Critical Care Reviews Newsletter 404 9th September 2019

The Critical Care Reviews Newsletter lists the best critical care research and open access articles from across the medical literature during the last seven days.
“The highlights of this week’s edition are randomised controlled trials on masks for preventing influenza among health care personnel & NIV in pneumonia-induced early mild ARDS; systematic reviews and meta analyses on predictors of gastrointestinal bleeding in adult ICU patients & recombinant human soluble thrombomodulin in patients with sepsis-associated coagulopathy; and observational studies on prophylactic pantoprazole in adult intensive care unit patients receiving dialysis & the incidence of maternal sepsis and sepsis-related maternal deaths in the USA.
There are also guidelines on acute pulmonary embolismsupraventricular tachycardia PICU admission, discharge, and triage; narrative reviews on post-cardiac arrest syndrome & antifungal drug dosing adjustment in critical patients with invasive fungal infections; editorials on advances that have led to increased survival in military casualties & critically ill obstetric patients in resource-limited settings; and commentaries on point-of-care ultrasound examination & caution with a new antibacterial.
This week’s Topic of the Week is neurocritical care, starting with a paper on the CT imaging in neurocritical care in today’s Paper of the Day. If you only have time to read one review article this week, try this one on fibrinolysis shutdown in trauma.
The full text of the newsletter is available via this link.

Advertisements

Intensive Care Medicine Volume 45 Number 9 September 2019

To view Intensive Care Medicine’s September issue’s contents page follow this link.
Articles published in this issue include “Acute ischaemic stroke: challenges for the intensivist”, “Safety and efficacy of erythropoiesis-stimulating agents in critically ill patients admitted to the intensive care unit: a systematic review and meta-analysis” and “Speckle tracking quantification of lung sliding for the diagnosis of pneumothorax: a multicentric observational study.”
To read the full text of any of these articles via the journal’s homepage requires a personal subscription to “Intensive Care Medicine” though some are available open access.  Individual articles can be ordered from the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.
The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Association between acute kidney injury and neurological outcome or death at 6 months in out-of-hospital cardiac arrest: A prospective, multicenter, observational cohort study

This paper by Oh and colleagues was first published online in the Journal of Critical Care during August 2019.
Purpose:  This study aimed to evaluate the association between acute kidney injury (AKI) and 6 months neurological outcome after out-of-hospital cardiac arrest (OHCA).
Materials and methods:  Prospective multi-center observational cohort included adult OHCA patients treated with targeted temperature management (TTM) across 20 hospitals in the South Korea between October 2015 and October 2017. The diagnosis of AKI was made using the Kidney Disease: Improving Global Outcomes criteria. The outcome was neurological outcome at 6 months evaluated using the modified Rankin scale (MRS).
Results:  Among 5676 patients with OHCA, 583 patients were enrolled. AKI developed in 348 (60%) patients. Significantly more non-AKI patients had good neurological outcome at 6 months (MRS 0–3) than AKI patients (134/235 [57%] vs. 69/348 [20%], P < .001). AKI was associated with poor neurological outcome at six months in multivariate logistic regression analysis (adjusted odds ratio: 0.206 [95% confidence interval: 0.099–0.426], P < .001]). Cox regression analysis with time-varying covariate of AKI showed that patients with AKI had a higher risk of death than those without AKI (hazard ratio: 2.223; 95% confidence interval: 1.630–3.030, P < .001).
Conclusions:  AKI is associated with poor neurological outcome (MRS 4–6) at 6 months in OHCA patients treated with TTM.

The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Effect of an ICU Diary on Post traumatic Stress Disorder Symptoms Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial.

This research by Garrouste-Orgeas and colleagues was published in JAMA during July 2019.
Importance:  Keeping a diary for patients while they are in the intensive care unit (ICU) might reduce their posttraumatic stress disorder (PTSD) symptoms.
Objectives:  To assess the effect of an ICU diary on the psychological consequences of an ICU hospitalization.
Design, Setting, and Participants:  Assessor-blinded, multicenter, randomized clinical trial in 35 French ICUs from October 2015 to January 2017, with follow-up until July 2017. Among 2631 approached patients, 709 adult patients (with 1 family member each) who received mechanical ventilation within 48 hours after ICU admission for at least 2 days were eligible, 657 were randomized, and 339 were assessed 3 months after ICU discharge.
Interventions:  Patients in the intervention group (n = 355) had an ICU diary filled in by clinicians and family members. Patients in the control group (n = 354) had usual ICU care without an ICU diary.
Main Outcomes and Measures:  The primary outcome was significant PTSD symptoms, defined as an Impact Event Scale-Revised (IES-R) score greater than 22 (range, 0-88; a higher score indicates more severe symptoms), measured in patients 3 months after ICU discharge. Secondary outcomes, also measured at 3 months and compared between groups, included significant PTSD symptoms in family members; significant anxiety and depression symptoms in patients and family members, based on a Hospital Anxiety and Depression Scale score greater than 8 for each subscale (range, 0-42; higher scores indicate more severe symptoms; minimal clinically important difference, 2.5); and patient memories of the ICU stay, reported with the ICU memory tool.
Results:  Among 657 patients who were randomized (median [interquartile range] age, 62 [51-70] years; 126 women [37.2%]), 339 (51.6%) completed the trial. At 3 months, significant PTSD symptoms were reported by 49 of 164 patients (29.9%) in the intervention group vs 60 of 175 (34.3%) in the control group (risk difference, -4% [95% CI, -15% to 6%]; P = .39). The median (interquartile range) IES-R score was 12 (5-25) in the intervention group vs 13 (6-27) in the control group (difference, -1.47 [95% CI, -1.93 to 4.87]; P = .38). There were no significant differences in any of the 6 prespecified comparative secondary outcomes.
Conclusions and Relevance:  Among patients who received mechanical ventilation in the ICU, the use of an ICU diary filled in by clinicians and family members did not significantly reduce the number of patients who reported significant PTSD symptoms at 3 months. These findings do not support the use of ICU diaries for preventing PTSD symptoms.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.

Critical Care Reviews Newsletter 403 1st September 2019

The Critical Care Reviews Newsletter lists the best critical care research and open access articles from across the medical literature during the last seven days.
“The highlights of this week’s edition are randomised controlled trials on the effects of vasopressin on transfusion requirements in trauma & complete vs culprit only PCI revascularization for myocardial infarction; a systematic review and meta analysis on IV immunoglobulin in sepsis; and an observational study looking at the association between acute kidney injury and neurological outcome or death at 6 months in out-of-hospital cardiac arrest. There is also a guideline on laboratory testing in the diagnosis of fungal infections; plus narrative reviews on hyperventilation in neurological patients & early brain injury after poor-grade subarachnoid hemorrhage; commentaries on death by organ donation & artificial intelligence in perioperative medicine; and correspondence on managing ICP-CPP & tidal volume.”
The full text of the newsletter is available via this link.

Measuring the nursing workload in intensive care with the Nursing Activities Score (NAS): A prospective study in 16 hospitals in Belgium

This paper by Bruyneel and colleagues was published online in the Journal of Critical Care during August 2019.
Purpose:  The evaluation of nursing workload is a common practice in intensive care units (ICUs). It allows the calculation of an optimal nurse/patient ratio (N/P) which is a major challenge to ensuring the quality of care while controlling the costs of health care. The objectives of this study were, therefore, to evaluate the N/P ratio and to study nursing activities in intensive care in French-speaking Belgium.
Methods:  The Nursing Activities Score (NAS) was prospectively recorded by shift for two periods of one month each in 16 French-speaking Belgian hospitals for a total of 316 ICU beds in 24 ICUs.
Results:  We included 3377 patients in the study, of which 64% were medical (versus surgical). The results for 24-hour NAS (68.6%) were significantly different from the NAS per shift (Morning: 61.3%, Afternoon: 58.4%, Night: 55.0%). Outliers were significantly more prevalent among men and patients who died and outliers had longer stays in the ICU. Finally, mobilization-positioning and clinical-administrative tasks took, on average, more time for nurses in the ICU.
Conclusions:  There is a significant difference in N/P ratio between the Belgian regulation (1/3) and the one calculated by the NAS (1/1.5). A systematic objective assessment of shift workload should be done to avoid N/P ratio differences in intensive care.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit: The ICU Visits Randomized Clinical Trial.

This article by the ICU Visits Study Group Investigators and the Brazilian Research in Intensive Care Network (BRICNet) was published in JAMA in July 2019
Importance:  The effects of intensive care unit (ICU) visiting hours remain uncertain.
Objective:  To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium.
Design, Setting and Participants:  Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018.InterventionsFlexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation.
Main Outcomes and Measures:  Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory).
Results:  Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation.
Conclusions and Relevance:  Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.