCPs perceived patient emotional care as most challenging due to the ICU workload and a lack of environmental support in fulfilling patient emotional needs. The co-creation session yielded nine technology-enabled solutions to address identified challenges. Finally, drawing from insights from both studies, four strategies were introduced that guide toward creating technology to provide holistic and personalized care for patients., Conclusion: Patient experience factors are intertwined, necessitating a multifactorial approach to support patient well-being. Viewing the ICU environment as a holistic unit, our findings provide guidance on creating healing environments using technology., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following conflicts of interest with respect to the research, authorship, and/or publication of this article: Chan Mi Kim is employed by the University of Twente through Top Technology Twente Connecting Industry program (TKI Topsector HTSM) fund. Esther van de Heide is employed by Philips. The remaining authors do not have a conflict of interest to declare.

Abdominal compartment syndrome (ACS) is a rare complication of extracorporeal membrane oxygenation (ECMO) and is associated with high morbidity and mortality. Despite being the treatment of choice for ACS, decompressive laparotomy (DL) has been a matter of debate in children supported with ECMO due to high bleeding risk and presumed futility. We report the first neonatal DL for ACS while on ECMO following congenital diaphragmatic hernia (CDH) repair. Given its excellent outcomes, our case challenges current literature and supports prompt bedside laparotomy to treat ACS on neonatal ECMO., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In the realm of hematologic disorders, acute leukemia is approached as an emergent disease given the multitude of complications and challenges that present both as a result of inherent disease pathology and adverse events associated with antineoplastic therapies and interventions. The heavy burden of leukemic cells may lead to complications including tumor lysis syndrome, hyperleukocytosis, leukostasis, and differentiation syndrome, and the initiation of treatment can further exacerbate these effects. Capillary leak syndrome is observed as a result of antineoplastic agents used in acute leukemia, and L-asparaginase, a bacterial-derived enzyme, has a unique side effect profile including association with thrombosis. Thrombohemorrhagic syndrome and malignancy-associated thrombosis are also commonly observed complications due to direct disequilibrium in coagulant and anticoagulant factors. Due to inherent effects on the white blood cell milieu, leukemia patients are inherently immunocompromised and vulnerable to life-threatening sepsis. Lastly, the advents of newer therapies such as chimeric antigen receptor (CAR) T-cells have clinicians facing the management of related toxicities on unfamiliar territory. This review aims to discuss these acute leukemia-associated complications, their pathology, and management recommendations., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Disease uncertainty refers to the inability to assign meaning to events related to the illness. Uncertainty of the disease can affect various aspects of human life such as psychological aspects., Objectives: This study aims to examine the relationship between disease uncertainty and perceived stress in COVID-19 patients., Methods: An analytical cross-sectional study was conducted on 212 hospitalized COVID-19 patients who were initially admitted to the intensive care units (ICUs) and later transferred to general wards within the same hospitals. Three instruments were utilized to collect data for this study. The Demographic Information Questionnaire, Mishel Uncertainty in Illness Scale (MUIS) for disease uncertainty, and Perceived Stress Questionnaire. For data analysis, both descriptive and inferential statistics were employed using IBM SPSS Statistics version 25., Results: The Pearson correlation coefficient matrix results showed a positive and significant relationship between uncertainty about the illness ( P  < .001, r = 0.829), ambiguity ( P  < .001, r = 0.795), complexity ( P  < .001, r  = 0.835), inconsistency or instability ( P  < .001, r  = 0.787), and unpredictability ( P  < .001, r  = 0.776) with perceived stress in COVID-19 patients transferred from the intensive care units., Conclusion: Based on the findings of the current study, both uncertainty and perceived stress are elevated among COVID-19 patients, and a significant and direct relationship exists between these two variables. Healthcare providers, particularly nurses, should address the uncertainties surrounding emerging diseases, both at the hospital and community levels., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Delirium is a neuropsychiatric syndrome common in critical illness. Worsening delirium severity is associated with poorer clinical outcomes, yet its assessment remains under-reported with most severity assessment tools not validated for critical care. The DRS-R98 is a widely applied and validated tool. The aim of this project is to report the validation and utility of the DRS-R98 in critical illness., Methods: This prospective, cohort study was conducted in adults with delirium admitted to a critical care unit and predicted to stay for ≥ 24 h. We excluded patients with severe neurological or communication barriers that would have interfered with the DRS-R98 assessment. Patients were screened using a delirium detection algorithm and the Confusion Assessment Method for the Intensive Care Unit. Eligible patient informations were collected and reported to qualified assessor/s before visiting clinical areas, confirming delirium presence and undertaking DRS- R98 assessments. To assess the tool's construct validity, an intensivist completed the Clinical Global Impression-Scale (CGI-S). To calculate the inter-rater reliability (IRR) a subset of patients were simultaneously evaluated by two assessors., Results: We assessed 22 patients, 73% were male, with a median age of 65 years (IQR14). The DRS -R98 mean (SD) severity score was 24 (+/-7.7), total scale was 29 (+/18.0), and CGI-S 3.5 (+/11.5). Assessment duration was 90 min (+/-55) and 15 min (+/-5) for record data extraction and clinical assessment respectively. The CGI-S significantly correlated with DRS-R98 severity (r = 0.626) and total (r = 0.628) scales. The DRS-R98 Cronbach's alpha was 0.896 for severity scale and 0.886 for total scale. The inter-rater reliability (IRR) was assessed in six patients and reported an inter-correlation coefficient of 0.505 (p = 0.124) and 0.565 (p = 0.93) for the severity and total scale respectively., Conclusions: In critical care, the Delirium Rating Scale R98 had good construct validity, excellent internal consistency, and moderate inter-rater reliability.

Background: Current guidelines recommend the use of ultrasound guidance for arterial cannulation. However, there are no recommendations on the best insertion site for radial artery cannulation in terms of catheter dwell time and incidence of complications., Methods: In this randomized controlled study 94 patients were randomly assigned into three groups, corresponding to three different sites of insertion for radial artery cannulation: hand wrist: (Site/group 1, n  = 29), distal quarter part of the forearm (Site/group 2, n  = 30) and the midpoint of the forearm (Site/group 3, n  = 35). Age, height, weight, and diagnosis of each patient were recorded prior to insertions which were performed by a single investigator experienced in ultrasound-guided vascular access., Results: Radial artery diameters were similar (2.4 ± 0.4 vs 2.5 ± 0.3 vs 2.6 ± 0.4 mm), however skin to vessel distances were different between groups, and the depth of the radial artery increased progressively from distal to proximal sites. There was a significant difference between groups in terms of success rates at the first attempt. Only two cannulations were successful at first attempt, and overall, only 17 of 35 cannulations were successful at Site 1. Arterial cannula dislodgement rate was highest at Site 1(8/29, 26.7%), while the longest dwell time was at Site 2 with a median of 4 (IQR 3) days., Conclusions: Considering the high removal rate at the wrist region and the high failure rate at the midpoint of the forearm, the distal quarter of the forearm can be identified as "the optimal insertion site' for ultrasound-guided radial artery cannulation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.