Disturbed Microbiome Clinically Detrimental in ICU

Patients in the intensive care unit with an imbalanced microbiome are at increased risk for complications and longer ICU stays, according to findings presented at Clinical Nutrition Week 2017 | Anesthesiology News

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Image source: François-Joseph Lapointe, Université de Montréal – Wellcome Images // CC BY 4.0

Image shows bacterial microbiome mapping – a bioartistic experiment.

Paul Wischmeyer, MD, professor of anesthesiology and surgery and director of perioperative research at Duke Clinical Research Institute, in Durham, N.C., who also is part of the ICU Microbiome Project, told meeting attendees that ICU patients experience significant microbiome perturbations and added complications, including acute respiratory distress syndrome (ARDS).

“ICU patients have massive loss of health-promoting bacteria and higher levels of pathogenic species, compared with healthy patients,” Dr. Wischmeyer said. “It is astonishing how rapidly pathogenic bacteria flourish and how this shift to dysbiosis appears to affect a variety of outcomes.”

Dr. Wischmeyer and his colleagues have been examining fecal and oral microbiome samples from 115 ICU patients treated at four hospitals and comparing them with samples from healthy people participating in the American Gut project. In previous research, they found decreases in populations of Bacteroides and Firmicutes, as well as the healthy bacterium, Faecalibacterium prausnitzii, which produces short-chain fatty acids that help preserve normal gut barrier function (mSphere 2016;1[4]. pii:e00199-16). Meanwhile, they discovered increases in the relative abundance of Proteobacteria, a phylum of gram-negative bacteria linked to infections in ICU and hospitalized patients.

ICU patients also tended to lose overall fecal microbiota diversity, with some patients having only one organism compose 95% of their fecal bacteria after a short time in the ICU, he explained.

Prevention of central venous line associated bloodstream infections in adult intensive care units

Despite the potential benefits central venous lines can have for patients, there is a high risk of bloodstream infection associated with these catheters | Intensive and Critical Care Nursing

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Aim: Identify and critique the best available evidence regarding interventions to prevent central venous line associated bloodstream infections in adult intensive care unit patients other than anti-microbial catheters.

Methods: A systematic review of studies published from January 2007 to February 2016 was undertaken. A systematic search of seven databases was carried out: MEDLINE; CINAHL Plus; EMBASE; PubMed; Cochrane Library; Scopus and Google Scholar. Studies were critically appraised by three independent reviewers prior to inclusion.

Results: Nineteen studies were included. A range of interventions were found to be used for the prevention or reduction of central venous line associated bloodstream infections. These interventions included dressings, closed infusion systems, aseptic skin preparation, central venous line bundles, quality improvement initiatives, education, an extra staff in the Intensive Care Unit and the participation in the ‘On the CUSP: Stop Blood Stream Infections’ national programme.

Conclusions: Central venous line associated bloodstream infections can be reduced by a range of interventions including closed infusion systems, aseptic technique during insertion and management of the central venous line, early removal of central venous lines and appropriate site selection.

Full reference: Velasquez Reyes, D.C. et al. (2017) Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review. Intensive and Critical Care Nursing. Published online: 26 June 2017

Early Antibiotics & Fluids Key in Sepsis Management

Sepsis and septic shock are medical emergencies that require immediate action | Anesthesiology News

Early resuscitation should begin with early antibiotics and fluids, as well as the identification of the source of infection, according to new guidelines that were released at the Society of Critical Care Medicine’s (SCCM) 2017 Critical Care Congress.

In addition, the new guidelines say a health care provider who is trained and skilled in the management of sepsis should reassess the patient frequently at the bedside. “It is not the initial assessment, but the frequent reassessment that will make a difference,” said Andrew Rhodes, MD, FRCP, FRCA, FFICM, the co-chair of the guidelines committee.

Read the full news story here

Does good critical thinking equal effective decision-making among critical care nurses?

The aim of this study was to understand whether critical care nurses’ critical thinking disposition affects their clinical decision-making skills | Intensive and Critical Care Nursing

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Background: A critical thinker may not necessarily be a good decision-maker, but critical care nurses are expected to utilise outstanding critical thinking skills in making complex clinical judgements. Studies have shown that critical care nurses’ decisions focus mainly on doing rather than reflecting. To date, the link between critical care nurses’ critical thinking and decision-making has not been examined closely in Malaysia.

Conclusion: While this small-scale study has shown a relationship exists between critical care nurses’ critical thinking disposition and clinical decision-making in one hospital, further investigation using the same measurement tools is needed into this relationship in diverse clinical contexts and with greater numbers of participants. Critical care nurses’ perceived high level of critical thinking and decision-making also needs further investigation.

Full reference: Ludin, S.L. (2017) Does good critical thinking equal effective decision-making among critical care nurses? A cross-sectional survey. Intensive and Critical Care Nursing. Published online: 26 June 2017

Latest issue of “Intensive and Critical Care Nursing” Volume 40 June 2017

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Titles of articles published in this issue include “Working together: a critical care nurses experiences of temporary staffing within Swedish health care: a qualitative study”, “burnout and job satisfaction of intensive care personnel and the relationship with personality and religious traits: an observational multi centre cross sectional study” and “Effect of nocturnal sound reduction on the incidence of delirium in intensive care unit patients: an interrupted time series analysis”

The content page of this issue can be accessed via this link.

To see the full text of any of these articles direct from the journal’s homepage requires a personal subscription.  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.

Issues of Intensive and Critical Care Nursing from issue older than one year ago can have their full text accessed via this link.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.

Early, Goal-Directed Therapy for Septic Shock – A Patient-Level Meta-Analysis.

This paper by the PRISM investigators led by Kathryn Rowan was published in the New England Journal of Medicine in June 2017 Volume 376 number 23.  The full text of the article is available to subscribers to this journal via this link.  The Library and Knowledge Service can obtain the full text of the article for registered members by requesting it via the library website document request form.

BACKGROUND:  After a single-center trial and observational studies suggesting that early, goal-directed therapy (EGDT) reduced mortality from septic shock, three multicenter trials (ProCESS, ARISE, and ProMISe) showed no benefit. This meta-analysis of individual patient data from the three recent trials was designed prospectively to improve statistical power and explore heterogeneity of treatment effect of EGDT.

METHODS:  We harmonized entry criteria, intervention protocols, outcomes, resource-use measures, and data collection across the trials and specified all analyses before unblinding. After completion of the trials, we pooled data, excluding the protocol-based standard-therapy group from the ProCESS trial, and resolved residual differences. The primary outcome was 90-day mortality. Secondary outcomes included 1-year survival, organ support, and hospitalization costs. We tested for treatment-by-subgroup interactions for 16 patient characteristics and 6 care-delivery characteristics.

RESULTS:  We studied 3723 patients at 138 hospitals in seven countries. Mortality at 90 days was similar for EGDT (462 of 1852 patients [24.9%]) and usual care (475 of 1871 patients [25.4%]); the adjusted odds ratio was 0.97 (95% confidence interval, 0.82 to 1.14; P=0.68). EGDT was associated with greater mean (±SD) use of intensive care (5.3±7.1 vs. 4.9±7.0 days, P=0.04) and cardiovascular support (1.9±3.7 vs. 1.6±2.9 days, P=0.01) than was usual care; other outcomes did not differ significantly, although average costs were higher with EGDT. Subgroup analyses showed no benefit from EGDT for patients with worse shock (higher serum lactate level, combined hypotension and hyperlactatemia, or higher predicted risk of death) or for hospitals with a lower propensity to use vasopressors or fluids during usual resuscitation.

CONCLUSIONS:  In this meta-analysis of individual patient data, EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics.

Meeting the needs of critical care patients after discharge home

With improved survival rates in critical care, increasing focus is being placed on survivorship and how best to support patients in returning to their former activity | Nursing in Critical Care

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Objectives: To describe former critical care patients’ perspectives on the support needed to optimize recovery.

Findings: Four themes of support were described: effective management of transfer anxiety, tailored information provision, timely access to services and a supportive social network.

Conclusion: Survivors of critical care should be equipped with information about their critical care stay, ongoing health issues and recovery and should be provided with holistic care at home. Critical care follow up was an effective way of meeting many of these needs, but this needs to be flexible to be useful to attendees. Peer support groups (face-to-face and online) provided information, reassurance, a social network and an avenue for those who had longer-lasting problems than current services provide for.

Relevance to clinical practice: Whilst there are commonalities in the problems faced by critical care survivors, recovery is highly individualized, and current support services do not have sufficient flexibility to cater for this. This study shows that many survivors experience after-effects of critical care that outlast the support they are given. These longer-term survivors are often excluded from research studies because of fears of recall bias, resulting in poor understanding of their experiences.

Full reference: Allum, L. et al. (2017) Meeting the needs of critical care patients after discharge home: a qualitative exploratory study of patient perspectives. Nursing in Critical Care. Version of Record online: 22 Jun 2017