Revisiting the Delphi technique - Research thinking and practice: A discussion paper

The Delphi technique is a research methodology which has traditionally been used to gain consensus among experts on complex issues characterised by uncertainty. Pioneered by the Rand Corporation in the 1950s for military applications, it has since been widely adopted across various fields, including nursing, health and social sciences and information systems on an array of multifaceted real-world issues. However, since its inception, the Delphi technique has undergone substantial methodological development and its use has now gone beyond its initial rationale. In the last two decades there has been a growing body of work illustrating an increasing methodological diversity of the method. While such diversity presents possibilities, it also challenges traditional application and methodological rigour. In an attempt to preserve the integrity of the method, generic and discipline specific guidelines have emerged providing general principles and standards. The aim of this paper is to present a much-needed critical reflection on the current application of the Delphi technique and its methodological development and to build on our paper from 2001 (Keeney et al., 2001). While the development of the Delphi method and its evolution are well recognised and reported in the literature, some controversies surrounding the approach remain and it is timely to revisit the method with a critical eye. Ultimately, the Delphi technique's flexibility is its significant strength, enabling the exploration of novel lines of inquiry, but it also presents a challenge. Striking the right balance between flexibility and rigour can lead to more meaningful insights and actionable outcomes from a Delphi study. Yet to achieve this, some level of consensus may need to be reached on the Delphi technique itself. In recognition of its 60th birthday, it is an opportune time to re-examine its key aspects and methodological advances and reflect on 'when is a Delphi not a Delphi?'

Quality of Life and Well-Being of Family Caregivers of Prolonged Mechanically Ventilated Patients: An Observational Study

IMPORTANCE

Although previous studies have examined the impact of caregiving on the quality of life (QOL) of caregivers of home-ventilated patients, few studies have dealt with the QOL of caregivers of family members who require prolonged mechanical ventilation in long-term-care facilities.

OBJECTIVE

To assess the personal experiences of caregivers of family members requiring prolonged mechanical ventilation by applying the Do-Live-Well framework to examine the potential associations among caregivers' QOL, well-being, level of burden, and participation.

DESIGN

A descriptive and correlative cross-sectional single-center study.

SETTING

A chronic ventilator-dependent division in a long-term acute-care facility.

PARTICIPANTS

Twenty-six family caregivers of patients requiring mechanical ventilation completed a series of questionnaires.

OUTCOME AND MEASURES

The World Health Organization Quality of Life-Brief, the Personal Wellbeing Index, the Zarit Burden Index, items measuring participation (from the Health Promotion Activities Scale and items based on the Do-Live-Well framework), and a sociodemographic questionnaire were administered.

RESULTS

High burden was correlated with low well-being and lower social relations (a domain of QOL). The perception and meaning attributed to the role of caregiving were correlated with QOL. Participation in health-promoting activities was associated with well-being and QOL.

CONCLUSIONS AND RELEVANCE

Participation in health-promoting activities and the caregivers' personal experiences were positively linked to QOL and well-being and linked negatively to burden. Although these findings require further investigation, they also point to the importance of developing occupational therapy support programs for family caregivers of mechanically ventilated patients. Plain-Language Summary: Caregivers of family members who require prolonged mechanical ventilation bear a heavy burden that can affect their quality of life. For this study 26 caregivers of family members hospitalized in a long-term acute care facility completed questionnaires on their quality of life, well-being, burden, participation in activities, and perceptions of their caregiving role. We found that quality of life was enhanced by participation in health-promoting activities and influenced by the caregivers' personal experiences and burden. Occupational therapy interventions should be designed to improve the quality of life of caregivers and to identify caregivers who are at risk of any negative effects on their quality of life and well-being.

Australian clinical practice guideline for physical rehabilitation and mobilisation in adult intensive care units

BACKGROUND

The evidence base for research on physical rehabilitation and mobilisation in the intensive care unit has led to uncertainty about best practice.

OBJECTIVE

The objective of this guideline was to develop evidence-based recommendations to support clinical decision-making for physical rehabilitation management of adults undergoing invasive mechanical ventilation in Australian intensive care units.

METHODS

The guideline development group, comprising national representation of clinical experts, methodologists, and consumers, followed a rigorous process, adhering to Australian National Health and Medical Research Council Guidelines for Guidelines, to create the recommendations. The guideline development group determined the scope of the guideline and defined the key clinical question. A systematic review was conducted to evaluate all available evidence based on the predefined outcomes. Meta-analyses were performed using a restricted maximum likelihood approach, and results were summarised in an evidence profile. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence, and the GRADE Evidence to Decision framework was used to formulate recommendations.

SUMMARY OF RECOMMENDATIONS

Based on the evidence profile and GRADE Evidence to Decision framework, the group developed three conditional recommendations and 14 Good Clinical Practice statements to guide practice. The guideline provides conditional recommendations in favour of undertaking physical rehabilitation and mobilisation in adults receiving invasive mechanical ventilation in the intensive care unit whilst acknowledging the uncertainty of evidence. It was endorsed by four key professional organisations.

CONCLUSION

The recommendations within this guideline were developed following best methodological practice. Despite the overall low certainty of evidence, the resulting guideline provides support to clinical decision-making, facilitates the translation of research into practice, and enhances the reach and impact of clinical research. Additionally, the guideline development group identified evidence gaps that could be addressed by future research.

TRIAL REGISTRATION

Not applicable.

Transient third nerve palsy in acute liver failure secondary to paracetamol overdose

Acute liver failure (ALF) secondary to paracetamol overdose is a life-threatening condition with significant systemic and neurological complications, including cerebral oedema. This case presents sequential bilateral third cranial nerve involvement in paracetamol-induced ALF, complicated by severe hyperammonaemia and intracranial hypertension. The patient initially developed transient right-sided pupillary fixed dilation followed by left-sided oculomotor nerve palsy. She was managed with advanced neuroprotective measures, hyperosmolar therapy and tailored high-dose continuous renal replacement therapy (CRRT), leading to resolution of both the cerebral oedema and neurological deficits. This report highlights the importance of recognising cranial nerve palsies as a feature of ALF-induced intracranial hypertension and demonstrates the value of individualised multidisciplinary critical care therapeutic strategies. In addition, it emphasises the challenges of intracranial pressure monitoring in ALF and the need for further research on optimal CRRT protocols to improve outcomes in critically ill patients.

Cardiac Surgery-Associated Acute Kidney Injury: An Updated Review of Current Preventive Strategies

Acute kidney injury (AKI) is a frequent and often severe postoperative complication following cardiac surgery, which is associated with poor outcomes in both the short and long terms. Numerous randomized clinical trials have been conducted to investigate various strategies for prevention of cardiac surgery-associated AKI. Unfortunately, most trials conducted to date have been negative. However, encouraging results have been reported with several interventions, including preoperative implementation of oxygen delivery-directed perfusion, novel drugs such as teprasiran and amino acids. Many of these studies, however, require validation in larger, multicenter trials, before their routine use in clinical practice can be recommended.

Oxygen and carbon dioxide targets after cardiac arrest: an updated systematic review

AIM

To perform an updated systematic review and meta-analysis of oxygen and carbon dioxide targets in patients with sustained return of spontaneous circulation after cardiac arrest.

METHODS

Searches were conducted in MEDLINE, Embase, and Evidence-Based Medicine Reviews from August 2019 to March 2025 for randomised trials comparing specific oxygen or carbon dioxide targets in post-cardiac arrest patients. Two investigators independently reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. The certainty of evidence was evaluated using GRADE methodology.

RESULTS

Fifteen manuscripts from 12 trials were included. All trials were limited to adult patients, primarily including out-of-hospital cardiac arrests. Five trials evaluated oxygen targets in the prehospital setting, while six evaluated oxygen targets and three evaluated carbon dioxide targets in the intensive care unit setting. Risk of bias was assessed as moderate for most outcomes. Meta-analyses found no differences in survival or favourable functional outcomes when comparing restrictive to liberal oxygen targets in either setting. There was also no difference in outcomes when comparing mild hypercapnia to normocapnia. The certainty of evidence was rated as low to moderate.

CONCLUSIONS

Among patients resuscitated from cardiac arrest, neither restrictive oxygen targets nor mild hypercapnia, compared to conventional targets, improved survival or functional outcomes.

Specific clinical conditions for colloids use

Intravenous fluids are among the most commonly prescribed drugs. Many preparations classified by composition as crystalloids or colloids, of natural or synthetic origin, are available in clinical practice. Guidelines favor crystalloids as first-choice fluids in most clinical situations, mainly because of the lack of advantage of using colloids in reducing mortality and organ complications and generating higher treatment costs. This review focuses on the evidence for the use of colloids in selected clinical conditions.

Preventing and Managing Tracheostomy-Related Emergencies in the Radiology Suite: Best Practices for Safety and Preparedness

Background

Airway emergencies in patients with tracheostomies are life-threatening and may arise from tube dislodgment, obstruction, bleeding, or improper handling during patient transfers. While these incidents are rare in radiology suites, the limited experience of staff with tracheostomy care heightens the risk of adverse outcomes. Prompt and well-coordinated responses are essential to ensure patient survival.

Objective

This review identifies risk factors for tracheostomy-related emergencies in radiology and offers evidence-based recommendations to improve patient safety, staff preparedness, and emergency response.

Methods

A comprehensive review of peer-reviewed literature, malpractice claims, clinical guidelines, and expert consensus statements was conducted. Databases including PubMed, Nexis Uni, and legal case repositories were searched for studies, reports, and expert recommendations related to tracheostomy emergencies. Findings were synthesized on complications, risk factors, and prevention strategies.

Results

Key risk factors for tracheostomy emergencies include improper tube securement prior to transfer, inadequate staff training, and failure to recognize and manage early signs of airway compromise. The first postoperative week following tracheostomy placement has elevated risk due to immaturity of the stoma. Evidence suggests that structured interventions, such as pre-procedure checklists, standardized emergency kits, and targeted staff education, significantly reduce the incidence of complications.

Conclusion

Implementing best practices, including pre-procedure preparedness and emergency management protocols, is crucial for minimizing tracheostomy-related complications in radiology settings. Increasing staff awareness and training on tracheostomy care and emergencies can improve patient outcomes and reduce the likelihood of litigation. To sustain competency and ensure rapid, effective responses to emergencies, institutions should implement consistent annual training programs focused on tracheostomy management. Regular simulation-based exercises and interdisciplinary training sessions can reinforce critical airway management skills, promote teamwork, and improve adherence to safety protocols. Future research should aim to assess the effectiveness of quality improvement initiatives in reducing tracheostomy-related adverse events.

Pediatric liver transplant for acute liver failure: Defining the standard nutrition and clinical evolution: An observational study

BACKGROUND

Pediatric acute liver failure (PALF) is a clinical diagnosis in which previously asymptomatic children exhibit a rapid loss of liver function.

OBJECTIVES

To describe the clinical and nutrition conditions at admission and during hospitalization in patients with PALF who underwent liver transplantation (LT) at a referral center and establish a possible association between nutrition status and prognosis in this population.

METHODS

A prospective study was conducted on children underwent LT because of PALF. Nutrition assessment was performed at admission and repeated weekly until hospital discharge, and their relationships with clinical outcomes were tested.

RESULTS

The study population consisted of 23 patients with a median age of 60 months and, in most cases, the etiology of acute liver failure (ALF) was indeterminate (69.6%). The majority of the patients were well nourished according to the z score body mass index-for-age (82.6%) and z arm circumference-for-age (zAC/A) (82.6%). A decline in nutrition status was observed in 47.6% of the patients, as indicated by a decrease in zAC. Clinical and nutrition improvement was demonstrated by the progressive increase in zAC, serum albumin levels, and phase angle (PA) values and by the reduction in C-reactive protein levels. There was no statistically significant relationship between nutrition status and clinical outcomes.

CONCLUSION

Most children and adolescents with ALF presented adequate nutrition status at the time of LT, and some patients worsened their nutrition status during hospitalization, suggesting that post-LT is a period of high nutrition risk, and early nutrition therapy (NT) must be a priority in these patients.

Cutoff Values for Screening Post-Intensive Care Syndrome Using the Post-Intensive Care Syndrome Questionnaire

Background: Post-intensive care syndrome (PICS) affects over half of intensive care unit (ICU) survivors, impairing their long-term health and quality of life. Although the Post-Intensive Care Syndrome Questionnaire (PICSQ) was developed to measure PICS, validated cutoff values for screening are lacking. This study aimed to determine optimal cutoff values for each domain of the PICSQ. Methods: A total of 475 ICU survivors completed the PICSQ three months after discharge. Receiver operating characteristic (ROC) curve analyses were conducted to determine optimal cutoff values for each domain. The criterion tools included the Hospital Anxiety and Depression Scale, the Posttraumatic Diagnostic Scale, the Activities of Daily Living scale, and the Montreal Cognitive Assessment. Health-related quality of life and hospital readmission rates were compared between groups classified by the determined cutoffs. Results: The optimal cutoff values were ≥3 for mental, ≥7 for physical, and ≥2 for cognitive domains, with area under the curve (AUC) values of 0.83, 0.84, and 0.80, respectively. The participants scoring above these cutoffs had significantly lower quality of life and higher readmission rates. Conclusions: The determined cutoff values may support early screening of PICS in ICU survivors, enabling timely interventions to improve long-term outcomes. Further research is needed to validate these values in diverse populations.

Recumbent FES-Cycling Exercise Improves Muscle Performance and Ambulation Capacity in Hospitalized Patients: A Randomized Controlled Trial

BACKGROUND

Acquired muscle weakness is a prevalent complication during hospitalization. Supportive technologies, such as functional electrical stimulation cycling (FES-cycling), are increasingly recognized as a tool with the potential to improve physical exercise in patients constrained to bed rest.

METHODS

In this randomized clinical trial, patients admitted to a high-complexity ward exhibiting clinical signs of muscle weakness (e.g., report of loss of strength, gait, or balance deficit due to weakness or restriction to bed) were enrolled. Participants were randomly allocated to a recumbent high-intensity, low-volume FES-cycling exercise or a control group. The primary outcomes measured were torque, power output, stimulation cost (neuromuscular efficiency), and ambulation capacity.

RESULTS

The analysis included 16 patients (eight in each group). Postintervention, the FES-cycling group presented a greater increase in both absolute (4.25 ± 3.15 vs. 0.04 ± 3.49 Nm, p = 0.02) and percentage torque (117 ± 88 vs. 8% ± 53%, p < 0.01) compared to the control. Similarly, the FES-cycling group presented higher absolute (3.91 ± 2.25 vs. 0.57 ± 1.82 watts, p < 0.01) and percentage power (61 ± 36 vs. 10% ± 23%, p < 0.01), along with a higher absolute (-2903 ± 2598 vs. -523 ± 1319 μC/watt, p = 0.03) and percentage stimulation cost (-33 ± 18 vs. -6% ± 1 8%, p = 0.01). Additionally, enhanced ambulation capacity was observed in the FES-cycling group, with 6 patients showing improvement versus 2 in the control group (p = 0.03).

CONCLUSIONS

Recumbent high-intensity, low-volume FES-cycling exercise increased muscle strength, power, and neuromuscular efficiency in hospitalized patients with muscle weakness. Improvements in ambulation capacity were also noted, supporting the intervention potential.

Predictive Factors of Successful Decannulation in Tracheostomy Patients: A Scoping Review

Background/Objective: Tracheostomy (TCT) creates an artificial airway, essential for overcoming obstructions or enabling long-term ventilation. Decannulation represents a critical step in recovery, with its success strongly influenced by the underlying indication for tracheostomy and the patient's clinical profile. Successful decannulation requires careful assessment of multiple factors, including respiratory function and underlying pathology. This scoping review aims to identify and categorize these predictive factors, crucial for optimizing decannulation protocols and patient outcomes. Methods: A scoping review was conducted using the PubMed, Web of Science, Cochrane Library, Embase, EBSCOhost, and Scopus databases (22 February 2025-3 March 2025) to identify studies regarding predictors of successful decannulation. Studies examining physiological, clinical, and demographic factors associated with decannulation outcomes were included. Data were extracted using a standardized form and synthesized narratively. Results: Fifty studies reported a male representation averaging 67% of the total patient population, comprising 2238 males and 1281 females aged 50-70 with acquired brain injuries, employing retrospective and prospective designs. Positive decannulation outcomes correlate with strong cough, effective secretion management, younger age, and robust neurological status. Adverse events were generally mild, with recannulation being infrequent. Conversely, advanced age, chronic lung disease, a high body mass index, and prolonged mechanical ventilation negatively influence decannulation success. Conclusions: It was highlighted that successful decannulation is the result of various physiological, clinical, and demographic factors. Significantly, strong respiratory function, demonstrated by powerful cough reflexes and efficient secretion control, stands out as a fundamental predictive factor.

Impact of tracheostomy on ICU stay in adult patients with ARDS: A systematic review

OBJECTIVE

To investigate the impact of tracheostomy on clinical outcomes in adults with acute respiratory distress syndrome (ARDS) who require mechanical ventilation (MV).

METHODS

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Three electronic databases including PubMed, The Cochrane Library, and EMBASE to identify relevant studies on ARDS patients receiving MV were searched from inception to July 31, 2024. The reviewers assessed the risk of bias of included studies according to the Cochrane Risk of Bias 1 tool or JBI checklists, as appropriate. Two reviewers independently screened the literature and extracted the data. Outcomes among patients who underwent tracheostomy were compared and analyzed.

RESULTS

Twenty studies involving 4,022 patients with ARDS who required tracheostomy were included, comprising 2 randomized controlled trials, 5 prospective studies, 12 retrospective studies, and 1 case series. On average, tracheostomized patients spent 30.2 days in the ICU and 44.8 days in the hospital, with an overall mean duration of MV of 27 days. Tracheostomy-related adverse events were reported in 15 studies and local bleeding was the most common complication. Of the 1,074 patients with tracheostomy, 626 (58.3%) were successfully weaned from the ventilator. Mortality outcomes were documented in 18 studies, indicating that 883 out of 2,302 (38.4%) of these patients died during hospitalization.

CONCLUSION

Tracheostomy in MV patients with ARDS does not have a clearly defined impact on ICU length of stay due to variability in study findings. However, it remains a safe intervention with generally minor complications. Future research should focus on standardized weaning protocols and multidisciplinary rehabilitation strategies to potentially improve patient outcomes.

IMPLICATIONS FOR CLINICAL PRACTICE

Tracheostomy allows for a more controlled and gradual weaning process in patients with ARDS requiring prolonged MV. Moreover, although current evidence does not indicate a significant reduction in ICU length of stay, tracheostomy contributes to more effective patient management during the weaning by facilitating oral hygiene, improving mobility, and enabling both verbal communication and oral feeding.

Reliability of pre-admission patient-reported outcome measures postoperatively assessed via proxies: a prospective, multicenter observational study

BACKGROUND

Pre-admission status obtained through patient-reported outcome measures is an essential metric in both clinical and research settings for prognostication and treatment decisions. It is frequently collected by proxies, although its reliability has yet to be thoroughly investigated. The objective was to determine the reliability of proxy assessments regarding pre-ICU admission status via patient-reported outcome measures and to explore the impact of the ICU setting on these assessments.

METHODS

Prospective multicentre observational study in two tertiary care university hospitals in Germany, including surgical adult patients able to independently answer the patient-reported outcome measures (SF-36, EQ-5D-5L, WHODAS 2.0, IADL, and Barthel Index) with a proxy available. Patients were interviewed pre-operatively, while proxies were interviewed post-operatively in the ICU or normal ward, depending on the patient's location. The reliability of patient-reported outcome measures was analyzed using Bland-Altman plots and Cohen's kappa.

RESULTS

Of 204 patient-proxy pairs, 102 were admitted to an ICU. The median patient and proxy age were 69 and 64 years, with 41% and 68% female, respectively. Bland-Altman plots demonstrated insufficient reliability of proxy ratings, as the 95% limits of agreement fell outside the minimal clinically important difference (MCID) for all questionnaires. However, a significant bias was evident only among ICU patients, showing worse ratings from proxies for the WHODAS 2.0, IADL, and subsets of the SF-36. For the EQ-5D, bias appeared in both the ICU and non-ICU cohorts. The dichotomous analysis of the within-pairs-difference supported the findings, revealing a high proportion of pairs with differences outside the MCID (n (%)-SF-36 PCS normal ward: 47 (46%), ICU: 58 (57%); SF-36 MCS normal ward: 59 (58%), ICU: 62 (61%); WHODAS 2.0 normal ward: 58 (57%), ICU: 78 (77%); EQ-5D-5L normal ward: 40 (39%), ICU: 46 (45%); Barthel-Index normal ward: 22 (22%), ICU: 21 (21%)). Cohen's kappa indicated moderate reliability for the IADL.

CONCLUSION

The reliability of proxy assessment with the instruments used was insufficient, exhibiting a significant bias in the pre-admission status of ICU patients; therefore, it should be applied with caution.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03785444-28th of December 2018).

Assessing the Impact of Nanoplastics in Biological Systems: Systematic Review of In Vitro Animal Studies

Nanoplastic (NP) pollution has emerged as a growing concern due to its potential impact on human health, although its adverse effects on different organ systems are not yet fully understood. This systematic scoping review, conducted in accordance with international guidelines, aimed to map the current evidence on the biological effects of NPs. In vitro animal studies assessing cellular damage caused by exposure to any type of NP were searched on PubMed, Web of Science, and Scopus. Data on primary outcomes related to genotoxicity and cytotoxicity (cell viability, oxidative stress, inflammation, DNA and cytoplasmic damage, apoptosis) were extracted from the included studies, and overall reporting quality was assessed. A total of 108 articles published between 2018 and 2024, mostly by China (54%), Spain (14%), and Italy (9%), were included. Polystyrene (PS) was the most frequently studied polymer (85%). NP sizes in solution ranged from 15 to 531 nm, with a higher prevalence in the 40-100 nm range (38%). The overall quality of studies was rated as moderate (60%), with many lacking essential details about cell culture conditions (e.g., pH of the medium, passage number, substances used). A higher frequency of negative effects from NP exposure was observed in respiratory cell lines, while immune, digestive, and hepatic cell lines showed greater resistance. Nervous, urinary, and connective tissue systems were impacted by NPs. Positively charged and smaller PS particles were consistently associated with higher toxicity across all systems. In summary, this review highlights the multifactorial nature of NP toxicity, influenced by size, surface charge, and polymer type. It also reveals a significant knowledge gap, stemming from the predominant use of immortalized monocultures exposed to commercially available PS NPs, the limited use of environmentally relevant particles, and the underutilization of advanced experimental models (e.g., organ-on-chip systems) that better mimic physiological conditions.

Incidence and factors associated with post-intensive care syndrome among caregivers of intensive care unit survivors: Protocol for a cohort study

BACKGROUND

During the last decades, intensive care unit (ICU) mortality rates have significantly decreased but this progress has come with unintended consequences for patients and their caregivers. The adverse health-related effects observed in caregivers during the post-ICU period are referred to as Post-Intensive Care Syndrome-Family (PICS-F). Despite growing awareness of PICS-F, the long-term challenges faced by caregivers of ICU patients are not well characterized with several gaps in knowledge remaining unaddressed. The proposed study aims to determine the incidence of PICS-F impairments and identify associated factors among caregivers of ICU survivors.

METHODS

We plan to conduct a longitudinal prospective cohort study involving 175 caregivers of ICU patients admitted to a public hospital in Chile. Data will be collected during ICU admission, after ICU discharge, 3 months and 6 months after hospital discharge. Questionnaires will evaluate caregivers' psychological, physical and cognitive outcomes and perceived social support, resilience, family satisfaction and caregiver burden. Factors associated with PICS-F impairments will be explored using generalised linear mixed models.

DISCUSSION

The current understanding of PICS-F is limited, particularly regarding the risk and protective factors associated with the syndrome among caregivers of ICU survivors. This study will contribute to addressing this gap by providing novel data about PICS-F and exploring previously unexamined factors linked to PICS-F such as family satisfaction, psychological buffers and caregiver burden.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT05827354. Registered on 25 April 2023.

Translation and validation of Malay version of NIOSH worker well-being questionnaire (WellBQ)

The NIOSH Worker Well-Being Questionnaire (WellBQ) offers a comprehensive framework to evaluate worker well-being across five domains: work evaluation, workplace policies, physical environment and safety, health status, and home/community influences. In Malaysia, traditional occupational safety and health (OSH) initiatives have primarily focused on workplace hazards, often neglecting broader psychosocial and organizational factors. To address this gap, this study adapted and validated the Malay version of the WellBQ for healthcare workers, ensuring cultural and contextual relevance. A rigorous translation process, including forward and backward translation, expert panel reviews, and pilot testing, was conducted to retain the original framework while addressing local nuances. Psychometric evaluation involved 366 healthcare workers from Hospital Universiti Sains Malaysia, employing Confirmatory Factor Analysis (CFA) to assess model fit, internal consistency, and construct validity. The Malay WellBQ demonstrated robust psychometric properties, with a Content Validity Index (CVI) of 0.92 and a Face Validity Index (FVI) of 0.98, reflecting high relevance and clarity. CFA confirmed an acceptable model fit (RMSEA = 0.050, CFI = 0.887, TLI = 0.877) and strong internal consistency (CR > 0.7). Convergent validity was observed across most subdomains, although some Average Variance Extracted (AVE) scores fell below 0.5, highlighting areas for refinement. Discriminant validity was achieved within domains but revealed overlaps between some domains, suggesting interconnected constructs. The Malay WellBQ is a reliable and culturally relevant tool for assessing worker well-being, offering actionable insights for workplace policy and intervention development. Further refinements are recommended to enhance construct validity across domains.

Improving weaning and liberation from mechanical ventilation for tracheostomy patients: a quality improvement initiative

For patients in the intensive care unit (ICU), prolonged mechanical ventilation is associated with poor outcomes. A quality improvement (QI) initiative with the aim of reducing median time on the ventilator for tracheostomy patients was undertaken at a tertiary care ICU in Toronto, Canada. A QI team was formed, and using QI methodology, a deep understanding of our local process was achieved. Based on this information and on the latest evidence on weaning, a standard tracheostomy weaning protocol was designed. The protocol was refined through three developmental and two testing plan-do-study-act cycles. This study was a prospective time series showing the effect of the implementation of our intervention on tracheotomy patients' time on the ventilator. The baseline median number of days on the ventilator after tracheostomy insertion was 17. Within 12 months of the introduction of the intervention, a shift in the data showing a reduction in the median time on the ventilator to 10.6 days had developed. Length of stay in the ICU was reduced by 4.3 days. Adherence and compliance to the protocol also improved over time. A standard tracheostomy weaning protocol was successfully developed, tested and implemented in a tertiary care ICU. Using strategies such as frequent communication with key stakeholders and incorporating a tracheostomy weaning progress sheet to document and track tracheostomy patients and their outcomes, this QI intervention has become engrained in the local culture at our centre. This weaning protocol has successfully reduced the median time on the ventilator for tracheostomy patients by over 6 days.

Crystalloids versus Colloids: Same Controversy, New Information

Intravenous fluid therapy is a regular component of care for cats and dogs with goals of restoring tissue perfusion, preventing organ dysfunction, and maintaining homeostasis. Veterinarians have a plethora of fluid choices, including hypertonic, hypotonic, and isotonic crystalloids, as well as synthetic and natural colloids. Studies published in both the human and veterinary medical literature have documented adverse events associated with synthetic and natural colloids. Reports of increased incidences of acute kidney injury, need for renal replacement therapy, and mortality in a variety of patient populations have called into question the use of synthetic colloids in humans and companion animals.

Association between arterial carbon dioxide tension and poor outcomes after cardiac arrest: A meta-analysis

BACKGROUND

Abnormal arterial carbon dioxide tension (PaCO2) is a common finding after cardiac arrest (CA). Inconsistent results regarding the association between abnormal PaCO2 and poor outcomes have been reported previously. We performed a meta-analysis to evaluate whether hypocapnia or hypercapnia is associated with an increased risk of hospital mortality and poor neurological outcomes in adult patients with CA.

METHODS

PubMed, Embase, and the Cochrane Library databases were searched through October 2024 to determine studies investigating the association between PaCO2 and the risk of hospital mortality and/or poor neurological outcomes in adult patients with CA. A random-effects model was used to calculate the pooled odds ratio (OR) with 95% confidence intervals (CIs) for cohort studies and relative risks (RRs) with 95% CIs for randomized controlled trials (RCTs).

RESULTS

A total of 14 cohort studies and 3 RCTs comprising 72344 patients were included. Pooled analysis indicated that hypocapnia was associated with an increased risk of hospital mortality (nine cohort studies, OR 1.37; 95% CI, 1.18-1.59; P < 0.0001) and poor neurological outcomes (five cohort studies, OR, 1.75; 95% CI, 1.04-2.96; P = 0.035). Within cohort studies, hypercapnia was associated with increased risk of hospital mortality (10 trials, OR 1.40; 95% CI, 1.13-1.73; P = 0.002), but not associated with poor neurological outcomes (six cohort studies, OR, 1.57; 95% CI, 0.87-2.83; P = 0.130). Within RCTs, mild hypercapnia was not associated with an increased risk of poor neurological outcomes after CA.

CONCLUSIONS

Current evidence indicated that hypocapnia was associated with an increased risk of hospital mortality and poor neurological outcomes after CA; however, hypercapnia was associated with an increased risk of hospital mortality but did not appear to be associated with increased poor neurological outcomes after CA.

SYSTEMATIC REVIEW PROTOCOL

INPLASY 2024100120. Registered 28 October 2024.

Continuous renal replacement therapy for severe transient hyperammonemia in a preterm infant weighing 1120 g: A case report

Transient hyperammonemia of the newborn is a rare form of hyperammonemia with an unclear, likely nongenetic etiology, primarily affecting larger preterm infants. However, lower birth weight and gestational age are associated with higher ammonia levels, increasing the risk of neurotoxicity and hepatotoxicity. Transient hyperammonemia of the newborn typically manifests as respiratory distress within the first 24 h post-birth, progressing to seizures and coma within 48 h. Continuous renal replacement therapy has demonstrated considerable efficacy in managing severe transient hyperammonemia of the newborn due to its high ammonia clearance rate; however, its application remains limited in very low birth weight preterm infants. Herein, we report the case of a male infant born at 28+2 weeks gestation, weighing 1120 g, who developed transient hyperammonemia of the newborn 22 h post-birth. Despite initial pharmacotherapy and peritoneal dialysis, his ammonia levels continued to rise, necessitating continuous renal replacement therapy. After 42 h of continuous renal replacement therapy, his ammonia levels decreased significantly and he recovered fully, eventually being discharged in good health. This case highlights continuous renal replacement therapy as a viable, life-saving intervention for severe transient hyperammonemia of the newborn, even in very low birth weight preterm infants.

Assessment of Hemodynamic Changes During Large-Volume Plasmapheresis with a Non-Invasive Cardiac Output Monitor in Patients with Neurological Disease: A Prospective Cohort Study

INTRODUCTION

Therapeutic large-volume plasmapheresis (LVP) effectively manages neurological diseases, such as Guillain-Barre syndrome (GBS) and myasthenia gravis (MG), but it induces alterations in intravascular volume, necessitating vigilant monitoring. This study investigated the hemodynamic changes and the utility of non-invasive cardiac output monitoring (NICOM) during LVP.

METHODS

This prospective observational study included 50 neurological patients receiving their first LVP cycle. Standard monitoring of heart rate (HR), non-invasive blood pressure (NIBP), pulse oximetry (SpO2), and cardiac output (CO) using NICOM was performed. Changes in HR, NIBP, CO, total peripheral resistance (TPR), stroke volume (SV), and stroke volume variation (SVV) were recorded at baseline and multiple time points during LVP.

RESULTS

The mean age was 36 ± 15.05 years. The mean arterial pressure (MAP) significantly decreased from baseline at 30 and 60 minutes, and LVP completion (P < 0.05). While HR and systolic/diastolic blood pressure (SBP/DBP) remained stable, SV, CO, and cardiac index (CI) significantly decreased (P < 0.05), peaking at 60 minutes. TPR significantly increased (P < 0.05) with a maximum of 30 minutes. The volume of plasma removed directly influenced CO, CI, and SV changes (P < 0.05).

DISCUSSION

LVP induced transient hemodynamic alterations, primarily affecting CO and TPR. Despite fluid replacement, significant changes occurred, highlighting the need for close CO monitoring, especially in GBS patients with potential autonomic dysfunction.

CONCLUSION

LVP significantly alters hemodynamics, impacting CO and TPR. Standard monitoring might miss these changes, emphasizing the importance of NICOM, particularly in neurological patients. Further research is warranted to solidify NICOM's role in optimizing LVP protocols and improving patient outcomes.

Acceptability of a physiotherapy-led intensive prone positioning service in intensive care: A qualitative study with multidisciplinary clinicians

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic resulted in an increased number of patients with COVID-19-related respiratory failure requiring prone positioning. To reduce pressure on nursing and medical staff in the intensive care unit (ICU), a physiotherapy-led intensive prone positioning (PhLIP) service was implemented.

OBJECTIVES

The aim of this study was to explore the acceptability of the PhLIP service from the perspective of nurses and doctors working in the ICU and the physiotherapists who delivered the service.

METHODS

A qualitative evaluation was conducted using semistructured interviews and focus groups, guided by the theoretical framework of acceptability (TFA). Participants included doctors, nurses, and physiotherapists who interacted with or delivered the PhLIP service.

RESULTS

A total of 19 interviews (eight doctors and 11 physiotherapists) and four focus groups (13 nurses) were conducted. Eleven themes were identified within the eight domains of the TFA. Overall, the PhLIP team was highly valued and appreciated (TFA: affective attitude); enabled high-quality care and improved ICU efficiency (TFA: perceived effectiveness); reduced risks to patients and staff (TFA: perceived safety and risk); and was empowering for the clinicians involved (TFA: self-efficacy). Being in the PhLIP team was physically and mentally exhausting, and the service put strain on the physiotherapy department due to reallocation of staff (TFA: burden). Having trust in the physiotherapists leading the prone positioning service was a key influence on nursing and medical acceptance of the service.

CONCLUSION

The PhLIP team delivered an acceptable service that improved clinical care and efficiency during the COVID-19 pandemic. Other ICUs should consider the availability, skills, and confidence in the team selected to implement an intensive prone positioning service, should the need arise again. Researchers using the TFA to explore acceptability of healthcare innovations should also consider the recipients' trust in those delivering the intervention.

Efficacy of adjuvant use of midodrine in patients with septic shock: An open label randomized controlled trial

BACKGROUND

Midodrine has been primarily studied as an adjunctive oral therapy to reduce the need for vasopressors in intensive care units (ICU). Nonetheless, the available results evaluating midodrine as an adjuvant therapy in the treatment of septic shock are limited and inconclusive. This study aims to evaluate the efficacy of midodrine, specifically focusing on its effect on mortality outcomes in patients with septic shock.

METHODS

This was an open-label randomized controlled trial. Patients with septic shock (n = 100) were randomized to either the control group, who received intravenous norepinephrine, or the midodrine group, who received intravenous norepinephrine and midodrine 10 mg every 8 h. The primary outcome was the 28-day in-hospital mortality. Secondary outcomes were 7-day ICU mortality, average dose of norepinephrine, duration of intravenous norepinephrine, ICU length of stay (LOS), and in-hospital LOS.

RESULTS

The 28-day mortality rate was 68% in the control group compared to 54% in the midodrine group (risk difference -14% (95% confidence interval (CI)) -32.9% to 4.9%). Similarly, the 7-day ICU mortality rate was 56% in the control group and 42% in the midodrine group (risk difference -14% (95% CI -33.4% to 5.4%)). The average intravenous norepinephrine dose in the midodrine group was significantly lower compared to the control group (mean difference 0.06 (95% CI 0.01-0.11), p = 0.002). However, midodrine did not have a significant impact on the duration of intravenous norepinephrine use (mean difference 0.66 (95% CI -0.56 to 1.88)). Midodrine did not significantly shorten the course of hospitalization. There was no significant difference in median ICU LOS between the control group and the midodrine group (4 vs. 5 days, respectively).

CONCLUSION

The findings did not demonstrate a significant reduction in mortality with adjuvant midodrine use in the treatment of septic shock. Midodrine appears to reduce the need for vasopressors. However, our findings did not support that midodrine shortens the duration of vasopressor use nor the course of hospitalization for patients with septic shock.

An Investigation of the Barriers to Care of Adult Patients With a Tracheostomy in Intensive Care Units and General Wards: Secondary Analysis of Qualitative Interview Data

AIMS AND OBJECTIVES

To investigate the barriers experienced by intensive care nurses and registered nurses and to provide optimal nursing for adult patients with a temporary tracheostomy in intensive care and general wards.

BACKGROUND

Tracheostomy is widely used in intensive care units, around 20% of intensive care unit patients undergo tracheostomy insertions and expect high quality of care. Caring for patients with a tracheostomy is complex and challenging task. An investigation of barriers to care for adult patients with a temporary tracheostomy in a hospital setting is essential to ensure that these patients receive the highest quality of care and to identify areas for improvement.

DESIGN

This paper applied secondary analysis to data from two qualitative studies, including narrative interviews and maximum variation sampling.

METHODS

Secondary analysis of primary qualitative datasets is appropriate when the analysis extends rather than exceeds the primary. The analysis was based on interview data collected from six intensive care nurses and six registered nurses from two university teaching hospitals in Norway. The interviews were audio-recorded and transcribed. The data was analysed using the qualitative analysis suggested by Graneheim and Lundman. This study adhered to the consolidated criteria for reporting in a qualitative research (COREQ) checklist.

RESULTS

Four main themes were identified as barriers to care for adult patients with a temporary tracheostomy in the hospital: encountering ambivalence, inadequate staffing levels, lack of patient continuity of care and lack of systematic follow-up.

CONCLUSIONS

Understanding barriers to care is crucial for hospitals and healthcare organisations to develop targeted interventions and educational programs to address these barriers and improve the care provided to adult patients with tracheostomies in hospital settings.

Perioperative Penicillin and Cephalosporin Antibiotic Allergy Assessment and Testing: The PREPARE Pilot Randomized Clinical Trial

Importance

Antibiotic allergy labels (AALs) impact patient health and perioperative outcomes. Antibiotic allergy delabeling could improve antibiotic prescribing and infection-related outcomes perioperatively.

Objective

To assess the feasibility and safety of antibiotic allergy assessment and delabeling in anesthesiologist-led preoperative assessment clinics and expand delabeling efforts outside of specialist allergy clinics.

Design, Setting, and Participants

This randomized clinical trial was a multicenter, phase 2 feasibility and safety trial conducted between December 14, 2020, and October 31, 2023, at outpatient preoperative anesthesiologist-led clinics at 3 tertiary hospitals in Melbourne, Australia. Participants were adults (age ≥18 years) with a reported β-lactam AAL likely to require intravenous antibiotic therapy for perioperative prophylaxis. Randomization was carried out on a 1:1 basis.

Interventions

Enhanced allergy assessment by anesthesiologists using a smartphone application with a decision support algorithm adapted from a validated antibiotic allergy assessment tool. Risk scores guided antibiotic allergy testing: direct oral challenge (low risk) or skin testing followed by oral challenge (medium to high risk).

Main Outcomes and Measures

The 2 primary feasibility outcomes were the proportion of patients randomized to intervention who received intervention per protocol and proportion of patients consenting to participate out of all eligible. The primary safety outcome was the proportion of the intervention group experiencing an antibiotic-associated adverse event (AE) within 90 days postsurgery.

Results

Of 150 patients enrolled, 74 were randomly assigned to receive the intervention and 76 to control. The median age was 67 years (range, 28-89 years); 78 (52%) were female and 72 (48%) were male. For feasibility of recruitment, 150 of 511 patients (29.4%; 95% CI, 25.4%-33.5%) with eligible AALs were enrolled. For feasibility of intervention delivery, 47 of 74 patients (63.5%; 95% CI, 51.5%-74.4%) randomized to intervention had allergy testing; 28 of 30 patients (93%) assessed as low risk and 19 of 44 patients (43%) assessed as moderate/high risk proceeded to allergy testing. Antibiotic-related AE were reported in 4 of 74 intervention patients (5.4%, 95% CI, 1.5%-13.3%), 1 event was immune mediated (benign rash) without a delay to surgery. There was less restricted antibiotic use in the intervention group (6 patients; 10.7%) compared with the control group (10 patients; 17.9%).

Conclusions and Relevance

Low-risk β-lactam AAL were successfully evaluated and delabeled by anesthesiologists in the preoperative clinic using the intervention. The absence of severe AE after the intervention provides reassurance that antibiotic allergy delabeling can be achieved as part of a preoperative workup without delaying surgery and may improve the choice of preferred β-lactam prophylaxis.

Trial Registration

anzctr.org.au Identifier: ACTRN12620001295932.

The "SOOTEST-ICU" bundle for optimizing cerebral hypoxia and reperfusion to minimize brain injury after resuscitation from cardiac arrest

BACKGROUND

Post-cardiac arrest brain injury remains the leading cause of mortality and long-term disability in patients following cardiac arrest (CA). However, optimizing clinical management strategies for bundled therapy after CA still faces challenges.

METHODS

For this literature review, we searched PubMed, Web of Science, and SpringerLink databases for high-quality studies published between December 1982 and July 1, 2024. The search included randomized clinical trials, meta-analyses, systematic reviews, and observational studies. References in included studies were also checked to identify additional sources.

RESULTS

Many studies have identified potential targets for interventions to mitigate brain injury and improve outcomes for post-resuscitated patients. To optimize clinical management strategies to minimize brain injury after CA, we developed the acronym "SOOTEST-ICU" bundle, which includes "SOOTEST" therapy to optimize peripheral oxygen delivery and "ICU" intervention to optimize the cerebral oxygen cascade. The order of the "SOOTEST" treatment was organized based on the severity and importance of brain oxygen affecting brain injury. It includes systolic blood pressure and mean arterial pressure management, oxygenation and ventilation management, original etiological treatment, temperature control, electrolytes and acid basic status, seizure control, and targeted substrate delivery. The acronym "ICU" intervention includes intracerebral oxygen delivery, cerebral oxygen diffusion, and oxygen utilization.

CONCLUSION

The "SOOTEST-ICU" therapy is developed to optimize oxygen and substrate cascades to minimize brain injury after CA.

The Liver Intensive Care Unit

Major advances in managing critically ill patients with liver disease have improved their prognosis and access to intensive care facilities. Acute-on-chronic liver failure (ACLF) is now a well-defined disease and these patients can be fast-tracked for liver transplantation (LT) with good outcomes if there are no contraindications. In acute liver failure, plasma exchange has improved prognosis for patients not eligible for immediate transplant. Further advances in novel therapies and refinement of the criteria for early LT in ACLF and also clinical implementation of artificial intelligence tools will probably constitute the next major breakthroughs in critically ill patients with liver disease.

CDSS score is favorable to ISTH score on outcomes for disseminated intravascular coagulation in patients with liver transplantation: a retrospective cohort study

Background

Limited data are available regarding disseminated intravascular coagulation (DIC) scores after liver transplantation (LT). As Chinese DIC Scoring System (CDSS) is widely accepted for assessing coagulation in China, this study was aimed to investigate the prognostic value of CDSS scores in patients with undergoing LT.

Method

A retrospective cohort study was conducted on patients who underwent LT from November 2009 to October 2021. We validated CDSS criteria by comparing with International Society on Thrombosis and Hemostasis (ISTH) score. Additionally, its prognostic value was evaluated with receiver operating characteristic (ROC) curves and odds ratio based on mortality rates at 28, 60, and 90 days, as well as the correlations between the CDSS score and acute physiological and chronic health assessment II (APACHE II), sequential organ failure assessment (SOFA) scores at 90-day mortality.

Results

A total of 569 LT patients were enrolled, of which 80 patients developed DIC with CDSS score and 305 patients with ISTH score. Patients with DIC using the CDSS exhibited higher APACHE II and SOFA scores than those with ISTH score. The incidences of acute kidney injury, infection, lymphocytopenia and mortality were higher in DIC patients with CDSS than in those with ISTH. When assessing the prognostic value for 28-day mortality, the CDSS demonstrated higher sensitivity (64.61% vs. 50.77%), but lower specificity (73.62% vs. 88.89%) compared to the ISTH, the areas under ROC (AUC) for the CDSS and ISTH scores were 0.739, 0.741 (p < 0.05) and the odds ratios (OR) for the CDSS and the ISTH were 6.228, 3.597, respectively (p < 0.05). The ORs for predicting mortality with 60-day (7.719 vs. 3.95) and 90-day (7.582 vs. 3.95) criteria with CDSS were higher than those with ISTH (p < 0.05). The Spearman's rank correlation coefficients between the CDSS and APACHE II scores, and the SOFA scores were 0.217 and 0.422, respectively, compared to 0.19 and 0.371 for the ISTH score (p < 0.001).

Conclusion

Disseminated intravascular coagulation presents a life-threatening complication in perioperative period of LT. The CDSS score has better prognostic value than the ISTH score for DIC patients after LT. A prospective randomized controlled study should be designed to further evaluate the findings.

Recruitment and retention of intensive care unit survivors in follow-up studies: A systematic review

BACKGROUND

Engaging intensive care unit survivors in research is challenging. Studies have reported recruitment and attrition rates; details are lacking on retention strategies and attrition.

OBJECTIVE

The aim of this study was to explore barriers and enablers to recruitment and retention in research of people post intensive care discharge.

METHODS

A convergent mixed-method review using the Joanna Briggs Institute (JBI) methodology considered studies that reported on recruitment, retention, and attrition rates of adult post-intensive care survivors in longitudinal studies. CINAHL Ultimate (CINAHL+), PubMed, Excerpta Medica Database (EMBASE), PsycINFO, Scopus, Proquest Health, and Medical Collection were searched in March 2024 using Medical Subject Headings terms and keywords related to post-intensive care survivors, patient selection, and research in peer-reviewed journals or theses published in English. Risk of bias was assessed with JBI's critical appraisal tools. Qualitative data were extracted and themed, and quantitative data were extracted using predefined data fields and qualitised. Synthesis was guided by the JBI mixed-method convergent integrated approach.

RESULTS

A total of 1608 records were identified; 12 high-quality articles were included, with a total of 2551 participants. Studies focussed on outcome measures following hospital discharge to the community. Three superordinate and eight subordinate themes emerged: factors influencing participation/nonengagement, retention strategies, and researcher insights. Attrition was predominantly due to mortality or ill health. Non-health-related themes included transport difficulties, expense, and inconvenience. Challenges included symptoms triggered by participation, being unaware of appointments, and not understanding study requirements. Enabling strategies included reminder calls, letters, cards, and home visits. Researcher insights included the impact of critical illness on survivors' wellbeing, finances, and communication challenges.

DISCUSSION

Recruitment and retention strategies were under-reported. Person-centred approaches considering survivors' challenges may increase recruitment and retention. Retention strategies should be evaluated to determine the impact on engagement or withdrawal from studies. The strong likelihood of attrition should be factored into sample size calculations to reduce risk of bias in longitudinal studies.

REGISTRATION

This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO [CRD42022315688]).

Experiences and Educational Needs of Hospital Staff Providing Care to Tracheostomy-Dependent Pediatric Patients

OBJECTIVE

To assess the experience and educational needs of hospital staff who care for pediatric patients with tracheostomies.

STUDY DESIGN

Staff were surveyed and participated in semi-structured, facilitated focus groups regarding their experiences caring for children with tracheostomies and their educational needs. Survey data were analyzed using descriptive statistics and Kruskal-Wallis nonparametric tests. Focus groups were transcribed verbatim and coded for thematic analysis.

RESULTS

Pediatric advanced practice providers, nurses, physicians, and respiratory therapists (152/353, 43%) completed the survey. Within the last year, 76% of staff had worked with a tracheostomy-dependent child. However, up to 59% of staff had not performed at least one tracheostomy skill (e.g., tracheostomy site assessment, tube change, etc.). Staff reported the least confidence in changing tracheostomy tubes and using home ventilators and rated these skills as most important for additional education. Forty-three staff members participated in 1 of 10 focus groups. Three themes were identified: building staff competencies in tracheostomy care, promoting the caregiver development of tracheostomy skills, and building caregiver preparedness for home life. Staff emphasized the need for participating in emergency simulations and developing their skills to better prepare caregivers for home life. They indicated a need to streamline the discharge process, gain knowledge of community resources, and develop a standardized team to provide discharge teaching.

CONCLUSIONS

Hospital staff responsible for providing care to tracheostomy-dependent pediatric patients had limited opportunities to learn and maintain their skills. Survey and focus group findings can guide development of continuing education to optimize the care of tracheostomy-dependent children.

Comparison of Postoperative Analgesic Profiles Between Transversus Abdominis Plane Block and Local Wound Infiltration in Living Donor Kidney Transplantation Recipients: A Propensity Score-Matched Analysis

Effective postoperative pain management is crucial for optimizing recovery and clinical outcomes in living donor kidney transplantation (LDKT). This retrospective study compared the efficacy and safety of transversus abdominis plane (TAP) block and local wound infiltration (LWI) for postoperative analgesia. A total of 524 LDKT recipients, matched through propensity scoring, were analyzed (262 per group). Pain intensity was assessed using the visual analog scale (VAS) at multiple postoperative time points, while opioid consumption was evaluated based on intravenous patient-controlled analgesia (IV-PCA) usage and rescue fentanyl doses. The TAP block group had significantly lower VAS pain scores at 1, 4, and 8 h postoperatively (p < 0.001) and required fewer opioids, as evidenced by reduced IV-PCA usage (55.9 ± 10.2 mL vs. 69.7 ± 18.2 mL; p < 0.001) and lower rescue fentanyl doses (67.7 ± 30.6 µg vs. 119.1 ± 71.8 µg; p < 0.001). Despite these differences in analgesic efficacy, no significant differences were observed between the groups in terms of postoperative nausea and vomiting or complications such as systemic toxicity and nerve injury. These findings suggest that the TAP block provides more effective early postoperative pain relief and reduces opioid requirements without increasing adverse events. Given its favorable safety profile and effectiveness, the TAP block is a valuable component of multimodal analgesia in LDKT recipients, supporting enhanced recovery while minimizing opioid-related complications.

Emergency medicine updates: Cardiac arrest airway management

INTRODUCTION

Cardiac arrest is the loss of systemic circulation. The approach to airway management is an important component of the resuscitation of patients in cardiac arrest.

OBJECTIVE

This paper evaluates key evidence-based updates concerning airway management in cardiac arrest.

DISCUSSION

Management of cardiac arrest focuses on cardiopulmonary resuscitation (CPR), including high-quality chest compressions and ventilation. Resuscitation should prioritize circulation with high-quality compressions, but as the resuscitation continues, airway management is necessary to provide ventilation. During initial CPR efforts, a compression to ventilation ratio of 30:2 is recommended. Bag-valve-mask (BVM) ventilation is an effective means of ventilation during CPR efforts, though providers should ensure appropriate mask seal with a two-person BVM strategy (one person holding the mask and one person ventilating) if possible. Breaths should be provided over less than 1 s with enough tidal volume to cause chest rise. Advanced airways include a supraglottic airway (SGA) or endotracheal tube via endotracheal intubation (ETI). If an advanced airway is present, one asynchronous ventilation should be provided every 8-10 s. An advanced airway may be considered with an asphyxial cause of arrest, those with prolonged arrest or transport, and cases managed with limited numbers of experienced personnel, though compressions must not be interrupted for placement of an advanced airway. An SGA is a viable option for an advanced airway. In settings with high ETI success rate, ETI may be performed, but in other settings SGA is recommended. If performing ETI, video laryngoscopy is associated with an improved view of the glottis and higher first pass success compared to direct laryngoscopy. Cricoid pressure is not recommended. Confirmation of ETI is necessary. Following ETI and return of spontaneous circulation, a lung protective strategy of ventilation is recommended while avoiding hypoxia.

CONCLUSIONS

An understanding of literature updates regarding airway management can improve the ED care of patients in cardiac arrest.

Management of adults with a tracheostomy: An international survey of speech-language pathologists' practice

PURPOSE

Speech-language pathologists are specialists in communication, swallowing, and weaning as core members of the multidisciplinary tracheostomy team. Inconsistent tracheostomy care is known to result in staff and patient frustration, delayed intervention, and patient harm. Little is known about international speech-language pathology tracheostomy practices.

METHOD

This global survey explored training, clinical practices, perceived knowledge, skills and roles, as well as barriers to change and successes. Questions consisted of likert scale and open-ended questions. 1 458 Speech-language pathologists completed the survey representing six continents and 52 countries.

RESULT

Overall, speech-language pathologists were confident in their knowledge and skills. Tracheostomy teams were viewed as a key facilitator of best care. Access to Flexible Endoscopic Evaluation of Swallowing was variable and considered valuable by all. Four key themes emerged: Knowledge and skills, roles and multidisciplinary tracheostomy team relationships, written documentation and protocols, and access to resources. Multidisciplinary tracheostomy team relationships and being valued as a professional were the most common concerns. Speech-language pathologists had a plethora of successes to share that had changed their workplace.

CONCLUSION

This survey shows speech-language pathologists are aligned internationally with common purpose and values. Speech-language pathologists voiced challenges in multidisciplinary tracheostomy team relationships, standardising practice, and resourcing. Benchmarking is the first step to targeted change and we hope this will support and empowerclinicians to continue to innovate tracheostomy practice.

Comparative balanced salt solution and 6 ​% hydroxyethyl starch in goal-directed therapy for major abdominal surgery: A systematic review and meta-analysis

Goal-directed fluid therapy (GDFT) improves postoperative outcomes in various surgeries, but the optimal fluid choice between balanced salt solutions (BSS) and hydroxyethyl starch (HES) remains debated. This meta-analysis compared postoperative outcomes of GDFT using BSS versus 6 ​% HES in elective major abdominal surgery. Comprehensive database searches identified eight RCTs (1739 patients) published between 2000 and 2024. No significant differences were found in overall postoperative complications [RR 1.04 (95 ​% CI 0.90-1.20); p ​= ​0.59], including renal, cardiovascular, respiratory complications, or mortality. However, BSS required significantly higher intraoperative fluid volumes [SMD 0.61 (95 ​% CI 0.42-0.80); p ​< ​0.001] and led to greater postoperative fluid balance [SMD 0.39 (95 ​% CI 0.20-0.59); p ​< ​0.001]. 6 ​% HES should not be used routinely. GDFT using BSS achieves the same outcomes at a lower cost and without the risk of bleeding.

Incidence and Associated Risk Factors for Falls in Adults Following Critical Illness: An Observational Study

OBJECTIVE

To explore the incidence of falls and associated risk factors in the first year after hospital discharge in survivors of critical illness.

DESIGN

Prospective single-site observational study.

SETTING

University-affiliated mixed ICU.

PATIENTS

One hundred ICU adults who required invasive ventilation for 48 hours and in an ICU for at least 4 days.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Falls were monitored prospectively for 1 year with completion of monthly falls calendars. Falls data included the number of people who had falls/no falls/recurrent falls, falls rate per person per year, and time to first fall. Fall severity was classified according to the Schwenck classification scheme to examine injurious falls requiring medical intervention. Other outcomes considered included assessments of balance, strength, function, cognition, psychologic health, and health-related quality of life. One hundred participants (31% female) were recruited with a mean age of 58.3 ± 16.2 years, and a median ventilation duration of 6.3 days [4.0-9.1]. Sixty-one percent fell at least once in the first year with the majority sustaining two or more falls (81.4%) and one in four sustained an injurious fall requiring medical attention. The falls incidence rate was 4.4 falls per person-year (95% CI, 3.2-5.9), with the highest incidence occurring less than 3 months after hospital discharge (5.9 falls/person-year [95% CI, 4.4-7.8]). Time to first fall or injurious fall was 36 [11-66] and 95 (95% CI, 40-155) days, respectively. Key risk factors for falls at the time of hospital discharge include comorbidities, higher discharge medications, balance, and muscle strength.

CONCLUSIONS

There was a high falls incidence in ICU survivors. The study findings suggest a critical window may exist within the first 3 months after hospital discharge and the need for screening, pharmacological optimization, and exercise training in this patient group.

Technology-based challenges of informal clinical communication in an Australian tertiary referral hospital: a survey-based assessment of user perspectives

BACKGROUND

Clinical communication failures result in errors, misdiagnosis, inappropriate treatment and poor care. Communication errors contribute to sentinel events and are an underlying factor in healthcare system issues.Formal clinical communication (FCC) tools, such as ISBAR (Identify, Situation, Background, Assessment, Response/Recommendation), improve patient outcomes. FCC governance is focused on electronic medical records (EMRs); however, much informal clinical communication (ICC) occurs outside of the EMR.ICC involves disparate platforms including pagers, SMS texts, encrypted messaging apps, phones and local radio networks. Documentation of ICC in the clinical record is low quality and not easily or routinely audited.

LOCAL PROBLEM

In 2019, our institution commenced a clinical governance assessment of ICC processes against version 2, Australian National Accreditation Standards for clinical communications. Process mapping of ICC indicated a paucity of relevant policy and procedures to govern ICC practices, with highly variable and overly complex processes.

AIMS

To document the technology used in informal communication between clinical and/or administrative staff.To document the self-perceived impact on staff of current communications methods.To document the self-perceived potential efficiency and safety impact of current communications methods.To identify key factors for consideration in organisation-wide informal clinical communication improvement.

METHOD

Multidisciplinary online staff cross-sectional survey using Microsoft Forms.

RESULTS

115 self-selected clinical and administrative staff completed the survey. Multiple communication channels are used for ICC. Respondents noted high levels of frustration, delay, interruption and inefficiency. Desired communication improvements and use considerations were identified.

CONCLUSIONS

There are gaps in governance standards for ICC. Sequential additions to technology platforms contribute to a high-risk communications environment. Staff perceptions of inefficiency, delay, frustration and a high level of patient safety risk were consistent across professions. This work informed the requirements for a subsequent development of an enterprise platform dedicated to improving ICC.

Effects of Nefopam on Postoperative Analgesia in Operating Room-Extubated Patients Undergoing Living Donor Liver Transplantation: A Propensity Score-Matched Analysis

In patients undergoing living donor liver transplantation (LDLT) with immediate postoperative extubation in the operating room (OR), rapid recovery of consciousness and spontaneous ventilation are essential, requiring effective analgesia without compromising respiratory function. This study evaluated whether intraoperative nefopam administration improves early postoperative pain control and reduces opioid consumption in this physiologically distinct population. A retrospective cohort of 376 adult LDLT recipients who met the criteria for OR extubation was analyzed. After propensity score matching, 182 patients who received intraoperative nefopam were compared with 182 matched controls. Pain intensity was measured using the visual analog scale (VAS), and total fentanyl consumption and opioid-related complications were recorded over the first 24 h postoperatively. Nefopam administration was associated with significantly lower VAS scores during the first 12 h after surgery (p < 0.001) and reduced 24 h fentanyl consumption (53.2 ± 20.8 mL vs. 58.6 ± 27.5 mL, p = 0.035). No serious adverse effects related to nefopam were observed. The incidence of postoperative nausea and vomiting did not differ significantly between the groups. These findings indicate that nefopam offers effective early analgesia and an opioid-sparing effect in LDLT recipients undergoing OR extubation, suggesting its clinical utility as a component of multimodal analgesia in this high-risk group. Although the reduction in opioid use did not translate into a decreased incidence of opioid-related complications, the favorable safety profile and analgesic efficacy of nefopam support further investigation through prospective trials to define its role in enhanced recovery protocols for OR-extubated LDLT recipients.

Contraindications to Whole-Body Cryostimulation (WBC). A position paper from the WBC Working Group of the International Institute of Refrigeration and the multidisciplinary expert panel

Background

Whole-Body Cryostimulation (WBC) is a treatment that involves short exposures of the entire body to very cold and dry air in specially adapted cryochambers. A growing body of literature suggests the safe application of this technique in medical settings.

Aim

The primary purpose of this study was to generate an international consensus on the updated contraindications for WBC through an interactive process of questionnaire interspersed with controlled feedback from a steering committee.

Design

The study design was based on a systematic review of the literature and Delphi methodology.

Setting

Administration of electronic online questionnaires concerning contraindications to WBC.

Population

A multidisciplinary panel of 48 experts in the fields of rehabilitation, cardiology, neurology, endocrinology, oncology, clinical nutrition or in the clinical application of WBC was invited to participate in this consensus study.

Methods

A systematic search of PubMed, Scopus and Embase databases was carried out to identify possible items for inclusion in a form. A two-round Delphi survey was then conducted according to international guidelines, consisting of an electronic online questionnaire. The experts had to rate their agreement with each item in the questionnaires on a 5-point Likert scale. Expert consensus was assessed.

Results

A total of 28 European experts participated in the Delphi survey. The first round consisted of 59 items, 3 of which were discarded after data analysis. The second round was rearranged according to the previous suggestions of the panellists. All 28 experts completed the two rounds. At the end of the survey, consensus was reached and a final list of temporal and absolute contraindications to WBC was identified.

Conclusions

This process resulted in multidisciplinary expert consensus statements on contraindications to WBC. The European experts agreed on most of the decisions and produced a list of contraindications.

Clinical rehabilitation impact

The results provide a robust evidence framework to help clinicians improve clinical practice and patient safety.

Association of Admission Times on Mortality in Adult Patients with Severe Community-Acquired Pneumonia

ObjectivesThe objective of this study was to examine the association between admission time and in-hospital mortality in patients with severe community-acquired pneumonia.Research DesignThe study population consisted of individuals who were enrolled between January 2019 and December 2023. These individuals were divided into two groups based on the time of admission: daytime admission from 8:00 am to 6:00 pm and nighttime admission from 6:00 pm to 8:00 am The primary endpoint of the study was in-hospital mortality. Binary logistic regression was employed to assess the association between admission time and in-hospital mortality.ResultsA total of 307 patients with severe community-acquired pneumonia were ultimately enrolled in the study. Of the total number of patients, 57% (175 patients) were admitted at night. A comparative analysis of the clinical outcomes in the two groups revealed that the mortality rate for patients admitted at night was 28%, which was not significantly different from that of patients admitted during the day, which was 35.6% (P = .155). The findings from binary logistic regression analyses revealed no statistically significant correlation between nighttime admissions and in-hospital mortality.ConclusionsThis study's findings indicate that nighttime admission for patients diagnosed with severe community-acquired pneumonia is not associated with an elevated risk of mortality. Conversely, there may be a reduced mortality rate for patients admitted during nighttime hours. However, further prospective multicenter studies are required in the future to confirm this.

Lack of Association Between Intraoperative Hypotension and Postoperative Acute Kidney Injury in Patients Undergoing Pancreaticoduodenectomy: A Retrospective Cohort Study

Background: Acute kidney injury (AKI) is a common postoperative event. Previous research suggests that intraoperative hypotension (IOH) is associated with postoperative AKI. This connection, however, has not been studied in patients undergoing pancreaticoduodenectomy. Methods: Based on a retrospective cohort study, we analyzed 844 adult patients who had pancreaticoduodenectomy between December 2016 and June 2020 in Henan Provincial People's Hospital. We graphically modeled the associations between the lowest intraoperative systolic and diastolic pressure and AKI using a restricted cubic spline with all covariates adjusted. The association between time under the above-specified systolic blood pressure (SPB) and diastolic blood pressure (DBP) thresholds and AKI, respectively, was investigated using logistic regression models. We further tested the robustness of our findings with a sensitivity analysis. Results: AKI occurred in 98 (11.6%) of the 844 patients in this cohort. Blood pressure components below the thresholds of 100 mmHg for systolic and 60 mmHg for diastolic were visual change points associated with increasing odds of AKI. The median (IQR) time under SBP < 100 mmHg was 15.0 (0, 40) min and 65.0 (18.8, 105.4) min for DBP < 60 mmHg. Time spent under the threshold of SBP less than 100 mmHg and DBP less than 60 mmHg was not significantly associated with AKI. Conclusions: We found no relationship between IOH and postoperative AKI after pancreaticoduodenectomy. More research is needed to investigate the complex aspects influencing intraoperative blood management in order to lessen the occurrence of AKI.

Effect of Intraoperative Nefopam on Postoperative Analgesia in Living Liver Donors Undergoing Laparoscopic Hepatectomy with Transversus Abdominis Plane Block: A Propensity Score-Matched Study

Laparoscopic surgery reduces tissue trauma and accelerates recovery, but postoperative pain remains a concern. Opioids are effective but have adverse effects, highlighting the need for multimodal analgesia. Nefopam, a non-opioid analgesic, provides pain relief without respiratory depression or dependence. This study aims to investigate the efficacy of intravenous nefopam combined with a transversus abdominis plane (TAP) block in living liver donors undergoing laparoscopic hepatectomy. This retrospective cohort analysis was conducted on 452 adult living donors who underwent laparoscopic hepatectomy with a TAP block between August 2013 and August 2018 at a single tertiary medical center. After propensity score matching, 296 patients were included, with 148 in the nefopam group and 148 in the non-nefopam group. The primary outcomes assessed were pain scores using the Numeric Rating Scale (NRS) at 1, 4, 8, 12, and 24 h postoperatively, opioid consumption, postoperative nausea and vomiting, and nefopam-related adverse effects. Nefopam significantly reduced NRS at 1, 4, and 8 h postoperatively (p < 0.001) and decreased fentanyl use in the post-anesthesia care unit (26.0 ± 32.2 μg vs. 60.5 ± 37.9 μg, p < 0.001) and total intravenous patient-controlled analgesia volume (p < 0.001). The incidence of postoperative nausea and vomiting and severe opioid-related complications did not differ between groups. Nefopam-related side effects were mild and self-limiting. Nefopam combined with a TAP block effectively reduces postoperative pain and opioid consumption in living liver donors, supporting its role in multimodal analgesia. Further research is needed to explore its broader applications.

Novel Strategies to Promote Intensive Care Unit Recovery via Personalized Exercise, Nutrition, and Anabolic Interventions

Survivors of critical illness experience significant morbidity, reduced physiologic reserve, and long-term complications that negatively impact quality of life. Although rehabilitative treatments are beneficial during early recovery, there is limited evidence regarding effective multimodal rehabilitation, nutrition, and anabolic nutrient/agent strategies for improving long-term outcomes. This review discusses novel personalized rehabilitation, nutrition, and anabolic nutrient/agent (ie, creatine, β-hydroxy-β-methylbutyrate, testosterone) approaches that allow for precise exercise and nutrition prescription and have potential to improve patient care, address continued medical needs, and optimize long-term recovery. Continued research is needed to further evaluate effectiveness and implementation of these strategies throughout the continuum of care.

Evaluation of a virtual multidisciplinary tracheostomy meeting for ward-based patients

BACKGROUND

Tracheostomy is frequently performed in an intensive care unit setting to progress the care of intubated patients. A multidisciplinary team follows up tracheostomised patients once transferred to the ward. A virtual tracheostomy multidisciplinary meeting (MDM) was established with the aim to standardize care for these patients.

METHODS

A retrospective review of ward-based patients discussed in a Tracheostomy MDM was performed at The Alfred Hospital, a tertiary hospital providing a state-wide trauma service. Two groups were compared; (i) Outreach group comprising patients who were managed prior to the establishment of the Tracheostomy MDM on the 26 July 2021; (ii) Virtual Tracheostomy MDM (V-MDM) group who were managed after the establishment of the Virtual Tracheostomy MDM. Primary outcome was decannulation time from ICU discharge.

RESULTS

There were 65 patients in the Outreach group over 134 weeks. There were 44 patients in the V-MDM group over 94 weeks. There was a significant difference between groups in the median time to decannulation from ICU discharge (P = 0.007) and the overall time to decannulation (P = 0.029) with the V-MDM group requiring a longer period with tracheostomy prior to decannulation. There were no significant differences in the overall hospital length of stay (LOS) or rate of adverse events.

CONCLUSION

Implementing a supplemental Tracheostomy MDM in a virtual format may not improve time to decannulation and can possibly delay decannulation compared to an established tracheostomy team led by ICU clinicians. Virtual Tracheostomy MDM may have a role in managing patients were a non-virtual ICU-led team is not feasible.

2024 update of the AGIHO guideline on diagnosis and empirical treatment of fever of unknown origin (FUO) in adult neutropenic patients with solid tumours and hematological malignancies

Febrile Neutropenia is an emergency in the treatment of cancer patients. It requires prompt and evidence-based clinical and antimicrobial management. The implementation of standard operating procedures (SOP) across hospitals and outpatient cancer departments can improve the outcome of FN patients by reducing FN-related morbidity and mortality and by the continuation of cancer treatment. This guideline describes an evidence-based approach to risk stratification, epidemiology, diagnosis, and treatment. It is provided by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and is an update of the 2017 version. Emerging aspects in epidemiology, diagnostic procedures, risk stratification, first-line antimicrobial treatment, empiric antifungal treatment and the duration of antimicrobial treatment are discussed and rated on evidence-based strength of recommendation and quality of evidence as described by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). By this, the aim of this guideline is to provide evidence-based recommendations on the management of febrile neutropenia in cancer patients for the practicing clinician.

Effect of Home Care on Physical Function in Post-Intensive Care Unit Patients: A Meta-Analysis

BACKGROUND

A decline in physical function is commonly observed after patients transition to their homes following hospital admission; this is especially true for patients requiring mechanical ventilation in an intensive care unit (ICU).

OBJECTIVE

This meta-analysis examines characteristics and effects of home-based or outpatient+home-based interventions used to improve physical function post-discharge in patients who received mechanical ventilation in an ICU.

METHODS

PRISMA guidelines were utilized. The literature search was conducted with the assistance of a medical librarian. Study inclusion criteria were post-ICU adult patients receiving mechanical ventilation who then had home-based or outpatient+home-based care to improve physical function after discharge. Effect size (Hedges' g) was calculated with random effects models.

RESULTS

Our search yielded 11 studies that met the inclusion criteria. The majority were randomized controlled trials, with 1 quasi-experimental study. All studies included physical therapists, and 2 included nurses. The 11 studies reported results for 39 physical function measurements. The overall pooled intervention effect across the 4 studies that utilized the 6-minute walk test was 0.32 (95% confidence intervals [CI]: 0.05 to 0.58), for the 3 studies that utilized the Timed Up and Go test it was 1.38 (95% CI: -0.09 to 2.84), and for the 8 studies that used the SF-36 Physical Function subscale, it was 0.31 (95% CI: 0.09 to 0.52).

CONCLUSIONS

This review's findings show that patients may improve their physical function after participating in specific intervention programs that are home-based alone or outpatient+home-based care. However, the effect sizes are small, so it may be useful to explore how to maximize the gains in physical function.