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Articles featured in this issue include “The
intensive care unit specialist: report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine”, “Clinical and economic burden of bloodstream infections in critical care patients with central venous catheters” and “Can early initiation of continuous renal replacement therapy improve patient survival with septic acute kidney injury when enrolled in early goal directed therapy?”.
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Tayyib, N. Coyer, F. & Lewis, P. Intensive and Critical Care Nursing. Published online: August 28, 2016
Background: The incidence of pressure ulcers (PUs) in intensive care units (ICUs) is high and numerous strategies have been implemented to address this issue. One approach is the use of a PU prevention bundle. However, to ensure success care bundle implementation requires monitoring to evaluate the care bundle compliance rate, and to evaluate the effectiveness of implementation strategies in facilitating practice change.
Aims: The aims of this study were to appraise the implementation of a series of high impact intervention care bundle components directed at preventing the development of PUs, within ICU, and to evaluate the effectiveness of strategies used to enhance the implementation compliance.
Method: An observational prospective study design was used. Implementation strategies included regular education, training, audit and feed-back and the presence of a champion in the ICU. Implementation compliance was measured along four time points using a compliance checklist.
Results: Of the 60 registered nurses (RNs) working in the critical care setting, 11 participated in this study. Study participants demonstrated a high level of compliance towards the PU prevention bundle implementation (78.1%), with 100% participant acceptance. No significant differences were found between participants’ demographic characteristics and the compliance score. There was a significant effect for time in the implementation compliance (Wilks Lambda = 0.29, F (3, 8) = 6.35, p < 0.016), indicating that RNs needed time to become familiar with the bundle and routinely implement it into their practice. PU incidence was not influenced by the compliance level of participants.
Conclusion: The implementation strategies used showed a positive impact on compliance. Assessing and evaluating implementation compliance is critical to achieve a desired outcome (reduction in PU incidence). This study’s findings also highlighted that while RNs needed time to familiarise themselves with the care bundle elements, their clinical practice was congruent with the bundle elements.
Phua, J. et al. Critical Care. Published online: 28 August 2016
Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.
In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.
These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).
While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.
Objectives To describe the incidence, characteristics and risk factors for critical care admission with severe maternal sepsis in the UK.
Design National cohort study.
Setting 198 critical care units in the UK.
Participants 646 pregnant and recently pregnant women who had severe sepsis within the first 24 hours of admission in 2008–2010.
Primary and secondary outcome measures Septic shock, mortality.
Results Of all maternal critical care admissions, 14.4% (n=646) had severe sepsis; 10.6% (n=474) had septic shock. The absolute risk of maternal critical care admission with severe sepsis was 4.1/10 000 maternities. Pneumonia/respiratory infection (irrespective of the H1N1 pandemic influenza strain) and genital tract infection were the most common sources of sepsis (40% and 24%, respectively). We identified a significant gradient in the risk of severe maternal sepsis associated with increasing deprivation (RR=6.5; 95% CI 4.9 to 8.5 most deprived compared with most affluent women). The absolute risk of mortality was 1.8/100 000 maternities. The most common source of infection among women who died was pneumonia/respiratory infection (41%). Known risk factors for morbidity supported by this study were: younger age, multiple gestation birth and caesarean section. Significant risk factors for mortality in unadjusted analysis were: age ≥35 years (unadjusted OR (uOR)=3.5; 95% CI 1.1 to 10.6), ≥3 organ system dysfunctions (uOR=12.7; 95% CI 2.9 to 55.1), respiratory dysfunction (uOR=6.5; 95% CI1.9 to 21.6), renal dysfunction (uOR=5.6; 95% CI 2.3 to 13.4) and haematological dysfunction (uOR=6.5; 95% CI 2.9 to 14.6).
Conclusions This study suggests a need to improve timely recognition of severe respiratory tract and genital tract infection in the obstetric population. The social gradient associated with the risk of severe sepsis morbidity and mortality raises important questions regarding maternal health service provision and usage.
Brink, H.L. et al. Intensive and Critical Care Nursing. Published online: 12 August 2016
Objective: ‘To identify parents’ experience of a follow up meeting and to explore whether the conversation was adequate to meet the needs of parents for a follow-up after their child’s death in the Paediatric Intensive Care Unit (PICU).
Design and setting: Qualitative method utilising semi-structured interviews with six pairs of parents 2–12 weeks after the follow-up conversation. The interviews were held in the parents’ homes at their request. Data were analysed using a qualitative, descriptive approach and thematic analysis.
Findings: Four main themes emerged: (i) the way back to the PICU; (ii) framework; (iii) relations and (iv) closure.
Conclusion: The parents expressed nervousness before the meeting, but were all pleased to have participated in these follow-up meetings. The parents found it meaningful that the follow-up meeting was interdisciplinary, since the parents could have answers to their questions both about treatment and care. It was important that the staff involved in the follow-up meeting were those who had been present through the hospitalisation and at the time of the child’s death. Parents experienced the follow-up meeting as being a closure of the course in the PICU, regardless the length of the hospitalisation.
Guilabert, P. et al. (2016) British Journal of Anaesthesia. 117 (3). pp.284-296.
Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the ‘goal-directed therapy’ concept, and the development of new colloid and crystalloid solutions.
Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns?
To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.
Kamdar, B.B. et al. Critical Care. Published online: 18 August 2016
Background: Poor sleep is common in the ICU setting and may represent a modifiable risk factor for patient participation in ICU-based physical therapy (PT) interventions. This study evaluates the association of perceived sleep quality, delirium, sedation, and other clinically important patient and ICU factors with participation in physical therapy (PT) interventions.
Method: This was a secondary analysis of a prospective observational study of sleep in a single academic medical ICU (MICU). Perceived sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) and delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates included demographics, pre-hospitalization ambulation status, ICU admission diagnosis, daily mechanical ventilation status, and daily administration of benzodiazepines and opioids via bolus and continuous infusion. Associations with participation in PT interventions were assessed among patients eligible for PT using a multinomial Markov model with robust variance estimates.
Results: Overall, 327 consecutive MICU patients completed ≥1 assessment of perceived sleep quality. After adjusting for all covariates, daily assessment of perceived sleep quality was not associated with transitioning to participate in PT the following day (relative risk ratio [RRR] 1.02, 95 % CI 0.96–1.07, p = 0.55). However, the following factors had significant negative associations with participating in subsequent PT interventions: delirium (RRR 0.58, 95 % CI 0.41–0.76, p <0.001), opioid boluses (RRR 0.68, 95 % CI 0.47–0.99, p = 0.04), and continuous sedation infusions (RRR 0.58, 95 % CI 0.40–0.85, p = 0.01). Additionally, in patients with delirium, benzodiazepine boluses further reduced participation in subsequent PT interventions (RRR 0.25, 95 % CI 0.13–0.50, p <0.001).
Conclusions: Perceived sleep quality was not associated with participation in PT interventions the following day. However, continuous sedation infusions, opioid boluses, and delirium, particularly when occurring with administration of benzodiazepine boluses, were negatively associated with subsequent PT interventions and represent important modifiable factors for increasing participation in ICU-based PT interventions.
Heiberg, J. et al. (2016). Anaesthesia. Volume 71(9). pp. 1091–1100
Image shows illustration of transesophageal echocardiography ultrasound diagram
Focused echocardiography is becoming a widely used tool to aid clinical assessment by anaesthetists and critical care physicians. At the present time, most physicians are not yet trained in focused echocardiography or believe that it may result in adverse outcomes by delaying, or otherwise interfering with, time-critical patient management.
We performed a systematic review of electronic databases on the topic of focused echocardiography in anaesthesia and critical care. We found 18 full text articles, which consistently reported that focused echocardiography may be used to identify or exclude previously unrecognised or suspected cardiac abnormalities, resulting in frequent important changes to patient management. However, most of the articles were observational studies with inherent design flaws. Thirteen prospective studies, including two that measured patient outcome, were supportive of focused echocardiography, whereas five retrospective cohort studies, including three outcome studies, did not support focused echocardiography. There is an urgent requirement for randomised controlled trials.
Attridge, R.T. et al. Journal of Critical Care | Published online: August 11, 2016
Purpose: Recent data have not demonstrated improved outcomes when guideline-concordant (GC) antibiotics are given to patients with healthcare-associated pneumonia (HCAP). This study was designed to evaluate the relationship between health outcomes and GC therapy in patients admitted to an ICU with HCAP.
Materials and Methods: We performed a population-based cohort study of patients admitted to >150 hospitals in the U.S. Veterans Health Administration system to compare baseline characteristics, bacterial pathogens, and health outcomes in ICU patients with HCAP receiving either GC-HCAP therapy, GC community-acquired pneumonia (GC-CAP) therapy, or non-GC therapy. The primary outcome was 30-day patient mortality. Risk factors for the primary outcome were assessed in a multivariable logistic regression model.
Results: A total of 3593 patients met inclusion criteria and received GC-HCAP therapy (26%), GC-CAP therapy (23%), or non-GC therapy (51%). GC-HCAP patients had higher 30-day patient mortality compared to GC-CAP patients (34% vs. 22%, P < .0001). After controlling for confounders, risk factors for 30-day patient mortality were vasopressor use (OR, 95% CI; 1.67, 1.30–2.13), recent hospital admission (1.53, 1.15–2.02), and receipt of GC-HCAP therapy (1.51, 1.20–1.90).
Conclusions: Our data do not demonstrate improved outcomes among ICU patients with HCAP who received GC-HCAP therapy.
Mohamed, Z.M. et al. Indian Journal of Critical Care Medicine. 2016;20:459-64
Background and Aims: The practice of intensive care includes withholding and withdrawal of care, when appropriate, and the goals of care change around this time to comfort and palliation. We decided to survey the attitudes, training, and skills of intensive care residents in relation to end-of-life (EoL) care. All residents at our institute who has worked for at least a month in an adult Intensive Care Unit were invited to participate.
Materials and Methods: After Institutional Ethics Committee approval, a Likert-scale questionnaire, divided into five composite measures of EoL skills including training and attitude, was handed over to individual residents and completed data were anonymized. Frequency and descriptive analysis was performed for the demographic variables. Central tendency, variability, and reliability were examined for the five composite measures. Scale internal consistency was checked by Cronbach’s coefficient alpha. Multivariate forward conditional regression analysis was conducted to examine the association of demographic data or EoL experience to composite measures.
Results: Of the 170 eligible residents, we received 120 (70.5%) responses.
Conclusions:Internal medicine residents have more experience in caring for dying patients and conducting EoL discussions. Even though majority of participants reported that they are comfortable with the concept of EoL care, this does not always reflect the actual practice in the hospital. There is a need for further training in skills around EoL care. As this is a self-assessment survey, the specific measures of attitudes and skills in EoL are poorly reflected, indicating a need for further research.