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Sepsis manifests as a dysregulated immune response to infection, damaging organs. Skin has a critical role in protecting the body. In sepsis, skin wound healing is impaired. The mechanisms behind it have been poorly studied. In this study, suction blister wounds were induced on intact abdominal skin in 15 septic patients. A single blister wound was biopsied from each patient and from 10 healthy controls. Immunohistochemical staining of growth factors and extracellular matrix (ECM) proteins was performed. Significance (p

Background: During the past decades, epidemiologic data of independent predictors of multiple organ failure (MOF), incidence, and mortality have changed. The aim of the study was to assess the potential changes in the incidence and outcomes of MOF during one decade (2008–2017). In addition, resource utilization was taken into account. Methods: Patients were eligible for inclusion if they were adults, admitted to the ICU between January 1, 2008 and December 31, 2017, and had complete data sets regarding MOF. MOF was defined as organ failure separately with and without central nervous system (CNS) failure. The onset of MOF was defined as being early (≤48 h of ICU admission) and late (>48 h after ICU admission). Results: Of a total of 13,270 patients enclosed in this study, 44.6% of the patients developed MOF with and 31.4% without CNS failure. MOF-related mortality decreased in patients with (adjusted IRR 0.972 [95% CI 0.948 to 0.996], p =0.022) and without (adjusted IRR 0.957 [95% CI 0.931 to 0.983], p =0.0013) CNS failure. In addition, the incidence (adjusted IRR 0.970 [95% CI 0.950 to 0.991], p =0.006) and mortality (adjusted IRR 0.968 [95% CI 0.940 to 0.996], p =0.025) of early-onset MOF decreased, while the incidence and mortality of late-onset MOF remained constant. The length of ICU (p =0.024) and hospital (p =0.032) stays decreased while the length of mechanical ventilation remained constant (p =0.41). Conclusions: Despite all improvements in intensive care during the last decades, the incidence of lateonset MOF remains a resource-intensive, morbid, and lethal condition. More research on etiologies, signs of organ failure, and where and when to start treatment is needed to improve the prognosis of late-onset MOF.

Background: The development of ventilator-associated pneumonia could be prevented in the nasotracheally intubated patients by a systematic search for and treatment of nosocomial sinusitis. However, the spreading of paranasal sinus changes with time is poorly defined. Purpose: To evaluate the occurrence and spreading of paranasal sinus changes among critically ill patients undergoing invasive ventilation in order to evaluate the association between paranasal changes and Intensive Care Unit (ICU)-related outcomes. Material and methods: This prospective, observational, single-center cohort study was conducted in a single tertiary-level teaching hospital in Finland during 2014–2015. All invasively ventilated adult patients referred for head computed tomography or magnetic resonance imaging scans from October 2014 to June 2015 were eligible for enrolment and monitored daily until discharge from the ICU or death. Results: During the study period, 6.8% (5.7 per 1,000 patient days) of patients had major findings in their maxillary, 20.3% (18.5 per 1,000 patient days) in sphenoidal, 6.8% (5.7 per 1,000 patient days) in ethmoidal, and 3.4% (2.9 per 1,000 patient days) in frontal sinuses. The spreading of paranasal sinus changes doubled in time. In addition, radiographically proved accumulation of fluid was within 39.0%, 35.6%, and 8.6% of maxillary, sphenoidal, and frontal sinuses, respectively. We found no association between ICU-related outcomes and paranasal sinus changes. Conclusion: Paranasal sinus changes were common and progressive among critically ill patients undergoing invasive ventilation, without unfavourable impact on ICU-related outcomes.

Early diagnosis is essential but challenging in severe sepsis. Quantifying and comparing metabolite concentrations in serum has been suggested as a new diagnostic tool. Here we used proton nuclear magnetic resonance spectroscopy (¹H NMR) based metabolomics to analyze the possible differences in metabolite concentrations between sera taken from septic patients and healthy controls, as well as between sera of surviving and non-surviving sepsis patients. We took serum samples from 44 sepsis patients when the first sepsis induced organ dysfunction was found. Serum samples were also collected from 14 age and gender matched healthy controls. The samples were analyzed by quantitative ¹H NMR spectroscopy for non-lipid metabolites. We found that the serum levels of glucose, glycine, 3-hydroxybutyrate, creatinine and glycoprotein acetyls (mostly alpha-1-acid glycoprotein, AGP) were significantly (p < 0.05) higher in sepsis compared to healthy sera, whereas citrate and histidine were significantly (p < 0.05) lower in sepsis patients compared to healthy controls. We found statistically significantly higher serum lactate and citrate concentrations in non-survivors compared to 30-day survivors. According to our study, 3-hydroxybutyrate, citrate, glycine, histidine, and AGP are candidates for further studies to enable identification of phenotype association in the early stages of sepsis.

Background: Nurse understaffing and increased nursing workload have been associated with increased risk of adverse patient outcomes and even mortality. Aim: To determine whether nurse staffing and nursing workload are associated with ventilator-associated pneumonia and mortality. Methods: This prospective, observational cohort study was conducted in a single tertiary-level teaching hospital in Finland during 2014–2015. The association between nurse staffing, nursing workload and prognosis was determined using daily nurse-to-patient ratios, Therapeutic Intervention Scoring System and Intensive Care Nursing Scoring System scores, and Intensive Care Nursing Scoring System indices. Ventilator-associated pneumonia was defined according to the Centers for Disease Control and Prevention criteria. Findings: Evaluable data was available for 85 patients. The overall ventilator-associated pneumonia and 28-day mortality rates were 23.5% and 35.3%, respectively. Nurse staffing, measured as the daily lowest nurse-to-patient ratio (P = 0.006) and median Intensive Care Nursing Scoring System index (P = 0.046), were significantly lower in patients with ventilator-associated pneumonia. In addition, nursing workload, measured as median scores obtained by the Therapeutic Intervention Scoring System (P = 0.009) and Intensive Care Nursing Scoring System (P = 0.03), was significantly higher in infected patients. The median (P = 0.02) and daily highest (P = 0.03) Intensive Care Nursing Scoring System scores were significantly higher in non-survivors. Conclusions: Lower nurse staffing and increased nursing workload are associated with ventilator-associated pneumonia and mortality, demonstrating that adequate staffing is a prerequisite for the availability and quality of critical care services.

Background: Considerable discrepancies have been observed in the implementation of strategies to liberate patients from mechanical ventilation. The aim of this study was to describe critical care nurses’ knowledge of and self-reported and documented adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate and evaluate how these practices differ between patients with and without ventilator-associated pneumonia and between survivors and nonsurvivors. Methods: The survey was conducted in a tertiary-level hospital in Finland from October 2014 to June 2015. Actual adherence was evaluated based on documentation of performed practices. Results: A total of 86 critical care nurses responded to the survey, and 85 patients were followed. The levels of knowledge of and self-reported adherence to low tidal ventilation were 84.5% and 90.2%, respectively, and the median tidal volume was at a target level in 74.4% of patients. Regarding daily sedation interruption, the level of knowledge was 85.7%, the level of self-reported adherence was 77.3%, and documented adherence was 33.3%. The levels of knowledge and self-reported adherence regarding spontaneous breathing trials were 61.9% and 71.6%, respectively. Adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate did not differ between patients with (n = 20) and without (n = 65) ventilator-associated pneumonia and between survivors (n = 55) and nonsurvivors (n = 30). Conclusions: Lung-protective ventilation, including low-tidal ventilation and avoidance of high inspiratory plateau pressures, was well implemented and adhered to. The levels of knowledge and self-reported adherence versus documented adherence regarding daily sedation interruption and spontaneous breathing trial demonstrated insufficient implementation of local guidelines. There was no effect on the outcome.

Background: The socioeconomic factors have an impact on case mix and outcome in critical illness, but how these factors affect the use of intensive care is not studied. The aim of this study was to evaluate the incidence of intensive care unit (ICU) admissions in patients from residential areas with different annual incomes. Methods: Single‐center, retrospective study in Northern Finland. All the non–trauma‐related emergency admissions from the hospital district area were included. The postal codes were used to categorize the residential areas according to each area’s annual median income: the low‐income area, €18,979 to €28,841 per year; the middle‐income area, €28,879 to €33,856 per year; and the high‐income area, €34,221 to €53,864 per year. Results: A total of 735 non–trauma‐related admissions were included. The unemployment or retirement, psychiatric comorbidities and chronic alcohol abuse were common in this population. The highest incidence, 5.5 (4.6–6.7)/1000/year, was in population aged more than 65 years living in high‐income areas. In working‐aged population, the incidence was lowest in high‐income areas (1.5 (1.3–1.8/1000/year) compared to middle‐income areas (2.2 (1.9–2.6)/1000/year, P = 0.001) and low‐income areas (2.0 (1.7–2.4)/1000/, P = 0.009). Poisonings were more common in low‐income areas. There were no differences in outcome. Conclusion: The incidence of ICU admission in working‐aged population was 25% higher in those areas where the annual median income was below the median annual income of €38,775 per inhabitant per year in Finland.

The outcome of acute drug poisoning is good. In only a few occasions specific treatments are needed. Toxicological screenings are recommended when acute drug poisoning is suspected. In this retrospective observational study the impact of routine screening on treatment decisions was analyzed. All patients with acute drug poisoning admitted to the emergency department of our university hospital during one year (2013) were retrospectively analyzed. The patients were categorized into two groups: those who received specific therapies due to the poisoning and those who received only symptomatic treatment. Results: there were a total of 318 cases with acute drug poisoning of which 120 led to intensive care treatment. Toxicological screening was performed in 225 cases (70.8%). The screening tests were more often taken from patients who were unconscious (89%) or had altered consciousness (79%) than from patients with normal consciousness (63%, P

Background: Although tissue perfusion is often decreased in patients with sepsis, the relationship between macrohemodynamics and microcirculatory blood flow is poorly understood. We hypothesized that alterations in retinal blood flow visualized by angiography may be related to macrohemodynamics, inflammatory mediators, and retinal microcirculatory changes. Methods: Retinal fluorescein angiography was performed twice during the first 5 days in the intensive care unit to observe retinal abnormalities in patients with sepsis. Retinal changes were documented by hyperfluorescence angiography; retinal blood flow was measured as retinal arterial filling time (RAFT); and intraocular pressure was determined. In the analyses, we used the RAFT measured from the eye with worse microvascular retinal changes. Blood samples for inflammation and cerebral biomarkers were collected, and macrohemodynamics were monitored. RAFT was categorized as prolonged if it was more than 8.3 seconds. Results: Of 31 patients, 29 (93%) were in septic shock, 30 (97%) required mechanical ventilation, 22 (71%) developed delirium, and 16 (51.6%) had retinal angiopathies, 75% of which were bilateral. Patients with prolonged RAFT had a lower cardiac index before (2.1 L/kg/m² vs. 3.1 L/kg/m², P = 0.042) and during angiography (2.1 L/kg/m² vs. 2.6 L/kg/m², P = 0.039). They more frequently had retinal changes (81% vs. 20%, P = 0.001) and higher intraocular pressure (18 mmHg vs. 14 mmHg, P = 0.031). Patients with prolonged RAFT had lower C-reactive protein (139 mg/L vs. 254 mg/L, P = 0.011) and interleukin-6 (39 pg/ml vs. 101 pg/ml, P

Background: Implementation of evidence‐based oral care protocols, nurse education programmes and assessment tools may reduce the risk of developing ventilator‐associated pneumonia by increasing critical care nurses’ knowledge and skills in adhering to current oral care recommendations. Aims: To evaluate the longitudinal effects of single‐dose simulation education with structured debriefing and verbal feedback on critical care nurses’ knowledge and skills in adhering to current oral care recommendations. Design: A randomized controlled trial with repeated measurements. Method: The data for the study were collected in a single academic centre in a 22‐bed adult, mixed, medical‐surgical intensive care unit in Finland from February 2012 to March 2014. The effectiveness of simulation education was evaluated through the validated Ventilator Bundle Questionnaire and Observation Schedule at baseline (n = 30) and 24 months (n = 17) after simulation education. Data were analysed using a linear mixed model and intention‐to‐treat analyses. Results: During the study period, the average knowledge score in the intervention group increased significantly (44·0% to 56·0% of the total score) in the final post‐intervention measurement (pt = 0·51, pg = 0·002, pt*g = 0·023). However, single‐dose simulation education with structured debriefing and verbal feedback had no impact on critical care nurses’ skill scores. Conclusion: Single‐dose simulation education had only a minimal effect on critical care nurses’ knowledge and skills in adhering to current oral care recommendations. Despite increased awareness, there was no significant difference in oral care practices between the study groups after simulation education. Relevance for clinical practice: The need for regularly repeated educational sessions with theoretical training and practical exercises and direct feedback is evident. Certain aspects of oral care, such as prevention of microaspiration of oropharyngeal secretions and moistening of oral mucosa and lips, require more reinforcement than others.

Background: The number of missions in the emergency medical services (EMS) has increased considerably in recent years. People are requesting ambulance for even minor illnesses and non‐medical problems, which is placing financial and resource burdens on the EMS. The aim of this study was to determine the rate of non‐transportation missions in Northern Finland and the reasons for these missions. Methods: All ambulance missions in two hospital districts in Northern Finland during the 6‐month period of January 1 through June 30, 2014, were retrospectively evaluated from the EMS charts to identify missions in which the patients were not transported by the EMS. The non‐transportation rates and reasons were calculated and expressed as percentages. Results: In 41.7% of the 13,354 missions, the patient was not transported from the scene by an ambulance. After a medical assessment and care was provided by the EMS, 48.2% of these non‐transport patients were evaluated as not needing further treatment in the emergency department and were directed to contact the municipal health care center during office hours. There was no need for any medical care in 39.9% of non‐transportation missions. Conclusion: This study showed a high rate of EMS missions resulting in non‐transportation in two hospital districts in Northern Finland. In the majority of these missions there was no need for emergency admission to an emergency department or for any medical care at all. These findings indicate that an improvement in the dispatch process and primary care resources might be of benefit.

Background: To evaluate how critical nurses’ knowledge of and adherence to current care hand hygiene (HH) guidelines differ between randomly allocated intervention and control groups before and after simulation education in both a simulation setting and clinical practice during a 2-year follow-up period. It was hypothesized that intervention group knowledge of and adherence to current HH guidelines might increase compared with a control group after simulation education. Methods: A prospective, parallel, randomized controlled trial with repeated measurements was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Oulu, Finland. Thirty out of 40 initially randomized critical care nurses participated in the baseline measurements; of these, 17 completed all the study procedures. Participants’ HH adherence was observed only in high-risk contact situations prior to and postendotracheal suctioning events using a direct, nonparticipatory method of observation. Participants’ HH knowledge was evaluated at the end of each observational session. Results: The overall HH adherence increased from a baseline value of 40.8% to 50.8% in the final postintervention measurement at 24 months (P = .002). However, the linear mixed model did not identify any significant group (P = .77) or time-group interactions (P = .17) between the study groups after 2 years of simulation education. In addition, simulation education had no impact on participants’ HH knowledge. Conclusions: After a single simulation education session, critical care nurses’ knowledge of and adherence to current HH guidelines remained below targeted behavior rates.

Background: Critical care nurses’ knowledge and skills in adhering to evidence-based guidelines for avoiding complications associated with intubation and mechanical ventilation are currently limited. We hypothesized that single simulation education session would lead to a long-lasting higher level of skills among critical care nurses. Material and methods: A randomized controlled trial was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Finland during the period February 2012–March 2014. Thirty out of 40 initially randomized critical care nurses participated in a 24-month follow-up study. Behavior and cognitive development was evaluated through a validated Ventilator Bundle Observation Schedule and Questionnaire at the baseline measurement and repeated 3 times during simulation and real-life clinic settings. Results: After simulation education, the average skills score increased from 46.8%–58.8% of the total score in the final postintervention measurement (Ptime