Background Latency in transferring patients from intensive care units (ICUs) to general wards impedes the optimal allocation of ICU resources, underscoring the urgency of initiatives to reduce it. This study evaluates the extent of ICU transfer latency and assesses the potential benefits of minimizing it.
Methods Transfer latency was measured as the time between the first transfer request and the actual ICU discharge at a single-center tertiary hospital in 2021. Computer-based simulations and cost analyses were performed to examine how reducing transfer latency could affect average hourly ICU bed occupancy, the proportion of time ICU occupancy exceeds 80%, and hospital costs. The first analysis evaluated all ICU admissions, and the second analysis targeted a subset of ICU admissions with longer transfer latency, those requiring infectious precautions.
Results A total of 7,623 ICU admissions were analyzed, and the median transfer latency was 5.7 hours. Eliminating transfer latency for all ICU admissions would have resulted in a 32.8% point decrease in the proportion of time ICU occupancy exceeded 80%, and a potential annual savings of $6.18 million. Eliminating transfer latency for patients under infectious precautions would have decreased the time ICU occupancy exceeded 80% by 13.5% points, and reduced annual costs by a potential $1.26 million.
Conclusions Transfer latency from ICUs to general wards might contribute to high ICU occupancy. Efforts to minimize latency for all admissions, or even for a subset of admissions with particularly long transfer latency, could enable more efficient use of ICU resources.
Background This study investigated the relationship between initial lactate levels and both mortality and morbidity in critically ill pediatric trauma patients requiring intensive care.
Methods This retrospective study at tertiary center’s pediatric intensive care unit from January 2020 to June 2024 aimed to characterize trauma patients and assess admission lactate levels' prognostic value.
Results A total of 190 critically ill pediatric trauma patients were included in the study. The mortality rate was 7.9%, with most deaths occurring within the first 48 hours of admission. Initial lactate levels ≥6.9 mmol/L demonstrated moderate predictive power (area under the curve [AUC], 0.878) for mortality. Pediatric Risk of Mortality III (PRISM III) score showed good predictive ability (AUC, 0.922), while Pediatric Trauma Scores exhibited variable predictive performance (AUC, 0.863). Higher initial lactate levels were significantly associated with severe brain injury, the need for intubation, and an increased incidence of thoracic or abdominal injuries.
Conclusions Initial lactate levels and PRISM III score are effective predictors of mortality in critically ill pediatric trauma patients. Lactate levels ≥5 mmol/L upon admission should prompt close monitoring and consideration of aggressive management strategies.
Corneal surface injuries occur frequently (59.4%) in critically ill patients, and the average time for their appearance is 8 days. Such injuries are primarily related to dry eye, which increases the risk of exposure injury in patients admitted to intensive care units. This can result in a severe ulcer or perforation that results in partial to total loss of vision, decreasing the quality of the patient's life. This is a sensitive nursing care area requiring further investigation. Thus, this review aims to analyse nursing interventions that aim to prevent ocular surface injuries. An integrative literature review was carried out from May to August 2023 in the Medline, CINAHL, Scopus, Web of Science, and PubMed databases using the Whittemore and Knafl methodology. Inclusion and exclusion criteria were subsequently applied to assess the results. After verifying result eligibility, seven documents were identified for data extraction and analysis. The results suggest the importance of recognizing risk factors for ocular injuries in critically ill patients, surveillance as a nursing competency, adequate ocular hygiene and effective lubrication, and managing environmental conditions to prevent corneal injuries. Implementing surveillance and intervention protocols for critically ill patients at risk of corneal injuries requires specialized training for critical care nurses. Specifically, environmental management, including temperature and humidity control, is highlighted as an area that merits further research.
Background A non-invasive method of measuring cardiac output (CO) can be beneficial in the care of critically ill patients. HemoVista (BiLab Co., Ltd.) is a medical device that measures CO non-invasively using multi-channel impedance plethysmography technology. The purpose of this study was to exploratively evaluate the performance of HemoVista in critically ill patients undergoing CO monitoring with the FloTrac (Edwards Lifesciences).
Methods After non-invasively installing the HemoVista sensor in critically ill patients whose CO was monitored with the FloTrac, CO values measured by both devices were collected for 30 minutes. Cardiac output measured by both devices was selected every 10 seconds, creating approximately 360 data pairs per patient. Linear correlation analysis with Pearson correlation coefficients, Bland-Altman analysis, and four-quadrant plot analysis were performed to evaluate the performance of HemoVista.
Results A total of 7,138 pairs of CO data from the 20 patients were included in the analysis. A significant correlation was observed between the two methods of measuring CO (Pearson's r=0.489, P<0.001). The mean bias was 1.03 L/min, the 95% CI for the limit of agreement was –1.83 L/min to 3.93 L/min and the percentage error was 55.8%. The concordance rate of time-dependent CO between the two devices was 14.6%.
Conclusions It was observed that the current version of HemoVista has unsuitable performance for use in intensive care units. To be used for critically ill patients, the algorithm must be improved and reevaluated with an enhanced version.
Background This meta-analysis aims to evaluate the effects of ketamine in critically ill intensive care unit (ICU) patients.
Methods We searched for randomized controlled trials (RCTs) in PubMed, Scopus, and the Cochrane Library; the search was performed initially in January but was repeated in December of 2023. We focused on ICU patients of any age. We included studies that compared ketamine with other traditional agents used in the ICU. We synthesized evidence using RevMan v5.4 and presented the results as forest plots. We also used trial sequential analysis (TSA) software v. 0.9.5.10 Beta and presented results as TSA plots. For synthesizing results, we used a random-effects model and reported differences in outcomes of two groups in terms of mean difference (MD), standardized MD, and risk ratio with 95% confidence interval. We assessed the risk of bias using the Cochrane RoB tool for RCTs. Our outcomes were mortality, pain, opioid and midazolam requirements, delirium rates, and ICU length of stay.
Results Twelve RCTs involving 805 ICU patients (ketamine group, n=398; control group, n=407) were included in the meta-analysis. The ketamine group was not superior to the control group in terms of mortality (in five studies with 318 patients), pain (two studies with 129 patients), mean and cumulative opioid consumption (six studies with 494 patients), midazolam consumption (six studies with 304 patients), and ICU length of stay (three studies with 270 patients). However, the model favored the ketamine group over the control group in delirium rate (four studies with 358 patients). This result is significant in terms of conventional boundaries (alpha=5%) but is not robust in sequential analysis. The applicability of the findings is limited by the small number of patients pooled for each outcome.
Conclusions Our meta-analysis did not demonstrate differences between ketamine and control groups regarding any outcome except delirium rate, where the model favored the ketamine group over the control group. However, this result is not robust as sensitivity analysis and trial sequential analysis suggest that more RCTs should be conducted in the future.
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Intra-abdominal hypertension can have severe consequences, including abdominal compartment syndrome, which can contribute to multi-organ failure. An increase in intra-abdominal hypertension is influenced by factors such as diminished abdominal wall compliance, increased intraluminal content, and certain systemic conditions. Regular measurement of intra-abdominal pressure is essential, and particular attention must be paid to patient positioning. Nonsurgical treatments, such as decompression of intraluminal content using a nasogastric tube, percutaneous drainage, and fluid balance optimization, play crucial roles. Additionally, point-of-care ultrasonography aids in the diagnosis and treatment of intra-abdominal hypertension. Emphasizing the importance of regular measurements, timely decompressive laparotomy is a definitive, but complex, treatment option. Balancing the urgency of surgical intervention against potential postoperative complications is challenging.
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Background Delirium occurs at high rates among patients in intensive care units and increases the risk of morbidity and mortality. The purpose of this study was to investigate the effects of environmental interventions on delirium.
Methods This prospective cohort study enrolled 192 patients admitted to the surgical intensive care unit (SICU) during the pre-intervention (June 2013 to October 2013) and post-intervention (June 2014 to October 2014) periods. Environmental interventions involved a cognitive assessment, an orientation, and a comfortable environment including proper sleep conditions. The primary outcomes were the prevalence, duration, and onset of delirium.
Results There were no statistically significant differences in incidence rate, time of delirium onset, general characteristics, and mortality between the pre-intervention and post-intervention groups. The durations of delirium were 14.4±19.1 and 7.7±7.3 days in the pre-intervention and post-intervention groups, respectively, a significant reduction (P=0.027). The lengths of SICU stay were 20.0±22.9 and 12.6±8.7 days for the pre-intervention and post-intervention groups, respectively, also a significant reduction (P=0.030).
Conclusions The implementation of an environmental intervention program reduced the duration of delirium and length of stay in the SICU for critically ill surgical patients.
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Background
Coronavirus disease 2019 (COVID-19) pandemic disrupted adherences to healthcare-associated infection (HAI) prevention protocols. Herein, we studied the characteristics of all HAIs occurring in critically ill COVID-19 patients.
Methods A retrospective, single-center cohort of critical COVID-19 patients during 2021. Microbiological samples were collected if HAI was suspected. We analyzed all factors that could potentially induce HAI, using septic shock and mortality as endpoints.
Results Sixty-four among 161 included patients (39.7%) presented a total of 117 HAIs with an incidence density of 69.2 per 1,000 hospitalization days. Compared to the prior COVID-19 period (2013–2019), the identification of HAI increased in 2021. HAIs were classified into ventilator-associated pneumonia (VAP; n=38), bloodstream infection (n=32), urinary tract infection (n=24), catheter-related infection (n=12), and fungal infection (n=11). All HAIs occurred significantly earlier in the post–COVID-19 period (VAP: 6 vs. 10 days, P=0.045, in 2017 and 2021). Acinetobacter baumannii (39.5%) and Klebsiella pneumoniae (27%) were the most commonly isolated pathogens that exhibited a multidrug-resistant (MDR) profile, observed in 89% and 64.5%, respectively. The HAI factors were laboratory abnormalities (odds ratio [OR], 6.4; 95% confidence interval [CI], 2.3–26.0), cumulative steroid dose (OR, 1.9; 95% CI, 1.3–4.0), and invasive procedures (OR, 20.7; 95% CI, 5.3–64.0). HAI was an independent factor of mortality (OR, 8.5; P=0.004).
Conclusions During the COVID-19 era, the incidence of HAIs increased and MDR isolates remained frequent. A severe biological inflammatory syndrome, invasive devices, and elevated cumulative steroid dosages were related to HAIs. HAI was a significant death factor.
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Background Percent fluid overload greater than 5% is associated with increased mortality. The appropriate time for fluid deresuscitation depends on the patient's radiological and clinical findings. This study aimed to assess the applicability of percent fluid overload calculations for evaluating the need for fluid deresuscitation in critically ill patients.
Methods This was a single-center, prospective, observational study of critically ill adult patients requiring intravenous fluid administration. The study's primary outcome was median percent fluid accumulation on the day of fluid deresuscitation or intensive care unit (ICU) discharge, whichever came first.
Results A total of 388 patients was screened between August 1, 2021, and April 30, 2022. Of these, 100 with a mean age of 59.8±16.2 years were included for analysis. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15.4±8.0. Sixty-one patients (61.0%) required fluid deresuscitation during their ICU stay, while 39 (39.0%) did not. Median percent fluid accumulation on the day of deresuscitation or ICU discharge was 4.5% (interquartile range [IQR], 1.7%–9.1%) and 5.2% (IQR, 2.9%–7.7%) in patients requiring deresuscitation and those who did not, respectively. Hospital mortality occurred in 25 (40.9%) of patients with deresuscitation and six (15.3%) patients who did not require it (P=0.007).
Conclusions The percent fluid accumulation on the day of fluid deresuscitation or ICU discharge was not statistically different between patients who required fluid deresuscitation and those who did not. A larger sample size is needed to confirm these findings.
Background It can be challenging for clinicians to predict which patients with respiratory failure secondary to coronavirus disease 2019 (COVID-19) will fail on high-flow nasal cannula (HFNC) oxygen and require escalation of therapy. This study set out to evaluate the association between the respiratory rate-oxygenation index (ROX) and HFNC failure in such patients and to assess whether ROX trajectory correlates with treatment failure.
Methods This was a single-centre, retrospective, observational study of patients with COVID-19 requiring HFNC, conducted over a 3-month period. ROX was calculated as “pulse-oximetry oxygen saturation (SpO2) over the fractional inspired oxygen concentration (FiO2)/respiratory rate” for each patient at 2, 4, and 12 hours from starting HFNC. HFNC failure was defined as escalation to continuous positive airway pressure ventilation or invasive mechanical ventilation (IMV). Time-to-event analyses were performed to account for the longitudinal data set and time-dependent variables.
Results We included 146 patients. Ninety-three (63.7%) experienced HFNC failure, with 53 (36.3%) requiring IMV. Higher ROX values were associated with a lower subhazard of HFNC failure on time-to-HFNC failure analysis (subhazard ratio, 0.29; 95% confidence interval [CI], 0.18–0.46; P<0.001). This remained true after controlling for informative censoring. Median ROX values changed differentially over time, increasing in the HFNC success group (0.06 per hour; 95% CI, 0.05–0.08; P<0.001) but not in the HFNC failure group (0.004 per hour; 95% CI, –0.05 to 0.08; P=0.890).
Conclusions A higher ROX is associated with a lower risk of HFNC failure. Monitoring ROX trajectory over time may help identify patients at risk of treatment failure. This has potential clinical applications; however, future prospective studies are required.
Providing critical nursing care for conscious mechanically ventilated patients is mediated via effective communication. This study aimed to identify and map the antecedents, attributes, consequences, and definition of nurse–conscious mechanically ventilated patient communication (N-CMVPC). This scoping review was conducted by searching the Cochrane Library and the CINAHL, EMBASE, PubMed, Web of Science, and Scopus databases, between 2001 and 2021. The keywords queried included "nurses," "mechanically ventilated patients," "mechanical ventilation," "intubated patients," "communication," "interaction," "relationships," "nurse–patient communication," "nurse–patient relations," "intensive care units," and "critical care." Studies related to communication with healthcare personnel or family members were excluded. The results indicated that N-CMVPC manifests as a set of attributes in communication experiences, emotions, methods, and behaviors of the nurse and the patient and is classified into three main themes, nurse communication, patient communication, and quantitative-qualitative aspects. N-CMVPC is a complex, multidimensional, and multi-factor concept. It is often nurse-controlled and can express itself as questions, sentences, or commands in the context of experiences, feelings, and positive or negative behaviors involving the nurse and the patient.
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Background Early recognition of deterioration events is crucial to improve clinical outcomes. For this purpose, we developed a deep-learning-based pediatric early-warning system (pDEWS) and aimed to validate its clinical performance.
Methods This is a retrospective multicenter cohort study including five tertiary-care academic children’s hospitals. All pediatric patients younger than 19 years admitted to the general ward from January 2019 to December 2019 were included. Using patient electronic medical records, we evaluated the clinical performance of the pDEWS for identifying deterioration events defined as in-hospital cardiac arrest (IHCA) and unexpected general ward-to-pediatric intensive care unit transfer (UIT) within 24 hours before event occurrence. We also compared pDEWS performance to those of the modified pediatric early-warning score (PEWS) and prediction models using logistic regression (LR) and random forest (RF).
Results The study population consisted of 28,758 patients with 34 cases of IHCA and 291 cases of UIT. pDEWS showed better performance for predicting deterioration events with a larger area under the receiver operating characteristic curve, fewer false alarms, a lower mean alarm count per day, and a smaller number of cases needed to examine than the modified PEWS, LR, or RF models regardless of site, event occurrence time, age group, or sex.
Conclusions The pDEWS outperformed modified PEWS, LR, and RF models for early and accurate prediction of deterioration events regardless of clinical situation. This study demonstrated the potential of pDEWS as an efficient screening tool for efferent operation of rapid response teams.
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Background Korea is rapidly becoming a super aging society and is facing the increased burden of critical care for the elderly people. Traditionally, far-advanced age has been regarded as a triage criterion for intensive care unit (ICU) admission. We evaluated how the characteristics and prognostic factors of very elderly patients (≥85 years) admitted to the ICU changed over the last decade.
Methods We retrospectively evaluated the data of patients admitted to the ICU over 11 years (2007–2017). The clinical characteristics and outcomes of the very elderly-patients group were evaluated. Factors associated with mortality were assessed by a cox regression analysis.
Results Comparing the first half (2007–2012) and the second half (2013–2017) of the study period, the proportion of very elderly group increased from 603/47,657 (1.3%), to 697/37,756 (1.8%) (P<0.001). Among 1,294 very elderly patients, 1,274 patients were analyzed excluding hopeless discharge (n=20). The non-surgical reasons for ICU admission (67.0% vs. 76.1%, P<0.001) and the percentage of patients with co-morbidities (78.3% vs. 82.7%, P=0.048) were increased. Nevertheless, the hospital mortality decreased (21.3% vs. 14.9%, P=0.001). High creatinine levels, use of vasopressors and ventilator weaning failure were associated with in-hospital mortality.
Conclusions The proportion of very elderly people in the ICU increased over the last decade. The non-surgical causes of ICU admission increased compared with the surgical causes. Despite an increasement in ICU admissions of very elderly patients, in-hospital mortality of very elderly ICU patients decreased.
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Background Enteral nutrition (EN) supply within 48 hours after intensive care unit (ICU) admission improves clinical outcomes. The “new ICU evaluation & development of nutritional support protocol (NICE-NST)” was introduced in an ICU of tertiary academic hospital. This study showed that early EN through protocolized nutritional support would supply more nutrition to improve clinical outcomes.
Methods This study screened 170 patients and 62 patients were finally enrolled; patients who were supplied nutrition without the protocol were classified as the control group (n=40), while those who were supplied according to the protocol were classified as the test group (n=22).
Results In the test group, EN started significantly earlier (3.7±0.4 days vs. 2.4±0.5 days, P=0.010). EN calorie (4.0±1.0 kcal/kg vs. 6.7±0.9 kcal/kg, P=0.006) and protein (0.17±0.04 g/kg vs. 0.32±0.04 g/kg, P=0.002) supplied were significantly higher in the test group. Although EN was supplied through continuous feeding in the test group, there was no difference in complications such as feeding hold due to excessive gastric residual volume or vomit, and hyper- or hypo-glycemia between the two groups. Hospital mortality was significantly lower in the group that started EN within 1.5 days (42.9% vs. 11.8%, P=0.018). The proportion of patients who started EN within 1.5 days was higher in the test group (40.9% vs. 17.5%, P=0.044).
Conclusions The NICE-NST may improve EN supply and mortality of critically ill patients without increasing complications.
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