Association between ICU quality and in-hospital mortality of V-V ECMO-supported patients-the ECMO quality improvement action (EQIA) study: a national cohort study in China from 2017 to 2019.

This cohort study was performed to explore the influence of intensive care unit (ICU) quality on in-hospital mortality of veno-venous (V-V) extracorporeal membrane oxygenation (ECMO)-supported patients in China. The study involved all V-V ECMO-supported patients in 318 of 1700 tertiary hospitals from 2017 to 2019, using data from the National Clinical Improvement System and China National Critical Care Quality Control Center. ICU quality was assessed by quality control indicators and capacity parameters. Among the 2563 V-V ECMO-supported patients in 318 hospitals, a significant correlation was found between ECMO-related complications and prognosis. The reintubation rate within 48 hours after extubation and the total ICU mortality rate were independent risk factors for higher in-hospital mortality of V-V ECMO-supported patients (cutoff: 1.5% and 7.0%; 95% confidence interval: 1.05-1.48 and 1.04-1.45; odds ratios: 1.25 and 1.23; P = 0.012 and P = 0.015, respectively). Meanwhile, the V-V ECMO center volume was a protective factor (cutoff of ≥ 50 cases within the 3-year study period; 95% confidence interval: 0.57-0.83, odds ratio: 0.69, P = 0.0001). The subgroup analysis of 864 patients in 11 high-volume centers further strengthened these findings. Thus, ICU quality may play an important role in improving the prognosis of V-V ECMO-supported patients.

Electrical impedance tomography to aid in the identification of hypoxemia etiology: Massive atelectasis or pneumothorax? A case report.

Background: Bedside ultrasound is often used to determine the etiology of hypoxaemia, but not always with definitive results. This case reports the application of electrical impedance tomography (EIT) and saline injection to determine the etiology of hypoxaemia in a complex case that could not be identified by bedside ultrasound. The determination of the etiology of hypoxaemia by EIT and saline injection, regional ventilation and perfusion information can be used as a new clinical diagnostic method. Case presentation: A post-cardiac surgery patient under prolonged mechanical ventilation for lung emphysema developed sudden hypoxemia in the intensive care unit (ICU). A line pattern and lung sliding sign abolishment were found in the left lung, but there was no evidence of a lung point sign on bedside ultrasound. Hence, the initial diagnosis was considered to be a massive pneumothorax. To further define the etiology, EIT and saline bolus were used to assess regional ventilation and perfusion. A massive ventilation defect was found in the left lung, in which regional perfusion was maintained, resulting in an intrapulmonary shunt in the left lung. Finally, the conjecture of a pneumothorax was ruled out considering the massive atelectasis. After the diagnosis was clarified, hypoxaemia was corrected by restorative ventilation of the left lung after changing the patient's posture and enhancing sputum drainage with chest physiotherapy. Conclusions: This was the clinical case involving EIT and saline bolus to establish the differential diagnosis and guide clinical decisions for patients with acute hypoxemia. This study highlighted that combination regional ventilation, EIT perfusion, and saline bolus provided helpful information for determining the etiology of hypoxemia. The results of this study contribute to the development of emergency patient management.

Role of Intensified Lung Physiotherapy Bundle on the Occurrence of Pneumonia After Cardiac Surgery.

Objective: The role of intensified lung physiotherapy bundle after cardiac surgery was investigated. Methods: A before- and after-surgery comparison was conducted between the study from January 1, 2018 to December 31, 2019 (control group), when traditional lung physiotherapy bundle was used, and from January 1, 2020 to May 1, 2021 (study group), when the intensified bundle was used. The baseline data, clinical features, incidence of postoperative pneumonia, and prognoses of all the enrolled cardiac surgery patients were analyzed. Results: In accordance with the study criteria, 358 patients were enrolled. The incidence rate of postoperative pneumonia was significantly lower in the study group than in the control group (14.2 vs. 22.7%, P = 0.037), as was in-hospital mortality (1.5 vs. 5.2%, P = 0.043). Patients receiving the intensified lung physiotherapy bundle had much shorter mechanical ventilation time (92 vs. 144 h, P < 0.0001), much shorter intensive care unit (ICU) stay (5 vs. 7 days, P < 0.001), and much shorter hospital stay (17 vs. 18.5 days, P = 0.022). The intensified lung physiotherapy bundle was an independent protective factor enabling the reduced occurrence of pneumonia (P = 0.007). On univariate analysis, this bundle significantly improved in-hospital mortality (P = 0.043). Conclusions: Our intensified lung physiotherapy bundle potentially reduces the rate of postoperative pneumonia after cardiac surgery. This bundle might also be adopted as a suitable reference guide for the prevention of other postoperative pulmonary complications.

Association between hospital and ICU structural factors and patient outcomes in China: a secondary analysis of the National Clinical Improvement System Data in 2019.

BACKGROUND: Hospital and ICU structural factors are key factors affecting the quality of care as well as ICU patient outcomes. However, the data from China are scarce. This study was designed to investigate how differences in patient outcomes are associated with differences in hospital and ICU structure variables in China throughout 2019. METHODS: This was a multicenter observational study. Data from a total of 2820 hospitals were collected using the National Clinical Improvement System Data that reports ICU information in China. Data collection consisted of a) information on the hospital and ICU structural factors, including the hospital type, number of beds, staffing, among others, and b) ICU patient outcomes, including the mortality rate as well as the incidence of ventilator-associated pneumonia (VAP), catheter-related bloodstream infections (CRBSIs), and catheter-associated urinary tract infections (CAUTIs). Generalized linear mixed models were used to analyse the association between hospital and ICU structural factors and patient outcomes. RESULTS: The median ICU patient mortality was 8.02% (3.78%, 14.35%), and the incidences of VAP, CRBSI, and CAUTI were 5.58 (1.55, 11.67) per 1000 ventilator days, 0.63 (0, 2.01) per 1000 catheter days, and 1.42 (0.37, 3.40) per 1000 catheter days, respectively. Mortality was significantly lower in public hospitals (ß = - 0.018 (- 0.031, - 0.005), p = 0.006), hospitals with an ICU-to-hospital bed percentage of more than 2% (ß = - 0.027 (- 0.034, -0.019), p < 0.001) and higher in hospitals with a bed-to-nurse ratio of more than 0.5:1 (ß = 0.009 (0.001, 0.017), p = 0.027). The incidence of VAP was lower in public hospitals (ß = - 0.036 (- 0.054, - 0.018), p < 0.001). The incidence of CRBSIs was lower in public hospitals (ß = - 0.008 (- 0.014, - 0.002), p = 0.011) and higher in secondary hospitals (ß = 0.005 (0.001, 0.009), p = 0.010), while the incidence of CAUTIs was higher in secondary hospitals (ß = 0.010 (0.002, 0.018), p = 0.015). CONCLUSION: This study highlights the association between specific ICU structural factors and patient outcomes. Modifying structural factors is a potential opportunity that could improve patient outcomes in ICUs.

Early mobilization implementation for critical ill patients: A cross-sectional multi-center survey about knowledge, attitudes, and perceptions of critical care nurses.

OBJECTIVE: To explore critical care clinicians' knowledge, attitudes and perceptions toward early mobilization of critically ill patients in ICUs. DESIGN: A cross-sectional national survey was conducted. From January to August 2020, ICU nurses in 11 hospitals were surveyed by using a questionnaire on the knowledge, attitudes and perceptions of ICU early mobilization. RESULTS: Totally 512 nurses completed the questionnaire. The respondents' mean score for knowledge of early mobilization was 6.89 ± 2.91. The level of knowledge was good in 2.5% (13/512), fair in 52.3% (268/512). The attitudes toward early mobilization were positive in 31.4% (161/512). In terms of perceived implementation of ICU early mobilization, 42.9% (220/512) of nurses did not believe that this should be a top priority in intensive care. The attitudes of nurses from different ICUs were significantly different (F = 3.58, P < 0.05). The knowledge (7.34 ± 2.78 vs. 6.49 ± 2.97, t = 3.37, P < 0.001) and attitudes (3.82 ± 0.58 vs. 3.52 ± 0.56, t = 5.63, P < 0.001) of nurses who had early mobilization related training were higher than those of nurses who had no training. CONCLUSIONS: The importance of early ICU early mobilization is increasingly recognized by critical care providers. However, there is still a gap in the knowledge, attitudes and perceptions of ICU early mobilization among nurses. In future studies, it is necessary to further systematically identify the reasons leading to the gaps in these aspects and implement targeted interventions around these gaps. Meanwhile, more nurses should be encouraged to participate in decision-making to ensure the efficient and quality implementation of ICU early mobilization practices.

Effect of Nurse-Led Goal-Directed Lung Physical Therapy on the Prognosis of Pneumonia in Sepsis Patients in the ICU: A Prospective Cohort Study.

BACKGROUND: Pneumonia poses a significant burden on healthcare systems. However, few studies have focused on nurse-led goal-directed lung physical therapy (GDLPT) for pneumonia in sepsis patients in the intensive care unit (ICU). OBJECTIVES: This study aimed to investigate the effects of nurse-led GDLPT on the prognosis of pneumonia in sepsis patients in the ICU. METHODS: We performed a prospective 2-phase (before-and-after) study over 3 years. After an observational phase (phase 1, n = 188), we designed, implemented, and evaluated a nurse-led GDLPT protocol (phase 2, n = 359) for pneumonia in sepsis patients in the ICU. The primary outcome was 28-day mortality. RESULTS: We evaluated 742 critically ill patients with sepsis from January 2017 to January 2020. Among the 742 sepsis patients, 609 were diagnosed with pneumonia and 547 who met the inclusion criteria were enrolled in the study. Compared with patients in phase 1, patients in phase 2 had significantly shorter mechanical ventilation duration (5 [4, 6] days vs. 5 [4, 8] days, p = 0.037), shorter ICU stay (9 [4, 16] days vs. 9 [6, 20] days, p = 0.010), lower ICU mortality (15.0% [54/359] vs. 25.5% [48/188], p = 0.003), and lower 28-day mortality (16.7% [60/359] vs. 27.1% ([51/188], p = 0.004). Multivariate logistic regression analysis revealed that nurse-led GDLPT (odds ratio 0.540, 95% confidence interval 0.345-0.846, p = 0.007), clinical pulmonary infection score (odds ratio 1.111, 95% confidence interval 1.012-1.221, p = 0.028), and ventilation day (OR 1.160, 95% CI, 1.058-1.240, p<0.001)were independent predictors of 28-day mortality for pneumonia in sepsis patients, and that nurse-led GDLPT was a protective factor. CONCLUSIONS: Nurse-led GDLPT improved the outcomes of pneumonia in sepsis patients, and was particularly associated with shortened mechanical ventilation duration and ICU stay, and reduced ICU mortality and 28-day mortality.

Impact of abdominal massage on enteral nutrition complications in adult critically ill patients: A systematic review and meta-analysis.

BACKGROUND: Adult critically ill patients are prone to complications when receiving enteral nutrition, including feeding intolerance. Although abdominal massage is an effective intervention, its effects on enteral nutrition complications in adult critically ill patients are controversial. OBJECTIVE: To summarize and evaluate the effect of abdominal massage on enteral nutrition complications in adult critically ill patients. METHODS: We searched databases (e.g., PubMed, the Cochrane Library, Embase, and Web of Science) from inception until November 2020 for relevant studies published in English. The methodological quality of selected studies was assessed with the Cochrane Risk of Bias 2.0 tool. And we used of PRISMA 2020 guidelines. The meta-analysis results were reported as mean difference (MD) and events, and the heterogeneity of the studies was evaluated using I2. RESULTS: Seven studies including 472 participants (aged≥18 years) met the inclusion criteria. The mean gastric residual volume (GRV) (MD=-42.41, 95% confidence interval [CI]: -71.43, -13.39; P = 0.004) and incidence of abdominal distension (odds ratio [OR]=0.08, 95%CI: 0.03, 0.19; P < 0.00001) were significantly lower in the massage therapy group compared with controls. The incidence of vomiting (OR=0.09, 95%CI: 0.01, 0.72; P = 0.02) and ventilator-associated pneumonia (VAP) (OR=0.20, 95%CI: 0.05, 0.77; P = 0.02) were statistically significantly lower in the abdominal massage group compared with controls. CONCLUSION: Abdominal massage reduces GRV, vomiting, abdominal distension, and VAP in adult critically ill patients. Given the limited number of reviewed studies, small number of patients examined, and short intervention periods, further randomized controlled trials are needed that use accurate methodology, longer interventions, and larger sample sizes to confirm the effect of abdominal massage on feeding intolerance in adult critically ill patients.

Implementation of Nurse-Led, Goal-Directed Lung Physiotherapy for Older Patients With Sepsis and Pneumonia in the ICU.

Objectives: This study aimed to investigate the effect of nurse-led, goal-directed lung physiotherapy (GDLPT) on the prognosis of older patients with sepsis caused by pneumonia in the intensive care unit. Methods: We conducted a prospective, two-phase (before-and-after) study over 3 years called the GDLPT study. All patients received standard lung therapy for sepsis caused by pneumonia and patients in phase 2 also received GDLPT. In this study, 253 older patients (age ≥ 65 years) with sepsis and pneumonia were retrospectively analyzed. The main outcome was 28 day mortality. Results: Among 742 patients with sepsis, 253 older patients with pneumonia were divided into the control group and the treatment group. Patients in the treatment group had a significantly shorter duration of mechanical ventilation [5 (4, 6) vs. 5 (4, 8) days; P = 0.045], and a lower risk of intensive care unit (ICU) mortality [14.5% (24/166) vs. 28.7% (25/87); P = 0.008] and 28 day mortality [15.1% (25/166) vs. 31% (27/87); P = 0.005] compared with those in the control group. GDLPT was an independent risk factor for 28 day mortality [odds ratio (OR), 0.379; 95% confidence interval (CI), 0.187-0.766; P = 0.007]. Conclusions: Nurse-led GDLPT shortens the duration of mechanical ventilation, decreases ICU and 28-day mortality, and improves the prognosis of older patients with sepsis and pneumonia in the ICU.

The Availability and Safety Study of Remimazolam Besylate for Injection on Sedation of ERAS Patients Under Mechanical Ventilation in ICU: Protocol for a Randomized, Open-Label, Controlled Trial.

Introduction: The most common physiological and psychological disorders associated with critical care patients are pain and anxiety. Sedatives and analgesics are commonly used to relieve these symptoms. However, the adverse effects of sedatives and analgesics are common and inevitable. As a new type of sedative drug, limited number of trials are available to evaluate Remimazolam Besylate's availability and safety compared with propofol. Methods: This study is a single center, randomized, open-label, controlled trial. A total of 84 patients who meet ERAS criteria and receive mechanical ventilation in ICU, aged ≥18 years old will be included. Patients will be randomized (1:1) into two groups: Remimazolam Besylate group and Propofol group. The Primary outcomes includes satisfaction rate of sedation and incidence rate of major clinical events. Secondary outcomes including incidence of delirium, time to weaning and extubation, Difficulty of nursing RASS, BIS and PI, 28-days survival, side-effect and vital signs during medications, total dose and dose per kilogram body weight of analgesic and sedatives and incidence of rescue therapy in experimental group. Ethics and Dissemination: This trial has been approved by the ethics boards of Peking Union Medical College Hospital. Recruitment began in January 2022 and will continue until June 2022. Dissemination plans include presentations at scientific conferences, scientific publications, stakeholder engagement efforts and presentation to the public via lay media outlets. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04947345.

Effect of nurse-led, goal-directed lung physiotherapy on prognosis of patients with sepsis caused by Acinetobacter baumannii pulmonary infection.

OBJECTIVES: To investigate the role of nurse-led, goal-directed lung physiotherapy on the prognosis of patients with sepsis caused by Acinetobacter baumannii pulmonary infection. METHODS: Patients with sepsis caused by A. baumannii pulmonary infection were recruited and divided into a control group (phase 1) and a treatment group (phase 2). Both groups received standard therapy for sepsis, and patients in phase 2 also received nurse-led, goal-directed lung physiotherapy. The primary outcome measure was 28-day mortality. RESULTS: Among 742 patients with sepsis, 201 were diagnosed with A. baumannii pulmonary infection. Compared with patients in phase 1, patients in phase 2 had a significantly shorter duration of mechanical ventilation {median 4 (interquartile range (IQR) 3-5] vs 5 (IQR 3-12) days; P = 0.004}, lower intensive care unit (ICU) mortality [13.6% (18/132) vs 27.5% (19/69); P = 0.016] and lower 28-day mortality [21.2% (28/132) vs 37.7% (26/69); P = 0.012]. As a protective factor, nurse-led, goal-directed lung physiotherapy (odds ratio 0.341, 95% confidence interval 0.155-0.751; P = 0.008) was an independent risk factor for 28-day mortality. CONCLUSIONS: Nurse-led, goal-directed lung physiotherapy shortened the duration of mechanical ventilation and ICU stay, and decreased ICU mortality and 28-day mortality in patients with sepsis caused by A. baumannii pulmonary infection.

Correlation between cytokines and coagulation-related parameters in patients with coronavirus disease 2019 admitted to ICU.

BACKGROUND: The novel SARS-CoV-2 caused a large number of infections and deaths worldwide. Thus, new ideas for an appropriated assessment of patients' condition and clinical treatment are of utmost importance. Therefore, in this study, the laboratory parameters of patients with coronavirus disease 2019 (COVID-19) were evaluated to identify the correlation between cytokine expression and other laboratory parameters. METHODS: A retrospective and single-center study was performed in Wuhan, involving 83 severe or critical COVID-19 patients admitted to the intensive care unit (ICU). Laboratory parameters in ICU patients with laboratory-confirmed infection of SARS-CoV2 were collected. The association between parameters was assessed by Spearman's rank correlation. RESULTS: Patients' median age was 66 years (IQR, 57-73), and 55 (66%) were men. Among the 83 patients, 61 (73%) had 1 or more coexisting medical condition. The median concentration of IL-2R, IL-6, IL8, IL10, and TNFα were above the normal range, without IL-1ß. A significant negative correlation between IL-6 and platelet count was discovered (r2 = -0.448, P < 0.001) as well as a significant correlation between IL-6 and other platelet parameters. Finally, a correlation between multiple cytokines and coagulation indicators was found, pro-inflammatory factors were found to be more associated to coagulation parameters, with the highest correlation between IL-6 and the International normalized ratio (INR) (r2 = 0.444, P < 0.001). CONCLUSIONS: Our results suggested that cytokines play an important role in the pathogenesis of COVID-19. In addition, IL-6 seems more relevant in the evaluation of the condition of COVID-19 patients.

[Prognostic outcomes of adherence to guideline of bundle therapy by key points of control strategies in septic shock patients].

OBJECTIVE: To evaluate the improvement of clinical septic shock guideline of bundle therapy by key points of control strategies and its impact on the outcomes of septic shock patients. METHODS: The quality control team and sepsis steering committee were established to apply key points of control strategies to improve the clinical septic shock guideline of bundle therapy. The time to resuscitation, antibiotics and cultures, the implementation rate of 6-hour resuscitation goals, glucose control and lung protective ventilation strategies were recorded during the plan-do-check-act (PDCA) steps. And the changes of length of ICU stay and hospital mortality were analyzed. RESULTS: Between July 2009 and December 2012, a total of 563 sequential septic shock patients were admitted. Demographics included median age, gender ratio, initial Acute Physiology and Chronic Health Evaluation II (Apache II) score and sources of infection showed no significant differences during this period. Compared with 2009, the time to resuscitation (65.1 ± 10.3 vs 99.7 ± 10.5 min, P < 0.01) , the time to cultures (55.9 ± 5.2 vs 71.5 ± 7.9 min, P < 0.01) and the time to antibiotics (58.1 ± 5.8 vs 152.8 ± 16.1 min, P < 0.01) significantly decreased in 2012. The implementation rate of 6-hour resuscitation goals (68.7% vs 28.7%, P < 0.01) , the implementation rate of glucose control (79.6% vs 40.0%, P < 0.01) and the implementation rate of lung protective ventilation strategies (74.1% vs 51.4%, P = 0.004) improved significantly form 2009 to 2012. The length of ICU stay (7.2 ± 1.5 vs 9.8 ± 2.7 d, P < 0.01) decreased. And hospital mortality decreased from 40.0% in 2009 to 23.1% in 2012 (P = 0.015). CONCLUSION: The key points of control strategies can improve the clinical septic shock guideline of bundle therapy performance so that there are significant decreases of length of ICU stay and hospital mortality of septic shock patients.