Critical Care Reviews Newsletter 338 3rd June 2018

Critical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature over the past seven days.  “The highlights of this week’s edition are the publication of the protocols and statistical analyses of the ICU-ROX and TARGET trials, two of the major multi-centre studies being discussed at #CCR19.  The are also many other great articles to read, including observational studies on ICU admissions for sepsis or pneumonia in Australia and New Zealand in 2017, outcomes in patients perceived as receiving excessive care, and community-acquired sepsis in European pediatric intensive care units; guidelines on Takotsubo syndrome, & cardiac and vascular surgery–associated acute kidney injury; narrative reviews on acute heart failure, the evidence base for fluid resuscitation, and mechanical CPR; plus a series of three editorials arguing the place of the Swan–Ganz catheter in contemporary critical care.”
The full text of newsletter 338 can be found via this link

A Randomized Trial of a Family-Support Intervention in Intensive Care Units.

This article was published online by the New England Journal of Medicine during May 2018.
Background:  Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences.
Methods:  We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates’ mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates’ mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay.
Results:   A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates’ mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates’ mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001).
Conclusions:  Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates’ burden of psychological symptoms, but the surrogates’ ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care.
The print copy of this issue of “The New England Journal of Medicine” is available in the Healthcare Library on D Level of Rotherham General Hospital.

Predicting Intensive Care Unit Readmission with Machine Learning Using Electronic Health Record Data

This article by Rojas and colleagues was published in Annals of the American Thoracic Society during May 2018.
Rationale:  Patients transferred from the intensive care unit (ICU) to the wards who are later readmitted to the ICU have increased length of stay, healthcare expenditure, and mortality compared to those who are never readmitted. Improving risk-stratification for patients transferred to the wards could have important benefits for critically ill hospitalized patients.
Objective:  We aimed to use a machine-learning technique to derive and validate an ICU readmission prediction model with variables available in the electronic health record (EHR) in real-time and compare it to previously published algorithms.
Methods:  This observational cohort study was conducted at an academic hospital in the United States with approximately 600 inpatient beds. A total of 24,885 ICU transfers to the wards were included, with 14,962 transfers (60%) in the training cohort and 9,923 transfers (40%) in the internal validation cohort. Patient characteristics, nursing assessments, ICD-9 codes from prior admissions, medications, ICU interventions, diagnostic tests, vital signs, and laboratory results were extracted from the EHR and used as predictor variables in a gradient boosted machine model. Accuracy for predicting ICU readmission was compared to the Stability and Workload Index for Transfer (SWIFT) score and Modified Early Warning Score (MEWS) in the internal validation cohort and also externally using the Medical Information Mart for Intensive Care (MIMIC-III) database (n=42,303 ICU transfers).
Results:  Eleven percent (2,834) of discharges to the wards were later readmitted to the ICU. The machine-learning derived model had significantly better performance (AUC 0.76) than either the SWIFT score (AUC 0.65), or MEWS (AUC 0.58); p value < 0.0001 for all comparisons. At a specificity of 95%, the derived model had a sensitivity of 28% compared to 15% for SWIFT score and 7% for the MEWS. Accuracy improvements with the derived model over MEWS and SWIFT were similar in the MIMIC III cohort.
Conclusions:  A machine learning approach to predicting ICU readmission was significantly more accurate than previously published algorithms in both our internal validation and the MIMIC-III cohort. Implementation of this approach could target patients who may benefit from additional time in the ICU or more frequent monitoring after transfer to the hospital ward.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Critical Care Reviews Newsletter 337 27th May 2018

Critical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature over the past seven days.  “The big news this week is the long-awaited results of the EOLIA trial, investigating ECMO in severe ARDS.  The other highlights of this edition are randomised controlled trials on family-support critcal care reviewsin the ICU & discontinuation order of vasopressors in the management of septic shock; systematic reviews and meta analyses on aldosterone antagonists in STEMI without heart failure & REBOA for exsanguination; and observational studies on withholding or withdrawing life-sustaining therapies in older adults in ICU & qSOAF in low- and middle-income countries.”

The full text of newsletter 337 can be found via this link

The organisation of critical care for burn patients in the UK: epidemiology and comparison of mortality prediction models

This article by Toft-Petersen and colleagues was published on-line in Anaesthesia in May 2018.
In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn-specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn-specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7-32 [0-98])% vs. 8 (1-18 [0-100])%, respectively) but in-hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn-specific models for patients managed on both specialist burn and general intensive care units.
The physical copy of Anaesthesia is available in the Healthcare Library on Level D of Rotherham Hospital.  However, this article has not yet been published in a physical issue and is only available on-line.  The full text of the article can be accessed by personal subscribers using this link.

Implementing an educational program to improve critical care nurses’ enteral nutritional support

This research by Kim and Chang was published in “Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses” in May 2018.
Background:  Although international nutrition societies recommend enteral nutrition guidelines for patients in intensive care units (ICUs), large gaps exist between these recommendations and actual clinical practice. Education programs designed to improve nurses’ knowledge about enteral nutrition are therefore required. In Korea, there are no educational intervention studies about evidence-based guidelines of enteral nutrition for critically ill patients.
Objectives:  We aimed to evaluate the effects of an education program to improve critical care nurses’ perceptions, knowledge, and practices towards providing enteral nutritional support for ICU patients.
Methods:  A quasi-experimental, one-group study with a pre- and post-test design was conducted from March to April 2015. Nurses (N = 205) were recruited from nine ICUs from four tertiary hospitals in South Korea. The education program comprised two sessions of didactic lectures. Data were collected before (pre-test) and 1 month after (post-test) the education program using questionnaires that addressed nurses’ perceptions, knowledge, and practices relating to providing enteral nutritional support for ICU patients.
Results:  After the program, nurses showed a significant improvement in their perceptions and knowledge of enteral nutrition for ICU patients. There was a significant improvement in inspecting nostrils daily, flushing the feeding tube before administration, providing medication that needs to be crushed correctly, changing feeding sets, and adjusting feeding schedules.
Conclusions:  The findings indicate that an enteral nutrition education program could be an effective strategy to increase critical care nurses’ support for the critically ill. This education program can be incorporated into hospital education or in-service training for critical care nurses to strengthen their perceptions and knowledge of nutritional support in the ICU. This may improve the clinical outcomes of ICU patients.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Critical Care Reviews Newsletter 336 20th May 2018

critcal care reviewsCritical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature over the past seven days.  “The highlights of this edition are randomised controlled trials comparing bougie with stylet for first-pass emergency intubation, tranexamic acid for hyperacute primary intracerebral haemorrhage, and standardized handoff curriculum for ICU handover; systematic reviews on low-dose corticosteroids for septic shock, and therapeutic hypothermia for patients following traumatic brain injury; and observational studies on sedation intensity, withholding or withdrawing of life-sustaining therapy in older adults, and frailty and failure to rescue after low-risk and high-risk inpatient surgery.”  The full text of newsletter 336 can be found via this link

Delirium prediction in the intensive care unit: comparison of two delirium prediction models

This article by Wassenaar and others was published in the May 2018 issue of Critical Care.
Background:  Accurate prediction of delirium in the intensive care unit (ICU) may facilitate efficient use of early preventive strategies and stratification of ICU patients by delirium risk in clinical research, but the optimal delirium prediction model to use is unclear. We compared the predictive performance and user convenience of the prediction model for delirium (PRE-DELIRIC) and early prediction model for delirium (E-PRE-DELIRIC) in ICU patients and determined the value of a two-stage calculation.
Methods:  This 7-country, 11-hospital, prospective cohort study evaluated consecutive adults admitted to the ICU who could be reliably assessed for delirium using the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist. The predictive performance of the models was measured using the area under the receiver operating characteristic curve. Calibration was assessed graphically. A physician questionnaire evaluated user convenience. For the two-stage calculation we used E-PRE-DELIRIC immediately after ICU admission and updated the prediction using PRE-DELIRIC after 24 h.
Results:  In total 2178 patients were included. The area under the receiver operating characteristic curve was significantly greater for PRE-DELIRIC (0.74 (95% confidence interval 0.71-0.76)) compared to E-PRE-DELIRIC (0.68 (95% confidence interval 0.66-0.71)) (z score of - 2.73 (p < 0.01)). Both models were well-calibrated. The sensitivity improved when using the two-stage calculation in low-risk patients. Compared to PRE-DELIRIC, ICU physicians (n = 68) rated the E-PRE-DELIRIC model more feasible.
Conclusions:  While both ICU delirium prediction models have moderate-to-good performance, the PRE-DELIRIC model predicts delirium better. However, ICU physicians rated the user convenience of E-PRE-DELIRIC superior to PRE-DELIRIC. In low-risk patients the delirium prediction further improves after an update with the PRE-DELIRIC model after 24h.
The full text of this article is available without need for a password via this link.

The Intensive Care Unit (ICU) course and outcome in Acute-on-chronic liver failure are comparable to other populations

This article by Meersseman et al was published in the Journal of Hepatology May 2018.
Background and aims:  Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation of cirrhosis, development of organ failure and high short term mortality. Whether the outcome in ACLF patients admitted to the ICU with organ failure differs from other ICU populations is unknown. We compared the clinical course and host response in ICU patients with or without ACLF, matched for baseline severity of illness scores and characteristics.
Methods:  From the large prospective EPaNIC randomized control trial database (n=4640), 133 patients were identified with cirrhosis of whom 71 fulfilled the CLIF criteria for ACLF. These patients were matched for type and severity of illness and demographics to 71 septic and 71 medical ICU patients from the same database without chronic liver disease. Clinical, biochemical and outcome parameters were compared in this cohort study of 213 patients. In a subset of 100 patients, day-1 serum cytokines were quantified.
Results:  The outcome of ACLF, when compared to septic or medical ICU patients, matched for baseline parameters of illness severity, was similar regarding length of ICU stay, development of new infections, organ failure and septic shock. ICU, hospital and 90-day mortality were similar between the groups. C-reactive protein and platelet levels were lower in ACLF throughout the first week. Cytokines on day 1 including IL-10, IL-1β, IL-6, and IL-8 were similarly elevated in ACLF and septic ICU patients. TNF-α levels were however higher in ACLF.
Conclusion: ACLF patients admitted to the ICU showed comparable clinical and ICU outcomes compared to ICU patients without chronic liver disease with similar baseline severity of illness characteristics. This suggests that ICU admission criteria should not be different in ACLF compared to other populations.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Economic Evaluation of a Patient-Directed Music Intervention for ICU Patients Receiving Mechanical Ventilatory Support

This article by Chlan and colleagues was published in the May issue of Critical Care Medicine.
Objectives:  Music intervention has been shown to reduce anxiety and sedative exposure among mechanically ventilated patients. Whether music intervention reduces ICU costs is not known. The aim of this study was to examine ICU costs for patients receiving a patient-directed music intervention compared with patients who received usual ICU care.
Design:  A cost-effectiveness analysis from the hospital perspective was conducted to determine if patient-directed music intervention was cost-effective in improving patient-reported anxiety. Cost savings were also evaluated. One-way and probabilistic sensitivity analyses determined the influence of input variation on the cost-effectiveness.
Setting:  Midwestern ICUs.
Patients:  Adult ICU patients from a parent clinical trial receiving mechanical ventilatory support.
Interventions:  Patients receiving the experimental patient-directed music intervention received a MP3 player, noise-canceling headphones, and music tailored to individual preferences by a music therapist.
Measurements and main results:  The base case cost-effectiveness analysis estimated patient-directed music intervention reduced anxiety by 19 points on the Visual Analogue Scale-Anxiety with a reduction in cost of $2,322/patient compared with usual ICU care, resulting in patient-directed music dominance. The probabilistic cost-effectiveness analysis found that average patient-directed music intervention costs were $2,155 less than usual ICU care and projected that cost saving is achieved in 70% of 1,000 iterations. Based on break-even analyses, cost saving is achieved if the per-patient cost of patient-directed music intervention remains below $2,651, a value eight times the base case of $329.
Conclusions:  Patient-directed music intervention is cost-effective for reducing anxiety in mechanically ventilated ICU patients.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.