A Framework for Developing a Multidisciplinary Approach to Prone Positioning in Acute Respiratory Distress Syndrome.

Prone position ventilation (PPV) is one of the few interventions with a proven mortality benefit in the management of acute respiratory distress syndrome (ARDS), yet it is underutilized as demonstrated by multiple large observational studies. Significant barriers to its consistent application have been identified and studied. But the complex interplay of a multidisciplinary team makes its consistent application challenging. We present a framework of multidisciplinary collaboration that identifies the appropriate patients for this intervention and discuss our institutional experience applying a multidisciplinary team to implement prone position (PP) leading up to and through the current COVID-19 pandemic. We also highlight the role of such multidisciplinary teams in the effective implementation of prone positioning in ARDS throughout a large health care system. We emphasize the importance of proper selection of patients and provide guidance on how a protocolized approach can be utilized for proper patient selection.

Peripheral Administration of Norepinephrine: A Prospective Observational Study.

BACKGROUND: Historically, norepinephrine has been administered through a central venous catheter (CVC) because of concerns about the risk of ischemic tissue injury if extravasation from a peripheral IV catheter (PIVC) occurs. Recently, several reports have suggested that peripheral administration of norepinephrine may be safe. RESEARCH QUESTION: Can a protocol for peripheral norepinephrine administration safely reduce the number of days a CVC is in use and frequency of CVC placement? STUDY DESIGN AND METHODS: This was a prospective observational cohort study conducted in the medical ICU at a quaternary care academic medical center. A protocol for peripheral norepinephrine administration was developed and implemented in the medical ICU at the study site. The protocol was recommended for use in patients who met prespecified criteria, but was used at the treating clinician's discretion. All adult patients admitted to the medical ICU receiving norepinephrine through a PIVC from February 2019 through June 2021 were included. RESULTS: The primary outcome was the number of days of CVC use that were avoided per patient, and the secondary safety outcomes included the incidence of extravasation events. Six hundred thirty-five patients received peripherally administered norepinephrine. The median number of CVC days avoided per patient was 1 (interquartile range, 0-2 days per patient). Of the 603 patients who received norepinephrine peripherally as the first norepinephrine exposure, 311 patients (51.6%) never required CVC insertion. Extravasation of norepinephrine occurred in 35 patients (75.8 events/1,000 d of PIVC infusion [95% CI, 52.8-105.4 events/1,000 d of PIVC infusion]). Most extravasations caused no or minimal tissue injury. No patient required surgical intervention. INTERPRETATION: This study suggests that implementing a protocol for peripheral administration of norepinephrine safely can avoid 1 CVC day in the average patient, with 51.6% of patients not requiring CVC insertion. No patient experienced significant ischemic tissue injury with the protocol used. These data support performance of a randomized, prospective, multicenter study to characterize the net benefits of peripheral norepinephrine administration compared with norepinephrine administration through a CVC.

Utility of a "Lavender Lounge" to Reduce Stress Among Critical Care Registered Nurses: A Cross-Sectional Study.

BACKGROUND: Work-related stressors are present in almost every profession, but many believe nurses caring for critically ill patients experience additional and unique stresses. Results of previous studies have demonstrated the potential benefits of various interventions to reduce stress among intensive care nurses. However, the practicality of nurses taking time out from a busy unit to meet their own needs remains in question. OBJECTIVES: To assess intensive care nurses' perceptions of the usability of a lounge designed to support them in refreshing and renewing themselves after stressful clinical situations. METHODS: This study used a descriptive, cross-sectional design and survey methodology with a convenience sample of registered nurses from a medical intensive care unit. RESULTS: Of 250 registered nurses eligible for participation, 54 (21.6%) completed surveys, and of those, 31 (57%) reported having used the lounge within the past month. Nurses reported having coverage provided by colleagues, visiting during their lunch break, and having low unit acuity were facilitators of lounge use. Barriers included high unit acuity, high unit census, and high patient care demands with no one available to cover patient assignments. CONCLUSIONS: The variables that lead to stress and burnout among medical intensive care unit nurses also prevent nurses from using a "relaxation room." A more effective approach may be organizational change that supports reduction of workload through increased staffing, prearranged breaks during shifts, and increased recovery time between shifts by limiting work to no more than 40 hours per week.

Abnormal thrombosis and neutrophil activation increase hospital-acquired sacral pressure injuries and morbidity in COVID-19 patients.

Hospitalized patients have an increased risk of developing hospital-acquired sacral pressure injury (HASPI). However, it is unknown whether SARS-CoV-2 infection affects HASPI development. To explore the role of SARS-CoV-2 infection in HASPI development, we conducted a single institution, multi-hospital, retrospective study of all patients hospitalized for ≥5 days from March 1, 2020 to December 31, 2020. Patient demographics, hospitalization information, ulcer characteristics, and 30-day-related morbidity were collected for all patients with HASPIs, and intact skin was collected from HASPI borders in a patient subset. We determined the incidence, disease course, and short-term morbidity of HASPIs in COVID-19(+) patients, and characterized the skin histopathology and tissue gene signatures associated with HASPIs in COVID-19 disease. COVID-19(+) patients had a 63% increased HASPI incidence rate, HASPIs of more severe ulcer stage (OR 2.0, p<0.001), and HASPIs more likely to require debridement (OR 3.1, p=0.04) compared to COVID-19(-) patients. Furthermore, COVID-19(+) patients with HASPIs had 2.2x increased odds of a more severe hospitalization course compared to COVID-19(+) patients without HASPIs. HASPI skin histology from COVID-19(+) patients predominantly showed thrombotic vasculopathy, with the number of thrombosed vessels being significantly greater than HASPIs from COVID-19(-) patients. Transcriptional signatures of a COVID-19(+) sample subset were enriched for innate immune responses, thrombosis, and neutrophil activation genes. Overall, our results suggest that immunologic dysregulation secondary to SARS-CoV-2 infection, including neutrophil dysfunction and abnormal thrombosis, may play a pathogenic role in development of HASPIs in patients with severe COVID-19.