Nelonemdaz Treatment for Patients With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial

OBJECTIVES

Nelonemdaz is a N-methyl d-aspartate receptor subtype 2B-selective N-methyl-D-aspartate receptor antagonist and a potent free-radical scavenger that might ameliorate hypoxic-ischemic brain injury after out-of-hospital cardiac arrest (OHCA). We investigated the efficacy of nelonemdaz for patients with OHCA.

DESIGN

A double-blind, placebo-controlled, randomized, multicenter phase II trial.

SETTING

This trial enrolled 105 patients at five sites in South Korea between November 18, 2018, and February 23, 2023.

PARTICIPANTS

OHCA patients undergoing targeted temperature management.

INTERVENTIONS

Patients were randomly assigned to high-dose (5250 mg), low-dose (3250 mg), and placebo groups at a 1:1:1 ratio.

MEASUREMENTS AND MAIN RESULTS

Patients with a median age of 61 years (82% male) were assigned to the high-dose (n = 37), low-dose (n = 35), and placebo (n = 33) groups. The primary outcome, the serum level of neuron-specific enolase (NSE) at 48-52 hours, was evaluated in 93 patients. There was no difference in serum NSE between high-dose (median and interquartile range; 23.7, 15.0-69.9) and placebo (17.5, 13.6-113.0) groups, or between low-dose (26.6, 16.2-83.4) and placebo groups (all p > 0.05). Brain MRI fractional anisotropy was significantly higher in the high-dose group compared with the placebo group (0.465, 0.449-0.485 vs. 0.441, 0.431-0.464; p = 0.028), but not between low-dose (0.462, 0.439-0.480) and placebo groups (p > 0.05). At day 90, the common odds ratio (95% CI) indicating a numerically favorable shift in the modified Rankin Scale was 1.25 (0.48-3.24) and 1.22 (0.47-3.20) in the high-dose and low-dose groups, respectively, compared with placebo group (all p > 0.05). No serious adverse events were reported.

CONCLUSIONS

Nelonemdaz treatment of patients after OHCA did not reduce serum NSE levels compared with controls. Patients treated with high-dose nelonemdaz showed higher brain MRI fractional anisotropy suggesting less cerebral white matter damage.

Haemodynamic management of septic shock

Septic shock is a significant challenge in the management of patients with burns and traumatic injuries when complicated by infection, necessitating prompt and effective haemodynamic support. This review provides a comprehensive overview of current strategies for vasopressor and fluid management in septic shock, with the aim to optimize patient outcomes. With regard to vasopressor management, we elaborate on the pharmacologic profiles and clinical applications of catecholamines, vasopressin derivatives, angiotensin II, and other vasoactive agents. Noradrenaline remains central to septic shock management. The addition of vasopressin, when sequentially added to noradrenaline, offers a non-catecholaminergic vasoactive effect with some clinical benefits and risks of adverse effects. Emerging agents such as angiotensin II and hydroxocobalamin are highlighted for their roles in catecholamine-resistant vasodilatory shock. Next, for fluid management, crystalloids are currently preferred for initial resuscitation, with balanced crystalloids showing benefits over saline. The application of albumin in septic shock warrants further research. High-quality evidence does not support large-volume fluid resuscitation, and an individualized strategy based on haemodynamic parameters, including lactate clearance and capillary refill time, is recommended. The existing knowledge suggests that early vasopressor initiation, particularly noradrenaline, may be critical in cases where fluid resuscitation takes inadequate effect. Management of refractory septic shock remains challenging, with novel agents like angiotensin II and methylene blue showing potential in recent studies. In conclusion, Further research is needed to optimize haemodynamic management of septic shock, particularly in developing novel vasopressor usage and fluid management approaches.

Extracorporeal Cardiopulmonary Resuscitation-Where Do We Currently Stand?

Extracorporeal cardiopulmonary resuscitation (eCPR) is a method of acute resuscitation for patients who have suffered a cardiac arrest through the utilization of an extracorporeal membrane oxygenation (ECMO) pump. The use and efficacy of eCPR is an active area of investigation with ongoing clinical investigation across the world. Since its inception, ECMO has been utilized for several conditions, but more recently, its efficacy in maintaining cerebrovascular perfusion in eCPR has generated interest in more widespread utilization, particularly in cases of out-of-hospital cardiac arrest. However, successful implementation of eCPR can be technically challenging and resource intensive and has been countered with ethical challenges beyond the scope of conventional in-hospital ECMO care. The aim of this review is to summarize the status of eCPR in the current era.

Nursing Skills in the Care of Patients With Respiratory Stomas in Hospitals With and Without Advanced Practice Tracheostomy Service

AIMS

To identify whether there are differences in knowledge regarding the management of patients with respiratory stomas among nurses working in hospitals with an advanced practice tracheostomy service compared to those without it.

DESIGN

Descriptive, cross-sectional, comparative, analytical survey study.

METHOD

The study was conducted from January to March 2023 in four tertiary care hospitals, two of which have an advanced practice tracheostomy service. A self-administered questionnaire was designed, consisting of 16 questions about nurses' specialised training in caring for tracheostomy patients. The study adhered to the STROBE checklist. Statistical analyses were performed using SPSS (24.0) from IBM.

RESULTS

Nurses in hospitals with a dedicated tracheostomy service obtained a higher mean score (7.1/10) and demonstrated greater anxiety when managing patients with stomas (p < 0.001), as well as an increased willingness to undergo specific training (p = 0.017) to reduce their lack of self-confidence.

CONCLUSIONS

A higher level of anxiety in the management of tracheostomised patients and a greater interest in receiving specific training have been observed among nurses in hospitals with advanced practice services (APTS), despite having greater training. Therefore, institutions should commit to incorporating advanced practice nurses and continuing education in the approach to ostomies among their professionals.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Implementing ongoing training programmes and specific tracheostomy services or units in hospitals would enable nurses to provide high-quality care for patients with respiratory stomas.

REPORTING METHOD

The study adhered to the STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

Neither patients nor the public were involved in the design or conduct of this research. Nurses participated exclusively in data collection.

Treatment outcomes of two surgical techniques in secondary reconstruction of unilateral cleft lip and ala nasi utilizing anthropometry assessment: a randomized controlled trial

BACKGROUND

An orofacial cleft significantly impacts the oral health-related quality of life of children and teenagers. Secondary reconstruction is a more complex procedure due to tissue deficiency and scarring. The study aimed to evaluate the use of Pfeifer's wave-line incision method and the rotational flap method in the secondary reconstruction of unilateral lip clefts in patients with unilateral cleft lip and ala nasi aged 5-25 years utilizing anthropometry assessment.

METHODS

It was a double-blinded, randomized, parallel-group, active-controlled trial with two arms. Twenty-four patients were randomly divided into two groups. Group 1: Rotational flap method. Group 2: Control group, Pfeifer's wave-line incision method. The following anthropometric measurements were considered: Lb(X):En-En: The horizontal position of the center of the cupid's bow. Ch-Lt(l:r): The distance between the cheilion and the tip of the cupid's bow. Lt-Lb(l:r): The length of the cupid's bow. Lt(Y)(l:r): The size of the upper lip. Lt-Lt'(l:r): The height of the vermilion at the tip of the cupid's bow. Photographs were performed according to the follow-up periods: At the baseline and before surgery (t0). Immediately after surgery (t1). Two weeks after surgery (t2). Six months after surgery (t3).

RESULTS

The rotational flap method did not outperform Pfeifer's method in the studied anthropometric measurements. In the rotational flap method group, there was a significant improvement in the mean value of Ch-Lt(l:r) from t0 (1.156 ± 0.206) to t3 (0.962 ± 0.098), and in the average value of Lt(Y)(l:r) from t0 (0.944 ± 0.023) to t3 (0.990 ± 0.011) (p < 0.05). In Pfeifer's method group, the mean value of Ch-Lt(l:r) was (1.141 ± 0.158) at t0, and then improved to become (1.007 ± 0.084) at t3 (p < 0.05), the average value of Ch-Lt(l:r) at t0 was (0.942 ± 0.026), which improved to (0.991 ± 0.012) at t3, and the average value of Lt-Lt'(l:r) increased from t0 (1.308 ± 1.174) to t3 (1.050 ± 0.054) (p < 0.05).

CONCLUSION

Pfeifer's wave-line incision and rotational flap methods achieve similar aesthetic results in the appearance of the lip or Cupid's bow after a 6-month follow-up.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN36320776, registered 06 November 2024.

Nutritional Support in the ICU

Critical illness is a complex condition that can have a devastating impact on health and quality of life. Nutritional support is a crucial component of critical care that aims to maintain or restore nutritional status and muscle function. A one-size-fits-all approach to the components of nutritional support has not proven beneficial. Recent randomized controlled trials challenge the conventional strategy and support the safety and potential benefits of below-usual calorie and protein intakes at the early, acute phase of critical illness. Further research is needed to define optimal nutritional support throughout the intensive care unit stay. Individualized nutritional strategies relying on risk assessment tools or biomarkers deserve further investigation in rigorously designed, large, multicenter, randomized, controlled trials. Importantly, although nutritional support is crucial, it might not be sufficient to enhance the recovery of critically ill patients. Thus, achieving the greatest efficacy may require individualized nutritional support combined with early, prolonged physical rehabilitation within a multimodal, holistic care program throughout the patient's recovery journey.

User-centred design of a patient portal for persons living with home mechanical ventilation and long-term tracheostomy: a mixed methods study

Patient portals are secure online platforms that offer patients access to various functions such as personal health information. While patient portals are being increasingly offered by health services, there are limited data on their use for persons living with home mechanical ventilation (HMV) and/or long-term tracheostomy. This study, conducted at an Australian hospital's home mechanical ventilation and long-term tracheostomy services, aimed to explore the perspectives and attitudes of patients and carers regarding the introduction of a patient portal. There were 231 survey responses and 6 semi-structured interview participants. Interest in using a patient portal was high with 87% of survey respondents indicating that they would consider using a patient portal if it were offered. Those that were more likely to be interested were younger, had higher levels of education, and reported being confident with using technology and accessing health information. The functions of a patient portal that were of most interest were the ability to view their own health information including ventilation and/or tracheostomy information and the ability to order ventilation and tracheostomy-related equipment. This study is the first step of a user-centered design for the implementation of a patient portal for persons living with home mechanical ventilation and/or long-term tracheostomy.

Unmet educational needs and expectations among tracheostomy recipients

OBJECTIVE

This study seeks to better understand unmet educational needs and treatment expectations in individuals with a tracheostomy.

STUDY DESIGN

Retrospective, cross-sectional survey.

METHODS

A survey was distributed to individuals who received a tracheostomy at a tertiary care center in the last five years as well as in Facebook support groups for tracheostomy and head and neck cancer patients. The survey focused on tracheostomy education, satisfaction with care, and gaps in treatment plan understanding. Primary outcome was rate of tracheostomy peri-operative experience being on-par with expectations.

RESULTS

Among 83 respondents, only report of pre-operative speech (p = 0.024) and swallow (p = 0.019) discussions were associated with peri-operative experience being on-par with expectations. Respondents were more likely to report importance of counseling regarding psychological well-being (p < 0.001) and post-operative social integration/interaction (p < 0.001) than they were to report receiving focused counseling about these topics. Qualitative analysis demonstrated the most frequently missing components of understanding of treatment plans included post-operative care and the post-operative experience (n = 19, 40.4 % each). Reasons for treatment not meeting expectations included lack of communication/education (n = 15, 39.5 %) and experience being worse than expected (n = 8, 21.1 %). Individuals frequently wanted more details of the experience of living with a tracheostomy (n = 25, 42.6 %) and details about tracheostomy care (n = 10, 16.4 %).

CONCLUSION

This study demonstrates significant gaps in informational needs for individuals receiving a tracheostomy, emphasizing the importance of guideline-directed tracheostomy counseling. Specifically, more information is needed regarding expected post-surgical experience, tracheostomy care and maintenance, psychosocial wellbeing, and communication support.

Use of point-of-care ultrasound during cardiac arrest in the intensive care unit: A cross-sectional survey

BACKGROUND

There is growing interest in the use of point-of-care ultrasound during cardiac arrest, but few studies document its use in the intensive care unit.

OBJECTIVE

We hypothesised this may reflect a low prevalence of use of point-of-care ultrasound during cardiac arrest or negative attitudes towards its use. We aimed to determine the self-reported prevalence, attitudes towards, and barriers to use of point-of-care ultrasound during cardiac arrest in the intensive care unit.

METHODS

We conducted a web-based survey over 3 months (08/08/2022-06/11/2022), of intensive care unit consultants and registrars in Victoria, Australia. Descriptive and mixed-methods analyses of Likert-type and free-text answers were performed.

RESULTS

The response rate was 91/398 (22.8%), split evenly between consultants and registrars. There was a broad range of clinical and ultrasound experience. Only 22.4% (22/91) of respondents reported using point-of-care ultrasound 75-100% of the time during their management of cardiac arrest. Respondents rated the value they place in point-of-care ultrasound during cardiac arrest 3 (interquartile range: 3-4) and that of a "skilled operator" 4 ((interquartile range; 4-5) on a 5-point scale. Free-text analysis suggested exclusion of "tamponade" (40/80 [50%] comments) as the most valuable use-case and "skill" as a personal barrier (20/73 [27.4%] comments). Personal and departmental barriers were not rated highly, although registrars perceived "lack of a structured training program" as a barrier. Respondents were equivocal in the value they gave point-of-care ultrasound during cardiac arrest but saw greater value when conducted by a skilled operator.

CONCLUSIONS

Point-of-care ultrasound was reported to be infrequently used in cardiac arrest, mostly due to self-perceived skill and lack of a structured training program.

Effectiveness, usability, and patient satisfaction of an mHealth application with an integrated ePRO system following lumbar degenerative spinal surgery: A quasi-experimental study

Introduction

There is a lack of comprehensive clinical research to assess potential benefits of mHealth solutions in post discharge follow-up care after spinal surgery.

Purpose

This quasi-experimental study evaluated the effectiveness, usability, and patient satisfaction of an mHealth pathway with an electronic Patient-Reported Outcome (ePRO)-based post-discharge nurse-led intervention for patients undergoing surgery for lumbar spine degenerative disorders, compared to standard care.

Methods

Conducted at a Danish tertiary spine center, this study represents the final stage of a three-phase participatory design. The primary outcome was patient quality of recovery, measured by the Quality of Recovery-15 (QoR-15) questionnaire. Secondary outcomes included patient-perceived usability, assessed with the Danish System Usability Scale (SUS). To capture additional patient insights, an open-ended feedback question was included at the end of the survey.

Results

Data from 150 patients (77 women and 73 men) were analyzed, with 104 in the intervention group and 46 in the comparison group. Both groups showed significant improvement over time, but no significant difference between groups. Of 154 potential SUS respondents, 110 participated. Analysis revealed 48 statements, categorized into five themes: (1) Usability and functionality of the mHealth solution, (2) Feedback on the QoR-15 questionnaire, (3) Safety and support, (4) Missing functions and suggestions for improvements, and (5) Patient satisfaction.

Conclusion

No significant differences in effectiveness between the mHealth pathway and standard care were found for post-surgery recovery in lumbar spine patients. Usability and patient satisfaction were generally high, though suggestions for improvements were noted. The study highlighted the importance of post-discharge support, suggesting that the intervention provided crucial security and support, potentially demonstrating compassion through nurse-led care.

Advance Care Planning Bundle: Using Technical and Adaptive Solutions to Promote Goal Concordant Care

BACKGROUND

Advance Care Planning (ACP) is critical to achieve goal-aligned care for patients. However, optimal implementation requires complex coordination and alignment across a healthcare system.

MEASURES

A survey of rapid response providers assessed usefulness of the ACP quality improvement bundle and perceptions of use and adherence.

INTERVENTION

We implemented a bundle of advance care planning tools and interventions using the technical-adaptive framework. These included orders, documentation templates and processes, and standard education.

OUTCOMES

Ninety-three rapid response providers completed the survey. 80.5% reported that overall, these quality improvement efforts have been very helpful or somewhat helpful in improving their ability to provide care consistent with the patient's goals.

CONCLUSIONS/LESSONS LEARNED

Implementation of technical and adaptive tools as a bundle for Advance Care Planning shows promise to improve and sustain goal-aligned care. Quality Improvement in ACP is a complex, iterative process involving both structural change and behavioral adaptation.

The Value of Tracheal Visualization in Tracheostomized Patients in Skilled and Long-Term Care Homes

Objective This study aims to assess the impact of tracheal visualization on weaning success among tracheostomized patients in skilled and long-term care facilities, highlighting its role in reducing complications and enhancing clinical outcomes. Methods A retrospective observational study was conducted on tracheostomized patients residing in skilled nursing homes in Florida between 2018 and 2023. The study included individuals aged 18 years or older with established tracheostomies. Routine tracheal visualization techniques were used to confirm tube placement, evaluate tracheal health, and detect complications such as infections, inflammation, or obstructions. Results Among the 21 patients analyzed, a weaning success rate of 23.8% was observed. Patients who successfully weaned had fewer comorbidities and higher tracheal health scores compared to those who did not. Routine tracheal visualization reduced complications related to tube malposition and facilitated timely interventions, such as correcting tube displacement or managing airway obstructions. Conclusions This study underscores the significance of incorporating tracheal visualization into care protocols for tracheostomized patients, especially in skilled nursing and long-term care settings. Future research should focus on developing standardized protocols to improve care quality and ensure patient safety, particularly in resource-constrained environments.

Adverse Events and Outcomes of High-volume Plasma Exchange in 50 Acute Liver Failure Patients: A Monocentric Retrospective Real-world Study

Background and aims

Acute liver failure (ALF) is a condition that mostly requires Intensive Care Unit (ICU) admission and sometimes necessitates emergency liver transplantation. High-volume plasma exchange (HVPE) may improve transplant-free survival (TFS) in ALF. Our study assessed complications of HVPE therapy and outcome in ALF patients.

Methods

We conducted a single-center retrospective study of all patients admitted to the ICU for ALF and who underwent HVPE between June 2016 and June 2021. The plasmapheresis technique used was centrifugation, and the volume exchanged was calculated as 15% of the ideal body weight. Dedicated staff prospectively collected clinical adverse effects, while biological data were retrospectively collected. The primary outcome was the rate of severe adverse effects (SAE, defined as severe manifestations of hypotension, allergy, metabolic disturbances or other life-threatening event) that occurred during HVPE sessions. Factors influencing day-21 TFS were also studied.

Results

One hundred twenty sessions were performed in 50 patients. The main etiology for ALF was paracetamol (52% of the patients). During the session, hemoglobin, platelet, transaminases, ammonia and bilirubin decreased, coagulation factors increased, and creatinine and lactate remained unchanged. At least one SAE was reported for 32 out of 120 sessions (26.7% [19%-35.5%], mostly severe alkalosis [24/117], hypotension [4/120] and hypocalcemia [4/119]). Arterial pH ≤ 7.43 following HVPE and paracetamol etiology were negatively and positively associated with day-21 TFS, respectively.

Conclusion

Severe adverse effects were frequent during HVPE performed for ALF, mainly severe alkalosis, hypotension and hypocalcemia. Post-HVPE, pH and paracetamol etiology were prognosis markers.

Post-Intensive Care Syndrome: Physical Impairments and Function

Patients surviving critical illness are at risk of persistent physical impairments related to Post Intensive Care Syndrome. Physical impairments and symptoms have potential for recovery, but frequently impact quality of life, performance of activities of daily living and participation in societal roles. Patient and illness-related risk factors directly relate and may predict physical functional outcomes providing opportunity for clinicians and scientist to develop targeted intervention strategies. Clinicians and scientists should screen and assess physical impairments and symptoms early following Intensive care unit discharge with a serial approach to promote for targeted and individualized treatment.

[Post-Intensive Care Syndrome: functional impairments of critical illness survivors]

With a decrease in mortality of critically ill patients in recent years, intensive care medicine research has shifted its focus on functional impairments of intensive care units (ICU) survivors. ICU survivorship is characterized by long-term impairments of cognition, mental health, and physical health. Since 2012, these impairments have been summarized with the umbrella term Post-Intensive Care Syndrome (PICS). Mental health impairments frequently entail new are aggravated symptoms of depression, anxiety, and posttraumatic stress disorder. Beyond impairments in the three PICS domains, critical illness survivors frequently suffer from chronic pain, dysphagia, and nutritional deficiencies. Furthermore, they have a higher risk for osteoporosis, bone fractures, and diabetes mellitus. Taken together, these sequelae reduce their health-related quality of life. Additionally, ICU survivors are challenged by social problems such as isolation, economic problems such as treatment costs and lost earnings, and return to previous employment. Yet, patients and caregivers have described post-ICU care as inadequate and fragmented. ICU follow-up clinics could improve post-ICU care, but there is insufficient evidence for their effectiveness. Thus far, large high-quality trials with multicomponent and interdisciplinary post-ICU interventions have mostly failed to improve patient outcomes. Hence, preventing PICS and minimizing risk factors by optimizing ICU care is crucial, e.g. by implementing the ABCDE bundle. Future studies need to identify effective components of post-ICU recovery interventions and determine which patient populations may benefit most from ICU recovery services.

Perioperative Acute Kidney Injury: Diagnosis, Prediction, Prevention, and Treatment

In this review, the authors define acute kidney injury in the perioperative setting, describe the epidemiologic burden, discuss procedure-specific risk factors, detail principles of management, and highlight areas of ongoing controversy and research.

Prospective evaluation of efficacy and safety of distal radial and radial artery access using a novel articulating-tip guidewire

BACKGROUND

Guidewire-facilitated access to peripheral vessels is commonplace in vascular access, but guidewire insertion into small vessels, such as the radial and distal radial arteries, can still be challenging. Failure to gain access on the first attempt may contribute to increased risks of procedural complications, such as vessel dissection, spasm, and occlusion. This research assessed the safety and efficacy of radial and distal radial artery access using a novel, FDA-cleared, small-core-diameter guidewire with an articulating tip, under ultrasound guidance.

METHODS

This was a prospective, single-arm, single-center trial. Patients in need of vascular access were screened for participation and enrolled in the study. Guidewire insertion was attempted by four physicians (three interventional radiologists and an interventional nephrologist) at 162 arterial sites-65 radial and 97 distal radial, having a mean diameter of 2.0 mm.

RESULTS

First-attempt successful placement of the guidewire in the artery occurred at 87.6% of access sites (142/162) and differences in the success rate between the radial and distal radial arteries or between vessels with diameter smaller or larger than 2 mm were not observed (62/68 and 67/77, respectively; p = 0.6). Four of the five reported adverse events were unrelated to the study device or procedure. Two of the three distal radial artery spasms occurred before the guidewire was used. The other two events were a radial artery spasm, and a distal radial artery site hematoma. All adverse events resolved spontaneously.

CONCLUSIONS

First-attempt placement of a novel articulating tip guidewire in the radial and distal radial arteries occurred at a high rate in our study and was not associated with safety concerns.

Oral blood pressure augmenting agents for intravenous vasopressor weaning

Intravenous (IV) vasopressors are essential in the management of hypotension and shock. Initiation of oral vasoactive agents to facilitate weaning of IV vasopressors to liberate patients from the intensive care unit is common despite conflicting evidence regarding the benefits of this practice. While midodrine appears to be the most frequently studied oral vasoactive agent for this purpose, its adverse effect profile may preclude its use in certain populations. In addition, some patients may require persistent use of IV vasopressors for hypotension refractory to midodrine. The use of additional and alternative oral vasoactive agents bearing different mechanisms of action is emerging. This article provides a comprehensive review of the pharmacology, clinical uses, dosing strategies, and safety considerations of oral vasoactive agents and their application in the intensive care setting.

Metabolic Reprograming of Macrophages: A New Direction in Traditional Chinese Medicine for Treating Liver Failure

Acute liver failure (ALF) is a fulminant clinical syndrome that usually leads to multiple organ failure and high mortality. Macrophages play a crucial role in the initiation, development, and recovery of ALF. Targeting macrophages through immunotherapy holds significant promise as a therapeutic strategy. These cells exhibit remarkable plasticity, enabling them to differentiate into various subtypes based on changes in their surrounding microenvironment. M1-type macrophages are associated with a pro-inflammatory phenotype and primarily rely predominantly on glycolysis. In contrast, M2-type macrophages, which are characterized by anti-inflammatory phenotype, predominantly obtain their energy from oxidative phosphorylation (OXPHOS) and fatty acid oxidation (FAO). Shifting macrophage metabolism from glycolysis to OXPHOS inhibits M1 macrophage activation and promotes M2 macrophage activation, thereby exerting anti-inflammatory and reparative effects. This study elucidates the relationship between macrophage activation and glucose metabolism reprograming from an immunometabolism perspective. A comprehensive literature review revealed that several signaling pathways may regulate macrophage polarization through energy metabolism, including phosphatidyl-inositol 3-kinase/protein kinase B (PI3K/AKT), mammalian target of rapamycin (mTOR)/hypoxia-inducible factor 1α (HIF-1α), nuclear factor-κB (NF-κB), and AMP-activated protein kinase (AMPK), which exhibit crosstalk with one another. Additionally, we systematically reviewed several traditional Chinese medicine (TCM) monomers that can modulate glucose metabolism reprograming and influence the polarization states of M1 and M2 macrophages. This review aimed to provide valuable insights that could contribute to the development of new therapies or drugs for ALF.

Workload of physiotherapy procedures in the adult intensive care unit: a descriptive study in a Brazilian teaching hospital

BACKGROUND

Physiotherapy techniques applied in intensive care units (ICU) aim to counteract functional decline and manage acute respiratory conditions. Treatment strategies vary depending on factors such as diagnosis, disease severity, and costs. Staffing resources and workload impact the duration and frequency of interventions. Understanding the workload of procedures may enhance patient care quality.

OBJECTIVE

To determine the frequency, duration, and workload of physiotherapy procedures applied to adult ICU patients. Secondarily, we analyzed the time spent per shift on teaching-related and non-procedure-related activities.

METHODS

Longitudinal panel study conducted in a 12-bed university hospital. Physiotherapy sessions applied to adult ICU patients were included. The list of procedures was derived using the Delphi method. The investigator followed physiotherapists to measure the duration of procedures and calculate a workload index for each (determined as duration x frequency). Duration of teaching-related and non-procedure-related tasks was also recorded.

RESULTS

A total of 339 physiotherapy sessions were analyzed across 79 shifts, involving 181 patients and 19 physiotherapists. Procedures with the highest workload index were: out-of-bed mobilization, patient positioning, passive limb mobilization, active exercises, artificial airway suctioning, and equipment management. Time distribution across the shifts was as follows: direct patient care 40% (SD 12%), non-procedure-related activities 20% (SD 6%), and teaching-related activities 10% (range: 4%-19%).

CONCLUSION

The procedures with the highest workload index were those directly related to rehabilitation, such as mobilization and exercises, and those not specific to patient condition, like positioning and equipment management. Physiotherapists spent most of their time in direct patient care, followed by indirect care activities and teaching.

A meta-analysis of prevalence of diabetic retinopathy in Asia

INTRODUCTION

Diabetic retinopathy (DR) is a common microvascular complication of diabetes. This review reports the prevalence of DR in Asia and guides healthcare provision in screening and treatment.

EVIDENCE ACQUISITION

Medline was searched for articles describing the prevalence of DR in Asia. Statistical analysis was performed using Freeman-Tukey double arcsine transformation and the DerSimonian and Laird model. The prevalence of DR was estimated according to the following subgroups: Economic status (high, middle, and low income), country, and ethnicity. The risk of bias of the articles was also assessed.

EVIDENCE SYNTHESIS

A total of 66 studies were included, and out of 2,599,857 patients with diabetes, 201,646 were diagnosed with DR. The overall prevalence of DR, non-proliferative DR (NPDR), proliferative DR (PDR) and maculopathy were recorded at 21.7% (CI: 19.1-24.6%), 19.9% (CI: 17.3-22.8%), 2.3% (CI: 1.6-3.4%) and 4.8% (CI: 3.5-6.7%) respectively. Low-income countries had the lowest prevalence of DR, NPDR, PDR and maculopathy compared to the middle- and high-income countries. Middle-income countries had the highest prevalence of DR (23.9%; CI: 19.4-29.2%), NPDR (21.1%; CI: 17.0-25.9%), moderate NPDR (7.9%; CI: 5.7-11.0%), PDR (3.0%; CI: 1.8-4.9%) and maculopathy (4.7%; CI: 3.0-7.4%), while high-income countries had the highest prevalence of mild (10.3%; CI: 4.2-23.2%) and severe NPDR (3.0%; CI: 1.0-8.4%).

CONCLUSIONS

One in five people with diabetes have diabetic retinopathy. It is imperative that public healthcare take heeds to heighten the screening program to provide all patients with diabetes equitable access to DR screening and ophthalmology services.

Rationale and development of a prehospital goal-directed bundle of care to prevent rearrest after return of spontaneous circulation

In patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC), rearrest while in the prehospital setting represents a significant barrier to survival. To date, there are limited data to guide prehospital emergency medical services (EMS) management immediately following successful resuscitation resulting in ROSC and prior to handoff in the emergency department. Post-ROSC care encompasses a multifaceted approach including hemodynamic optimization, airway management, oxygenation, and ventilation. We sought to develop an evidenced-based, goal-directed bundle of care targeting specified vital parameters in the immediate post-ROSC period, with the goal of decreasing the incidence of rearrest and improving survival outcomes. Here, we describe the rationale and development of this goal-directed bundle of care, which will be adopted by several EMS agencies within California. We convened a group of EMS experts, including EMS Medical Directors, quality improvement officers, data managers, educators, EMS clinicians, emergency medicine clinicians, and resuscitation researchers to develop a goal-directed bundle of care to be applied in the field during the period immediately following ROSC. This care bundle includes guidance for prehospital personnel on recognition of impending rearrest, hemodynamic optimization, ventilatory strategies, airway management, and diagnosis of underlying causes prior to the initiation of transport.

Policy Proposals for Mitigating Intensive Care Unit Strain: Insights from the COVID-19 Pandemic

Intensive care unit (ICU) strain, characterized by a discrepancy between perceived or actual intensive care resources and demand, significantly impacts patient outcomes and healthcare worker well-being. The coronavirus disease (COVID-19) pandemic exacerbated ICU strain, leading to increased mortality and extended hospital stays, affecting both critically ill patients with and without COVID-19. A systematic review identified 16 leading and lagging indicators of ICU capacity strain, including queuing, premature and after-hours ICU discharge, use of temporary space, length of stay, burnout, staffing and nurse-to-patient ratio, ICU census, acuity and turnover, standardized mortality ratio, readmissions, availability of critical supplies, ventilator use, and surgery cancellation. However, variability in operational definitions and limited evidence regarding the reliability, validity, usability, and feasibility limit the value of single indicators for informed strategic planning and policy guidance. Regional and national policies and programs are essential to enhance real-time monitoring for effective management of critical care resources, and they mitigate the impact of ICU strain, facilitating complex interhospital transfers to reduce strain and ensuring comprehensive strategies for enhancing ICU resilience. Proactive regional cooperation is advocated for policy formulation, knowledge exchange, and resource allocation to anticipate and mitigate ICU strain, ensuring equitable healthcare access during global health crises. The policy implications for future preparedness emphasize the importance of evidence-based triage and adaptable patient management strategies alongside ethical considerations in resource allocation and the role of behavioral economic insights in optimizing resource utilization and collaborative healthcare practices. This multifaceted approach for addressing ICU strain comprehensively and effectively during a pandemic would promote health equity and enhance healthcare system resilience under both routine operations and crisis conditions.

Inability to Sit-to-Stand in Medical ICUs Survivors: When and Why We Should Care

OBJECTIVES

To investigate the prevalence and association with mortality of inability to perform sit-to-stand independently in critically ill survivors 3 months following medical ICU (MICU) discharge.

DESIGN

Prospective cohort study.

SETTING

Six MICUs at a tertiary care hospital.

PATIENTS

MICU survivors who could sit-to-stand independently before the index hospitalization.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Inability to sit-to-stand (yes/no) was measured at four points following MICU discharge: upon ICU discharge, 1, 2, and 3 months afterward. Mortality was evaluated at 6- and 12-month post-MICU discharge. Among 194 participants, 128 (66%) had inability to sit-to-stand upon MICU discharge. Recovery occurred, with rates decreasing to 50% at 1 month, 38% at 2 months, and 36% at 3 months post-MICU discharge, plateauing at 2 months. Inability to sit-to-stand at 3 months was significantly associated with 21% mortality at 12 months and a 4.2-fold increased risk of mortality (adjusted hazard ratio, 4.2; 95% CI, 1.61-10.99), independent of age, Sequential Organ Failure Assessment score, and ICU-acquired weakness. Notably, improvement in sit-to-stand ability, even from "totally unable" to "able with assistance," correlates with reduced mortality risk.

CONCLUSIONS

Inability to sit-to-stand affects about 36% of MICU survivors even at 3 months post-ICU discharge, highlighting rehabilitation challenges. Revisiting sit-to-stand ability post-ICU discharge is warranted. Additionally, using sit-to-stand as a screening tool for interventions to improve return of its function and mortality is suggested.

Association of cumulative oxygen and carbon dioxide levels with neurologic outcome after pediatric cardiac arrest resuscitation: A multicenter cohort study

Objective

We aimed to (1) determine the association between cumulative PaO2 and PaCO2 exposure 24 h post-return of circulation and survival with favorable neurologic outcome. And (2) to assess adherence to American Heart Association post-cardiac arrest care treatment goals (PaO2 75-100 mmHg and PaCO2 35-45 mmHg).

Design and setting

Prospectively collected data were analysed from five Pediatric Resuscitation Quality collaborative sites supplemented with retrospective PaO2 and PaCO2 data.

Patients

Children aged 1 day-17 years with return of circulation after cardiac arrest, admitted 2019-2022, with ≥ 4 arterial blood gasses spanning at least 12 h within 24 h post-return of ciculation, were eligible. Congenital cyanotic heart disease events were excluded.

Measurements

Area under the curve calculation provided hourly cumulative PaO2 and PaCO2 exposures per child and similarly guideline recommended cumulative ranges. The primary outcome was survival to hospital discharge with favorable neurologic outcome defined as a Pediatric Cerebral Performance Category 1-3, or no pre-arrest baseline difference.

Main results

Among 292 included children (median age 2.6 years (IQR 0.4-10.9)), 57 % survived to discharge and 48 % had favorable neurologic outcome (88 % of survivors). Cumulative PaO2 and PaCO2 exposure 0-24 h post-return of circulation were not significantly associated with favorable neurologic outcome in multivariable analysis (OR 1.0, 95 %CI 0.98-1.02 and OR 0.97, 95 %CI 0.87-1.09 respectively). Cumulative PaO2 and PaCO2 remained within guideline recommended ranges for 24 % and 58 % of children respectively with median areas under the curve over 0 - 24 h of 2664 mmHg (2151 - 3249 mmHg) for PaO2 and 948 mmHg (853 - 1051 mmHg) for PaCO2. AHA post-cardiac arrest care guideline recommendations for PaO2 (1800-2400 mmHg) and PaCO2 (840-1080 mmHg) were recalculated as area under the curve ranges. Achieving both normoxia and normocapnia was observed in 12 % of children.

Conclusions

Cumulative PaO2 and PaCO2 exposure in the first 24 h post-return of circulation was not associated with survival with favorable neurologic outcome. Pediatric AHA post-cardiac arrest care guideline normoxia and normocapnia goals were often not met. Larger cohort studies are necessary to improve the accuracy of cumulative exposure calculations, assess the long-term effects of PaO2 and PaCO2 exposure, and explore the influence of other post-cardiac arrest care therapeutic strategies.

Rehabilitation and Social Determinants of Health in Critical Illness Recovery Literature: A Systematic Review

OBJECTIVES

Patients who survive critical illness navigate arduous and disparate recovery pathways that include referrals and participation in community-based rehabilitation services. Examining rehabilitation pathways during recovery is crucial to understanding the relationship on patient-centered outcomes. Furthermore, an understanding of social determinants of health (SDOH) in relation to outcomes and rehabilitation use will help ensure equitable access for future care. Therefore, there is a need to define and understand patient care pathways, specifically rehabilitation after discharge, through a SDOH lens after surviving a critical illness to improve long-term outcomes.

DATA SOURCES

MEDLINE, PubMed, Web of Science Core Collection (Clarivate), the CINAHL, and the Physiotherapy Evidence Database.

STUDY SELECTION AND DATA EXTRACTION

A systematic review of the literature was completed examining literature from inception to March 2024. Articles were included if post-hospital rehabilitation utilization was reported in adult patients who survived critical illness. Discharge disposition was examined as a proxy for rehabilitation pathways. Patients were grouped by patient diagnosis for grouped analysis and reporting of data. Two independent researchers reviewed manuscripts for inclusion and data were extracted by one reviewer using Covidence. Both reviewers used the Newcastle-Ottawa Scale to assess risk of bias.

DATA SYNTHESIS

Of 72 articles included, only four articles reported detailed rehabilitation utilization. The majority of the studies included were cohort studies (91.7%) with most articles using a retrospective design (56.9%). The most common patient population was acute respiratory diagnoses (51.4%). Most patients were discharged directly home from the hospital (75.4%). Race/ethnicity was the most frequently reported SDOH (43.1%) followed by insurance status (13.9%) and education (13.9%).

CONCLUSIONS

The small number of articles describing rehabilitative utilization allows for limited understanding of rehabilitation pathways following critical illness. The reporting of detailed rehabilitation utilization and SDOH are limited in the literature but may play a vital role in the recovery and outcomes of survivors of critical illness.

Clinical and Laboratory Features and Treatment Outcomes of Dengue Fever in Pediatric Cases

Background Globally, dengue fever (DF) is the leading cause of arthropod-borne viral illness, which considerably contributes to an atrocious death rate. The disease is now endemic in some parts of the world, including Bangladesh. The disorder exhibits a wide range of clinical and laboratory features in children. Judicial fluid resuscitation during the critical phase and prompt referral to the appropriate health facility can be lifesaving. Objectives This research appraised clinical and laboratory features and treatment outcomes of DF in pediatric cases. Methods This prospective investigative work was conducted at Islami Bank Hospital, Dhaka, India, from July to October 2023. The study included 135 admitted pediatric cases of DF, either dengue nonstructural protein 1 (NS1) or anti-dengue antibody IgM or IgG positive. Results Among the selected cases, boys were more predominant than girls, and most patients were in the age group of 5 to 10 years (n=46, 34%), most of them belonging to lower-middle-class families (n=56, 41.5%). All of the study participants had raised body temperatures, and most had abdominal pain (n=82, 60.7%), vomiting (n=77, 57%), cough (n=43, 31.9%), headache (n=38, 28.2%), body aches (n=32, 23.7%), and diarrhea (n=23, 17%). Dengue NS1 was positive in 91.1% (n=123) of cases. Raised hematocrit was found in 36.3% (n=49) of cases, leukopenia in 47% (n=63), and thrombocytopenia in 69.6% (n=94) of cases. Most of our patients were categorized as having DF (68.1%, n=92), followed by dengue with warning signs (16.3%, n=22), and severe dengue was present in 15.6% (n=21) of patients. Most were treated with crystalloid, and some with crystalloid and colloid solution. Fortunately, most of them recovered with no death. Conclusion DF may manifest with varied clinical and laboratory features in children. Appropriate treatment of critical phases, depending on clinical and laboratory features, is crucial to reducing dengue-induced miseries and fatal clinical outcomes among the pediatric population.

Efficacy of Enhanced Rehabilitation Initiated After Hospital Discharge to Improve Quality of Life in Survivors of Critical Care: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This systematic review and meta-analysis evaluated the effects of enhanced rehabilitation initiated after hospital discharge on the quality of life (QOL) in survivors of critical care. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedure. MEDLINE, CENTRAL, Ichushi, Embase, PEDro, and Cumulated Index to Nursing and Allied Health Literature (CINAHL) databases and the International Clinical Trials Registry Platform and ClinicalTrials.gov (for ongoing or unpublished trials) were searched till January 2024. We identified randomized controlled trials (RCTs) with intensive care unit (ICU) survivors focusing on the effects of enhanced rehabilitation initiated after hospital discharge. Enhanced rehabilitation encompasses protocolized programs offering more intensive, frequent, or longer sessions than standard care. Primary outcomes were physical and mental components of the summary of the standardized QOL scale (SF-36) and adverse events. We calculated pooled-effect estimates for these components, expressing the mean difference (MD) and 95% confidence interval (CI). Risk of bias was evaluated using the Risk of Bias 2 tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Nine RCTs (573 patients) were included. Enhanced rehabilitation resulted in no difference in the physical component-summary score (two studies: n=79, MD=3.03, 95% CI: -1.37 to 7.43, I2=0%, low-certainty evidence) and a higher mental component-summary score (two studies: n=79, MD=7.27, 95% CI: 2.08-12.46, I2=0%, low-certainty evidence). The evidence on the effect of enhanced rehabilitation on adverse events was very uncertain (nine studies: n=558, risk difference: 0.04, 95% CI: 0.00-0.07, I2=65%, very low-certainty evidence). Seven studies reported no adverse event occurrence, one reported a serious event requiring hospitalization in the intervention group, and another reported a minor event in the intervention group with none in controls. Enhanced rehabilitation initiated after hospital discharge may improve the mental component of QOL for survivors in the critical care. Due to the smaller number of studies included, the results need further confirmation.

Analyzing collaborations in clinical trials in Korea using association rule mining

Identifying how trial sites collaborate is essential for multicenter trials. The ways in which collaboration among trial sites is established can vary according to study phase and clinical trial domains. In this study, we employed association rule mining to reveal trial collaboration. We used trial approval data provided by the Ministry of Food and Drug Safety in Korea and organized the trial sites. We collected trial information from 2012 to 2023 and categorized the trials according to study phase and clinical trial domain. We performed association rule mining based on study phase and clinical trial domain. We identified 209 valid trial sites and analyzed 11,107 clinical trials conducted during this period. By study phase, phase 1 trials accounted for the largest number (5,451), followed by phase 3 (2,492), others (1,826), and phase 2 (1,338). We found that phase 1 clinical trials had the highest lift metrics. The mean lift for phase 1 trials was 5.40, which was significantly greater than that of phase 2 (1.68) and phase 3 trials (1.72). Additionally, the network structure for trial collaboration in phase 1 trials was highly condensed, with several trial sites located in Seoul and Gyeonggi-do. Different trial collaboration characteristics were noted among clinical trial domains, with mean and variability of the lift metrics for pediatrics being the highest. In conclusion, association rule mining can identify collaborations among trial sites. Collaboration in phase 1 trials is relatively more exclusive than in other phases, and aspects of collaboration differ among clinical trial domains.

PRACTICE: Development of a Core Outcome Set for Trials of Physical Rehabilitation in Critical Illness

Rationale: Findings from individual trials of physical rehabilitation interventions in critically ill adults have limited potential for meta-analysis and informing clinical decision-making because of the heterogeneity in selection and reporting of outcomes used for evaluation. Objectives: The objective of this study was to determine a core outcome set (COS) for use in all future trials evaluating physical rehabilitation interventions delivered across the critical illness continuum of recovery. Methods: An international, two-round, online, modified Delphi consensus process, following recommended standards, was conducted. Participants (N = 329) comprised three stakeholder groups-researchers, n = 58 (18%); clinicians, n = 247 (75%); and patients and caregivers, n = 24 (7%)-and represented 26 countries and nine healthcare professions. Participants rated the importance of a range of relevant outcomes. Outcomes included in the COS were those prioritized of "critical importance" by all three stakeholder groups. Results: Survey response rates were 88% (Round 1) and 91% (Round 2). From a total of 32 initial outcomes, the following outcomes reached consensus for inclusion in the COS: physical function, activities of daily living, survival, health-related quality of life, exercise capacity, cognitive function, emotional and mental well-being, and frailty. Conclusions: This study developed a consensus-generated COS for future clinical research evaluating physical rehabilitation interventions in critically ill adults across the continuum of recovery. Ascertaining recommended measurement instruments for these core outcomes is now required to facilitate implementation of the COS.

Psychosocial Outcomes of Subpectoral vs. Prepectoral Breast Reconstruction: A Comparative Analysis

Introduction Breast reconstruction plays a critical role in restoring psychosocial well-being for patients after mastectomy. While both subpectoral and pre-pectoral implant placements are common, their impact on psychosocial outcomes remains understudied. This study investigates the influence of implant placement on patient-reported psychosocial well-being using BREAST-Q (Breast-Related Quality of Life Questionnaire). Methods We reviewed 69 patients who underwent breast reconstruction at Basildon Hospital between 2017 and 2023, utilizing BREAST-Q scales to evaluate psychosocial well-being, physical outcomes, and satisfaction with breasts. Statistical analysis was conducted using independent t-tests to compare psychosocial scores between patients who received subpectoral versus pre-pectoral implants. Results Subpectoral placement was significantly associated with higher psychosocial scores compared to pre-pectoral placement (75.7 vs. 61.9, p=0.046). No significant differences were observed in satisfaction with breasts between the two groups. Linear regression analysis revealed that subpectoral placement was an independent predictor of improved psychosocial outcomes, even after adjusting for other variables. Conclusions Subpectoral implant placement appears to offer superior psychosocial outcomes in breast reconstruction patients compared to pre-pectoral placement. These findings suggest that subpectoral placement should be considered the preferred option for patients prioritizing psychosocial well-being post-reconstruction. Further research is needed to explore the long-term effects of implant placement on quality of life.

Perioperative fluid management: evidence-based consensus recommendations from the international multidisciplinary PeriOperative Quality Initiative

Fluid therapy is an integral component of perioperative management. In light of emerging evidence in this area, the Perioperative Quality Initiative (POQI) convened an international multiprofessional expert meeting to generate evidence-based consensus recommendations for fluid management in patients undergoing surgery. This article provides a summary of the recommendations for perioperative fluid management of surgical patients from the preoperative period until hospital discharge and for all types of elective and emergency surgery, apart from burn injuries and head and neck surgery. Where evidence was lacking, recommendations for future research were generated. Specific recommendations are made for fluid management in elective major noncardiac surgery, cardiopulmonary bypass, thoracic surgery, neurosurgery, minor noncardiac surgery under general anaesthesia, and critical illness. There are ongoing gaps in knowledge resulting in variation in practice and some disagreement with our consensus recommendations. Perioperative fluid management should be individualised, taking into account the type of surgery and important patient factors, including intravascular volume status and acute and chronic comorbidities. Recommendations are made for further research in perioperative fluid management to address important gaps.

Association Between Restricting Symptoms and Disability After Critical Illness Among Older Adults

OBJECTIVES

Older adults who survive critical illness are at risk for increased disability, limiting their independence and quality of life. We sought to evaluate whether the occurrence of symptoms that restrict activity, that is, restricting symptoms, is associated with increased disability following an ICU hospitalization.

DESIGN

Prospective longitudinal study of community-living adults 70 years old or older who were interviewed monthly between 1998 and 2018.

SETTING

South Central Connecticut, United States.

PATIENTS

Two hundred fifty-one ICU admissions from 202 participants who were discharged alive from the hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Occurrence of 15 restricting symptoms (operationalized as number of symptoms and presence of ≥ 2 symptoms) and disability in activities of daily living, instrumental activities of daily living, and mobility was ascertained during monthly interviews throughout the study period. We constructed multivariable Poisson regression models to evaluate the association between post-ICU restricting symptoms and subsequent disability over the 6 months following ICU hospitalization, adjusting for known risk factors for post-ICU disability including pre-ICU disability, frailty, cognitive impairment, mechanical ventilation, and ICU length of stay. The mean age of participants was 83.5 years ( sd , 5.6 yr); 57% were female. Over the 6 months following ICU hospitalization, each unit increase in the number of restricting symptoms was associated with a 5% increase in the number of disabilities (adjusted rate ratio, 1.05; 95% CI, 1.04-1.06). The presence of greater than or equal to 2 restricting symptoms was associated with a 29% greater number of disabilities over the 6 months following ICU hospitalization as compared with less than 2 symptoms (adjusted rate ratio, 1.29; 95% CI, 1.22-1.36).

CONCLUSIONS

In this longitudinal cohort of community-living older adults, symptoms restricting activity were independently associated with increased disability after ICU hospitalization. These findings suggest that management of restricting symptoms may enhance functional recovery among older ICU survivors.

The NICU tracheostomy team: multidisciplinary collaboration for improvement in survival of complex patients

OBJECTIVE

Evaluate feasibility and impact of "Tracheostomy Team" on survival and length of stay (LOS) at a level IV NICU.

METHODS

Plan-do-study-act cycles targeted five Global Tracheostomy Collaborative "key drivers". From January 2017 to December 2022 multidisciplinary, bimonthly bedside rounds were conducted.

RESULTS

After 3 cycles, in-hospital survival among 39 patients with tracheostomy improved and sustained from 67% to 100% (baseline 18/27; 66.7%; QI 35/39, 89.7%; p = 0.03). Median LOS (days [IQR]) did not significantly differ between baseline and QI (237 [57-308] vs. 217 [130-311]; p = 0.9). Among patients with BPD, median LOS was higher after QI interventions (baseline 248 [222-308] vs. QI 332.5 [283.5-392]; p = .02). Special cause variation resulted from peak increase in LOS during the COVID19 pandemic (2021). Tracheitis/pneumonia was treated significantly more frequently in QI BPD patients.

CONCLUSION

Multidisciplinary approach is feasible, resulting in improved survival without a sustained increase in LOS. Future QI efforts should address post-operative infectious complications.

Effect of introduction of a rapid response system and increasing Medical Emergency Team (MET) activity on mortality over a 20-year period in a paediatric specialist hospital

Background

Rapid Response Systems are hospital-wide patient-focused systems aiming to improve recognition of acute deterioration in patients and trigger a rapid response aimed at preventing potentially avoidable adverse events such as cardiac arrest and death. In 1994, the Royal Children's Hospital in Brisbane, Australia, was one of the first institutions to adopt a paediatric rapid response system (RRS). The purpose of this study was to investigate the impacts of both introduction of a paediatric RRS and increasing RRS activations (MET dose) on hospital mortality.

Methods

Prospectively collected data from institutional databases at a specialist paediatric hospital was used to determine hospital mortality rate pre- and post- implementation of the RRS. An interrupted time series model using segmented regression was utilised to assess the pre-intervention trend, as well as immediate and sustained effects of RRS implementation on hospital mortality. Univariate linear regression examined potential effects of MET dose on mortality.

Results

Hospital mortality rate did not change significantly over 15 years before RRS implementation. In the first year after implementation, mortality rate fell significantly (-1.4; 95 %CI -2.27 to -0.52; p = 0.0027). For each year that passed after the intervention, there was no significant change in hospital mortality rate (Estimate: -0.08; 95 %CI -0.17 to 0.02; p = 0.11). Univariate linear regression modelling showed that with every unit increase in MET Dose, hospital mortality rate decreased by -0.13 (95 % CI: -0.27 to 0; p = 0.05).

Conclusions

Utilising data from one of the earliest and longest duration single-centre cohort of paediatric MET events, this study reaffirms the association between implementation of a paediatric RRS and decreased hospital mortality. The study also provides novel evidence of the impact of MET dose on patient outcome in the paediatric population. It is recommended that factors influencing the benefit of rapid response systems in paediatric populations are further identified so that this life saving initiative can be optimised.

Evaluation and management of neurological complications in acute liver failure

Neurological complications in acute liver failure are the most common cause of mortality in this group of patients. Almost all neurologic complications arise from underlying increase in intracranial pressure in ALF. In addition to symptomatic management, the treatment relies on measures to bring down ICP. Recently role of renal replacement therapy is gaining a lot of ground in ALF management, primarily due to its ammonia lowering effects indirectly leading to decrease in ICP. In this review we cover the neurologic issues in ALF in detail. We discuss the various non invasive techniques for ICP monitoring & their current application in ALF patients. We also focus on the management protocols in ALF & their role in improving the ICP & hence the outcome.

A journey through transitional care-family members' experiences post a life-threatening situation: A qualitative study

BACKGROUND

Being a family member to someone who suffers from a serious illness can change one's perspectives about life. A sudden and severe illness can result in a demanding journey that involves acute admission to hospital, intensive care, post-care, and finally, returning home.

AIM

To describe the experience of staying beside a next of kin throughout the healthcare journey, from the onset of illness at home, to the intensive care unit, post-care, and returning home.

METHODS

The study employed a qualitative design, with data collected via semi-structured interviews and analysed using reflexive thematic analysis. A purposive sampling was used to recruit participants (n = 14), who had experiences of staying beside a next of kin throughout the healthcare journey from the onset of illness to discharge from the hospital.

FINDINGS

Family members' experiences were captured under the overarching theme Journey through an emotional turmoil and the themes Entering a new world, Continuing the journey towards something unknown, and Striving for the new normal at home. They described going through a non-linear process, characterised by transitions or changes in several aspects. The transitions included shifts in the roles that the family members played, in the various environments they found themselves in, and in the progression of the patient's illness or injury.

CONCLUSION

The study suggested that family members with a next of kin who experienced life-threatening situations undergo challenging transitions. The informal caregiver role placed on family members of intensive care unit-survivors significantly impacts their lives and the healthcare systems should prioritise providing high-quality support to family members throughout the entire healthcare journey. Elevating the importance of nursing care within the healthcare system can contribute to delivering holistic care and facilitating transitions. Further research should focus on understanding the support that family members perceive as necessary to facilitate their transition and enhance their well-being.

Advanced strategies for intensive care management of acute liver failure

Acute liver failure (ALF) is defined as the loss of hepatic function in conjunction with hepatic encephalopathy and coagulopathy. There is histological evidence of profound hepatocyte damage. If it is not aggressively managed, ALF can be fatal within a few days. It is a rare disease, often occurring in patients without prior liver disease. Despite numerous causes, ALF usually presents as acute liver necrosis with a clinical picture that includes cognitive dysfunction, increased aminotransferases, and severe coagulopathy. It is essential to distinguish between ALF and acute-on-chronic liver failure (ACLF). Causes for ALF include paracetamol Acute liver failure (ALF) is characterized by acute liver dysfunction associated with overdose, right heart failure (ischemic liver injury), viral hepatitis (A, B, D and E), autoimmune hepatitis and drug-induced liver injury (including some herbal and nutritional supplements). In developed countries, the prevalence of ALF is 1:1,000,000. Survival rates have increased due to improved ICU management.

Liver assistive devices in acute liver failure: Current use and future directions

Acute liver failure (ALF) is a rare syndrome where rapid deterioration of liver function occurs after an acute insult in a patient without prior chronic liver disease and leads to jaundice, hepatic encephalopathy (HE), and oftentimes multiorgan failure (MOF). At this time, the only definitive treatment for ALF is LT but some patients, particularly APAP-induced ALF patients, may have ongoing regenerative capacity of the liver and may not require LT with ongoing supportive management. As a result, extracorporeal liver support (ECLS) has been a topic of interest both as a bridge to LT and as a bridge to spontaneous recovery and aims to remove damaging toxins that further aggravate liver failure, stimulate regeneration of the liver, and improve pathophysiologic consequences of liver failure. There are currently two categories of ECLS (artificial and bioartificial). Artificial ECLS does not incorporate active hepatocytes and are based on the principles of filtration and adsorption and includes renal replacement therapy (RRT), plasma adsorption including plasma exchange and Prometheus (Fractionated Plasma Separation and Adsorption), and albumin dialysis including MARS (Molecular Adsorbent Recirculating System) and SPAD (Single Pass Albumin Dialysis). Bioartificial ECLS incorporates active hepatocytes (human or porcine in origin) to improve liver detoxification capacity and to support hepatic synthetic function and includes ELAD (Extracorporeal Liver Assist Device) and HepatAssist.

Minimally-invasive tracheostomy (MIT): A care bundle for safety improvement in high-risk critically ill patients

BACKGROUND

Detailed reports are scarce on minimally-invasive tracheostomy (MIT) techniques for critically ill patients with challenging anatomy or complex coagulopathies. In such high-risk patients, conventional percutaneous dilatational tracheostomy (PDT) may lead to severe complications.

METHODS

Aiming to broaden the scope of MIT for patients previously excluded due to high risks, we developed a new care bundle (MIT technique), specifically designed for intensive care specialists. Our study examined the outcomes of MIT in 32 high-risk patients treated in an ICU of a University Hospital with specific focus on gastrointestinal and liver diseases.

RESULTS

We have modified the conventional PDT technique by incorporating an initial skin incision, blunt dissection, diaphanoscopy-guided probe puncture, and continuous bronchoscopic monitoring. Our care bundle also introduces an anterolateral approach for tracheal entry, a significant advancement for patients with complex neck anatomy or dense vasculature, where an anterolateral trajectory avoids midline blood vessels. This enhanced method has proven to be safer than traditional PDT, with a notable absence of post-procedural hemorrhages, cannula misplacements, or infections.

CONCLUSION

The use of our refined care bundle enabled swift minimally-invasive tracheostomy in high-risk patients without the occurrence of serious complications.

Renal dysfunction in surgical patients

PURPOSE OF REVIEW

To provide an overview of the current diagnostic criteria for acute kidney injury (AKI) including their limitations and to discuss prevention and treatment approaches in the perioperative setting.

RECENT FINDINGS

AKI is common in the perioperative period and is associated with worse short- and long-term outcomes. Current definitions of AKI have several limitations and lead to delayed recognition of kidney dysfunction which is why novel diagnostic approaches by using renal biomarkers may be helpful. In general, prevention of the development and progression of AKI is vital as a causal treatment for AKI is currently not available. Optimization of kidney perfusion and avoidance of nephrotoxic drugs reduce the occurrence of AKI in surgical patients. Angiotensin II as a new vasopressor, the use of remote ischemic preconditioning, and amino acids may be approaches with a positive effect on the kidneys.

SUMMARY

Evidence suggests that the implementation of supportive measures in patients at high risk for AKI might reduce the occurrence of AKI. Novel biomarkers can help allocating resources by detecting patients at high risk for AKI.

Altered Mental Status in the Solid-Organ Transplant Recipient

Patients undergoing solid-organ transplantation (SOT) face a tumultuous journey. Prior to transplant, their medical course is characterized by organ dysfunction, diminished quality of life, and reliance on organ support, all of which are endured in hopes of reaching the haven of organ transplantation. Peritransplant altered mental status may indicate neurologic insults acquired during transplant and may have long-lasting consequences. Even years after transplant, these patients are at heightened risk for neurologic dysfunction from a myriad of metabolic, toxic, and infectious causes. This review provides a comprehensive examination of causes, diagnostic approaches, neuroimaging findings, and management strategies for altered mental status in SOT recipients. Given their complexity and the numerous etiologies for neurologic dysfunction, liver transplant patients are a chief focus in this review; however, we also review lesser-known contributors to neurological injury across various transplant types. From hepatic encephalopathy to cerebral edema, seizures, and infections, this review highlights the importance of recognizing and managing pre- and posttransplant neurological complications to optimize patient outcomes.

Accidental tracheostomy decannulation: Risk factors and complications in pediatric patients using the NSQIP-P database

BACKGROUND

Accidental tracheostomy decannulation (ATD) is a life-threatening event in pediatric patients. The factors associated with ATD in children are largely unknown. Utilizing the National Surgical Quality Improvement Pediatric (NSQIP-P) dataset, we sought to identify the incidence of ATD and associated factors.

METHODS

Patients who underwent surgery at continuously enrolled American College of Surgeons NSQIP-P hospitals from January 1, 2012, to December 31, 2021, were included. Those who underwent a tracheostomy (CPT 31600 or 31601) as a primary or concurrent procedure were analyzed. ATD was defined by the NSQIP-P REINTUB variable. Multivariable logistic regression analysis and propensity score matching were performed to identify independent associations between demographic variables, relevant comorbidities, intraoperative factors, and ATD. Multivariable regression analyses were performed to identify any association between ATD and unplanned reoperation, pneumonia, extended length of stay, and death in 30 days in both pre-matched and matched cohorts.

RESULTS

A total of 5229 patients undergoing tracheostomy were included in the final analysis for the pre-matched cohort. ATD occurred in 93 (1.8 %) patients, with 42 % (n = 39) of these cases occurring within the first two postoperative days. In the matched cohort, female gender (P = 0.002) and structural pulmonary/airway abnormality (P = 0.016) were independently associated with ATD. Additionally, ATD was associated with unplanned reoperation (P < 0.001) and pneumonia (P = 0.024). The pre-matched cohort showed consistent results with the matched cohort.

DISCUSSION

Accidental decannulation is a serious complication following pediatric tracheostomy. By identifying patients at higher risk for ATD and the timing of its occurrence, providers can employ measures targeting these patients during their highest risk period. The sequelae associated with ATD further emphasize the importance of preventing this complication.

Leg Cycle Ergometry in Critically Ill Patients - An Updated Systematic Review and Meta-Analysis

BACKGROUND

Cycle ergometry is a rehabilitation strategy used in the intensive care unit (ICU) which may help mitigate post-ICU impairments. We aimed to systematically review and summarize evidence examining the efficacy and safety of cycle ergometry in the ICU.

METHODS

We included randomized controlled trials (RCTs) of critically ill adults with any diagnosis admitted to the ICU for >24 hours, comparing cycling interventions to control (no cycling). The primary outcome was physical function, using a hierarchical approach to standardize this outcome across trials. We performed random-effects meta-analyses and assessed the certainty of effect estimates using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

We included 33 RCTs that enrolled 3274 patients. Cycling may improve physical function at ICU discharge (12 RCTs, 1291 patients, standardized mean difference [SMD], 0.33 [95% confidence interval (CI), 0.05 to 0.62], low certainty) and posthospital discharge (8 RCTs, 865 patients, SMD, 0.23, [95% CI, 0.04 to 0.42], low certainty). Cycling may decrease ICU length of stay (29 RCTs, 2575 patients, mean difference [MD], 1.06 days fewer [95% CI, 0.33 to 1.80 days fewer], low certainty) and probably decreases hospital length of stay (22 RCTs, 2060 patients, MD, 1.48 days fewer [95% CI, 0.47 to 2.49 days fewer], moderate certainty). Cycling may have no effect on ICU mortality (17 RCTs, 2039 patients, risk ratio, 12 fewer deaths per 1000 [95% CI, 43 fewer to 23 more], low certainty). The pooled rate of adverse events in the intervention group was 1% (11 RCTs, 4623 sessions, [95% CI, 0 to 2%], low certainty) and in the comparison group, 2% (6 RCTs, 3365 sessions, [95% CI, 0 to 5%], low certainty).

CONCLUSIONS

In this meta-analysis, we found that cycling with critically ill patients may improve physical function at ICU discharge and after hospital discharge, may reduce ICU length of stay, and probably reduces hospital length of stay, with no effect on other outcomes including mortality. We observed low to very low certainty of evidence for all but one outcome of interest. Adverse events were uncommon. (PROSPERO number, CRD 42018092132.).

Early tracheostomy in ventilated COVID-19 patients reduces incidence of ventilator-associated pneumonia

Tracheostomy can reduce mechanical ventilation (MV) duration, ICU and hospital length of stay (LOS), and ventilator-associated pneumonia (VAP) risk in critically ill patients. The timing of tracheostomy in COVID-19 patients has been studied, but its impact on VAP incidence has rarely been analyzed. This study investigated tracheostomy timing's impact on VAP incidence, ventilation time, ICU and hospital LOS, and mortality in critically ill COVID-19 patients. It was conducted at the University Hospital in Wroclaw, Poland, from October 1, 2020, to June 30, 2021. Of 60 tracheostomized patients, 21 (35%) developed VAP. Early tracheostomy (≤ 13 days) resulted in 8/42 (19%) VAP cases, while late tracheostomy (> 13 days) had 13/18 (72%) VAP cases, showing a significantly lower VAP risk in the early group (p < 0.05). VAP incidence rates were 7.9 and 22.8 per 1000 patient-days for early and late groups, respectively. Early tracheostomy patients had shorter median MV duration (18 vs. 33 days, p < 0.05), ICU LOS (20 vs. 31 days, p < 0.05) and hospital LOS (25 vs. 47 days, p < 0.05). Early tracheostomy in critically ill COVID-19 patients significantly reduced VAP risk, MV duration, ICU, and hospital LOS.