Feasibility of mobilisation in ICU: a multi-centre point prevalence study of mobility practices in the UK.

BACKGROUND: Early mobilisation in critical care is recommended within clinical guidance; however, mobilisation prevalence across the UK is unknown. The study aimed to determine the proportion of patients mobilised out of bed within 48-72 h, to describe their physiological status, and to compare this to published consensus safety recommendations for out-of-bed activity. METHODS: A UK cross-sectional, multi-centre, observational study of adult critical care mobility practices was conducted. Demographic, physiological and organ support data, mobility level, and rationale for not mobilising out of bed, were collected for all patients on 3rd March 2022. Patients were categorised as: Group 1-mobilised ICU Mobility Scale (IMS) ≥ 3; Group 2-not-mobilised IMS < 3 with physiological reasons; or Group 3-not-mobilised IMS < 3 with non-physiological barriers to mobilisation. Rationale for the decision to not mobilise was collected qualitatively. Regression analysis was used to compare the physiological parameters of Group 1 (mobilised) versus Group 2 (not-mobilised with physiological reasons). Patients were stratified as 'low-risk', 'potential-risk' or 'high-risk' using published risk of adverse event ratings. RESULTS: Data were collected for 960 patients across 84 UK critical care units. Of these 393 (41%) mobilised, 416 (43%) were not-mobilised due to physiological reasons and 151 (16%) were not mobilised with non-physiological reasons. A total of 371 patients had been admitted for ≤ 3 days, of whom 180 (48%) were mobilised, 140 (38%) were not mobilised with physiological reasons, and 51 (14%) were not mobilised with non-physiological reasons. Of the 809 without non-physiological barriers to mobilisation, 367 (45%) had a low risk of adverse event rating and 120 (15%) a potential risk, of whom 309 (84%) and 78 (65%) mobilised, respectively. Mobility was associated with a Richmond Agitation-Sedation Scale of - 1 to + 1, lower doses of vasoactive agents, a lower inspired oxygen requirement. CONCLUSION: Although only 40% of patients mobilised out of bed, 89% of those defined 'low-risk' did so. There is significant overlap in physiological parameters for mobilisation versus non-mobilisation groups, suggesting a comprehensive physiological assessment is vital in decision making rather than relying on arbitrary time points. CLINICAL TRIALS REGISTRATION: NCT05281705 Registered March 16, 2022. Retrospectively registered.

Unanticipated demand of Physiotherapist-Deployed Airway Clearance during the COVID-19 Surge 2020 a single centre report.

Bronchial secretion management was not an anticipated clinical problem in patients intubated and ventilated with COVID-19. Yet 63 (62%) of our intubated and ventilated patients demonstrated a moderate or greater sputum load, as recorded by physiotherapists on 5 or more days of the patient's ICU stay. The efficacy of airway clearance in these patients was further compounded by ineffective or absent cough and increased secretion tenacity, dramatically increasing the workload of critical care physiotherapists. We provide data to support the modelling of critical care physiotherapy staffing for future COVID-19 surges.

The oxygen cost of rehabilitation interventions in mechanically ventilated patients: an observational study.

OBJECTIVE: Early rehabilitation is assumed to be a crucial intervention to facilitate weaning from mechanical ventilation in critically ill patients and to limit their long-term functional dependence. However, little is known about the physiological load imposed on patients during such interventions. Without the ability to quantify the exercise intensity of rehabilitation interventions it is impossible to establish a clear separation between usual care and intervention groups in randomised controlled trials. This may explain the lack of definitive benefit of rehabilitation in published trials. We sought to characterise the physiological load, measured as oxygen consumption (V˙O2), of the physical activities carried out during rehabilitation interventions in mechanically ventilated participants. DESIGN: Observational study. SETTING: Single centre medical-surgical university hospital ICU. PARTICIPANTS: 26 mechanically ventilated participants ventilated >7 days, able to participate in a rehabilitation program. INTERVENTION: Oxygen consumption (measured by the Medgraphics Ultima breath-by-breath gas exchange analysis system) and heart rate were measured continuously pre-, during and post-standard rehabilitation sessions. RESULTS: 52 sessions were recorded in 26 participants. There was considerable variation in the oxygen cost of the physical activities between participants. The recovery time for 1 in 4 rehabilitation sessions was longer than the rehabilitation activity time. CONCLUSIONS: Absolute exercise intensity in mechanically ventilated ICU participants, as measured by oxygen consumption, is not activity-dependent.

The Association between Supraphysiologic Arterial Oxygen Levels and Mortality in Critically Ill Patients. A Multicenter Observational Cohort Study.

Rationale: There is conflicting evidence on harm related to exposure to supraphysiologic PaO2 (hyperoxemia) in critically ill patients.Objectives: To examine the association between longitudinal exposure to hyperoxemia and mortality in patients admitted to ICUs in five United Kingdom university hospitals.Methods: A retrospective cohort of ICU admissions between January 31, 2014, and December 31, 2018, from the National Institute of Health Research Critical Care Health Informatics Collaborative was studied. Multivariable logistic regression modeled death in ICU by exposure to hyperoxemia.Measurements and Main Results: Subsets with oxygen exposure windows of 0 to 1, 0 to 3, 0 to 5, and 0 to 7 days were evaluated, capturing 19,515, 10,525, 6,360, and 4,296 patients, respectively. Hyperoxemia dose was defined as the area between the PaO2 time curve and a boundary of 13.3 kPa (100 mm Hg) divided by the hours of potential exposure (24, 72, 120, or 168 h). An association was found between exposure to hyperoxemia and ICU mortality for exposure windows of 0 to 1 days (odds ratio [OR], 1.15; 95% compatibility interval [CI], 0.95-1.38; P = 0.15), 0 to 3 days (OR 1.35; 95% CI, 1.04-1.74; P = 0.02), 0 to 5 days (OR, 1.5; 95% CI, 1.07-2.13; P = 0.02), and 0 to 7 days (OR, 1.74; 95% CI, 1.11-2.72; P = 0.02). However, a dose-response relationship was not observed. There was no evidence to support a differential effect between hyperoxemia and either a respiratory diagnosis or mechanical ventilation.Conclusions: An association between hyperoxemia and mortality was observed in our large, unselected multicenter cohort. The absence of a dose-response relationship weakens causal interpretation. Further experimental research is warranted to elucidate this important question.

Euglycaemic ketoacidosis: a potential new hazard to plastic surgery day case and inpatient procedures.

A woman aged 44 underwent elective standard abdominoplasty and bilateral mastopexy (superiorly based pedicle with vertical scar) following weight loss of 8.5 stone (53.9 kg) over a 5-year period. She had type 2 diabetes and her antidiabetic medications included metformin, liraglutide and empagliflozin. Towards the end of the first postoperative day, she reported gradual onset of nausea, vomiting and abdominal pain. Her condition continued to deteriorate overnight, becoming tachycardic and tachypnoeic. Urgent investigations showed severe diabetic ketoacidosis with euglycaemia. She was managed with fluid resuscitation, insulin infusion and intravenous sodium bicarbonate in the high dependency unit. She made a complete clinical and biochemical recovery and was discharged on day 9 postoperatively. This case illustrates a diagnostic challenge of a serious life-threatening complication of diabetes in the postoperative period associated with a novel class of antidiabetic medications, sodium-glucose cotransporter 2 inhibitors.

Monitoring tissue perfusion, oxygenation, and metabolism in critically ill patients.

Alterations in oxygen transport and use are integral to the development of multiple organ failure; therefore, the ultimate goal of resuscitation is to restore effective tissue oxygenation and cellular metabolism. Hemodynamic monitoring is the cornerstone of management to promptly identify and appropriately manage (impending) organ dysfunction. Prospective randomized trials have confirmed outcome benefit when preemptive or early treatment is directed toward maintaining or restoring adequate tissue perfusion. However, treatment end points remain controversial, in large part because of current difficulties in determining what constitutes "optimal." Information gained from global whole-body monitoring may not detect regional organ perfusion abnormalities until they are well advanced. Conversely, the ideal "canary" organ that is readily accessible for monitoring, yet offers an early and sensitive indicator of tissue "unwellness," remains to be firmly identified. This review describes techniques available for real-time monitoring of tissue perfusion and metabolism and highlights novel developments that may complement or even supersede current tools.

A multidisciplinary team approach to weaning from prolonged mechanical ventilation.

OBJECTIVE: To establish whether multidisciplinary team-led strategies to maintain continuity across the weaning process result in an increase in the proportion of patients surviving prolonged mechanical ventilation and reduce the length of time patients are ventilated. DESIGN: A quality improvement programme was conceived and implemented for patients receiving mechanical ventilation for >21 days. SETTING: University teaching hospital general intensive care unit. INTERVENTIONS: The introduction of long-term weaning plans. MEASUREMENTS AND MAIN RESULTS: Intensive care unit survival odds ratio and 95% confidence interval. 0.181 (0.06-0.49) P<0.01 and hospital survival odds ratio and 95% confidence interval 0.2 (0.08-0.61) P<0.01, Duration of mechanical ventilation (median 95@ confidence interval ) 53 days (32-37) vs 43 days (39-44) P=0.03. CONCLUSION: Long-term weaning plans led by a multidisciplinary, team were associated with a reduction in intensive care unit and hospital mortality, and duration of mechanical ventilation in patients ventilated for ≥ 21 days. Strategies to maintain continuity in this patient parent group are likely fundamental to improving outcome.

Evaluation of molecular mechanics calculated binding energies for isolated and monolayer organic molecules on graphite.

The calculated molecule-surface binding energy, E(cal)( *), for physical adsorption was determined using molecular mechanics MM2 parameters for a model graphite surface and various organic molecules. The results for E(cal)( *) were compared to published experimental binding energy values, E( *), from gas chromatography (GC) or thermal desorption (TD). The binding energies from GC were for isolated molecules in the Henry's law region of adsorption, and the binding energies from TD were for molecules in monolayer coverage on a highly oriented pyrolytic graphite (HOPG). A simple desorption model was used to allow the calculation of monolayer coverage to include both molecule-surface and molecule-molecule interactions and then the results were compared to experimental values. For the 14 TD organic adsorbates (polyaromatic hydrocarbons, alcohols, benzene, substituted benzenes, methane, chloroalkanes, N,N-dimethylformamide, and C(60) Buckyball), the experimental versus calculated binding energies were E( *)=1.1193E(cal)( *) and r(2)=0.967. The GC E( *) values were also well correlated by calculated E(cal)( *) values for a set of 11 benzene and methyl substituted benzenes and for another set of 10 alkanes and haloalkanes. The TD E(cal)( *) mechanics computation provides a useful comparison to the one for GC data since adsorbate-adsorbate interactions as well as adsorbate-surface must be considered.

Adolescent mothers: resilience, family health work and health-promoting practices.

AIMS: This paper reports a study examining the relationships among mother's resilience, family health promotion (i.e. health work) and mother's health-promoting lifestyle practices in single-parent families led by adolescent mothers by testing hypotheses derived from the Developmental Model of Health and Nursing. BACKGROUND: Research on families led by adolescent mothers has focussed primarily on negative maternal and child outcomes while ignoring the capacities of these families, including their efforts to promote the health and well-being of both mothers and children. METHODS: This replication study was conducted with convenience sample of 41 adolescent mothers recruited using a variety of strategies. Mothers were asked to provide verbal responses to items on three study instruments: The Resilience Scale, a measure of mother's resilience, the Health Options Scale, a measure of family health work and the Health Promoting Lifestyle Profile a measure of mother's health promoting lifestyle practices, as well as a demographic questionnaire. RESULTS: Consistent with the theory, moderate positive relationships were observed between mothers' resilience and both family health work (r = 0.34, P = 0.01) and mothers' health-promoting lifestyle practices (r = 0.42, P < 0.001). As predicted, moderate correlations were also observed between health work and mother's health promoting lifestyle practices (r = 0.62, P < 0.001). With the effects of employment status and professional support held constant, mother's resilience and health work explained 30.2% of the variance in mother's health-promoting lifestyle practices. CONCLUSIONS: The study validates theoretical relationships among concepts in the developmental model of health and nursing and contributes to better understanding health promotion in families led by adolescent mothers.

Vasoconstrictor effect and mechanism of action of endothelin-1 in human radial artery and vein: implication of skin flap vasospasm.

Vasospasm in the vascular pedicle is a major cause of ischemic necrosis in autogenous skin transplantation (i.e., skin free flap surgery), and the pathophysiology is unclear. The clinical impression is that veins are more susceptible to vasospasm than arteries in the vascular pedicle of skin free flaps. The purpose of this study was to compare the vasoconstrictor response of the human radial artery (RA) and radial vein (RV) to endothelin (ET)-1 and to investigate the mechanism mediating ET-1-induced vasoconstriction. The isometric tension of RA and RV rings (4 mm) obtained from the vascular pedicle of human radial forearm skin free flaps were studied in organ chambers containing Krebs bicarbonate buffer. It was observed that ET-1 elicited concentration-dependent (5 x 10 (-11)to 2 x 10 (-8) ) contractions in RA and RV rings with similar contractile potency. However, the concentration-dependent contractile response to ET-1 was significantly (P < 0.05) higher in RV rings than in RA rings, with the maximum contractile response twice as high in RV rings than in RA rings. The contractile response to ET-1 in RA and RV rings was blocked by the ET receptor antagonist BQ 123 (10 (-5M)), but not by the ET receptor antagonist BQ 788 (5 x 10 (-6)). The ET(B) receptor agonist BQ 3020 (10 (-10) to 2 x 10(-8) ) had no significant contractile effect in RA and RV rings. Furthermore, the L-type Ca channel antagonist nifedipine (5 x 10 (-6)), the protein kinase C (PKC) inhibitor chelerythrine (10(-5M)), and the intracellular Ca chelator BAPTA-AM (10(-5M)) significantly reduced the contractile potency of ET-1 in RA rings and the maximum contractile response to ET-1 in RA and RV rings. It was concluded that the human RV is more responsive than RA to the contractile effect of ET-1. The contractile response to ET-1 in RA and RV is predominantly mediated by ET(A) receptors and the postreceptor mechanism involves L-type Ca (2+) channels, PKC, and intracellular Ca(2+).