Translation and Psychometric Validation of the German Version of the Iceland-Family Perceived Support Questionnaire (ICE-FPSQ): A Cross-Sectional Study

Supporting families experiencing critical illness through family interventions is essential to ease illness burden, enable family management, and reduce their risk for adverse health. Thus far, there is no validated German instrument to measure the perceived support families receive from nurses. We translated the 14-item Iceland-Family Perceived Support Questionnaire (ICE-FPSQ) and tested its psychometric properties with 77 family members of intensive care patients. Compared with the original instrument, the construct validity of the German ICE-FPSQ (FPSQ-G) showed unstable results with a partially divergent structure, most likely caused by the limited sample size. The first two principal components explained 61% of the overall variance and a good internal consistency with a Cronbach's alpha of .92. The FPSQ-G is a promising instrument to measure family members' perceptions of the support they received from nurses in the acute critical care setting but requires further validation.

Highlights in the clinical nutrition literature: A critical appraisal of current research

Within the American Society for Parenteral and Enteral Nutrition (ASPEN), the Physician Engagement Committee (PEC) was created in 2017 by the ASPEN Board of Directors with the goal of growing the physician community both nationally and internationally. The PEC meets each month throughout the year to develop educational and research initiatives. In 2022, the PEC began an initiative to systematically review and evaluate practice-changing literature annually with the overall aim to highlight these studies at the annual ASPEN conferences and to critically discuss the potential clinical implications. The objective of the held meeting session was to present identified key papers in the fields of critical care medicine, gastroenterology and hepatology, and adult internal medicine that were published in 2022, which would complement the knowledge of the pathogenesis, diagnosis, and management of nutrition topics as well as to identify areas of future research. Overall, several large-scale randomized controlled studies were identified in each of these sections, with practice-changing major results. This manuscript summarizes the information that was presented and the discussions that followed.

Bedside open tracheostomy in COVID-19 patients - a safe and swift approach

BACKGROUND

Tracheostomy can be performed as an open surgical procedure, percutaneous, or hybrid and forms an important step in the management of patients infected with coronavirus disease 2019 (COVID-19) requiring weaning from mechanical ventilation. The purpose of this article is to share our experience to performing bedside surgical tracheostomy in COVID-19 patients in a safe and effective manner, whilst minimising the risk of viral transmission, to optimise patient outcomes and reduce risk to healthcare professionals.

MATERIAL AND METHODS

As recommended by ENT UK, we prospectively established a COVID Airway Team within the ENT department at Birmingham Heartlands Hospital, consisting of four head and neck consultant surgeons to perform either open-bedside, open-theatre or percutaneous tracheostomy in COVID-19 patients. A specific stepwise method for bedside open surgical tracheostomy was based on ENT UK and British Laryngological Society recommendations.

RESULTS

Thirty patients underwent tracheostomy during the study period (14 bedside-open, 5 open-theatre, 11 percutaneous). Mean duration of mechanical intubation prior to bedside-open tracheostomy was 14.5 days. The average time for open-bedside tracheostomy was 9 minutes compared to 31 minutes for open-theatre. There were no significant tracheostomy related complications with bedside-open tracheostomy. No healthcare professional involved reported acute COVID-19 infection.

CONCLUSIONS

We describe our effective, safe and swift approach to bedside open tracheostomy during the COVID-19 pandemic. Our experience demonstrated a short mean procedural time, with no tracheostomy-related complications and no reported viral transmission amongst the healthcare members involved.

Worth a try or a last resort: Healthcare professionals' experiences and opinions of above cuff vocalisation

BACKGROUND

Above cuff vocalisation (ACV) involves the application of an external flow of air via the subglottic port of a tracheostomy. ACV can facilitate vocalisation and may improve swallowing and quality of life for patients with a tracheostomy. A recent systematic review highlighted the limited evidence available for the acceptability, effectiveness, safety or optimal implementation of ACV.

AIMS

To explore the experience of healthcare professionals (HCPs) using ACV and their perceptions of best practice.

METHODS AND PROCEDURES

Semi-structured interviews were conducted with a range of HCPs with experience using ACV. Topics included: experiences with ACV, management of ACV, opinions about ACV, impact of COVID-19, future directions for ACV and impact on length of stay. Interviews were conducted online from December 2020 to March 2022. Data were analysed using reflexive thematic analysis.

OUTCOMES AND RESULTS

Twenty-four HCPs were interviewed from seven countries and five professional groups. Four interconnected themes were developed: (1) moral distress amplifying the need to fix patients; (2) subjectivity and uncertainty leading to variations in practice and purpose; (3) knowledge and experience leading to control and caution; and (4) worth a try or a last resort. Theme four contained three sub-themes: (a) part of the toolbox; (b) useful but limited tool; and (c) following the patient's lead. The moral distress experienced by HCPs and their essential 'need to fix' patients seems to underpin the varied opinions of ACV. These opinions appear to be formed primarily on the basis of experience, because of the underlying subjectivities and uncertainties. As knowledge and experience with ACV increased, and adverse events were experienced, most HCPs became more cautious in their approach to ACV.

CONCLUSIONS AND IMPLICATIONS

More research is needed to reduce the subjectivities and uncertainties surrounding ACV. The implementation of standardised procedures, processes, and competencies may help to reduce the frequency of adverse events and support a more controlled approach. Widening the focus of the purpose of ACV to include swallowing may help to maximise the potential benefits.

WHAT THIS PAPER ADDS

What is already known on the subject There is limited and low-quality evidence for above cuff vocalisation (ACV) and clinical application and practice varies substantially. However, the reasons for this variation in practice and healthcare professionals' (HCPs') opinions of ACV were unclear. What this study adds HCPs' experiences and opinions of ACV vary as a result of the uncertainty and subjectivity surrounding ACV compounded by their personal experiences with it. A need for caution also appears to emerge as HCPs become more familiar and experienced with using ACV. What are the clinical implications of this work? Implementing standardised procedures, safety processes and competencies may help to compensate for the uncertainty and subjectivity surrounding ACV and may reduce the frequency of adverse events. Widening the focus of purpose of ACV, including swallowing in addition to communication, may increase the number of potential candidates and increase the potential benefits of ACV. Using multidisciplinary team (MDT) simulation training for ACV competency development might help to improve MDT working and ACV implementation.

Association Between Modified Frailty Index and Postoperative Outcomes of Tracheostomies

OBJECTIVE

The 5-item modified frailty index (mFI-5) has been used to stratify patients based on the risk of postoperative complications in several surgical procedures but has not yet been done in tracheostomies. This study investigates the association between the mFI-5 score and tracheostomy complications.

STUDY DESIGN

Retrospective database review.

SETTING

United States hospitals.

METHODS

The National Surgical Quality Improvement Program database was queried for tracheostomy patients between 2005 and 2018. The mFI-5 was calculated for each patient by assigning 1 point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Univariate and multivariable analyses were conducted to determine associations between the mFI-5 score and postoperative complications.

RESULTS

A total of 4438 patients undergoing tracheostomies were queried and stratified into the following groups: mFI = 0 (N = 1741 [39.2%], mFI = 1 (N = 1720 [38.8%]), mFI = 2 (N = 726 [16.4%]), and mFI of 3 or higher (N = 251 [5.7%]). Univariate analysis showed that patients with higher mFI-5 scores had a greater proportion of smoking, dyspnea, obesity, steroid use, emergency cases, complications, reoperations, and mortality (P < .001). Multivariable analyses found associations between mFI-5 score and any complication (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.16, P = .035), mortality (OR: 2.32, 95% CI: 1.15-4.68, P = .019), and any medical complication (OR: 2.75, 95% CI: 1.88-4.02, P < .001).

CONCLUSION

This study suggests an association between the mFI-5 score and postoperative complications in tracheostomies. mFI-5 score can be used to stratify tracheostomy patients by operative risk.

Effects of Targeted Hypercapnia on Mortality and Length of Stay of Post-cardiac Arrest Patients: A Systematic Review and Meta-Analysis

Therapeutic hypercapnia has been proposed as a potential strategy to enhance cerebral perfusion and improve outcomes in patients after cardiac arrest. However, the effects of targeted hypercapnia remain unclear. We conducted a systematic review and meta-analysis to evaluate the impact of hypercapnia compared to normocapnia on mortality and length of stay in post-cardiac arrest patients. We searched major databases for randomized controlled trials and observational studies comparing outcomes between hypercapnia and normocapnia in adult post-cardiac arrest patients. Data on in-hospital mortality and the ICU and hospital length of stay were extracted and pooled using random-effects meta-analysis. Five studies (two randomized controlled trials (RCTs) and three observational studies) with a total of 1,837 patients were included. Pooled analysis showed hypercapnia was associated with significantly higher in-hospital mortality compared to normocapnia (56.2% vs. 50.5%, OR 1.24, 95% CI 1.12-1.37, p<0.001). There was no significant heterogeneity (I2 = 25%, p = 0.26). No statistically significant differences were found for ICU length of stay (mean difference 0.72 days, 95% CI -0.51 to 1.95) or hospital length of stay (mean difference 1.13 days, 95% CI -0.67 to 2.93) between the groups. Sensitivity analysis restricted to mild hypercapnia studies did not alter the mortality findings. This meta-analysis did not find a mortality benefit with targeted hypercapnia compared to normocapnia in post-cardiac arrest patients. The results align with current guidelines recommending a normal partial pressure of arterial carbon dioxide (PaCO2) target range and do not support routinely targeting higher carbon dioxide levels in this setting.

Association of active mobilisation variables with adverse events and mortality in patients requiring mechanical ventilation in the intensive care unit: a systematic review and meta-analysis

BACKGROUND

Mobilisation during critical illness is now included in multiple clinical practice guidelines. However, a large, randomised trial and systematic review have recently identified an increased probability of adverse events and mortality in patients who received early active mobilisation in the intensive care unit (ICU). We aimed to determine the effects of mobilisation compared with usual care on adverse events and mortality in an acute ICU setting. In subgroup analyses, we specifically aimed to investigate possible sources of harm, including the timing and duration of mobilisation achieved, ventilation status, and admission diagnosis.

METHODS

In this systematic review with frequentist and Bayesian analyses, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, SCOPUS, Web of Science, and PEDro electronic databases, as well as clinical trial registries (ICTRP and ClinicalTrials.gov), from inception to March 16, 2023, without language restrictions. Eligible studies were randomised controlled trials that examined active mobilisation compared with either no mobilisation or mobilisation commencing later, or at a lower frequency or intensity, in adults who were critically ill during or after a period of mechanical ventilation in an acute ICU setting. Two authors independently screened reports, extracted data, and assessed the risk of bias using the Cochrane risk-of-bias tool (version 1). The primary outcome was the number of adverse events that occurred during the implementation of mobilisation, with the effect of mobilisation on mortality being the secondary outcome. Risk ratios (RRs) with 95% CIs were calculated in R (version 4.0.3) using random-effects modelling, with Bayesian analysis completed to calculate the probability of treatment harm (ie, RR >1). Subgroup analyses were completed to investigate the association of various factors of mobilisation on adverse events and mortality: duration of mobilisation (longer [≥20 min per day] vs shorter [<20 min per day]), timing of commencement (early [≤72 h from ICU admission] vs late [>72 h from ICU admission]), ventilation status at commencement (all patients mechanically ventilated vs all patients extubated), and ICU admission diagnosis (surgical vs medical). This study was registered with PROSPERO, CRD42022369272.

FINDINGS

After title and abstract screening of 14 440 studies and review of 466 full texts, 67 trials with 7004 participants met inclusion criteria, with 59 trials contributing to the meta-analysis. Of the 67 included studies, 15 (22%) did not mention adverse events and 13 (19%) reported no adverse events occurring across the trial period. Overall, we found no effect of mobilisation compared with usual care on the occurrence of adverse events (RR 1·09 [95% CI 0·69-1·74], p=0·71; I2 91%; 32 731 events, 20 studies; very low certainty), with a 2·96% occurrence rate (693 events in 23 395 intervention sessions; 25 studies). Mobilisation did not have any effect on mortality (RR 0·98 [95% CI 0·87-1·12], p=0·81; I2 0%; n=6218, 58 studies; moderate certainty). Subgroup analysis was hindered by the large amount of data that could not be allocated and analysed, making the results hypothesis generating only.

INTERPRETATION

Implementation of mobilisation in the ICU was associated with a less than 3% chance of an adverse event occurring and was not found to increase adverse events or mortality overall, providing reassurance for clinicians about the safety of performing this intervention. Subgroup analyses did not clearly identify any specific variable of mobilisation implementation that increased harm.

FUNDING

None.

Novel Definitions of Wellness and Distress among Family Caregivers of Patients with Acute Cardiorespiratory Failure: A Qualitative Study

Rationale: Family caregivers of patients with acute cardiorespiratory failure are at high risk for distress, which is typically defined as the presence of psychological symptoms such as anxiety, depression, or posttraumatic stress. Interventions to reduce caregiver distress and increase wellness have been largely ineffective to date. An incomplete understanding of caregiver wellness and distress may hinder efforts at developing effective support interventions. Objectives: To allow family caregivers to define their experiences of wellness and distress 6 months after patient intensive care unit (ICU) admission and to identify moderators that influence wellness and distress. Methods: Primary family caregivers of adult patients admitted to the medical ICU with acute cardiorespiratory failure were invited to participate in a semistructured interview 6 months after ICU admission as part of a larger prospective cohort study. Interview guides were used to assess caregiver perceptions of their own well-being, record caregiver descriptions of their experiences of family caregiving, and identify key stress events and moderators that influenced well-being during and after the ICU admission. This study was guided by the Chronic Traumatic Stress Framework conceptual model, and data were analyzed using the five-step framework approach. Results: Among 21 interviewees, the mean age was 58 years, 67% were female, and 76% were White. Nearly half of patients (47%) had died before the caregiver interview. At the time of the interview, 9 caregivers endorsed an overall sense of distress, 10 endorsed a sense of wellness, and 2 endorsed a mix of both. Caregivers defined their experiences of wellness and distress as multidimensional and composed of four main elements: 1) positive versus negative physical and psychological outcomes, 2) high versus low capacity for self-care, 3) thriving versus struggling in the caregiving role, and 4) a sense of normalcy versus ongoing life disruption. Postdischarge support from family, friends, and the community at large played a key role in moderating caregiver outcomes. Conclusions: Caregiver wellness and distress are multidimensional and extend beyond the absence or presence of psychological outcomes. Future intervention research should incorporate novel outcome measures that include elements of self-efficacy, preparedness, and adaptation and optimize postdischarge support for family caregivers.

Prevalence and characteristics of medical emergency teams in Switzerland: a nationwide survey of intensive care units

BACKGROUND

Medical Emergency Teams (METs) have been implemented in many hospitals worldwide and are considered an integral part of the hospital patient safety system. However, data on prevalence, staffing and activation criteria of METs are scarce. Such data are important as they may help to identify areas of quality improvement and barriers to implementation of rapid response systems (RRS). This survey aimed to analyze current characteristics, prevalence, and organization of METs in Switzerland.

METHODS

We conducted a cross-sectional nationwide online survey, inviting physicians' and nurses' representatives from all registered adult intensive care units (ICU) in Switzerland.

RESULTS

Of the 74 hospitals invited to participate in the survey, 57 responded (response rate 77%). We obtained 82 individual responses (from 50 physicians and 32 nurses). Twenty-five hospitals (44%) have a MET in place. In most Swiss hospitals, METs are composed of ICU consultants (64%) and ICU nurses (40%) and are activated by phone, with a usual response time of less than 10 minutes. The most common triggers are single abnormal vital signs (80%), while multiple-parameter warning scores are less commonly used (28%). While more than half of the nurses have regular trainings for their MET members (57%), most MET physicians (63%) do not. Systematic data collection of MET calls occurs in only 43% of institutions. Finally, the most common reasons for not having a MET are staff shortage (44%) and lack of funding (19%).

CONCLUSIONS

Less than 50% of Swiss hospitals with an adult ICU have a MET in place. METs in Switzerland typically include an ICU doctor and an ICU nurse and are available 24/7. Major barriers to MET introduction are staff shortage and lack of funding.

The associates of anxiety among lung cancer patients: Dehydroepiandrosterone (DHEA) as a potential biomarker

OBJECTIVE

Anxiety is a prevalent comorbidity in lung cancer (LC) patients associated with a decline in quality of life. Dehydroepiandrosterone (DHEA), a neuroactive steroid, levels rise in response to stress. Prior research on the association between DHEA and anxiety has yielded contradictory results and no study has investigated this association in LC patients.

METHODS

A total of 213 patients with LC were recruited from a general hospital. Data on demographic and cancer-related variables were collected. Using the Chinese version of the Hospital Anxiety and Depression Scale (HADS), the degree of anxiety was determined. Cortisol, DHEA, and Dehydroepiandrosterone sulfate (DHEA-S) levels in saliva were measured. Adjusting for confounding variables, a multivariate regression analysis was conducted.

RESULTS

147 men and 66 women comprised our group with an average age of 63.75 years. After accounting for demographic and treatment-related factors, anxiety levels were significantly correlated with, post-traumatic stress symptoms (PTSSs) (β = 0.332, p < 0.001) and fatigue (β = 0.247, p = 0.02). Association between anxiety and three factors, including DHEA, PTSSs, and fatigue, was observed in patients with advanced cancer stages (III and IV) (DHEA β = 0.319, p = 0.004; PTSS β = 0.396, p = 0.001; fatigue β = 0.289, p = 0.027) and those undergoing chemotherapy (DHEA β = 0.346, p = 0.001; PTSS β = 0.407, p = 0.001; fatigue β = 0.326, p = 0.011).

CONCLUSIONS

The association between anxiety and DHEA remained positive in advanced cancer stages and chemotherapy patients. Further study is necessary to determine whether DHEA is a potential biomarker of anxiety in LC patients.

Novel Method for Sealing Tracheostomies Immediately after Decannulation-An Acute Clinical Feasibility Study

Tracheostomy decannulation leaves an iatrogenic passage in the upper airways. Inadequate sealing leads to pulmonary dysfunction and reduced voice quality. This study aimed to investigate the feasibility and impact of intratracheal tracheostomy sealing on laryngeal airflow and voice quality immediately after decannulation (ClinicalTrials.gov: NCT06138093). Fifteen adult, tracheostomized, intensive care unit patients were included from our hospital. A temporary, silicone-based sealing disc was inserted in the tracheostomy wound immediately after decannulation. Spirometry with measurement of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and peak expiratory flow (PEF) were performed as measures of airway flow. Voice recordings were assessed using an equal appearing interval scale from 1 to 5. Median FVC, FEV1, PEF, and voice quality score with interquartile range (IQR) was 883 (510-1910) vs. 1260 (1005-1723) mL (p < 0.001), 790 (465-1255) vs. 870 (617-1297) mL (p < 0.001), 103 (55-211) vs. 107 (62-173) mL (p = 0.720), and 2 (1-2.5) vs. 4 (3-5) points (p < 0.001), respectively, with open tracheostomy vs. after sealing the tracheostomy with the intratracheal sealing disc. This feasibility study showed that tracheostomy sealing with the intratracheal disc was safe and led to immediate improvements in FVC, FEV1, and voice quality.

The COVID-19 Tracheostomy Experience at a Large Academic Medical Center in New York during the First Year

Background: New York City was the epicenter of the initial surge of the COVID-19 pandemic in the United States. Tracheostomy is a critical procedure in the care of patients with COVID-19. We hypothesized that early tracheostomy would decrease the length of time on sedation, time on mechanical ventilation, intensive care unit length of stay, and mortality. Methods: A retrospective analysis of outcomes for all patients with COVID-19 who underwent tracheostomy during the first year of the COVID-19 pandemic at the Mount Sinai Hospital in New York City, New York. All adult intensive care units at the Mount Sinai Hospital, New York. Patients/subjects: 888 patients admitted to intensive care with COVID-19. Results: All patients admitted to the intensive care unit with COVID-19 (888) from 1 March 2020 to 1 March 2021 were analyzed and separated further into those intubated (544) and those requiring tracheostomy (177). Of those receiving tracheostomy, outcomes were analyzed for early (≤12 days) or late (>12 days) tracheostomy. Demographics, medical history, laboratory values, type of oxygen and ventilatory support, and clinical outcomes were recorded and analyzed. Conclusions: Early tracheostomy resulted in reduced duration of mechanical ventilation, reduced hospital length of stay, and reduced intensive care unit length of stay in patients admitted to the intensive care unit with COVID-19. There was no effect on overall mortality.

Effects of education, income and employment on ICU and post-ICU survival - A nationwide Swedish cohort study of individual-level data with 1-year follow up

PURPOSE

The aim of this study was to examine relationships between education, income, and employment (socioeconomic status, SES) and intensive care unit (ICU) survival and survival 1 year after discharge from ICU (Post-ICU survival).

METHODS

Individual data from ICU patients were linked to register data of education level, disposable income, employment status, civil status, foreign background, comorbidities, and vital status. Associations between SES, ICU survival and 1-year post-ICU survival was analysed using Cox's regression.

RESULTS

We included 58,279 adults (59% men, median length of stay in ICU 4.0 days, median SAPS3 score 61). Survival rates at discharge from ICU and one year after discharge were 88% and 63%, respectively. Risk of ICU death (Hazard ratios, HR) was significantly higher in unemployed and retired compared to patients who worked prior to admission (1.20; 95% CI: 1.10-1.30 and 1.15; (1.07-1.24), respectively. There was no consistent association between education, income and ICU death. Risk of post-ICU death decreased with greater income and was roughly 16% lower in the highest compared to lowest income quintile (HR 0.84; 0.79-0.88). Higher education levels appeared to be associated with reduced risk of death during the first year after ICU discharge.

CONCLUSIONS

Significant relationships between low SES in the critically ill and increased risk of death indicate that it is important to identify and support patients with low SES to improve survival after intensive care. Studies of survival after critical illness need to account for participants SES.

Lessons for the next pandemic: analysis of the timing and outcomes including post-discharge decannulation rates for tracheostomy in severe COVID-19 respiratory failure

PURPOSE

COVID-19 patients with respiratory failure frequently require prolonged ventilatory support that would typically warrant early tracheostomy. There has been significant debate on timing, outcomes, and safety of these procedures. The purpose of this study was to determine the epidemiological, hospital, and post-discharge outcomes of this cohort, based on early (ET) versus late (LT) tracheostomy.

METHODS

Retrospective review (March 2020-January 2021) in a 5-hospital system of ventilated patients who underwent tracheostomy. Demographics, hospital/ICU length of stay (LOS), procedural characteristics, APACHE II scores at ICU admission, stabilization markers, and discharge outcomes were analyzed. Long-term decannulation rates were obtained from long-term acute care facility (LTAC) data.

RESULTS

A total of 97 patients underwent tracheostomy (mean 61 years, 62% male, 64% Hispanic). Despite ET being frequently performed during active COVID infection (85% vs. 64%), there were no differences in complication types or rates versus LT. APACHE II scores at ICU admission were comparable for both groups; however, > 50% of LT patients met PEEP stability at tracheostomy. ET was associated with significantly shorter ICU and hospital LOS, ventilator days, and higher decannulation rates. Of the cohort discharged to an LTAC, 59% were ultimately decannulated, 36% were discharged home, and 41% were discharged to a skilled nursing facility.

CONCLUSIONS

We report the first comprehensive analysis of ET and LT that includes LTAC outcomes and stabilization markers in relation to the tracheostomy. ET was associated with improved clinical outcomes and a short LOS, specifically on days of pre-tracheostomy ventilation and in-hospital decannulation rates.

Tigecycline-associated hypofibrinogenemia: A single center, retrospective, controlled study

BACKGROUND

Tigecycline-associated hypofibrinogenemia has been reported as an important adverse effect in recent years, but controlled studies minimizing confounding factors are needed. The objective of our study was to assess changes in fibrinogen levels in patients for hospitalization, comparing two antibiotic episodes (tigecycline and other) within the same patients.

METHODS

The retrospective, self-controlled case series study was conducted at our University Hospitals. The study compared the change in fibrinogen levels during the patient's hospitalization for tigecycline (TigePer) and another antibiotic period (OtherPer). In addition, bleeding events, bleeding risk (determined by the IMPROVE bleeding risk score), as well as 15- and 30-day mortality rates between TigePer and OtherPer were compared.

RESULTS

The study enrolled 50 patients with 100 episodes of antibiotic treatment. The median age (interquartile range) of the patients was 68.5 (21.5) years, and 38 % were female. As compared to OtherPer, TigePer had a statistically significant reduction in fibrinogen levels (p < 0.001), with a hypofibrinogenemia rate of 40 % in TigePer as compared to 2 % in OtherPer (p < 0.001). TigePer demonstrated a significantly higher 15-day mortality rate (p = 0.006). No significant differences were observed between the two periods in terms of bleeding risk, rate of bleeding events, and 30-day mortality rate (p > 0.05).

CONCLUSION

Hypofibrinogenemia and other coagulopathies, without associated bleeding events, are more frequently observed in patients receiving tigecycline. Therefore, it is crucial for clinicians to monitor fibrinogen levels during tigecycline use.

Efficacy of the "Start to move" protocol on functionality, ICU-acquired weakness and delirium: A randomized clinical trial

OBJECTIVE

To evaluate the efficacy of the Start to move protocol compared to conventional treatment in subjects over 15 years of age hospitalized in the ICU on an improvement in functionality, decrease in ICU-acquired weakness (DAUCI), incidence of delirium, days of mechanical ventilation (MV), length of stay in ICU and mortality at 28 days.

DESIGN

randomized controlled clinical trial.

SETTING

Intensive Care Unit.

PARTICIPANTS

Includes adults older than 15 years with invasive mechanical ventilation more than 48h, randomized allocation.

INTERVENTIONS

Start to move protocol and conventional treatment.

MAIN VARIABLES OF INTEREST

Functionality, incidence of ICU-acquired weakness, incidence of delirium, days on mechanical ventilation, ICU stay and mortality-28 days, ClinicalTrials.gov number, NCT05053724.

RESULTS

69 subjects were admitted to the study, 33 to the Start to move group and 36 to conventional treatment, clinically and sociodemographic comparable. In the "Start to move" group, the incidence of IUCD at ICU discharge was 35.7% vs. 80.7% in the "conventional treatment" group (p=0.001). Functionality (FSS-ICU) at ICU discharge corresponds to 26 vs. 17 points in favor of the "Start to move" group (p=0.001). The difference in Barthel at ICU discharge was 20% in favor of the "Start to move" group (p=0.006). There were no significant differences in the incidence of delirium, days of mechanical ventilation, ICU stay and 28-day mortality. The study did not report adverse events or protocol suspension.

CONCLUSIONS

The application of the "Start to move" protocol in ICU showed a reduction in the incidence of IUAD, an increase in functionality and a smaller decrease in Barthel score at discharge.

Teamwork matters: team situation awareness to build high-performing healthcare teams, a narrative review

Healthcare today is the prerogative of teams rather than of individuals. In acute care domains such as anaesthesia, intensive care, and emergency medicine, the work is complex and fast-paced, and the team members are diverse and interdependent. Three decades of research into the behaviours of high-performing teams provides us with clear guidance on team training, demonstrating positive effects on patient safety and staff wellbeing. Here we consider team performance through the lens of situation awareness. Maintaining situation awareness is an absolute requirement for safe and effective patient management. Situation awareness is a dynamic process of perceiving cues in the environment, understanding what they mean, and predicting how the situation may evolve. In the context of acute clinical care, situation awareness can be improved if the whole team actively contributes to monitoring the environment, processing information, and planning next steps. In this narrative review, we explore the concept of situation awareness at the level of the team, the conditions required to maintain team situation awareness, and the relationship between team situation awareness, shared mental models, and team performance. Our ultimate goal is to help clinicians create the conditions required for high-functioning teams, and ultimately improve the safety of clinical care.

Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Clinical Practice Update on Optimal Post Cardiac Arrest and Refractory Cardiac Arrest Patient Care

Survival to hospital discharge among patients with out-of-hospital cardiac arrest (OHCA) is low and important regional differences in treatment practices and survival have been described. Since the 2017 publication of the Canadian Cardiovascular Society's position statement on OHCA care, multiple randomized controlled trials have helped to better define optimal post cardiac arrest care. This working group provides updated guidance on the timing of cardiac catheterization in patients with ST-elevation and without ST-segment elevation, on a revised temperature control strategy targeting normothermia instead of hypothermia, blood pressure, oxygenation, and ventilation parameters, and on the treatment of rhythmic and periodic electroencephalography patterns in patients with a resuscitated OHCA. In addition, prehospital trials have helped craft new expert opinions on antiarrhythmic strategies (amiodarone or lidocaine) and outline the potential role for double sequential defibrillation in patients with refractory cardiac arrest when equipment and training is available. Finally, we advocate for regionalized OHCA care systems with admissions to a hospital capable of integrating their post OHCA care with comprehensive on-site cardiovascular services and provide guidance on the potential role of extracorporeal cardiopulmonary resuscitation in patients with refractory cardiac arrest. We believe that knowledge translation through national harmonization and adoption of contemporary best practices has the potential to improve survival and functional outcomes in the OHCA population.

The impact of critical illness on patients' physical function and recovery: An explanatory mixed-methods analysis

OBJECTIVES

To determine how the perception of physical function 6-months following critical illness compares to objectively measured function, and to identify key concerns for patients during recovery from critical illness.

RESEARCH METHODOLOGY AND DESIGN

A nested convergent parallel mixed methods study assessed physical function during a home visit 6-months following critical illness, with semi-structured interviews conducted at the same time.

SETTING

Participants were recruited from two hospitals at one healthcare network in Melbourne, Australia from September 2017 to October 2018 with follow-up data completed in April 2019.

MAIN OUTCOME MEASURES

Physical function was assessed through four objective outcomes: the functional independence measure, six-minute walk test, functional reach test, and grip strength. Semi structured interviews focused on participants function, memories of the intensive care and hospital stay, assistance required on discharge, ongoing limitations, and the recovery process.

FINDINGS

Although many participants (12/20, 60%) stated they had recovered from their critical illness, 14 (70%) had function below expected population norms. Decreased function on returning home was commonly reported, although eleven participants were described as independent and safe for discharge from hospital-based staff. The importance of family and social networks to facilitate discharge was highlighted, however participants often described wanting more support and issues accessing services. The effect of critical illness on the financial well-being of the family network was confirmed, with difficulties accessing financial support identified.

CONCLUSION

Survivors of critical illness perceived a better functional state than measured, but many report new limitations 6-months after critical illness. Family and friends play a crucial role in facilitating transition home and providing financial support.

IMPLICATIONS FOR CLINICAL PRACTICE

Implementation of specific discharge liaison personnel to provide education, support and assist the transition from hospital-based care to home, particularly in those without stable social supports, may improve the recovery process for survivors of critical illness.

Early Mobilization and Rehabilitation of Critically-Ill Patients

Post-intensive care unit (ICU) syndrome may occur after ICU treatment and includes ICU-acquired weakness (ICU-AW), cognitive decline, and mental problems. ICU-AW is muscle weakness in patients treated in the ICU and is affected by the period of mechanical ventilation. Diaphragmatic weakness may also occur because of respiratory muscle unloading using mechanical ventilators. ICU-AW is an independent predictor of mortality and is associated with longer duration of mechanical ventilation and hospital stay. Diaphragm weakness is also associated with poor outcomes. Therefore, pulmonary rehabilitation with early mobilization and respiratory muscle training is necessary in the ICU after appropriate patient screening and evaluation and can improve ICU-related muscle weakness and functional deterioration.

Harnessing In Situ Simulation to Identify Human Errors and Latent Safety Threats in Adult Tracheostomy Care

BACKGROUND

Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. In situ simulation has been used as a quality improvement tool to audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care.

METHODS

From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes.

RESULTS

Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36-64) among participants.

CONCLUSION

An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.

Enhancing Communication in Critically Ill Patients with a Tracheostomy: A Systematic Review of Evidence-Based Interventions and Outcomes

Background

Tracheostomy, a common procedure performed in intensive care units (ICU), is associated with communication impairment and affects patient well-being. While prior research has focused on physiological care, there is a need to address communication needs and quality of life (QOL). We aimed to evaluate how different types of communication devices affect QOL, speech intelligibility, voice quality, time to significant events, clinical response and tolerance, and healthcare utilization in patients undergoing tracheostomy.

Methods

Following PRISMA guidelines, a systematic review was conducted to assess studies from 2016 onwards. Eligible studies included adult ICU patients with a tracheostomy, comparing different types of communication devices. Data were extracted and synthesized to evaluate QOL, speech intelligibility, voice quality, time to significant events (initial communication device use, oral intake, decannulation), clinical response and tolerance, and healthcare utilization and facilitators/barriers to device implementation.

Results

Among 9,228 studies screened, 8 were included in the review. Various communication devices were employed, comprising both tracheostomy types and speaking valves, highlighting the multifaceted nature of interventions. Quality of life improvements were observed with voice restoration interventions, but challenges such as speech intelligibility impairments were noted. The median time for initial communication device usage post-intervention was 11.4 ± 5.56 days. The median duration of speech tolerance ranged between 30-60 minutes to 2-3 hours across different studies. Complications such as air trapping or breathing difficulties were reported in 15% of cases. Additionally, the median ICU length of stay post-intervention was 36.5 days. Key facilitators for device implementation included early intervention, while barriers ranged from service variability to physical intolerance issues.

Conclusion

Findings demonstrate that various types of communication devices can significantly enhance the quality of life, speech intelligibility, and voice quality for patients undergoing tracheostomy, aligning with the desired outcomes of improved clinical response and reduced healthcare utilization. The identification of facilitators and barriers to device implementation further informs clinical practice, suggesting a tailored, patient-centered approach is crucial for optimizing the benefits of communication devices in this population.

The effects of inspiratory muscle training on physical function in critically ill adults: Protocol for a systematic review and meta-analysis

INTRODUCTION

Inspiratory muscle training (IMT) is one possible strategy to ameliorate respiratory muscle weakness due to invasive mechanical ventilation. Recent systematic reviews have focused on respiratory outcomes with minimal attention to physical function. The newest systematic review searched the literature until September 2017 and a recent preliminary search identified 5 new randomized controlled trials focusing on IMT in critical care. As such, a new systematic review is warranted to summarize the current body of evidence and to investigate the effect of IMT on physical function in critical care.

MATERIALS AND METHODS

We will search for three main concepts ("critical illness", "inspiratory muscle training", "RCT") across six databases from their inception (MEDLINE, EMBASE, Emcare, AMED, CINAHL, CENTRAL) and ClinicalTrials.gov. Two reviewers will independently screen titles, abstracts, and full texts for eligibility using the Covidence web-based software. Eligible studies must include: (1) adult (≥18 years) patients admitted to the intensive care unit (ICU) who required invasive mechanical ventilation for ≥24 hours, (2) an IMT intervention using a threshold device with the goal of improving inspiratory muscle strength, with or without usual care, and (3) randomized controlled trial design. The primary outcome of interest will be physical function. We will use the Cochrane Risk of Bias Tools (ROB2) and will assess the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. This protocol has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA- P) guidelines and is registered with the International Prospective Register of Systematic Reviews (PROSPERO).

CONCLUSION

Results will summarize the body of evidence of the effect of IMT on physical function in critically ill patients. We will submit our findings to a peer-reviewed journal and share our results at conferences.

Increasing the precision of simulated percutaneous dilatational tracheostomy-a pilot prototype device development study

Percutaneous dilatational tracheostomy (PDT) is a bedside medical procedure which sites a new tracheostomy tube in the front of the neck. The critical first step is accurate placement of a needle through the neck tissues into the trachea. Misplacement occurs in around 5% of insertions, causing morbidity, mortality, and delays to recovery. We aimed to develop and evaluate a prototype medical device to improve precision of initial PDT-needle insertion. The Guidance for Tracheostomy (GiFT) system communicates the relative locations of intra-tracheal target sensor and PDT-needle sensor to the operator. In simulated "difficult neck" models, GiFT significantly improved accuracy (mean difference 10.0 mm, ANOVA p < 0.001) with ten untrained laboratory-based participants and ten experienced medical participants. GiFT resulted in slower time-to-target (mean difference 56.1 s, p < 0.001) than unguided attempts, considered clinically insignificant. Our proof-of-concept study highlights GiFT's potential to significantly improve PDT accuracy, reduce procedural complications and offer bedside PDT to more patients.

Trends in pre-hospital volume resuscitation of blunt trauma patients: a 15-year analysis of the British (TARN) and German (TraumaRegister DGU®) National Registries

INTRODUCTION

Fluid resuscitation has long been a cornerstone of pre-hospital trauma care, yet its optimal approach remains undetermined. Although a liberal approach to fluid resuscitation has been linked with increased complications, the potential survival benefits of a restrictive approach in blunt trauma patients have not been definitively established. Consequently, equipoise persists regarding the optimal fluid resuscitation strategy in this population.

METHODS

We analysed data from the two largest European trauma registries, the UK Trauma Audit and Research Network (TARN) and the German TraumaRegister DGU® (TR-DGU), between 2004 and 2018. All adult blunt trauma patients with an Injury Severity Score > 15 were included. We examined annual trends in pre-hospital fluid resuscitation, admission coagulation function, and mortality rates.

RESULTS

Over the 15-year study period, data from 68,510 patients in the TARN cohort and 82,551 patients in the TR-DGU cohort were analysed. In the TARN cohort, 3.4% patients received pre-hospital crystalloid fluids, with a median volume of 25 ml (20-36 ml) administered. Conversely, in the TR-DGU cohort, 91.1% patients received pre-hospital crystalloid fluids, with a median volume of 756 ml (750-912 ml) administered. Notably, both cohorts demonstrated a consistent year-on-year decrease in the volume of pre-hospital fluid administered, accompanied by improvements in admission coagulation function and reduced mortality rates.

CONCLUSION

Considerable variability exists in pre-hospital fluid resuscitation strategies for blunt trauma patients. Our data suggest a trend towards reduced pre-hospital fluid administration over time. This trend appears to be associated with improved coagulation function and decreased mortality rates. However, we acknowledge that these outcomes are influenced by multiple factors, including other improvements in pre-hospital care over time. Future research should aim to identify which trauma populations may benefit, be harmed, or remain unaffected by different pre-hospital fluid resuscitation strategies.

Comparative impact of COVID-19 infection on tracheostomy patients

PURPOSE

We study outcomes after tracheostomy in COVID-19 positive patients versus COVID-19 negative patients who underwent tracheostomy during the same time frame in an effort to better understand the influence of COVID-19 despite variances in virus strain and treatment practices.

MATERIALS AND METHODS

This is a retrospective cohort study of all Veterans Affairs centers nationwide, using data provided by the Veterans Affairs Informatics and Computing Infrastructure. Our cohort consisted of veteran patients who underwent tracheostomy between March 2020 and September 2022. Patients who tested positive for COVID-19 within three months prior to tracheostomy were compared to patients who had never tested positive for COVID-19.

RESULTS

956 patients were included in the analysis, and nearly 96 % of these patients were male. The COVID-19 positive group spent one more week on the ventilator and experienced lower rates of successful ventilator weaning (hazard ratio 0.74, 95 % confidence interval [0.62, 0.88], P < 0.001). Survival curves were non-proportional, and while the COVID-19 positive group had higher 30-day mortality (relative risk 1.37, 95 % confidence interval [1.09, 1.73], P = 0.007), the COVID-19 negative group had higher long-term mortality.

CONCLUSIONS

Our findings suggest that while infection with COVID-19 has a significant effect on short-term outcomes after tracheostomy, chronic comorbidities seem to have the more enduring impact. In spite of prolonged ventilation and higher short-term mortality, tracheostomy in COVID-19 can be a positive intervention that does not necessarily predestine patients to the same level of long-term morbidity and mortality of typical tracheostomies.

Association among blood pressure, end-tidal carbon dioxide, peripheral oxygen saturation and mortality in prehospital post-resuscitation care

Aim

Post-resuscitation care is described as the fourth link in a chain of survival in resuscitation guidelines. However, data on prehospital post-resuscitation care is scarce. We aimed to examine the association among systolic blood pressure (SBP), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide (EtCO2) after prehospital stabilisation and outcome among patients resuscitated from out-of-hospital cardiac arrest (OHCA).

Methods

In this retrospective study, we evaluated association of the last measured prehospital SBP, SpO2 and EtCO2 before patient handover with 30-day and one-year mortality in 2,611 patients receiving prehospital post-resuscitation care by helicopter emergency medical services in Finland. Statistical analyses were completed through locally estimated scatterplot smoothing (LOESS) and multivariable logistic regression. The regression analyses were adjusted by sex, age, initial rhythm, bystander CPR, and time interval from collapse to the return of spontaneous circulation (ROSC).

Results

Mortality related to SBP and EtCO2 values were U-shaped and lowest at 135 mmHg and 4.7 kPa, respectively, whereas higher SpO2 shifted towards lower mortality. In adjusted analyses, increased 30-day mortality and one year mortality was observed in patients with SBP < 100 mmHg (OR 1.9 [95% CI 1.4-2.4]) and SBP < 100 (OR 1.8 [1.2-2.6]) or EtCO2 < 4.0 kPa (OR 1.4 [1.1-1.5]), respectively. SpO2 was not significantly associated with either 30-day or one year mortality.

Conclusions

After prehospital post-resuscitation stabilization, SBP < 100 mmHg and EtCO2 < 4.0 kPa were observed to be independently associated with higher mortality. The optimal targets for prehospital post-resuscitation care need to be established in the prospective studies.

A single-center real-world review of 10 kHz high-frequency spinal cord stimulation outcomes for treatment of chronic pain

Objective

To compare pragmatic real-world 10-kHz high-frequency spinal cord stimulation (HF-SCS) outcomes at a single academic center to the industry-sponsored SENZA-RCT and Stauss et al. study.

Methods

This single-center retrospective study included patients with refractory back or limb pain trialed and/or permanently implanted with the Nevro HF-SCS system from 2016 to 2021. Demographic and outcome data were obtained from the electronic medical record (EMR) and real-world global database maintained by Nevro Corp. Data obtained from the global database were confirmed using the EMR. Main outcome measures included positive responder status (≥50% patient-reported percentage pain reduction (PRPPR)), improvement in function, improvement in sleep, and reduction in pain medication usage. Comparison groups included patient outcomes from the SENZA-RCT and Stauss et al. study.

Results

Patients (N = 147) trialed with HF-SCS were reviewed, with data available for 137. Positive trialed patient responder rate (≥50% PRPPR) was 77% (106/137, 95CI 70-84%) vs. 87% (1393/1607, 95CI 85-89%) Stauss et al. vs. 93% (90/97, 95CI 88-98%) SENZA-RCT HF-SCS. At the last available follow-up, positive implanted patient responder rate was 73% (58/80, 95CI 63-82%) vs. 78% (254/326, 95CI 73-82%) Stauss et al. vs. 79% (71/90, 95CI 70-87%) SENZA-RCT HF-SCS. Sixty-seven percent (59/88, 95CI 57-77%) reported improved function vs. 72% (787/1088, 95CI 70-75%) Stauss et al.; 45% (31/69, 95CI 33-57%) reported improved sleep vs. 68% (693/1020, 95CI 65-71%) Stauss et al. and 16% (9/56, 95CI 6-26%) reported decrease in medication use vs. 32% (342/1070, 95CI 29-35%) Stauss et al.

Conclusion

Patient responder rates in this retrospective pragmatic real-world study of HF-SCS are consistent with previous industry-sponsored studies. However, improvements in quality-of-life measures and reduction in medication usage were not as robust as reported in industry-sponsored studies. The findings of this non-industry-sponsored, independent study of HF-SCS complement those of previously published studies by reporting patient outcomes collected in the absence of industry sponsorship.

Outcomes for COVID-19 Patients Undergoing Tracheostomy With or Without Extracorporeal Membrane Oxygenation (ECMO)

Introduction The coronavirus disease 2019 (COVID-19) pandemic led to the more common use of venovenous (VV) extracorporeal membrane oxygenation (ECMO) for adults with acute respiratory distress syndrome (ARDS). While tracheostomy is generally understood to decrease the risks of prolonged endotracheal intubation, there is conflicting data regarding the benefit of tracheostomy in patients on ECMO. The purpose of this study is to determine whether ECMO cannulation before tracheostomy impacted patient outcomes. Methods This is a retrospective chart review of patients who underwent tracheostomy for COVID-19-related ARDS at a tertiary academic center from March 2020 through March 2022. Patients were separated into two groups based on whether they were cannulated for ECMO prior to tracheostomy. Fisher's exact test or Wilcoxon rank sum test was used to compare the two groups. Results A total of 24 patients were included in the study, with 13 in the ECMO group and 11 in the non-ECMO group. There was no significant difference in age, comorbidities, race, or gender between the groups. Patients on ECMO had a longer time from admission to intubation (seven days vs. three days, p=.002), were more likely to have multiple intubations (54% vs 9%, p= .033), had increased rates of postoperative bleeding (62% vs. 18%, p = .047), and had a higher mortality rate (39% vs. 0%, p= .041). Conclusions ECMO cannulation prior to tracheostomy for COVID-19-related ARDS is associated with poorer outcomes. It is unclear whether this is related to a more severe disease burden in these patients. Further study is needed to evaluate this and guide future management.

Tracheostomy-related durable medical equipment: Insurance coverage, gaps, and barriers

PURPOSE

Tracheostomy care is supply- and resource-intensive, and airway-related adverse events in community settings have high rates of readmission and mortality. Devices are often implicated in harm, but little is known about insurance coverage, gaps, and barriers to obtaining tracheostomy-related medically necessary durable medical equipment. We aimed to identify barriers patients may encounter in procuring tracheostomy-related durable medical equipment through insurance plan coverage.

MATERIALS AND METHODS

Tracheostomy-related durable medical equipment provisions were evaluated across insurers, extracting data via structured telephone interviews and web-based searches. Each insurance company was contacted four times and queried iteratively regarding the range of coverage and co-pay policies. Outcome measures include call duration, consistency of explanation of benefits, and the number of transfers and disconnects. We also identified six qualitative themes from patient interviews.

RESULTS

Tracheostomy-related durable medical equipment coverage was offered in some form by 98.1 % (53/54) of plans across 11 insurers studied. Co-pays or deductibles were required in 42.6 % (23/54). There was significant variability in out-of-pocket expenditures. Fixed co-pays ranged from $0-30, and floating co-pays ranged from 0 to 40 %. During phone interviews, mean call duration was 19 ± 10 min, with an average of 2 ± 1 transfers between agents. Repeated calls revealed high information variability (mean score 2.4 ± 1.5). Insurance sites proved challenging to navigate, scoring poorly on usability, literacy, and information quality.

CONCLUSIONS

Several factors may limit access to potentially life-saving durable medical equipment for patients with tracheostomy. Barriers include out-of-pocket expenditures, lack of transparency on coverage, and low-quality information. Further research is necessary to evaluate patient outcomes.

Endoscopic papillectomy could be rewarding to patients with early stage duodenal ampullary carcinoma?

BACKGROUND/PURPOSE

There is currently no consensus on the use of endoscopic papillectomy (EP) for early stage duodenal ampullary adenocarcinoma. This study aimed to evaluate the feasibility of EP for patients with early stage duodenal ampullary adenocarcinoma.

METHODS

Patients who underwent EP for ampullary adenocarcinomas were investigated. Complete and clinical complete resection rates were evaluated. Clinical complete resection was defined as either complete resection or resection with positive or unknown margins but no cancer in the surgically resected specimen, or no recurrence on endoscopy after at least a 1-year follow-up.

RESULTS

Adenocarcinoma developed in 30 patients (carcinoma in situ [Tis]: 21, mucosal tumors [T1a(M)]: 4, tumors in the sphincter of Oddi [T1a(OD)]: 5). The complete resection rate was 60.0% (18/30) (Tis: 66.7% [14/21], T1a[M]: 50.0% [2/4], and T1a[OD]: 40.0% [2/5]). The mean follow-up period was 46.8 months. The recurrence rate for all patients was 6.7% (2/30). The clinical complete resection rates of adenocarcinoma were 89.2% (25/28); rates for Tis, T1a(M), and T1a(OD) were 89.4% (17/19), 100% (4/4), and 80% (4/5), respectively.

CONCLUSIONS

EP may potentially achieve clinical complete resection of early stage (Tis and T1a) duodenal ampullary adenocarcinomas.

Post-Cardiac Arrest Care in Adult Patients After Extracorporeal Cardiopulmonary Resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients.

DATA SOURCES

A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted.

STUDY SELECTION

Selection includes original research, review articles, and guidelines.

DATA EXTRACTION

Information from relevant publications was reviewed, consolidated, and formulated into a narrative review.

DATA SYNTHESIS

We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/C o2 , and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes.

CONCLUSIONS

Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field.

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs.

HOW TO CITE THIS ARTICLE

Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

Development of a clinical practice guideline for physiotherapy management of adults invasively ventilated with community-acquired pneumonia

BACKGROUND AND SETTING

Patients hospitalised with community-acquired pneumonia (CAP) are frequently admitted to an intensive care unit (ICU) for invasive mechanical ventilation and receive treatment by physiotherapists. However, clinical physiotherapy practice is variable for this ICU cohort.

OBJECTIVES

To develop a clinical practice guideline for physiotherapy management of adults invasively ventilated with CAP using the best available evidence.

METHODS

Guideline development using evidence synthesis according to the GRADE and JBI approaches, incorporating findings from four preceding phases of a mixed-methods research program: systematic review and meta-analysis, national survey of Australian ICU physiotherapy practice, e-Delphi study to determine expert consensus, and multidisciplinary peer-review of the expert consensus statements by senior ICU clinicians to determine validity and applicability of the statements for translation into practice.

RESULTS

The guideline comprises 26 recommendations, encompassing physiotherapy assessment, patient selection and prioritisation, and treatment. Physiotherapy treatment covers domains of humidification, patient positioning, hyperinflation techniques, manual chest wall techniques, normal saline instillation, active treatment, and mobilisation. Recommendations are rated as strong or conditional based on JBI criteria, and certainty of evidence according to GRADE. Considerations for practice are provided within the guideline to enhance clarity and practicality, particularly for conditional recommendations where evidence is limited or conflicting.

CONCLUSION

This guideline, based on the best available evidence for clinical physiotherapy practice for adults invasively ventilated with CAP, is intended to support clinicians with clinical decision making. Further research is required to evaluate guideline implementation into clinical practice, and incorporate the values and preferences of ICU patients and their families. CONTRIBUTION OF PAPER.

Urea cycle disorders in critically Ill adults

PURPOSE OF REVIEW

Urea cycle disorders (UCDs) cause elevations in ammonia which, when severe, cause irreversible neurologic injury. Most patients with UCDs are diagnosed as neonates, though mild UCDs can present later - even into adulthood - during windows of high physiologic stress, like critical illness. It is crucial for clinicians to understand when to screen for UCDs and appreciate how to manage these disorders in order to prevent devastating neurologic injury or death.

RECENT FINDINGS

Hyperammonemia, particularly if severe, causes time- and concentration-dependent neurologic injury. Mild UCDs presenting in adulthood are increasingly recognized, so broader screening in adults is recommended. For patients with UCDs, a comprehensive, multitiered approach to management is needed to prevent progression and irreversible injury. Earlier exogenous clearance is increasingly recognized as an important complement to other therapies.

SUMMARY

UCDs alter the core pathway for ammonia metabolism. Screening for mild UCDs in adults with unexplained neurologic symptoms can direct care and prevent deterioration. Management of UCDs emphasizes decreasing ongoing ammonia production, avoiding catabolism, and supporting endogenous and exogenous ammonia clearance. Core neuroprotective and supportive critical care supplements this focused therapy.

Magnitude and time to peak oxygenation effect of prone positioning in ventilated adults with COVID-19 related acute hypoxemic respiratory failure

BACKGROUND

Prone positioning may improve oxygenation in acute hypoxemic respiratory failure and was widely adopted in COVID-19 patients. However, the magnitude and timing of its peak oxygenation effect remain uncertain with the optimum dosage unknown. Therefore, we aimed to investigate the magnitude of the peak effect of prone positioning on the PaO2 :FiO2 ratio during prone and secondly, the time to peak oxygenation.

METHODS

Multi-centre, observational study of invasively ventilated adults with acute hypoxemic respiratory failure secondary to COVID-19 treated with prone positioning. Baseline characteristics, prone positioning and patient outcome data were collected. All arterial blood gas (ABG) data during supine, prone and after return to supine position were analysed. The magnitude of peak PaO2 :FiO2 ratio effect and time to peak PaO2 :FIO2 ratio effect was measured.

RESULTS

We studied 220 patients (mean age 54 years) and 548 prone episodes. Prone positioning was applied for a mean (±SD) 3 (±2) times and 16 (±3) hours per episode. Pre-proning PaO2 :FIO2 ratio was 137 (±49) for all prone episodes. During the first episode. the mean PaO2 :FIO2 ratio increased from 125 to a peak of 196 (p < .001). Peak effect was achieved during the first episode, after 9 (±5) hours in prone position and maintained until return to supine position.

CONCLUSIONS

In ventilated adults with COVID-19 acute hypoxemic respiratory failure, peak PaO2 :FIO2 ratio effect occurred during the first prone positioning episode and after 9 h. Subsequent episodes also improved oxygenation but with diminished effect on PaO2 :FIO2 ratio. This information can help guide the number and duration of prone positioning episodes.

Functional electrical stimulation cycling-based muscular evaluation method in mechanically ventilated patients

BACKGROUND

Intensive care acquired muscle weakness is a common feature in critically ill patients. Beyond the therapeutic uses, FES-cycling could represent a promising nonvolitional evaluation method for detecting acquired muscle weakness.

OBJECTIVES

To assess whether FES-cycling is able to identify muscle dysfunctions, and to evaluate the survival rate in patients with detected muscle dysfunction.

METHODS

A prospective observational study was carried out, with 29 critically ill patients and 20 healthy subjects. Maximum torque and power achieved were recorded, in addition to the stimulation cost, and patients were followed up for six months.

RESULTS

Torque (2.64 [1.53 to 4.81] vs 6.03 [4.56 to 6.73] Nm) and power (3.31 [2.33 to 6.37] vs 6.35 [5.22 to 10.70] watts) were lower and stimulation cost (22 915 [5069 to 37 750] vs 3411 [2080 to 4024] μC/W) was higher in patients compared to healthy people (p < 0.05). Surviving patients showed a nonsignificant difference in power and torque in relation to nonsurvivors (p > 0.05), but they had a lower stimulation cost (4462 [3598 to 11 788] vs 23 538 [10 164 to 39 836] μC/W) (p < 0.05). In total, 34% of all patients survived during the six months of follow-up. Furthermore, 62% of patients with a stimulation cost below 15 371 μC/W and 7% of patients with a stimulation cost above 15 371 μC/W survived.

CONCLUSIONS

FES-cycling has good sensitivity and specificity for detecting muscle disorders. Critical patients have low torque and power and a high stimulation cost. Stimulation cost is related to survival. A low stimulation cost was related to a 3 times greater chance of survival.

Survivorship outcomes for critically ill patients in Australia and New Zealand: A scoping review

INTRODUCTION

Impairments after critical illness, termed the post-intensive care syndrome, are an increasing focus of research in Australasia. However, this research is yet to be cohesively synthesised and/or summarised.

OBJECTIVE

The aim of this scoping review was to explore patient outcomes of survivorship research, identify measures, methodologies, and designs, and explore the reported findings in Australasia.

INCLUSION CRITERIA

Studies reporting outcomes for adult survivors of critical illness from Australia and New Zealand in the following domains: physical, functional, psychosocial, cognitive, health-related quality of life (HRQoL), discharge destination, health care use, return to work, and ongoing symptoms/complications of critical illness.

METHODS

The Joanna Briggs Institute scoping review methodology framework was used. A protocol was published on the open science framework, and the search used Ovid MEDLINE, Scopus, ProQuest, and Google databases. Eligible studies were based on reports from Australia and New Zealand published in English between January 2000 and March 2022.

RESULTS

There were 68 studies identified with a wide array of study aims, methodology, and designs. The most common study type was nonexperimental cohort studies (n = 17), followed by studies using secondary analyses of other study types (n = 13). HRQoL was the most common domain of recovery reported. Overall, the identified studies reported that impairments and activity restrictions were associated with reduced HRQoL and reduced functional status was prevalent in survivors of critical illness. About 25% of 6-month survivors reported some form of disability. Usually, by 6 to12 months after critical illness, impairments had improved.

CONCLUSIONS

Reports of long-term outcomes for survivors of critical illness in Australia highlight that impairments and activity limitations are common and are associated with poor HRQoL. There was little New Zealand-specific research related to prevalence, impact, unmet needs, ongoing symptoms, complications from critical illness, and barriers to recovery.

Lung Ultrasound Score as a Predictor of Failure to Wean COVID-19 Elderly Patients off Mechanical Ventilation: A Prospective Observational Study

Background

The lung ultrasound score was developed for rapidly assessing the extent of lung ventilation, and it can predict failure to wean various types of patients off mechanical ventilation. Whether it is also effective for COVID-19 patients is unclear.

Methods

This single-center, prospective, observational study was conducted to assess the ability of the 12-region lung ultrasound score to predict failure to wean COVID-19 patients off ventilation. In parallel, we assessed whether right hemidiaphragmatic excursion or previously published predictors of weaning failure can apply to these patients. Predictive ability was assessed in terms of the area under the receiver operating characteristic curve (AUC).

Results

The mean age of the 35 patients in the study was (75 ± 9) years and 12 patients (37%) could not be weaned off mechanical ventilation. The lung ultrasound score predicted these failures with an AUC of 0.885 (95% CI 0.770-0.999, p < 0.001), and a threshold score of 10 provided specificity of 72.7% and sensitivity of 92.3%. AUCs were lower for previously published predictors of weaning failure, and right hemidiaphragmatic excursion did not differ significantly between the two groups.

Conclusion

The lung ultrasound score can accurately predict failure to wean critically ill COVID-19 patients off mechanical ventilation, whereas assessment of right hemidiaphragmatic excursion does not appear helpful in this regard.

Trial Registration

https://clinicaltrials.gov/ct2/show/NCT05706441.

Measuring quality of recovery (QoR-15) after degenerative spinal surgery: A prospective observational study

Introduction

The Quality of Recovery (QoR-15) score evaluates patient's recovery after surgery and anesthesia. There is a lack of studies focusing on the patients' quality of recovery in the early post-discharge phase after elective lumbar spine surgery.

Research question

We aimed to identify the QoR-15 score in patients who underwent surgery for degenerative low back conditions. Furthermore, we aimed to identify the individual items of the QoR-15 that are crucial for the patients' quality of recovery.

Material and methods

The study was conducted at a spine center in Denmark from December 2021 to September 2022. Data were collected, using a mobile health application, preoperatively and at 3 time points after hospital discharge. Descriptive analysis followed by within-subjects longitudinal repeated measures was conducted. The individual items of the QoR-15 score were explored using a heatmap.

Results

Data from 46 patients were analysed. The mean QoR-15 sum score at baseline was 105.4 ± 18.3. The mean QoR-15 sum scores were 108.1 ± 19.2 on post-discharge day 1, 118.5 ± 17.4 on day 7, and 120.7 ± 20.9 on day 14. The mean QoR-15 score from day 1 to day 7 improved significantly. Eight of the 15 items influenced the overall QoR-15 score.

Discussion and conclusion

This study applied the QoR-15 score in lumbar spine surgery patients. We identified specific items from the QoR-15 scale that are crucial to improving patients' recovery after hospital discharge. Further research is needed to identify specific needs in the post-discharge period in this group of patients.

Discovery and Characterization of VU0542270, the First Selective Inhibitor of Vascular Kir6.1/SUR2B KATP Channels

Vascular smooth muscle KATP channels critically regulate blood flow and blood pressure by modulating vascular tone and therefore represent attractive drug targets for treating several cardiovascular disorders. However, the lack of potent inhibitors that can selectively inhibit Kir6.1/SUR2B (vascular KATP) over Kir6.2/SUR1 (pancreatic KATP) has eluded discovery despite decades of intensive research. We therefore screened 47,872 chemically diverse compounds for novel inhibitors of heterologously expressed Kir6.1/SUR2B channels. The most potent inhibitor identified in the screen was an N-aryl-N'-benzyl urea compound termed VU0542270. VU0542270 inhibits Kir6.1/SUR2B with an IC50 of approximately 100 nM but has no apparent activity toward Kir6.2/SUR1 or several other members of the Kir channel family at doses up to 30 µM (>300-fold selectivity). By expressing different combinations of Kir6.1 or Kir6.2 with SUR1, SUR2A, or SUR2B, the VU0542270 binding site was localized to SUR2. Initial structure-activity relationship exploration around VU0542270 revealed basic texture related to structural elements that are required for Kir6.1/SUR2B inhibition. Analysis of the pharmacokinetic properties of VU0542270 showed that it has a short in vivo half-life due to extensive metabolism. In pressure myography experiments on isolated mouse ductus arteriosus vessels, VU0542270 induced ductus arteriosus constriction in a dose-dependent manner similar to that of the nonspecific KATP channel inhibitor glibenclamide. The discovery of VU0542270 provides conceptual proof that SUR2-specific KATP channel inhibitors can be developed using a molecular target-based approach and offers hope for developing cardiovascular therapeutics targeting Kir6.1/SUR2B. SIGNIFICANCE STATEMENT: Small-molecule inhibitors of vascular smooth muscle KATP channels might represent novel therapeutics for patent ductus arteriosus, migraine headache, and sepsis; however, the lack of selective channel inhibitors has slowed progress in these therapeutic areas. Here, this study describes the discovery and characterization of the first vascular-specific KATP channel inhibitor, VU0542270.

Effects of anesthesia on long-term survival in cancer surgery: A systematic review and meta-analysis

Backgrounds

The association between anesthesia and long-term oncological outcome after cancer surgery remains controversial. This study aimed to investigate the effect of propofol-based anesthesia and inhalation anesthesia on long-term survival in cancer surgery.

Methods

A comprehensive literature search was performed in PubMed, Medline, Embase, and the Cochrane Library until November 15, 2023. The outcomes included overall survival (OS) and recurrence-free survival (RFS). The hazard ratio (HR) and 95 % confidence interval (CI) were calculated with a random-effects model.

Results

We included forty-two retrospective cohort studies and two randomized controlled trials (RCTs) with 686,923 patients. Propofol-based anesthesia was associated with improved OS (HR = 0.82, 95 % CI:0.76-0.88, P < 0.00001) and RFS (HR = 0.80, 95 % CI:0.73-0.88, P < 0.00001) than inhalation anesthesia after cancer surgery. However, these positive results were only observed in single-center studies (OS: HR = 0.76, 95 % CI:0.68-0.84, P < 0.00001; RFS: HR = 0.76, 95 % CI:0.66-0.87, P < 0.0001), but not in multicenter studies (OS: HR = 0.98, 95 % CI:0.94-1.03, P = 0.51; RFS: HR = 0.95, 95 % CI:0.87-1.04, P = 0.26). The subgroup analysis revealed that propofol-based anesthesia provided OS and RFS advantages in hepatobiliary cancer (OS: HR = 0.58, 95 % CI:0.40-0.86, P = 0.005; RFS: HR = 0.62, 95 % CI:0.44-0.86, P = 0.005), gynecological cancer (OS: HR = 0.52, 95 % CI:0.33-0.81, P = 0.004; RFS: HR = 0.51, 95 % CI:0.36-0.72, P = 0.0001), and osteosarcoma (OS: HR = 0.30, 95 % CI:0.11-0.81, P = 0.02; RFS: HR = 0.32, 95 % CI:0.14-0.75, P = 0.008) surgeries.

Conclusion

Propofol-based anesthesia may be associated with improved OS and RFS than inhalation anesthesia in some cancer surgeries. Considering the inherent weaknesses of retrospective designs and the strong publication bias, our findings should be interpreted with caution. Well-designed multicenter RCTs are still urgent to further confirm these findings.

Perioperative management of kidney transplantation in China: A national survey in 2021

Perioperative anaesthesia management has an important significance for kidney transplantation; however, the related consensus remains limited. An electronic survey with 44 questions was developed and sent to the chief anaesthesiologist at 115 non-military medical centres performing kidney transplantation in China through WeChat. A response rate of 81.7% was achieved from 94 of 115 non-military medical centres, where 94.4% of kidney transplants (10404 /11026) were completed in 2021. The result showed an overview of perioperative practice for kidney transplantations in China, identify the heterogeneity, and provide evidence for improving perioperative management of kidney transplantation. Some controversial therapy, such as hydroxyethyl starch, are still widely used, while some recommended methods are not widely available. More efforts on fluid management, hemodynamical monitoring, perioperative anaesthetics, and postoperative pain control are needed to improve the outcomes. Evidence-based guidelines for standardizing clinical practice are needed.

Recent Treatment Strategies for Acute Pancreatitis

Acute pancreatitis (AP) is a leading gastrointestinal disease that causes hospitalization. Initial management in the first 72 h after the diagnosis of AP is pivotal, which can influence the clinical outcomes of the disease. Initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis, plays a fundamental role in AP treatment. Recent updates for fluid resuscitation, including treatment goals, the type, rate, volume, and duration, have triggered a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution. Evidence of the clinical benefit of early enteral feeding is becoming definitive. The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has recently been investigated to distinguish between inflammation and infection in patients with AP. Although urgent ERCP (within 24 h) should be performed for patients with gallstone pancreatitis and cholangitis, urgent ERCP is not indicated in patients without cholangitis. The management approach for patients with local complications of AP, particularly those with infected necrotizing pancreatitis, is discussed in detail, including indications, timing, anatomical considerations, and selection of intervention methods. Furthermore, convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is also important for improving the prognosis and preventing recurrence in patients with AP. This review focuses on recent updates on the initial and convalescent management strategies for AP.

The Determinants of COVID-19-Related Stress Among Caregivers of Individuals at High Risk During the Pandemic

BACKGROUND

Informal caregivers offer a range of support-physical, emotional, and social-to individuals under their care, thereby exposing themselves to potential mental health risks. During the outbreak of COVID-19, caregivers have emerged as a demographic particularly vulnerable to mental health issues owing to their caregiving roles. The aim of the study is to identify the determinants influencing COVID-19-related stress among caregivers of individuals at elevated risk of coronavirus infection.

MATERIALS AND METHODS

A cross-sectional study was undertaken, utilizing a sample of 1,556 participants who were enlisted via social media and an online survey questionnaire. Participants provided sociodemographic data and completed both the Depression Anxiety Stress Scale (DASS-21) and the COVID-19 Stress Scale (CSS) to assess their mental health status.

RESULTS

The mean age of the participants was 30.76±6.97 years. Of these, 42.35% (n = 659) resided with individuals at high risk for COVID-19, and 72.75% were female. Statistically significant differences were observed in DASS-21 subscale scores as well as in CSS scores for contamination, socioeconomic consequences, traumatic stress, perceived danger, compulsive checking, xenophobia, and total scores between those living and not living with COVID-19 high-risk individuals. Factors such as residing with a COVID-19 high-risk individual, education level, and DASS-21 subscale scores were identified as significant predictors of CSS scores.

CONCLUSION

The study reveals those caregivers for individuals at high risk for COVID-19 experience elevated levels of depression, anxiety, stress, and COVID-19-related stress. Factors such as living with a high-risk individual, educational level, and mental health status were significant predictors of COVID-19-related stress. Further research is needed to evaluate the mental well-being of caregivers and to develop effective interventions.

Exploring the Efficacy of Midodrine for Tapering Off Vasopressors

Sepsis and septic shock represent critical conditions, often necessitating vasopressor support in the intensive care unit (ICU). Midodrine, an oral vasopressor, has gathered attention as a potential adjunct to vasopressor therapy, aiming to facilitate weaning and improve clinical outcomes. However, the efficacy of midodrine remains questionable, with conflicting evidence from clinical trials and meta-analyses. This article provides a comprehensive review of the literature on midodrine's role in ICU settings by gathering evidence from multicenter trials, retrospective studies, and meta-analyses. While some studies suggest a limited benefit of midodrine in expediting vasopressor weaning and reducing ICU/hospital stays, others report potential advantages, particularly in reducing mortality rates among septic shock patients. Ongoing efforts aim to address knowledge gaps surrounding midodrine's efficacy and safety.