Feasibility analysis of a novel non-invasive ultrasonographic method for the measurement of intra-abdominal pressure in the intensive care unit.

Increased intra-abdominal pressure (IAP) is an important vital sign in critically ill patients and has a negative impact on morbidity and mortality. This study aimed to validate a novel non-invasive ultrasonographic approach to IAP measurement against the gold standard intra-bladder pressure (IBP) method. We conducted a prospective observational study in an adult medical ICU of a university hospital. IAP measurements using ultrasonography by two independent operators, with different experience levels (experienced, IAPUS1; inexperienced, IAPUS2), were compared with the gold standard IBP method performed by a third blinded operator. For the ultrasonographic method, decremental external pressure was applied on the anterior abdominal wall using a bottle filled with decreasing volumes of water. Ultrasonography looked at peritoneal rebound upon brisk withdrawal of the external pressure. The loss of peritoneal rebound was identified as the point where IAP was equal to or above the applied external pressure. Twenty-one patients underwent 74 IAP readings (range 2-15 mmHg). The number of readings per patient was 3.5 ± 2.5, and the abdominal wall thickness was 24.6 ± 13.1 mm. Bland and Altman's analysis showed a bias (0.39 and 0.61 mmHg) and precision (1.38 and 1.51 mmHg) for the comparison of IAPUS1 and IAPUS2 and vs. IBP, respectively with small limits of agreement that were in line with the research guidelines of the Abdominal Compartment Society (WSACS). Our novel ultrasound-based IAP method displayed good correlation and agreement between IAP and IBP at levels up to 15 mmHg and is an excellent solution for quick decision-making in critically ill patients.

Managing patient-ventilator asynchrony with a twice-daily screening protocol: A retrospective cohort study.

PURPOSE: Severe patient-ventilator asynchrony (PVA) might be associated with prolonged mechanical ventilation and mortality. It is unknown if systematic screening and application of conventional methods for PVA management can modify these outcomes. We therefore constructed a twice-daily bedside PVA screening and management protocol and investigated its effect on patient outcomes. MATERIALS AND METHODS: A retrospective cohort study of patients who were intubated in the emergency department and directly admitted to the medical intensive care unit (ICU). In phase 1 (6 months; August 2016 to January 2017), patients received usual care comprising lung protective ventilation and moderate analgesia/sedation. In phase 2 (6 months; February 2017 to July 2017), patients were additionally managed with a PVA protocol on ICU admission and twice daily (7 am, 7 pm). RESULTS: A total of 280 patients (160 in phase 1, 120 in phase 2) were studied (age = 64.5 ± 21.4 years, 107 women [38.2%], Acute Physiology and Chronic Health Evaluation II score = 27.1 ± 8.5, 271 [96.8%] on volume assist-control ventilation initially). Phase 2 patients had lower hospital mortality than phase 1 patients (20.0% versus 34.4%, respectively, P = 0.011), even after adjustment for age and Acute Physiology and Chronic Health Evaluation II scores (odds ratio = 0.46, 95% confidence interval = 0.25-0.84). CONCLUSIONS: Application of a bedside PVA protocol for mechanically ventilated patients on ICU admission and twice daily was associated with decreased hospital mortality. There was however no association with sedation-free days or mechanical ventilation-free days through day 28 or length of hospital stay.

Nurse-performed screening for postextubation dysphagia: a retrospective cohort study in critically ill medical patients.

BACKGROUND: Swallowing difficulties are common, and dysphagia occurs frequently in intensive care unit (ICU) patients after extubation. Yet, no guidelines on postextubation swallowing assessment exist. We aimed to investigate the safety and effectiveness of nurse-performed screening (NPS) for postextubation dysphagia in the medical ICU. METHODS: We conducted a retrospective cohort study of mechanically ventilated patients who were extubated in a 20-bed medical ICU. Phase I (no NPS, October 2012 to January 2014) and phase II (NPS, February 2014 to July 2015) were compared. In phase II, extubated patients received NPS up to three times on consecutive days; patients who failed were referred to speech-language pathologists. Outcomes analyzed included oral feeding at ICU discharge, reintubation, ICU readmission, postextubation pneumonia, ICU and/or hospital mortality, and ICU and/or hospital length of stay (LOS). Subgroup analysis was done for patients extubated after >72 h of mechanical ventilation, as the latter may predispose patients to postextubation dysphagia. Multivariable adjustments for Acute Physiology and Chronic Health Evaluation (APACHE) II score and comorbidities were done because of baseline differences between the phases. RESULTS: A total of 468 patients were studied (281 in phase I, 187 in phase II). Patients in phase II had higher APACHE II scores than those in phase I (27.2 ± 8.2 vs. 25.4 ± 8.2; P = 0.018). Despite this, patients in phase II showed a 111 % increase in (the odds of) oral feeding at ICU discharge and a 59 % decrease in postextubation pneumonia (multivariate P values 0.001 and 0.006, respectively). In the subgroup analysis, NPS was associated with a 127 % increase in oral feeding at ICU discharge, an 80 % decrease in postextubation pneumonia, and a 25 % decrease in hospital LOS (multivariate P values 0.021, 0.004, and 0.009, respectively). No other outcome differences were found. CONCLUSIONS: NPS for dysphagia is safe and may be superior to no screening with respect to several patient-centered outcomes.

'Death rounds to support critical care nurses: a qualitative study'.

OBJECTIVE: Providing end-of-life care has a significant psychological impact on critical care nurses. Little is known about whether critical care nurses find death rounds useful as a support system. This study aimed to describe critical care nurses' perceptions of attending death rounds. METHODS: This study was conducted using a qualitative descriptive design, using one-to-one audio-recorded interviews. The study was conducted at a 20-bed medical intensive care unit in a 1200-bed public tertiary hospital in Singapore. One-to-one interviews were conducted with 14 nurses using a semi-structured interview guide. Data was analysed using thematic analysis. RESULTS: Critical care nurses valued attending death rounds. They found death rounds to be an outlet to express themselves and remember patients, to draw and give peer support, to build nursing and interprofessional cohesiveness and to learn to improve palliative care. The death rounds were optimal when they felt safe to share, when there was a good facilitator, when the hierarchy was flat and when the audience was interdisciplinary. The barriers to a successful death round were the rounds being too formal, timing and not knowing the patients. CONCLUSION: Death rounds are a viable way to support critical care nurses in providing end-of-life care.