Severe community-acquired pneumonia (sCAP): advances in management and future directions

Severe community-acquired pneumonia (sCAP) is a major global health challenge, with high morbidity and mortality, especially among patients requiring intensive care. Despite advancements in antimicrobial therapies and supportive care, sCAP remains a significant threat, particularly for those needing invasive mechanical ventilation or vasopressor support. Recent progress in diagnostics, therapeutics and management strategies offers hope for improved outcomes. Pathogen-specific management is now central to sCAP care, with molecular diagnostics enhancing pathogen detection accuracy and enabling tailored antimicrobial therapy. These tools help combat antimicrobial resistance by reducing unnecessary broad-spectrum antibiotic use.Host immune responses in sCAP vary widely and significantly impact outcomes. Some patients face an overwhelming pathogen burden, while others experience excessive immune responses, such as acute respiratory distress syndrome. This distinction is vital for guiding immunomodulatory therapies, as immunosuppression may benefit hyperinflammatory states but harm those overwhelmed by infection. Corticosteroids, though controversial, show potential benefits in select populations but carry risks like secondary infections and hyperglycaemia, requiring a nuanced approach.Non-invasive respiratory support strategies, such as high-flow nasal oxygen, have transformed care by improving oxygenation and reducing the need for invasive ventilation. However, their efficacy depends on timing, patient tolerance and disease severity, necessitating careful monitoring.Global disparities in sCAP management, particularly in low-income and middle-income countries, highlight the need for region-specific guidelines and scalable solutions. Limited access to advanced diagnostics and critical care resources exacerbates poor outcomes, underscoring the importance of investments in affordable diagnostics, infection control and multidisciplinary training. Emerging technologies, such as artificial intelligence and advanced imaging, promise to revolutionise sCAP management by enabling precision medicine and real-time insights into disease severity. A holistic, multidisciplinary approach integrating these advancements is essential to improving outcomes and advancing personalised care for this life-threatening condition.

The utility of an algorithm based on procalcitonin monitoring in patients with sepsis

OBJECTIVE

The aim of the study was to develop and validate an algorithm based on procalcitonin (PCT) monitoring to predict the prognosis of patients with sepsis.

DESIGN

The design was a retrospective and observational prospective study.

SETTING

The study was set in intensive care units (ICUs) in 2 different hospitals in Spain.

PATIENTS

Patients in the study included 101 patients with sepsis aged ≥18 years.

INTERVENTIONS

In the retrospective study, PCT results from patients admitted to the ICU in 2011-2012 were collected. In the prospective study, PCT was determined at specific time points as indicated by the algorithm from March 2018 to April 2019. The primary outcome measure, 28-day mortality, was the main variable of interest.

RESULTS

The study developed an algorithm based on early PCT monitoring for predicting the prognosis of patients with sepsis. The algorithm was initially developed retrospectively in 1 cohort and subsequently validated prospectively in another cohort.

CONCLUSIONS

The developed algorithm provides information on the prognosis of patients with sepsis, distinguishing between those with a good prognosis and those with a poor prognosis (defined as mortality).

Exploring fluoroquinolone resistance mechanisms and the effects of carbonyl cyanide 3-chlorophenylhydrazone (CCCP) in Acinetobacter baumannii

Objectives

This study aims to investigate the prevalence and mechanisms of fluoroquinolone resistance in Acinetobacter baumannii strains isolated from hospitals in Hamadan, west of Iran. It investigates the role of specific resistance genes and mutations in contributing to this resistance. In addition, the effects of carbonyl cyanide 3-chlorophenylhydrazone (CCCP) on the susceptibility of A. baumannii to fluoroquinolones will be evaluated to identify potential strategies to combat this growing problem.

Methods

A total of 102 A. baumannii isolates were collected from various clinical specimens between February and August 2023. Antimicrobial susceptibility testing was performed using the Kirby-Bauer disk diffusion method according to CLSI guidelines, focusing on eight antibiotics, including ciprofloxacin and levofloxacin. Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) evaluations were also performed for these fluoroquinolones. The presence of plasmid-dependent fluoroquinolone resistance (PMQR) genes and mutations in the gyrA and parC genes were assessed by PCR. The effect of CCCP on antibiotic susceptibility and expression of efflux pump encoding gene was evaluated by real-time PCR.

Results

The study revealed alarmingly high resistance rates among the 102 A. baumannii isolates, with 97% resistant to imipenem, 96% to gentamicin, 92% to ciprofloxacin, and 86% to levofloxacin. Of the isolates, 87 were classified as multidrug resistant (MDR). Several resistance genes were identified, including qnrS (77.45%), oqxA (73.52%), and qnrA (72.54%). Mutations in the gyrA and parC genes were detected in several isolates, contributing to the observed resistance. In addition, treatment with CCCP resulted in a significant reduction in MICs for both ciprofloxacin and levofloxacin, highlighting its potential role in mitigating resistance.

Conclusion

The findings underscore the urgent need for improved surveillance and treatment strategies due to the high prevalence of fluoroquinolone resistance. While CCCP demonstrated potential in restoring antibiotic susceptibility, further studies are needed to assess its clinical applicability and potential toxicity. Additionally, the study is limited by its focus on a single geographic region, and further investigations across broader populations are necessary to generalize these findings.

Knowledge and Practice of Mechanical Ventilation Humidification Systems in Latin American ICUs

Background: Humidification of inspired gases is critical for maintaining airway integrity in mechanically ventilated patients. However, airway instrumentation and the use of cold, dry medical gases can disrupt this process, necessitating external humidification systems. This study aimed to assess knowledge and practices regarding humidification systems in mechanical ventilation among health care professionals in Latin American ICUs. Methods: A cross-sectional, digital survey was conducted from April to August 2024, targeting ICU professionals across Latin America. The questionnaire assessed operational and clinical knowledge of heat-and-moisture exchangers (HMEs) and heated humidifiers, as well as their use in mechanical ventilation. Participants were recruited through professional societies and personal networks. Data were analyzed using descriptive and inferential statistics, with significance set at P < .05. Results: A total of 510 valid responses were analyzed, representing 20 countries. Most respondents were respiratory therapists (73%) with over 5 years of ICU experience (43%). HMEs were the first-line option for mechanical ventilation in 68% of cases, whereas 69% used humidification systems in noninvasive ventilation, favoring heated humidifiers. The median correct response rate showed significant differences by profession (P < .001) and education level (P < .001). Only 31% of respondents correctly identified the recommended minimum absolute humidity, and only 5.3% reported routine maintenance of heated systems. Conclusions: This study highlights critical gaps in knowledge and practices related to humidification systems in ICUs. The observed differences in performance based on profession and level of training suggest that continuing education and specialization are essential to optimize clinical practice.

Prevalence of Post-intensive care syndrome among intensive care unit-survivors and its association with intensive care unit length of stay: Systematic review and meta-analysis

BACKGROUND

Post-intensive Care Syndrome (PICS) is defined as various physical, psychological, and cognitive, impairments that can arise during an ICU stay, continue after leaving the ICU, or even persist following hospital discharge. It impacts both patients and their family's quality of life. Various primary studies worldwide have reported prevalence of PICS among ICU survivors. However, these studies exhibit inconsistency and wide variations. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence of post intensive care syndrome among intensive care unit survivors along with its association with ICU length of stay.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist for this review. We searched PubMed/Medline, CINHAL, Embase, and Google scholar to retrieve articles. The Newcastle Ottawa Scale (NOS) was used for quality assessment of articles. The random effects model with I-squared test was used to estimate the prevalence of PICS and its association with ICU length of stay. To identify the source of heterogeneity within the included studies, meta-regression and subgroup analysis were used. We employed Egger's regression test and funnel plots for assessing publication bias. STATA version 17.0 software was used for all statistical analyses. A p-value of < 0.05 with 95% confidence interval was used declare statistically significant.

RESULTS

A total of 19 articles with a population of 10179 ICU-survivors were included in this review. The pooled prevalence of PICS was found to be 54.35% (95% CI = 45.54, 63.15). In sub-group analysis by region, the highest prevalence was observed in studies done in south and north America with overall prevalence of 61.95% (95% CI = 28.33, 95.62). Among the three domains of PICS (physical, cognitive and mental domains), the highest prevalence score was observed in the physical domain with overall prevalence of 45.99% (95% CI = 34.66, 57.31). In this meta-analysis, those patients who stayed more than four days in the ICU were 1.207 [95% CI = 1.119, 1.295] times more likely to develop at least one among the three domains of PICS in the post-intensive care period than their counterparts.

CONCLUSION

This systematic review and meta-analysis demonstrate a high prevalence of PICS among ICU survivors, and highlight the significant association between ICU length of stay and the development of PICS. These findings underscore the need for targeted interventions to mitigate the long-term effects of critical illness, particularly for patients with prolonged ICU stays.

Nosocomial Infections in Trauma Patients Receiving Extracorporeal Membrane Oxygenation

Background: The risk of infections in acute trauma patients receiving extracorporeal membrane oxygenation (ECMO) has not been well defined, but this population is among the sickest in the hospital. This study characterizes the blood and respiratory pathogens in trauma patients receiving ECMO and tests the hypothesis that trauma patients receiving ECMO pose a unique risk for nosocomial infections. Methods: All trauma patients (n = 50) who required ECMO at a level 1 trauma center between July 2014 and September 2023 were retrospectively reviewed. Blood and respiratory samples were examined for pathogens. Burn injuries were excluded from this study. Results: Most were male (88%) and sustained blunt injuries (60%), of which the most common mechanism was motor vehicle collision (37%). The median intensive care unit (ICU) length of stay was 26 days (interquartile range [IQR]: 12-54), median ventilator days was 22 (IQR: 9-51), and median length of ECMO treatment was eight days (IQR: 4-18). The most common ECMO type was veno-venous (80%). Blood stream and/or respiratory infections were detected in 22 (44%) patients. The most common was respiratory infection (70.2%). Gram-negative pathogens were most common in both blood stream (53.3%) and respiratory infections (75%). Among the blood stream pathogens, 20% were multi-drug resistant. Among the respiratory pathogens, 41.7% were multi-drug resistant. The median number of days from ECMO cannulation to blood stream infection was 10 days (IQR: 4-16) and the median number of days to respiratory infection was seven days (IQR: 3-11). Mortality was 22.7% (n = 5) among patients who had a respiratory and/or blood stream infection and 60% (n = 17) in ECMO patients who had no infection (p = 0.007). Conclusion: Almost half of trauma patients receiving ECMO had nosocomial infections, which is comparable with the infection rate of trauma patients in the ICU not on ECMO. Larger studies are needed to further assess infection risk in these patients and provide guidelines to mitigate this risk.

Genetic Factors Related to the Development or Progression of Mesoamerican Endemic Nephropathy

Over the past two decades, Mesoamerican endemic nephropathy (MeN) has become a major public health problem in certain regions of Mexico and Central American countries. The etiology of this disease is multifactorial, and important environmental factors have been described, such as chronic heat stress, recurrent episodes of dehydration, infections, and exposure to toxins of chemical and biological origin. Genetic and epigenetic factors have been proposed to play significant roles in MeN. Recent studies have analyzed the role of these factors in MeN. In some cases, these factors appear to be associated with accelerated deterioration of established kidney disease due to preexisting endothelial dysfunction and tubulopathy. In other cases, they appear to be associated with early kidney damage, even before occupational exposure, suggesting that they may play a relevant role in the genesis of the disease. Other factors appear to act as risk reducers for developing MeN in areas with a high prevalence of the disease. Therefore, this disease has a rather complex multifactorial etiology, with possible polygenic contributions, possible epigenetic phenomena, and multiple environmental factors.

Effectiveness of Vascular Catheter Removal Versus Retention in Non-ICU Patients with CRBSI or CABSI in Retrospective, Single-Center Study

Catheter-associated bloodstream infections (CABSIs) and catheter-related bloodstream infections (CRBSIs) are significant causes of morbidity and mortality worldwide. The current practice favors the removal of vascular access devices (VADs); however, the evidence on this topic remains inconclusive. This study evaluates the clinical outcomes in terms of in-hospital mortality and catheter retention vs. removal in CABSI and CRBSI cases. A retrospective, observational, single-center study was conducted at Luigi Sacco Hospital, Milan, Italy (May 2021-December 2023), and it analyzed non-ICU adult patients with VADs diagnosed with CRBSIs or CABSIs. Clinical and microbiological data were collected to assess the outcomes based on catheter management. Among 1874 patients with VADs, 147 were included, with 164 VAD infection events (92 CABSIs and 72 CRBSIs). Overall, 35 (23.8%) patients with CABSIs and CRBSIs died. Out of those who retained the catheter 19 (35.8%) patients died, while among removal patients 16 (17%) died (p = 0.018). A Candida spp. isolation was found to be significantly associated with a higher likelihood of catheter removal (p = 0.04). Our findings suggest that, in non-ICU CRBSI and CABSI cases, VAD removal may be associated with improved outcomes when feasible.

Breastfeeding attributable fraction of triple negative breast cancer in the US

Rates of triple negative breast cancer (TNBC) are higher in Black women than in non-Hispanic White women. Breastfeeding duration and younger age at first birth are known risk factors for TNBC and vary by race. To quantify the contribution of these risk factors to disparities in TNBC, we calculated the population-attributable fraction (PAF). A PubMed search was performed to identify relevant studies and pooled odds ratios for breastfeeding for < 6 months and age at first birth < 25 years were calculated. PAF was calculated using the Levin formula. PAF of breastfeeding for < 6 months was 12% (95% confidence interval (CI) 5-20%) among White women and 15% (95%CI 3-26%) among Black women. We estimate that up to 15% of annual new TNBC in Black women and 12% in White women might be avoided by supporting breastfeeding. Policies supporting breastfeeding could hence reduce TNBC incidence and lessen racial disparities.

Clinical value of calibrated abdominal compression plus transthoracic echocardiography to predict fluid responsiveness in critically ill infants: a diagnostic accuracy study

BACKGROUND

Predicting fluid responsiveness is challenging in infants. It is however crucial to avoid unnecessary volume expansion, which can lead to fluid overload. We tested the hypothesis that the stroke volume changes induced by a calibrated abdominal compression (ΔSV-AC) could predict fluid responsiveness in infants without cardiac disease.

METHODS

This prospective single center study of diagnostic test accuracy was conducted in a general pediatric intensive care unit (PICU). Children under the age of two with acute circulatory failure and requiring a 10 mL.kg-1 crystalloid volume expansion over 20 min, ventilated or not ventilated, were eligible. Stroke volume was measured by transthoracic echocardiography at baseline, during a gentle calibrated abdominal compression (22 mmHg for 30 s), and after volume expansion. The area under the receiver operating characteristic curve (AUROC) of ΔSV-AC was measured to predict fluid responsiveness, defined as a 15% stroke volume increase after volume expansion.

RESULTS

Twenty-seven cases of volume expansion were analyzed, in 21 patients. Seventeen VE cases were administrated to spontaneously breathing children. Fluid responsiveness was observed in 12 cases. The AUROC of ΔSV-AC was 0.93 (95% confidence interval (95%CI) 0.82-1). The best threshold value for ΔSV-AC was 9.5%. At this threshold value, sensitivity was 92% (95%CI 62-100), specificity was 87% (95%CI 60-98), positive and negative predictive values were 85% (95%CI 60-95) and 93% (95%CI 66-99) respectively.

CONCLUSIONS

Echocardiographic assessment of stroke volume changes induced by a calibrated abdominal compression is a promising method to predict fluid responsiveness in infants without cardiac disease hospitalized in PICU.

TRIAL REGISTRATION

ClinicalTrials.gov registration number NCT05919719, June 22, 2023, retrospectively registered, https://clinicaltrials.gov/study/NCT05919719 .

10 key issues for prevention, monitoring and non-pharmacological treatment of delirium in critically ill patients

In intensive care units, due to critical illness nature and environment special characteristics, it is relatively common for admitted patients to develop acute confusional syndrome (ACS) or delirium. The nurse's duties are to carry out interventions that reduce the presentation of this process, which is still an important complication as it is related to longer periods of mechanical ventilation, longer ICU and hospital stays, higher mortality; both in-hospital and after discharge and grater long term cognitive dysfunction. Therefore, nurses participation is essential to prevent and treat delirium, and more specifically in the autonomous part with non-pharmacological measures such as pain control, avoid under or oversedation, promoting restful sleep and facilitating family support among other measures. The objective is to carry out an update that describes 10 key points focused on the tools for detecting/monitoring delirium and non-pharmacological measures for its prevention and treatment. Based on the review of the literature, the 10 most common interventions are described to serve as an action plan to be included in the care plans of patients affected with delirium, providing quality care to prevent and/or treat delirium in critical patients.

Research Ethics Challenges, Controversies and Difficulties in Intensive Care Units-A Systematic Review of Theoretical Concepts

Background: Research in the intensive care unit (ICU), which involves critically ill patients, families and healthcare professionals, poses significant ethical challenges. The aim of this PRISMA-guided systematic review is to identify major challenges for research ethics in the ICU. Methods: Pubmed and Scopus databases were searched in November-December 2024 for papers discussing theoretical concepts or specific aspects related to ethical issues in ICU research, retaining 70 papers on ICU research challenges, difficulties or controversies. Results: A total of 10 papers described general concepts related to research ethics in the ICU, 16 studies focused on the methodology or some of the study steps, and 6 papers focused on ICU trials, while 38 studies focused on special patient categories or special situations of critical patients. None of the included papers addressed all of the issues we identified regarding the ethical challenges. Conclusions: ICU research is challenging from a moral point of view. Significant ethical difficulties arise during the design and implementation phases, hampering the study's exactness. Being a vulnerable population with limited decision-making capacity and research-associated risks, alternative consent methods need to be considered. This systematic review provides a checklist of aspects that could generate ethical dilemmas and might constitute a starting point in the conduct of research studies, preventing unethical research.

Analysis of the nurse workload and impact of patient volume and flow in a Surgical ICU

INTRODUCTION

A poor Nurse-to-Patient (N:P) ratio has a negative impact on the health of both patients and professionals. There are several tools to quantify the Nurse Workload (NW) and adjust nurse staffing. The use of such tools in the Intensive Care Units (ICU) can facilitate the adaptation of Nursing resources to patients' real needs and improve working conditions.

OBJECTIVE

To determine the NW in a Surgical ICU.

METHODOLOGY

Descriptive, transversal and unicentric study during March and April 2023. Determination of the operative N:P ratio adequated to the NW using the "Nursing Activities Score" (NAS). Measurement of the NW using NAS and "Valoración de Cargas de Trabajo y Tiempos de Enfermería" (VACTE) scales, together with the proposed NW indicators. Management and efficiency analysis of the Nursing Resources using the "Work Utilization Ratio" Index (WUR). Identification of work days and shifts with greater workload. Bivariate analysis relating NAS and VACTE to reason for admission. Calculation of the NW of each reason for admission relating the stay average and its NAS and VACTE average. Correlation analysis between scales.

RESULTS

1705 records per scale were collected. NAS per patient median: 55.70 (IR: 51.30-60.38), (95%CI: 54.74-56.66). NAS per patient mean: 56,67 (SD: ±8,28), (95%CI: 55.72-57.63). NW per bed NAS: 63.39, VACTE: 652.93. NAS per nurse: 135.23%. B:P Ratio: 1:1.09. Operative N:P Ratio: 1:1.76. WUR > 1. Correlation coefficient between scales: 0.45.

CONCLUSIONS

There is a shortage of nurses in relation to the work generated. An update in the scales is required. The NAS per nurse is more effective than the NAS per patient for the adequacy of the Nursing workforce. The new proposed indicators might be suitable to determine the NW and to optimize the calculation of Nursing resources.

Predictors of early line removal and successful line retention in potential central line-associated blood stream infections (CLABSIs) in haematology patients: A retrospective cohort study

BACKGROUND

Patients with haematologic malignancies are at risk of central line associated bloodstream infections (CLABSI) and their adverse outcomes. Line removal is often considered necessary for cure but creates substantial morbidity, and neutropenic patients often have alternative sources of bloodstream infection (BSI). Patients suitable for a line retention strategy remain ill-defined.

METHODS

We conducted a single centre retrospective cohort study of haematology inpatients who developed BSI with a central line in situ. Line retention was defined as line remaining in situ for ≥72 hours post BSI. The primary outcome was failure of line retention, defined as line removal >72 hours post BSI or recurrent BSI with the same organism within 3 months. Predictors of failure of line retention, early line removal (<72 hours) and IDSA central line related BSI (CRBSI) (research-definition CRBSI) were assessed using multivariable analysis.

RESULTS

Of 288 episodes of BSI included between 1/1/2018 and 31/12/2022, 209 cases had retention of line >72 hours and 52 of these (24.9%) experienced failed line retention, with prolonged culture positivity predicting this outcome, and source of BSI other than the line associated with successful line retention on multivariate analysis. 79 (27.4%) had early line removal, with factors associated including intensive care admission, prolonged positive cultures and meeting research-definition CRBSI. Only 27 (9.4%) BSI episodes met the research-definition CRBSI.

CONCLUSIONS

Many central lines were removed despite infrequent formal CLABSI diagnoses. Thorough assessments for alternative sources and use of non-invasive diagnostics including repeat blood cultures prior to line removal, may allow increased appropriate retention of lines.

The experiences of clinical staff approaching families for organ donation consent: A systematic review and thematic synthesis of qualitative studies

Healthcare professionals (HCPs) play an essential role in organ donation (OD) particularly when approaching families to discuss consent to OD. We synthesized the evidence on experiences of HCPs when approaching potential organ donor families. Fourteen electronic databases were searched to identify studies describing HCP experiences or associations between HCP experiences and consent rates. Methodological quality was assessed by independent reviewers using the Mixed Methods Appraisal Tool. Qualitative data were analysed using thematic synthesis, while quantitative data were summarized by narrative review. Ninety-two studies were included. HCP experiences were conceptualised as a paradox due to the challenges to negotiate the boundaries between life and death. Organisational and personal aspects broadly shape the experiences of professionals. Studies suggest that staff experiences can be improved by training and education, however, quantitative studies did not show a strong association between OD training and improved consent rates. The complexities of the family approach were evident in the variety of interactions between HCPs and the donor family, which may explain why there is no uniform approach across settings and countries. The review highlights the challenges faced by professionals when negotiating policy and practice and informs recommendations to support staff involved in the OD process worldwide.

Comparison of various video laryngoscopes for nasotracheal intubation in simulated difficult airway scenarios: a randomized self-controlled crossover trial

BACKGROUND

Nasotracheal intubation (NTI) is particularly challenging in patients with rigid neck or micrognathia. Advancements in video laryngoscopy may improve NTI outcomes. We compared performance of direct laryngoscope (DL), King Vision videolaryngoscope (KVL), and C-MAC videolaryngoscope (VL) in normal, rigid neck, and micrognathia airway.

METHODS

A randomized, self-controlled crossover trial was conducted with 20 anesthesiologists who performed NTI on a high-fidelity mannequin under three airway conditions. Device order was randomized using a computer-generated sequence, and outcome assessors were blinded to the sequence of devices used. Primary outcomes were time to glottic view and intubation. Secondary outcomes included ease of intubation and force on incisors.

RESULTS

The median difference (95%CI) in time to intubation suggested that CMAC was better than KVL in normal airway (-9.0[-13.0 to-6.0], p < 0.001), rigid neck (-12.0[-18.0 to -6.5], p < 0.001) and micrognathia (-16.5[-20.0 to -13.5], p < 0.001). When compared to DL, CMAC was better for micrognathia (-8.0[-5.5 to-10.5], p = 0.001) but comparable for normal airway and rigid neck. C-MAC also exerted the least force on incisors, minimizing dental trauma.

CONCLUSION

The C-MAC VL demonstrated superior performance across all airway conditions, offering faster, safer, and easier NTI, making it the preferred device in challenging scenarios.

TRIAL REGISTRATION

Clinical Trial Registry of India: (CTRI/2022/05/042821) www.ctri.nic.in.

Patient perception of frailty assessment in intensive care units: A phenomenological study

Frail patients admitted to the Intensive Care Unit (ICU) have a poorer outcome that may be related to Post ICU Syndrome, readmissions or death within a year of discharge. Assessing frailty can help guide decision-making and care planning.

OBJECTIVE

To explore the perception of patients in relation to the assessment of frailty in the ICU.

METHODOLOGY

Qualitative phenomenological study through semi-structured interviews in the ICU of a public hospital of intermediate complexity. Thirteen patients with experience of admission to the ICU participated. A thematic analysis of the discourse was carried out following Braun and Clarke's proposal.

RESULTS

Three themes and seven subthemes were identified as pivotal in describing the patients' experience: perception of own frailty, coping styles and resources for dealing with frailty, and the value of monitoring the evolution of frailty. Participants understand frailty as opposed to strength, from a multidimensional perspective and linked to the idea of loss of capabilities. They try to deal with fragility by coping and struggling with it, drawing on intrapersonal and interpersonal resources. They place value on monitoring the evolution of frailty insofar as they feel considered and supported.

CONCLUSIONS

The patients' narratives evidence the important repercussion that an ICU admission has on the physical and psycho-socio-emotional dimensions of patients and caregivers. The assessment of frailty and the monitoring of its evolution at discharge is valued as important to be able to adapt care and significant as a facilitator of emotional support. There is a clear need for support at discharge in the different spheres and for accompanying the patient throughout their recovery to enable an early return to their life prior to admission.

Practice of oxygen administration in patients hospitalized in internal medicine wards and intensive care units: A single-center prospective, observational study

BACKGROUND

Oxygen is widely used to treat hypoxemia.

OBJECTIVE

To determine the frequency of inappropriate oxygen administration in patients admitted to Internal Medicine (IM) wards and intensive care units (ICU).

DESIGN AND SETTING

Single-center prospective, observational study in a tertiary university hospital in Ankara, Türkiye.

METHODS

Patients who were hospitalized in the IM wards and ICU and were receiving oxygen were recruited. Every 6 hours, the oxygenation parameters were noted, and the averages over the first 24 hours of oxygen usage were recorded. Inappropriate usage was defined as oxygen flow rates > 6 L/min in the nasal cannula and < 5 L/min and > 10 L/min in the simple face mask, application of the simple face mask in chronic obstructive lung disease (COPD) exacerbation, SpO2 > 98% in general, or SpO2 > 92% in COPD exacerbation.

RESULTS

Of the 397 patients, 20% in the IM wards and 50% of 124 in the ICU received oxygen. The oxygen method used was nasal cannula in 51%, simple face mask in 21%, and high-flow nasal cannula in 4% of the patients. Among the simple face mask applications, 46% were < 5 L/min and 5% were > 10 L/min. Among the 62% of patients with COPD exacerbations, the SpO2 was > 92%.

CONCLUSION

The frequency of oxygen use was 20% among patients hospitalized in IM wards and 50% among patients in the ICU. Almost half of the simple face mask applications were inappropriate.

Construction and validation of an interpretable XGBoost machine learning model to predict ESBL positivity rates based on urinalysis data

BACKGROUND

Microbiological culture and drug susceptibility testing of urine samples have lengthy turnaround times, increasing the risk of extended-spectrum β-lactamase (ESBL)-positive urinary tract infection (UTI) patients progressing to sepsis.

OBJECTIVE

To develop an efficient machine learning model for the identification of ESBL positivity in UTI patients.

METHODS

This retrospective study included 528 samples that had undergone drug susceptibility testing, based on inclusion and exclusion criteria. Variables were screened using Lasso regression, with 70% of the samples used to construct nine machine learning models (XGBClassifier, LogisticRegression, LGBMClassifier, AdaBoostClassifier, SVC, MLPClassifier, ComplementNB, GaussianNB, and GradientBoostingClassifier). Model selection was based on criteria including accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), F1 score, Kappa score, and Area Under the Curve (AUC). The best model type was identified through ten-fold cross-validation, which was then built using the remaining 30% of the data as a test set. Interpretations of predictive results were provided using the SHAP model, clarifying the impact of each feature on predictions and enhancing model transparency and interpretability.

RESULTS

The variables selected by the Lasso regression model are as follows: gender + urinary protein + urobilinogen + leukocytes + occult blood + age + pH + specific gravity + leukocyte count + erythrocyte count + epithelial cell count + cast count.The XGBoost model outperformed others in ten-fold cross-validation, with scores on the validation set as follows: AUC (95%CI): 0.924 (0.860-0.989); cutoff: 0.664(0.637-0.690); accuracy: 0.862(0.839-0.885); sensitivity: 0.9(0.879-0.920); specificity: 0.725(0.618-0.832); PPV: 0.923(0.896-0.950); NPV: 0.667(0.626-0.707); F1 score: 0.911(0.896-0.925); Kappa: 0.603(0.527-0.679). The final model achieved an AUC of 0.968 and accuracy of 0.943 on the test set.

CONCLUSION

This study developed a rapid and efficient machine learning model capable of identifying ESBL positivity based solely on routine urine test data.

Diagnosis and management of paroxysmal sympathetic hyperactivity: a narrative review of recent literature

Paroxysmal sympathoexcitatory syndrome is a clinical syndrome, recognized in a subgroup of survivors of severe acquired brain injury, of simultaneous, paroxysmal transient increases in sympathetic [elevated heart rate, blood pressure, respiratory rate, temperature, sweating] and motor [posturing] activity. Coupled with the absence of uniform treatment guidelines, it is prone to underdiagnosis and misdiagnosis, leading to the adoption of inappropriate treatment protocols, which may adversely affect the prognosis of patients. This narrative review summarized the existing literature and provided a comprehensive account of the research history and terminology of PSH, epidemiology and pathogenesis, diagnostic criteria, therapeutic options, and prognosis, hoping to bring new ideas to the clinical treatment of PSH.

A retrospective observational cohort study of oral azithromycin treatment for Legionnaires' disease

BACKGROUND

Legionnaires' disease (LD) is typically treated with macrolides, including the azalide azithromycin, or quinolones. In 2013, guidelines for empirical treatment of community-acquired pneumonia at Christchurch Hospital, New Zealand were changed to prioritize oral azithromycin over IV clarithromycin.

OBJECTIVES

To determine whether the change in antimicrobial guidelines led to altered outcomes for patients subsequently confirmed to have LD.

METHODS

Patients with confirmed LD between 2010 and 2020 were identified from clinical and laboratory data. Hospital records were used to identify mortality, ICU admission, length of hospital stay, time to clinical stability, and time to first anti-Legionella treatment. Mean differences, risk ratios (RRs) and an interrupted time series with propensity adjustment were used to compare patient outcomes before and after the guideline change.

RESULTS

There were 323 patients included: 128 before and 195 after the change. Patient outcomes generally improved after the change including: mortality within 30 days (RR 0.4, 95% CI 0.2-0.8); ICU admission (RR 0.6, 95% CI 0.5-0.9); length of stay (difference -2.3 days, 95% CI -4.3 to -0.4); and time to clinical stability (difference -2.4 days, 95% CI -4.3 to -0.5). The interrupted time series analysis suggested improvements in patient outcomes may have occurred regardless of the guideline change.

CONCLUSIONS

Outcomes for patients with LD were not worsened by the change in antimicrobial guidelines and may have improved. Overall rates of mortality were low. This result was reassuring given the harm that may result from unnecessary use of IV compared with oral antimicrobial agents.

Assessment of incidence and risk factors of COVID-19-associated candidemia using diagnosis procedure combination data

BACKGROUND

Candidemia is an important coronavirus disease 2019 (COVID-19)-associated invasive fungal infection. Patients with COVID-19 may be susceptible to candidemia; however, evidence regarding its incidence, risk factors, and involvement in mortality is insufficient.

OBJECTIVES

To explore the incidence of and potential risk factors for candidemia in patients with severe or critical COVID-19 and evaluate the relationship between candidemia and mortality in patients with severe or critical COVID-19.

METHODS

The incidence of candidemia in patients with severe and critical COVID-19 was evaluated using administrative claims data from acute care hospitals in Japan. Multivariable regression models were used to explore potential risk factors for candidemia and their contribution to mortality in patients with severe and critical COVID-19.

RESULTS

Candidemia occurred in 0.3-1.1 % of patients with severe or critical COVID-19. Renal impairment, use of steroid, blood transfusion, and use of central venous catheter were potential risk factors for candidemia in patients with severe to critical COVID-19.

CONCLUSIONS

Candidemia in patients with COVID-19 was an independent risk factor for mortality. Candidemia in patients with severe to critical COVID-19 is a grave complication and may increase mortality.

Clinical Outcomes of Children Meeting the At-Risk for PARDS Criteria Before PICU Admission: A Single-Center Study

OBJECTIVE

To evaluate the ability of the criteria "At-risk for PARDS" to identify patients with acute respiratory infection hospitalized outside the pediatric intensive care unit (PICU) who are at high risk of developing pediatric acute respiratory distress syndrome (PARDS) and describe the timing for the identification. The secondary aim was to explore clinical outcome differences between patients with and without risk for PARDS.

METHODS

We conducted an observational prospective cohort study from June to August 2019. Children under 15 years old hospitalized in a pediatric ward due to an acute respiratory tract infection were included.

MAIN RESULTS

A total of 177 patients with a median age of 12 (IQR 5; 25) months were included. Registered data included demographics, respiratory support, at-risk for PARDS and PARDS diagnosis according to PALICC consensus. PICU admission, hospital length of stay (LOS) and intrahospital mortality were the outcomes compared between children with and without risk for PARDS. The at-risk criteria, within 48 h of admission, showed an overall accuracy, sensitivity, and specificity of 82.5%, 100%, and 81.9% respectively, to detect patients that progress to PARDS. The at-risk for PARDS criteria was met in 37 cases (20.9%), which also were more likely to developed PARDS (6/37 [16.2%] vs. 0/140 [0%]; p < 0.001), had higher admission to PICU (16/37 [43.2%] vs. 0 [0%]; p < 0.001) and hospital LOS (7 [6; 12] days vs. 5 [3-6] days; p < 0.001), compared with the group without at-risk for PARDS.

CONCLUSIONS

The at-risk for PARDS criteria within 48 h of admission demonstrated an adequate ability to identify patients with a respiratory infection at increased risk of developing PARDS. Patients who met the at-risk for PARDS criteria before PICU admission presented with unfavorable clinical outcomes compared with those without risk.

AARC and PALISI Clinical Practice Guideline: Pediatric Critical Asthma

To address the lack of guidance for clinicians in their care of children with critical asthma, a multidisciplinary team of medical providers used Grading of Recommendations, Assessment, Development, and Evaluation methodology to make the following recommendations: 1. We suggest the use of continuous inhaled short-acting β agonist (SABA) over frequent intermittent SABA in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 2. We suggest the use of either high- or low-dose continuous inhaled SABA regimens in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 3. We suggest the use of either dexamethasone or methylprednisolone (or an equivalent dose of prednisone/prednisolone) for children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 4. We suggest the use of intravenous (IV) magnesium (intermittent or continuous) as an adjunct therapy in children treated for critical asthma. (Conditional recommendation, low certainty of evidence) 5. We cannot recommend for or against the use of IV methylxanthines as an adjunct therapy in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 6. We suggest the use of an IV SABA infusion as an adjunct therapy in children treated for critical asthma. (Conditional recommendation, low certainty of evidence) 7. We cannot recommend for or against the application of high-flow nasal cannula versus conventional oxygen therapy in children presenting with critical asthma with persistent hypoxemia and/or respiratory distress. (Conditional recommendation, very low certainty of evidence) 8. We suggest the use of bi-level positive airway pressure over conventional oxygen therapy in children presenting with critical asthma with persistent hypoxemia and/or respiratory distress. (Conditional recommendation, very low certainty of evidence) 9. We cannot recommend for or against the application of bi-level positive airway pressure over high-flow nasal cannula for children hospitalized with critical asthma with persistent hypoxemia and/or respiratory distress. (Conditional recommendation, very low certainty of evidence) 10. We cannot recommend for or against the application of heliox in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 11. We suggest the use of a dedicated protocol or pathway for managing children treated for critical asthma. (Conditional recommendation, low certainty of evidence).

Integrating Multimodal EHR Data for Mortality Prediction in ICU Sepsis Patients

Rapid and accurate prediction of mortality risk among intensive care unit (ICU) sepsis patients is crucial for timely intervention and improving patient outcomes. However, due to the multimodal and dynamic time-series nature of patient visit information and the limited data samples, it is challenging to obtain discriminative patient representations, leading to suboptimal mortality prediction results. To address this issue, we design a time-aware graph embedding attention model (TGAM) to integrate multimodal data and predict mortality in ICU sepsis patients. Our approach involves modeling and generating patient representations that encompass not only demographic information but also dynamic time-series data reflecting patient health status. Additionally, the graph convolutional network is used to obtain informative concept embeddings from medical ontologies, and an improved transformer is used to capture the temporal information of the patient's health status and handle missing values, overcoming the limitations of small samples. The experimental results on the MIMIC-III and MIMIC-IV datasets demonstrate that TGAM significantly improves prediction accuracy, with AUROC scores of 87.65% and 87.00% on the MIMIC-III and MIMIC-IV datasets, respectively, outperforming baseline models by over 5 percentage points. TGAM also achieves higher sensitivity, specificity, and AUPRC metrics, and lower Brier Score compared with baseline models, highlighting its effectiveness in identifying high-risk patients. These findings suggest that TGAM has the potential to become a valuable tool for identifying high-risk sepsis patients, enabling clinicians to make more informed and timely intervention decisions.

Elastic static power, its correlation with acute respiratory distress syndrome severity: A Bayesian post-hoc analysis of the Mechanical Power Day cross-sectional trial

OBJECTIVE

The relationship between different power equations and the severity of acute respiratory distress syndrome (ARDS) remains unclear. This study aimed to evaluate various power equations: total mechanical power, total elastic power (comprising elastic static and elastic dynamic power), and resistive power, in a cohort of mechanically ventilated patients with and without ARDS. Bayesian analysis was employed to refine estimates and quantify uncertainty by incorporating a priori distributions.

DESIGN

A Bayesian post-hoc analysis was conducted on data from the Mechanical Power Day study.

SETTING

113 intensive care units across 15 countries and 4 continents.

PATIENTS

Adults who received invasive mechanical ventilation in volume-controlled mode, with (mild and moderate/severe ARDS) and without ARDS.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

ARDS, Elastic static power.

RESULTS

Elastic static power was 5.8 J/min (BF: 0.3) in patients with mild ARDS and 7.4 J/min (BF: 0.9) in moderate/severe ARDS patients. Bayesian regression and modeling analysis revealed that elastic static power was independently correlated with mild (a posteriori Mean: 1.3; 95% Credible Interval [Cred. Interval]: 0.2-2.2) and moderate/severe ARDS (a posteriori Mean: 2.8; 95% Cred. Interval: 1.7-3.8) more strongly than other power equations.

CONCLUSIONS

Elastic static power was found to have the strongest correlation with ARDS severity among the power equations studied. Prospective studies are needed to further validate these findings.

[Translated article] National survey and consensus document on dosing strategies for beta-lactam antibiotics against multidrug-resistant gram-negative bacilli (MDR-GNB) in critically ill patients undergoing extracorporeal life-support techniques: The DOSEBL study protocol

INTRODUCTION

Infections caused by multidrug-resistant gram-negative bacilli (MDR-GNB) in critically ill patients present a challenge for timely and appropriate antibiotic treatment. This is particularly important in patients undergoing extracorporeal life-support techniques such as renal replacement therapy and extracorporeal membrane oxygenation. These techniques can introduce additional pharmacokinetic alterations, potentially leading to suboptimal exposure to antibiotics. This study aims to outline dosing strategies and therapeutic drug monitoring protocols for new β-lactam antibiotics effective against MDR-GNB in critically ill patients undergoing extracorporeal life-support techniques at a national level. Additionally, the study seeks to develop a consensus document, based on available evidence.

METHODS

The project will comprise two main phases: I) a national survey and II) the development of a consensus document. This consensus document, undertaken according to ACCORD guidelines, will encompass: a) establishment of a multidisciplinary panel of experts, b) prospective registration of the consensus, c) evidence synthesis, d) modified Delphi rounds. The antimicrobials to be included will be: meropenem, ceftazidime/avibactam, ceftolozane/tazobactam, cefiderocol, meropenem/vaborbactam, imipenem/relebactam, and aztreonam. Extracorporeal life-support techniques will include continuous renal replacement therapy, conventional intermittent hemodialysis, and extracorporeal membrane oxygenation.

DISCUSSION

The availability of extracorporeal life-support techniques has expanded significantly in recent years, alongside a rise in the prevalence of infections caused by MDR-GNB. There is a need to develop evidence-based tools of high quality to standardize dosing and monitoring strategies for new β-lactam antibiotics.

[Translated article] Activities of clinical pharmacists in intensive care units

The main objective of the activity carried out in an intensive care unit (ICU) and in general, in all hospitalization units, is to provide all the human and material resources to offer the best therapeutic care to admitted patients. Work in multidisciplinary teams, made up of specialists in intensive care medicine as those responsible for the patients, doctors from other specialties, specialized nursing, physiotherapists, nutritionists, and clinical pharmacists is an optimal approach to achieve the proposed objective. The activities of the clinical pharmacist can be developed at different levels (basic, intermediate, and excellent) depending on the degree of involvement, the time dedicated, the training, and the available resources. This article aims to establish an initial work guide, through recommendations aimed at the activity to be developed by the clinical pharmacist in the ICU in relation to critical patient care and quality improvement, which serves as a reference for those pharmacists who go to develop pharmaceutical care activities in critical patients.

Continuous deep sedation versus minimal sedation after cardiac arrest and resuscitation (SED-CARE): A protocol for a randomized clinical trial

BACKGROUND

Sedation is often provided to resuscitated out-of-hospital cardiac arrest (OHCA) patients to tolerate post-cardiac arrest care, including temperature management. However, the evidence of benefit or harm from routinely administered deep sedation after cardiac arrest is limited. The aim of this trial is to investigate the effects of continuous deep sedation compared to minimal sedation on patient-important outcomes in resuscitated OHCA patients in a large clinical trial.

METHODS

The SED-CARE trial is part of the 2 × 2 × 2 factorial Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) trial, a randomized international, multicentre, parallel-group, investigator-initiated, superiority trial with three simultaneous intervention arms. In the SED-CARE trial, adults with sustained return of spontaneous circulation (ROSC) who are comatose following resuscitation from OHCA will be randomized within 4 hours to continuous deep sedation (Richmond agitation and sedation scale (RASS) -4/-5) (intervention) or minimal sedation (RASS 0 to -2) (comparator), for 36 h after ROSC. The primary outcome will be all-cause mortality at 6 months after randomization. The two other components of the STEPCARE trial evaluate sedation and temperature control strategies. Apart from the STEPCARE trial interventions, all other aspects of general intensive care will be according to the local practices of the participating site. Neurological prognostication will be performed according to European Resuscitation Council and European Society of Intensive Care Medicine guidelines by a physician blinded to the allocation group. To detect an absolute risk reduction of 5.6% with an alpha of 0.05, 90% power, 3500 participants will be enrolled. The secondary outcomes will be the proportion of participants with poor functional outcomes 6 months after randomization, serious adverse events in the intensive care unit, and patient-reported overall health status 6 months after randomization.

CONCLUSION

The SED-CARE trial will investigate if continuous deep sedation (RASS -4/-5) for 36 h confers a mortality benefit compared to minimal sedation (RASS 0 to -2) after cardiac arrest.

Ceftaroline for bloodstream infections caused by methicillin-resistant Staphylococcus aureus: a multicentre retrospective cohort study

OBJECTIVES

To evaluate the effectiveness of ceftaroline vs. vancomycin or daptomycin in the treatment of methicillin-resistant Staphylococcus aureus bloodstream infections (BSIs) (MRSA-BSIs).

METHODS

This multicentre retrospective study conducted in 15 Spanish hospitals included data from the first MRSA-BSIs of adult patients between January 2019 and December 2022. The ceftaroline group included patients who received ceftaroline for ≥72 hours within the first week of BSI onset; the standard-of-care (SOC) group included patients who received vancomycin or daptomycin ≥72 hours after BSI onset. Primary outcome was 30-day all-cause mortality; secondary outcomes included 90-day mortality and incidence of adverse events (AEs). Propensity-score matching and Cox proportional hazards analyses were performed.

RESULTS

A total of 429 MRSA-BSIs were included: 133 in the ceftaroline group and 296 in the SOC group. More patients in the ceftaroline group had a Sequential Organ Failure Assessment score >2 (51.1% vs. 36.5%; p < 0.01), complicated BSI (66.2% vs. 42.2%; p < 0.01), infective endocarditis (18.8% vs. 6.4%; p < 0.01) and prescribed in combination treatment (65.4% vs. 11.5%; p < 0.01), with no statistically significant differences in 30-day mortality: 23.3% ceftaroline (95% CI, 16.1-30.5%) vs. 16.2% SOC (95% CI, 12.0-20.4%), p 0.08. There were no statistically significant differences in 90-day mortality (33.1% ceftaroline vs. 26.7% SOC; p 0.17). After propensity-score matching, 105 patients treated with ceftaroline were matched with 105 controls: the 30-day mortality rates were 21.9% and 16.2% (p 0.38). Cox regression analysis of the entire cohort (n = 429) revealed that age (hazard ratio [HR], 1.05; 95% CI, 1.03-1.07) and Sequential Organ Failure Assessment score >2 (HR, 2.34; 95% CI, 1.50-3.65) were associated with 90-day mortality risk, although ceftaroline treatment did not demonstrate a significant effect (HR, 1.00; 95% CI, 0.97-1.02). Incidence of AEs was 12.0% in ceftaroline vs. 4.4% in the SOC group (p < 0.01). Most AEs occurred when ceftaroline was used in combination vs. monotherapy (17.2% vs. 2.2%; p 0.01).

DISCUSSION

Ceftaroline was an effective treatment for MRSA-BSIs but was commonly prescribed in combination showing a higher incidence of AEs.

Scaling Autologous Epidermal Cell Therapies: iPSC-Derived Keratinocytes and In Vivo Chimerism for Skin Regeneration

Severe skin injuries and genetic disorders such as epidermolysis bullosa present significant clinical challenges due to limitations in current epidermal replacement therapies. While promising, cultured epithelial autografts (CEAs) suffer from prolonged culture times, cellular senescence, and low-quality clinical outcomes, limiting their widespread application. Recent advancements in iPSC-derived keratinocytes (iKeratinocytes) and in vivo chimerism offer transformative potential for scalable and personalised skin regeneration. Advances in understanding transcriptional networks, mRNA delivery, CRISPR-based genome editing, and automated biomanufacturing processes can enable improved and efficient protocols for generating iKeratinocytes. Despite these advances, there are still challenges for scaling iKeratinocytes, including optimising xeno-free culture systems and developing reproducible methods for generating multilayered skin with appendages. Interspecies chimerism utilising lineage-specific ablation systems and targeted in utero delivery of organ progenitor cells can enable human epidermal tissue development within animal hosts, offering an alternative novel platform for scaling epidermal cell and skin generation. This method, however, requires further refinements for complete ablation and detachment of target cells in the animal hosts and improved human cell integration in chimeric models. Together, iKeratinocytes and in vivo chimerism hold great promise for advancing autologous epidermal cell therapies and enabling broader clinical adoption and improved outcomes for patients with severe skin injuries and genetic disorders.

Severe COVID-19 in Non-Smokers: Predictive Factors and Outcomes

Background: The COVID-19 pandemic revealed an unexpected pattern known as the "smoker's paradox", with lower rates of severe disease among smokers compared to non-smokers, highlighting the need for the specific investigation of disease progression in non-smoking populations. Objective: To identify early mortality predictors in non-smoking patients with severe COVID-19 through the evaluation of clinical, laboratory, and oxygenation parameters. Methods: This retrospective observational cohort study included 59 non-smokers hospitalized with COVID-19 between November and December 2020. Clinical parameters, laboratory findings, and respiratory support requirements were analyzed on Days 1 and 7 of hospitalization. ROC curves were constructed to assess the predictive value of the parameters. Results: The overall mortality rate was 54.2%. The seventh-day SOFA score showed the strongest predictive value (AUC = 0.902, p = 0.004), followed by pCO2 (AUC = 0.853, p = 0.012). Significant differences between survivors and non-survivors were observed in acid-base parameters, oxygenation indices, and hematological markers. Mortality rates varied significantly with ventilation type: 84.6% for IMV and 50% for NIMV, with no deaths in HFNC patients. Conclusions: Multiple parameters measured on Day 7 of hospitalization demonstrate significant predictive value for mortality in non-smoking COVID-19 patients, with the SOFA score being the strongest predictor. The type of respiratory support significantly influences outcomes, suggesting the importance of careful ventilation strategy selection.

The Effectiveness and Safety of Beta Antagonists in Patients With Burns: An Updated Meta-Analysis

AimsThe purpose of this systematic review was to assess the safety and effectiveness of beta antagonists for improving clinical care in burn patients, compared to placebo.MethodsArticles from randomized-controlled trials were identified by a literature search on PubMed and Cochrane. We included relevant trials involving patients with burn. Trials were eligible if they evaluated propranolol and compared to usual care or placebo. We conducted a meta-analysis using a random-effects model.ResultsA total of 2114 patients were included from 14 RCTs. Beta-blocker-treated patients had decreased heart rates (WMD = -14.73, 95% CIs = [-19.14, -10.32]), mean arterial pressure (WMD = -2.76, 95% CIs = [-3.81, -1.70]), rate pressure product (WMD = -1.13, 95% CIs = [-1.56, -0.71]), reduced time for wound healing (WMD = -5.08, 95% CIs [-8.97, -1.18]), and lower resting energy expenditure (WMD = -168.83, 95% CIs [-232.03, -105.63]). However, use of beta-blockers did not reduce mortality rate (WMD = 0.98, 95% CIs [0.68, 1.41]), incidence of sepsis (RR = 0.82, 95% CIs = [0.50, 1.35]), or length of stay in hospital (WMD = -1.50, 95% CIs [-4.76, 1.77]) compared with placebo.ConclusionOur findings indicate that the administration of propranolol to burned patients does not contribute to increased mortality rates, reduced length of hospital stays, or heightened sepsis occurrence. It demonstrates a protective effect on heart function by reducing heart rate, resting energy expenditure, rate pressure product, and wound healing. More randomized-controlled and multi-center studies are needed to effectively establish the use of beta antagonists in burn patients.

Requesting Relatives' Consent for Intensive Care for Organ Donation: An Empirical Analysis of Spanish Transplant Coordinators' Practices

BACKGROUND

Intensive care to facilitate organ donation (ICOD) involves the initiation or continuation of intensive care for patients with devastating brain injury for donation purposes. In the Spanish system, relatives undergo an early interview to request consent for this procedure. If they consent, a waiting time is agreed upon in the expectation that death by neurological criteria occurs and donation after brain death takes place. Otherwise, relatives can decide on donation after circulatory determination of death or withdrawal of life support. This study analyzes how Spanish transplant coordinators interact with relatives in early interviews and follow-ups on potential donation pathways.

METHODS

Semistructured interviews were conducted with a random stratified sample of 23 Spanish transplant coordination teams to explore strategies, practices, and perceptions of ICOD consent requests. The interviews were recorded, transcribed, and analyzed using content analysis.

RESULTS

Previous coordination with other units and information retrieval regarding patient and relatives' situations is crucial. The development of early interviews includes an introduction to the family, identification of decision makers, empathizing with relatives and offering condolences, reaffirming the fatal prognosis, explaining the possibility of donating based on the patient's will, confirming the family's understanding and resolving doubts, and ensuring comfort and assessing family needs.

CONCLUSIONS

Approaching families to obtain ICOD consent is a regular practice for Spanish coordination teams. It involves a highly professional and diversified set of strategies based on establishing a support relationship for relatives. Our study provides strategies that serve as a reference for obtaining ICOD consent from families in other settings.

[Analysis of patient safety indicators in complications due to care during hospitalization]

OBJECTIVE

To Analyze AHRQ Patient Safety Indicators (PSI) obtained through the Minimum Basic Data Set (MBDS) in improving patient safety.

METHOD

Observational descriptive and retroprective study. The CMBD hospital discharge registry of 342 hospitals of the National Health System was included. The MBDS indicators and analysis axes were from 2021 and the hospitalization MBDS information included the following general data: total discharges, average stay, average age and % mortality. Four patient safety indicators were analyzed: Pressure ulcers (PSI 03), Iatrogenic pneumothorax (PSI 06), Accidental puncture or tear in adults (PSI 15) and CVC-related to bloodstream infection (PSI 07).

RESULTS

The PSI 06 and PSI 07 categories not only have a higher number of discharges, but also a longer average stay and mortality. In comparison, PSI 03 and PSI 15 categories show a much lower number of discharges, and a lower mortality and average stay. Conditions associated with PSI 06 and PSI 07 categories could be more severe or complex, leading to a longer hospital stay and a higher risk of mortality. According to relative risk analyses, all indicators show a slightly higher mortality risk in men than in women.

CONCLUSIONS

Advanced age and serious diagnoses, such as circulatory diseases or neoplasia, are associated with higher mortality and hospital stay. In relation to hospital size, smaller ones show higher risks and worse mortality outcomes. Therefore, these results could guide strategies to optimize resources and focus interventions on the most vulnerable groups.

Early prediction of sepsis in emergency department patients using various methods and scoring systems

BACKGROUND

Early recognition of sepsis, a common life-threatening condition in intensive care units (ICUs), is beneficial for improving patient outcomes. However, most sepsis prediction models were trained and assessed in the ICU, which might not apply to emergency department (ED) settings.

AIM

To establish an early predictive model based on basic but essential information collected upon ED presentation for the follow-up diagnosis of sepsis observed in the ICU.

STUDY DESIGN

This study developed and validated a reliable model of sepsis prediction among ED patients by comparing 10 different methods based on retrospective electronic health record data from the MIMIC-IV database. In-ICU sepsis was identified as the primary outcome. The potential predictors encompassed baseline demographics, vital signs, pain scale, chief complaints and Emergency Severity Index (ESI). 80% and 20% of the total of 425 737 ED visit records were randomly selected for the train set and the test set for model development and validation, respectively.

RESULTS

Among the methods evaluated, XGBoost demonstrated an optimal predictive performance with an area under the curve (AUC) of 0.90 (95% CI: 0.90-0.91). Logistic regression exhibited a comparable predictive ability to XGBoost, with an AUC of 0.89 (95% CI: 0.89-0.90), along with a sensitivity and specificity of 85% (95% CI: 0.83-0.86) and 78% (95% CI: 0.77-0.80), respectively. Neither of the five commonly used severity scoring systems demonstrated satisfactory performance for sepsis prediction. The predictive ability of using ESI as the sole predictor (AUC: 0.79, 95% CI: 0.78-0.80) was also inferior to the model integrating ESI and other basic information.

CONCLUSIONS

The use of ESI combined with basic clinical information upon ED presentation accurately predicted sepsis among ED patients, strengthening its application in ED.

RELEVANCE TO CLINICAL PRACTICE

The proposed model may assist nurses in risk stratification management and prioritize interventions for potential sepsis patients, even in low-resource settings.

First-pass success rate and predictive factors for stylet use in videolaryngoscopic intubations with a Macintosh blade: a prospective observational study

PURPOSE

The aim of this study was to evaluate the first-pass success rate of videolaryngoscopic intubations without a stylet using a Macintosh blade and to identify predictive factors for successful intubation.

METHODS

We conducted a prospective observational study of 224 adult patients scheduled for elective videolaryngoscopic intubations using a Macintosh blade. We excluded patients who had cervical spine issues, airway disease, anticipated difficult intubation, or a body mass index > 35 kg·m-2, or who required rapid sequence induction. We initially attempted intubations without a stylet, with laryngeal manipulation on the second attempt if needed, and a stylet added after two failures. We evaluated the first-pass success rate and identified predictive factors using multivariable logistic regression, incorporating demographic, conventional, and ultrasonographic airway parameters. We performed ultrasound examination after induction of general anesthesia. We developed and evaluated a prediction model using receiver operating characteristic curve analysis.

RESULTS

The first-pass success rate was 80% (180/224), increasing to 96% (215/224) after laryngeal manipulation on the second attempt. Nine patients (4%) required a stylet. Longer sternomental distance (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.01 to 1.53; P = 0.04) and increased thyromental height (OR, 1.14; 95% confidence interval [CI], 1.07 to 1.21; P < 0.001) were associated with first-pass success without a stylet. Limited (OR, 0.39; 95% CI, 0.16 to 1.00; P = 0.049) or severely limited (OR, 0.05; 95% CI, 0.01 to 0.19; P < 0.001) cervical spine movement negatively affected success.

CONCLUSIONS

Routine stylet preparation for elective videolaryngoscopic intubations with a Macintosh blade may not be necessary, as only a small percentage of patients required it.

Experience with extracorporeal membrane oxygenation support in Latin America between 2016 and 2020

OBJECTIVE

To document the experience with ECMO therapy in healthcare institutions across Latin America between 2016 and 2020.

DESIGN

Cross-sectional study.

SETTING

Private and public health institutions from 7 countries.

PARTICIPANTS

ECMO Intensive Care Units.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

General characteristics of the center (country, ELSO center, year of first cannulation, public or private network, ECMO devices available, mobile ECMO), professional category (nurses, physicians, specialists and other professionals), nurse-to-patient ratio, interventions applied(support indications, scores, mechanical ventilation at ECMO commencement, anticoagulation and hemolysis, circuit monitoring and patient perfusion, antibiotic prophylaxis), and patient outcomes (complications and survival) in ECMO centers.

RESULTS

Thirteen ECMO units were included. These units reported 133 consoles and 1629 ECMO cannulations. Of these, 1018 corresponded to adult patients, 468 to pediatric patients, and 143 to newborn infants. A total of 310 medical specialists were involved in ECMO care, of whom 70.3% had received ECMO training. The nurse-to-patient ratio was 1:1 in most centers (76.9%, n = 10). Amongst adult patients, the most common indication for initiating ECMO support was refractory hypoxemia, whereas in pediatric patients, it was a post-cardiotomy shock. The mean overall survival rate of the patients at the time of decannulation was 55.7% (95%CI 53.0-58.3).

CONCLUSIONS

The ICUs with ECMO in Latin America participating in this study have demonstrated operational capabilities enabling them to achieve outcomes comparable to those of other ECMO units across the world.

Increasing heterogeneity is associated with IL-6 expression in the lungs following mechanical ventilation

This study aimed to characterize how peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP) influence regional lung volume heterogeneity as a result of mechanical ventilation and the influence of this heterogeneity on markers of inflammation within the lungs. Four groups of BALB/C mice (n = 7 or 8 per group) were mechanically ventilated for 2 h using low or high (12 cmH2O or 20 cmH2O) peak inspiratory pressure (PIP) with or without 2 cmH2O positive end-expiratory pressure (PEEP). Four-dimensional computed tomography (4-DCT) images were acquired using synchrotron-based radiation source at baseline and after 2 h. Regional tidal volumes were obtained by 4-D cross-correlational X-ray velocimetry, whereas end-expiratory volume was quantified by Hounsfield units. Tissue was harvested from 10 lung regions, and expression of IL-6 and monocyte chemo-attractant protein 1 (MCP-1) was quantified using qPCR. We found a significant reduction in specific end-expiratory volume (sEEV) in mice ventilated with low PIP and no PEEP and a reduction in tidal volume in groups without PEEP. End-expiratory volume heterogeneity decreased in the low PIP and no PEEP group, whereas tidal volume heterogeneity decreased in the equivalent high PIP group, potentially due to regional redistribution of lung volumes. We found associations between IL-6 expression and tidal volume heterogeneity. In this study, we have demonstrated that changes in PIP and PEEP impact atelectasis, overdistension, and heterogeneity, and that increases in tidal volume heterogeneity may be driving IL-6-mediated biotrauma. These findings highlight the importance of considering the spatial distribution of tidal volumes as a driver of lung injury during mechanical ventilation.NEW & NOTEWORTHY The combination of low inspiratory and expiratory pressure promotes atelectasis but is not associated with markers of injury in the healthy lung during short-term ventilation. High inspiratory pressures promote tidal volume heterogeneity, which is correlated with the expression of genetic markers of lung injury. These data suggest that heterogeneity in tidal volume may be a key driver of biotrauma in the healthy, mechanically ventilated lung.

Surveillance of device-associated infection rates at adult intensive care units in the VINCat program (2010-2022)

INTRODUCTION

Surveillance is an essential part of the control of device-related nosocomial infections (NI) in intensive care units (UCIs). The aim of this study was to analyze the evolution of device-related infection rates in ICUs over the last 13 years, including ventilator-associated pneumonia (VAP), catheter-related bloodstream infection (CRBSI) and catheter-associated urinary tract infection (CAUTI).

MATERIAL AND METHODS

Patients admitted to the 44 ICUs at 43 participating hospitals of the VINCat Program from 2010 to 2022 were included, taking into account three periods: first period (2010-2013), second period (2014-2017) and third period (2018-2022). Hospitals were classified into three groups according to their size: small (<200 beds), medium (200-500 beds) and large (>500 beds). Complexity was assessed based on the use of invasive mechanical ventilation. The incidence rate of VAP, CRBSI and CAUTI was recorded at least during three consecutive months/year in each unit by an intensivist with extensive experience.

RESULTS

The device utilization ratio (DUR) of mechanical ventilation was 0.39, varying between 0.38 in large hospitals and 0.42 in small hospitals. The DUR of central venous catheter was 0.6, ranging from 0.59 (large hospitals) to 0.64 (small). The DUR of urinary catheter was 0.66, with a range of 0.65 (large hospitals) to 0.68 (small). The complexity of the different ICUs influenced the DUR of the different devices and the infections associated with them. The average rates of VAP, CRBSI, and CAUTI were 6.4, 1.9, and 3.4 episodes per 1000 device days respectively.

CONCLUSIONS

Surveillance systems provide information on intra-ICU infections. ICU complexity, measured in terms of the use of mechanical ventilation, influences device-associated infections.

The Norwegian national trauma registry: development process and essential data insights

BACKGROUND

Understanding trauma epidemiology, patient demographics, injury characteristics, and outcomes is essential for optimising trauma systems. The Norwegian Trauma Registry (NTR) monitors and improves the Norwegian Trauma System, setting care standards and overseeing system development. The registry was officially recognised as a national register in 2013. This study outlines the establishment of the population-based national registry and provides an overview of selected data.

METHODS

Norway's trauma system includes trauma centres, acute care hospitals, and prehospital services. The registry collects injury details, clinical outcomes, and patient experiences. Local NTR databases that are linked to a central database are maintained at each hospital, and only certified data registrars can enter and validate data. This enables data linkages across hospitals. The NTR includes potentially severely injured patients but also includes undertriaged patients (defined as severely injured patients who are not met by a trauma team activation upon hospital arrival). Descriptive statistics were used to analyse data from trauma patients registered between 2015 and 2023. Patient-Reported Outcome Measures (PROMs) from 2022 were also assessed.

RESULTS

From 2015 to 2023, 78 275 trauma patients were recorded, with annual patient inclusion rising from 7586 in 2015 to 9759 in 2023. All 38 Norwegian hospitals contributed data in 2023. Median age was 41 years (IQR: 21-62), and 66.5% were men. The highest injury rate was among those aged 15-24 years. Penetrating injuries accounted for 4.6% of cases. Severely injured patients with New Injury Severity Score (NISS) ≥ 16 totalled 16 678 (21.3%), while 10 509 (13.4%) had an Injury Severity Score (ISS) ≥ 16. Polytrauma was identified in 3783 (4.9%) of patients using the Newcastle definition and in 2508 (3.2%) patients using the Berlin definition. In 2023, a trauma team was activated for 8731(89.4%) patients recorded in the registry. PROMs data from 2022 showed that 47.2% (1018/2157) of the patients reported anxiety or depression 12 months post-injury. Among those without physical injuries, 8.0% (11/138) were out of work or education. Of the severely injured patients (NISS ≥ 16) who were employed or in education prior to the injury, 26.4% (83/314) had not returned to work or education after 12 months.

CONCLUSIONS

The Norwegian Trauma Registry has been successfully implemented in all trauma hospitals in Norway, enabling comprehensive data collection to support trauma care improvements and research.

Activities of the clinical pharmacist in the intensive care units

The main objective of the activity carried out in an intensive care unit and in general in all hospitalization units, is to provide all the human and material resources to offer the best therapeutic care to admitted patients. Work in multidisciplinary teams, made up of specialists in Intensive Care Medicine as those responsible for the patients, doctors from other specialties, specialized nursing, physiotherapists, nutritionists and clinical pharmacists is an optimal approach to achieve the proposed objective. The activities of the clinical pharmacist can be developed at different levels (basic, intermediate and excellent) depending on the degree of involvement, the time dedicated, the training and the available resources. This article aims to establish an initial work guide, through recommendations aimed at the activity to be developed by the clinical pharmacist in the ICU in relation to critical patient care and quality improvement, which serves as a reference for those pharmacists who go to develop pharmaceutical care activities in critical patients.

Burden and Outcomes of Severe Lower Respiratory Tract Infections with Unknown Etiology: A Retrospective Observational Study on Epidemiological Trends Over an 8-Year Period (2016-2024)

INTRODUCTION

Severe lower respiratory tract infections often require hospitalization, but a significant proportion lack microbiological diagnosis, leading to challenges in management. This study aimed to compare clinical outcomes of S-LRTIs with unknown versus known bacteria or viral etiology in Lombardy, Italy.

METHODS

A retrospective study analyzed respiratory infection-related hospitalizations in Lombardy over 8 years (2016-2024) using patient discharge charts. Patients were categorized into four groups: bacterial, viral (non-COVID-19), COVID-19-related, and unknown etiology. Outcomes included length of stay, intensive care unit admissions, and intra-hospital mortality. Temporal, seasonal, and age-specific trends were evaluated.

RESULTS

Among 683,741 hospitalizations, 338,211 (49.5%) were of unknown etiology, showing a 12.3% intra-hospital mortality rate (41,627 deaths) and 4.0% intensive care unit admission rate (13,625 admissions). COVID-19-related hospitalizations had the highest intra-hospital mortality rate (22.0%, 36,446 deaths in 165,605 COVID-19-related hospitalizations) and number of intensive care unit admissions (14,725 admissions, 8.9% of COVID-19-related hospitalizations), while viral non-COVID-19 hospitalizations showed the lowest intra-hospital mortality rate (3.2%, 1114 deaths in 34,769 viral-non-COVID-19 hospitalizations) and shortest length of stay (11.9 days). Hospitalizations with unknown etiology were more common in minors (42,190 episodes, 57.6% of total in < 18 years) and elderly (358,534 episodes, 56.2% of total in > 75 years), especially during warm seasons. Post-pandemic years saw increased bacterial and viral hospitalizations alongside a reduced proportion of those without an unknown etiology.

CONCLUSIONS

Respiratory infection-related hospitalizations with unknown etiology are associated with distinct seasonal and demographic patterns, and poorer outcomes compared to viral non-COVID-19 hospitalizations. COVID-19 reshaped S-LRTI epidemiology and diagnostic approaches, highlighting the need for comprehensive pathogen panels and tailored management strategies, while promoting their expanded use. Future research should integrate detailed clinical data to improve understanding and outcomes of severe respiratory infections, especially in vulnerable populations.

Imaging findings for severe traumatic brain injury

Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in young patients. The Marshall classification predicts six-month mortality and divides severe TBI patients into six groups based on CT findings in the acute phase of trauma. MRI also has prognostic value because it detects 30% more traumatic lesions, especially brainstem injury and diffuse axonal injury. Diffuse axonal injury occurs in three different anatomical areas, graded according to severity, and the greater the trauma, the deeper the brain involvement extends. Traumatic brainstem injuries with the worst prognosis are those of posterior location, with bilateral or haemorrhagic involvement. This article analyses the prognostic value of CT and MRI in the assessment of severe TBI and describes the main intracranial traumatic injuries.

Use of an electrospun bioveil is safe and does not decrease skin graft take on burn wounds: A randomised, controlled clinical trial

INTRODUCTION

Split-thickness skin autografts are the gold standard for surgical treatment of burns. In preclinical studies, the use of SKINHEALTEX PLGA, an electrospun poly(lactic-co-glycolide) acid (PLGA) bioveil, placed between autografts and their bed has shown potential to stimulate dermal regeneration, increase graft take and improve scar quality. These properties have not yet been evaluated in human clinical trials.

OBJECTIVE

The primary goal of this study was to evaluate tolerability and safety of SKINHEALTEX PLGA on human tissues, specifically, split-thickness skin autografts and wound beds of debrided burns.

MATERIALS AND METHODS

A double-blind randomised controlled clinical trial was conducted with adult patients with deep burns requiring surgical treatment, for 4 years (November 2018 to September 2022). Each patient acted as their own control, and they were followed for 12 months. In the control area a skin autograft was applied, while in the treatment area SKINHEALTEX PLGA was interposed between the autograft and the bed. The outcome variables were incidence of adverse events, the percentage of graft take (evaluated clinically), and Vancouver Scar Scale and Patient and Observer Scar Assesment Scale scores.

RESULTS

The bioveil was well tolerated in the 26 patients that were recruited. No adverse events related to SKINHEALTEX PLGA were observed. No statistically significant differences were observed in split-thickness skin autograft take and subsequent scar quality between the control group (split-thickness skin autografts alone) and the autograft and SKINHEALTEX PLGA group.

CONCLUSION

This is the first clinical trial investigating the application of an electrospun biomaterial in the treatment of burns using skin autografts. SKINHEALTEX PLGA is a biocompatible and safe product that can be applied as an interface between autografts and the debrided bed of a burn without reducing graft take. Further research is needed to assess the value of SKINHEALTEX PLGA for burn wounds and its potential as an administration route of molecules than enhance dermal regeneration in burn patients.