Interrupções e distrações durante a preparação e administração de medicamentos de alto risco: Estudo transversal / Interruptions and distractions during the preparation and administration of high-risk medications: A cross-sectional study / Distracciones e interrupciones durante la preparación y administración de medicamentos de alto riesgo: Estudio transversal

Resumo Enquadramento: Estudos indicam que as interrupções contribuem para erros clínicos e falhas em procedimentos. Objetivo: Analisar as interrupções vivenciadas pelos enfermeiros durante a preparação e administração de medicamentos de alto risco. Metodologia: Foi realizado um estudo transversal numa unidade de cuidados intensivos e numa unidade de internamento. As interrupções vivenciadas pelos enfermeiros durante o processo de medicação foram observadas com a ajuda de duas checklists. A amostra foi selecionada por conveniência em abril e maio de 2019. Os dados quantitativos foram analisados através de estatística descritiva no programa IBM SPSS Statistics, versão 24.0, enquanto os dados qualitativos foram tratados por meio da análise de conteúdo. Resultados: Observaram-se 137 interrupções em 193 processos de medicação. A maioria das interrupções foi iniciada por outros membros da equipa de cuidados de saúde por meio de conversas. Estas interrupções foram maioritariamente prejudiciais e ocorreram durante a fase de preparação. A estratégia multitarefa foi utilizada para as gerir. Conclusão: As interrupções ocorridas durante o processo de medicação eram maioritariamente associadas com comunicações profissionais e sociais. A sua relevância diferiu consoante a fase do processo.

Abstract Background: Interruptions have been reported to contribute to clinical errors and procedural failures. Objective: To analyze the interruptions experienced by nurses during the preparation and administration of high-risk medications. Methodology: A cross-sectional study was conducted in an intensive care and inpatient unit. The interruptions experienced by nurses during the medication process were observed through two checklists. The sample was selected by convenience in April-May 2019. Descriptive statistics was used to analyze quantitative data in IBM SPSS Statistics software, version 24.0, while content analysis was used to analyze qualitative data. Results: In 193 medication processes, there were 137 interruptions. Other members of the healthcare team initiated most interruptions through conversations. These interruptions were mostly negative and occurred during the preparation phase. The multitasking strategy was used to manage them. Conclusion: Interruptions during the medication process were primarily associated with professional and social communications. The impact of these interruptions varied depending on the phase of the process.

Resumen Marco contextual: Se ha reportado la participación de distracciones en errores clínicos y fallos de procedimiento. Objetivo: Analizar las distracciones del personal de enfermería durante la preparación y administración de fármacos de alto riesgo. Metodología: Estudio transversal desarrollado en una unidad de cuidados intensivos y una unidad de hospitalización. Se observaron distracciones del personal de enfermería durante el proceso de medicación a través de dos listas de control. La muestra fue seleccionada por conveniencia (abril-mayo 2019). Los datos cuantitativos se analizaron mediante estadística descriptiva (IBM SPSS Statistics, versión 24.0). Los datos cualitativos se analizaron mediante análisis de contenido. Resultados: Hubo 137 distracciones en 193 procesos de medicación. La mayoría de las distracciones fueron iniciadas por otros miembros del equipo sanitario a través de conversaciones. La mayoría se produjeron en la fase de preparación y fueron negativas y se gestionaron mediante la estrategia multitarea. Conclusión: Las distracciones durante el proceso de medicación se referían principalmente a las comunicaciones profesionales y sociales. La importancia de esas distracciones variaba en función de la fase del proceso.

Glycemic Management in Patients with COVID-19 Admitted to the Intensive Care Unit: Evaluation of Glycemic Control and Drug Therapy.

Background: Emerging evidence describes the high incidence and strong impact of hyperglycemia on the outcomes of critically ill patients with a diagnosis of COVID-19. Given resource limitations during the COVID-19 pandemic, clinicians moved away from using continuous IV infusions of insulin to manage hyperglycemia. Objective: To evaluate glycemic control in critically ill patients receiving various medication regimens to manage their hyperglycemia. Methods: This retrospective cohort study involved 120 mechanically ventilated adult patients (> 18 years) with COVID-19 who were admitted to the intensive care unit (ICU) between February 2020 and December 2021. The following data were collected for the first 14 days of the ICU admission: blood glucose values (up to 4 times daily), hypoglycemia events, and antihyperglycemic medication regimens. Results: The use of IV insulin infusions maintained glucose measurements within the target range of 4 to 10 mmol/L more often than any other medication regimen, with 60% of measured values falling within the target range. The use of a sliding-scale insulin regimen maintained 52% of glucose measurements within the target range. Oral hypoglycemic agents performed relatively poorly, with only 12% to 29% of glucose measurements within range. The coadministration of corticosteroids led to worse glycemic control across all medication regimens. Conclusions: This study confirmed that ICUs should continue using the standard protocol of IV insulin infusion to achieve recommended blood glucose targets in critically ill patients with COVID-19, particularly those receiving corticosteroids.

Contexte: Des données probantes émergentes font état de l'incidence élevée et des fortes répercussions de l'hyperglycémie sur les résultats des patients gravement malades ayant reçu un diagnostic de COVID-19. Vu les ressources restreintes pendant la pandémie de COVID-19, les cliniciens se sont éloignés de l'utilisation des perfusions continues d'insuline par IV pour gérer l'hyperglycémie. Objectif: Évaluer le contrôle glycémique chez les patients gravement malades qui reçoivent divers régimes médicamenteux pour gérer leur hyperglycémie. Méthodologie: Cette étude de cohorte rétrospective portait sur 120 patients adultes (> 18 ans) atteints de la COVID-19 ventilés mécaniquement ayant été admis à une unité de soins intensifs entre février 2020 et décembre 2021. Les données suivantes ont été recueillies pendant les 14 premiers jours de l'admission en USI : valeurs glycémiques (jusqu'à 4 fois par jour), événements d'hypoglycémie et régimes de médicaments antihyperglycémiants. Résultats: L'utilisation de perfusions d'insuline par intraveineuse permettait de maintenir les mesures de glucose dans la plage cible de 4 à 10 mmol/L plus souvent que tout autre schéma thérapeutique, avec 60 % des mesures se situant dans la plage cible. L'utilisation d'un schéma thérapeutique à insuline à échelle mobile a permis de maintenir 52 % des mesures de glucose dans la plage cible. Les résultats des hypoglycémiants oraux étaient relativement mauvais, avec seulement 12 % à 29 % des mesures de glucose se situant dans la plage cible. L'administration concomitante de corticostéroïdes a entraîné un moins bon contrôle glycémique dans tous les schémas thérapeutiques. Conclusions: Cette étude a confirmé que les unités de soins intensifs devraient continuer à utiliser le protocole standard de perfusion d'insuline par IV pour atteindre les objectifs de glycémie recommandés chez les patients gravement malades atteints de la COVID-19, en particulier ceux recevant des corticostéroïdes.

[Initial diagnosis and treatment of shock]. / Initiale Diagnostik und Therapie des Schocks.

BACKGROUND: Structured procedures have been established internationally for the initial clinical care of patients with traumatic injuries. Comparable concepts have not yet been applied to the initial clinical care of life-threatening nontraumatic emergencies. In 2022, a working group of the German Society for Acute and Emergency Medicine (DGINA) presented the Advanced Critical Illness Life Support (ACiLS) concept for the care of nontraumatic emergencies and offers corresponding training courses. OBJECTIVE: To present systematic clinical first aid for patients with the leading symptom of shock according to the ACiLS concept. RESULT: The (PR_E-)AUD2IT basic algorithm used in the ACiLS concept divides the initial care of a critically ill patient into the elements of preparation, resources, initial care, medical history, examination, differential diagnosis, diagnostics, interpretation and to do, interrupted by three team time-out elements for structured communication. The use of this concept is demonstrated here using the example of shock. CONCLUSION: The ACiLS concept has the potential to improve the quality of initial care of nontraumatic emergencies in emergency department shock rooms and intensive care units. Further evaluations in practice and training capacities are essential.

Relationship between the albumin-corrected anion gap and short-term prognosis among patients with cardiogenic shock: a retrospective analysis of the MIMIC-IV and eICU databases.

OBJECTIVES: We aimed to investigate the association between the albumin-corrected anion gap (ACAG) and the prognosis of cardiogenic shock (CS). DESIGN: A multicentre retrospective cohort study. SETTING: Data were collected from the Medical Information Mart for Intensive Care (MIMIC-IV) and eICU Collaborative Research Database (eICU-CRD) datasets. PARTICIPANTS: 808 and 700 individuals from the MIMIC-IV and eICU-CRD, respectively, who were diagnosed with CS. PRIMARY AND SECONDARY OUTCOMES: The primary endpoint was short-term all-cause mortality, including intensive care unit (ICU), in-hospital and 28-day mortality. The secondary endpoints were the 28-day free from the ICU duration and the length of ICU stay. RESULTS: CS patients were divided into two groups according to the admission ACAG value: the normal ACAG group (≤20 mmol/L) and the high ACAG group (> 20 mmol/L). CS patients with higher ACAG values exhibited increased short-term all-cause mortality rates, including ICU mortality (MIMIC-IV cohort: adjusted HR: 1.43, 95% CI=1.05-1.93, p=0.022; eICU-CRD cohort: adjusted HR: 1.38, 95% CI=1.02-1.86, p=0.036), in-hospital mortality (MIMIC-IV cohort: adjusted HR: 1.31, 95% CI=1.01-1.71, p=0.03; eICU-CRD cohort: adjusted HR: 1.47, 95% CI=1.12-1.94, p=0.006) and 28-day mortality (adjusted HR: 1.42, 95% CI: 1.11 to 1.83, p=0.007). A positive linear correlation was observed between the ACAG value and short-term mortality rates via restricted cubic splines. Compared with the AG, the ACAG presented a larger area under the curve for short-term mortality prediction. In addition, the duration of intensive care was longer, whereas the 28-day free from the ICU duration was shorter in patients with a higher ACAG value in both cohorts. CONCLUSION: The ACAG value was independently and strongly associated with the prognosis of patients with CS, indicating that the ACAG value is superior to the conventional AG value.

Coping strategies of intensive care units nurses in alarm management: a qualitative research study.

BACKGROUND: Intensive care units are critical environments where various alarm systems play a pivotal role in patient monitoring and safety. Alarm fatigue can lead to slower response times and missed alarms, compromising patient safety and increasing stress and burnout among intensive care unit nurses. Understanding how intensive care unit nurses respond to and manage these alarms is crucial in evaluating their impact on patient care and nursing well-being. METHODS: This descriptive qualitative study explored the experiences of intensive care unit nurses in alarm management. Conducted in the medical and surgical intensive care units of a Northern Taiwan medical center, the study involved 15 nurses. Semi-structured interviews were utilized to investigate the working experiences of ICU nurses in alarm management and to identify their coping strategies for dealing with the constant inundation of medical device alarms. The interviews were transcribed, and content analysis was applied to identify key themes in the responses. RESULTS: The study revealed five main themes in intensive care unit nurses' strategies for managing alarms: (1) Mastering alarm signals and acting; (2) Team monitoring for life preservation; (3) Enhancing senses and distinguishing carefully; (4) Learning from the lessons of incidents for vigilant reflection; and (5) Detach alarms' influence on daily life. These coping strategies are effective in alarm management, safeguarding patients' lives, enhancing the serenity of the clinical environment, and mitigating the physical and mental exhaustion caused by alarm fatigue. CONCLUSIONS: Intensive Care Unit nurses develop various coping strategies to manage medical device alarms, based on their experience. These strategies are crucial in maintaining patient safety and reducing nurse alarm fatigue. They can also be used for nursing education and clinical training.

Consensus statements for the establishment of medical intensive care in low-resource settings: international study using modified Delphi methodology.

BACKGROUND: The inadequacy of intensive care medicine in low-resource settings (LRS) has become significantly more visible after the COVID-19 pandemic. Recommendations for establishing medical critical care are scarce and rarely include expert clinicians from LRS. METHODS: In December 2023, the National Association of Intensivists from Bosnia and Herzegovina organized a hybrid international conference on the topic of organizational structure of medical critical care in LRS. The conference proceedings and literature review informed expert statements across several domains. Following the conference, the statements were distributed via an online survey to conference participants and their wider professional network using a modified Delphi methodology. An agreement of ≥ 80% was required to reach a consensus on a statement. RESULTS: Out of the 48 invited clinicians, 43 agreed to participate. The study participants came from 20 countries and included clinician representatives from different base specialties and health authorities. After the two rounds, consensus was reached for 13 out of 16 statements across 3 domains: organizational structure, staffing, and education. The participants favored multispecialty medical intensive care units run by a medical team with formal intensive care training. Recognition and support by health care authorities was deemed critical and the panel underscored the important roles of professional organizations, clinician educators trained in high-income countries, and novel technologies such as tele-medicine and tele-education. CONCLUSION: Delphi process identified a set of consensus-based statements on how to create a sustainable patient-centered medical intensive care in LRS.

Pharmacokinetic Research in Pediatric Extracorporeal Therapies: Current State and Future Directions.

Extracorporeal life support (ECLS), including extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), are life-saving therapies for critically ill children. Despite this, these modalities carry frustratingly high mortality rates. One driver of mortality may be altered drug disposition due to a combination of underlying illness, patient-circuit interactions, and drug-circuit interactions. Children receiving ECMO and/or CRRT routinely receive 20 or more drugs, and data supporting optimal dosing is lacking for most of these medications. The Pediatric Paracorporeal and Extracorporeal Therapies Summit (PPETS) gathered an international group of experts in the fields of ECMO, CRRT, and other ECLS modalities to discuss the current state of these therapies, disseminate innovative support strategies, share clinical experiences, and foster future collaborations. Here, we summarize the conclusions of PPETS and put forward a pathway to optimize pharmacokinetic (PK) research in this population. We must prioritize specific medications for in-depth study to improve drug use in ECLS and patient outcomes. Based on frequency of use, potential for adverse outcomes if dosed inappropriately, and lack of existing PK data, a list of high priority drugs was compiled for future research. Researchers must additionally reconsider study designs, emphasizing pooling of resources through multi-center studies and the use of innovative PK modeling techniques. Finally, the integration of validated PK models into clinical practice must be streamlined to deliver optimal medication use at the bedside. Focusing on the proposed list of highlighted medications and key methodological considerations will maximize the impact of future research.

Brain tissue oxygen monitoring in moderate-to-severe traumatic brain injury: Physiological determinants, clinical interventions and current randomised controlled trial evidence.

Modern intensive care for moderate-to-severe traumatic brain injury (msTBI) focuses on managing intracranial pressure (ICP) and cerebral perfusion pressure (CPP). This approach lacks robust clinical evidence and often overlooks the impact of hypoxic injuries. Emerging monitoring modalities, particularly those capable of measuring brain tissue oxygen, represent a promising avenue for advanced neuromonitoring. Among these, brain tissue oxygen tension (PbtO2) shows the most promising results. However, there is still a lack of consensus regarding the interpretation of PbtO2 in clinical practice. This review aims to provide an overview of the pathophysiological rationales, monitoring technology, physiological determinants, and recent clinical trial evidence for PbtO2 monitoring in the management of msTBI.

Recommendations for the College of Intensive Care Medicine (CICM) trainee research project: A modified Delphi study.

Objective: To determine the perceived barriers and enablers to efficient completion of the College of Intensive Care Medicine (CICM) of Australia and New Zealand Formal Project - a trainee research project mandated for award of CICM Fellowship - and to develop consensus-based recommendations to support Intensive Care trainees and supervisors. Design: A two-stage modified Delphi study was conducted. In stage one, an anonymous electronic survey was distributed with three targeted open-ended questions relating to perceived key steps, barriers to, and improvements for efficient completion of the Formal Project. A thematic analysis used the survey results to generate a list of close-ended questions.In stage two, a consensus panel comprising of 30 panellists including CICM trainees, Formal Project supervisors and assessors, and critical care researchers, underwent a Delphi process with two rounds of voting and discussion to generate consensus-based recommendations. Setting: Surveys were distributed to Intensive Care Units across Australia and New Zealand. The consensus panel convened at the Queensland Critical Care Research Network Annual Scientific Meeting in Redcliffe, Queensland, Australia, on 9 June 2023. Participants: CICM trainees, Formal Project supervisors and assessors, and critical care researchers in Australia and New Zealand. Main outcome measures: Consensus-based recommendations for the CICM Formal Project. Results: We received 88 responses from the stage one survey. Stage two finalised 22 consensus-based recommendations, centring on key steps of the research process, resources for trainees, and support and training for supervisors. Conclusions: Twenty-two recommendations were developed aiming to make the process of completing the mandatory CICM research project more efficient, and to improve the quality of research produced from these projects.

Natural language processing in the intensive care unit: A scoping review.

Objectives: Natural language processing (NLP) is a branch of artificial intelligence focused on enabling computers to interpret and analyse text-based data. The intensive care specialty is known to generate large volumes of data, including free-text, however, NLP applications are not commonly used either in critical care clinical research or quality improvement projects. This review aims to provide an overview of how NLP has been used in the intensive care specialty and promote an understanding of NLP's potential future clinical applications. Design: Scoping review. Data sources: A systematic search was developed with an information specialist and deployed on the PubMed electronic journal database. Results were restricted to the last 10 years to ensure currency. Review methods: Screening and data extraction were undertaken by two independent reviewers, with any disagreements resolved by a third. Given the heterogeneity of the eligible articles, a narrative synthesis was conducted. Results: Eighty-seven eligible articles were included in the review. The most common type (n = 24) were studies that used NLP-derived features to predict clinical outcomes, most commonly mortality (n = 16). Next were articles that used NLP to identify a specific concept (n = 23), including sepsis, family visitation and mental health disorders. Most studies only described the development and internal validation of their algorithm (n = 79), and only one reported the implementation of an algorithm in a clinical setting. Conclusions: Natural language processing has been used for a variety of purposes in the ICU context. Increasing awareness of these techniques amongst clinicians may lead to more clinically relevant algorithms being developed and implemented.

The association between nutritional status measured by body mass index and outcomes in the pediatric intensive care unit.

Aim/Introduction: The relationship between nutritional status upon admission to a pediatric intensive care unit (PICU) and clinical outcomes remains unclear. We examined the relationship between nutrition status, as indicated by body mass index-for-age (BMI-for-age), and clinical outcomes in the PICU. Method: In this retrospective study at a tertiary care center, records of 1,015 critically ill children and adolescents aged one month to 18 years old with available anthropometric parameters were included. The nutritional status upon admission was determined by calculating the BMI-for-age z-score using the WHO growth charts as the reference. The participants were categorized as underweight (BMI-for-age z-score < -2), normal weight (-2 ≤ BMI-for-age z-score ≤ +1), and overweight/obese (BMI-for-age z-score > +1). Multi-variate odds ratios (OR) with 95% confidence intervals (CI) were used to investigate the association between malnutrition (being underweight and overweight/obese) and odds of Prolonged PICU stay (≥7 days) and PICU mortality after controlling for descriptive characteristics, Glasgow Coma Scale score status, fluctuations in serum sodium, and acute kidney injury confounders. Results: The proportions of patients in underweight, normal weight, and overweight/obese categories were 34.2%, 45.8%, and 20%, respectively. During the study period, 21.5% of patients had prolonged PICU stay, and 5.6% of patients in PICU died. Compared to normal-weight patients, underweight patients had higher odds of prolonged PICU stay (OR: 1.52; 95% CI: 1.05-2.22) and PICU mortality (OR: 2.12; 95% CI: 1.22-4.01). Age- and gender-stratified full-adjusted analysis showed that the increased odds of prolonged PICU stay remained significant among underweight boys and underweight individuals aged 5-19 years old. Furthermore, the increased odds of PICU mortality remained significant among underweight individuals aged 2-5 years old. However, being overweight or obese during PICU admission did not demonstrate a significant association with our outcomes in the total sample or subgroup analysis. Conclusion: Our findings showed that PICU patients who were underweight had higher odds of prolonged PICU stay and PICU mortality than their normal-weight counterparts. This underscores the importance of closely monitoring underweight patients in the PICU upon admission in order to improve clinical outcomes.

Admission chest CT scan of intensive care patients with interstitial lung disease: Unveiling its limited predictive value through visual and automated analyses in a retrospective study (ILDICTO).

BACKGROUND: Clinical course prediction of patients with interstitial lung disease (ILD) admitted to the intensive care unit (ICU) for acute respiratory failure (ARF) can be challenging. This study aimed to characterize the prognostic value of admission chest CT-scan in this situation. METHODS: We retrospectively included ILD patients admitted to a French ICU for acute respiratory failure requiring oxygen. Patients with lymphangitis carcinomatosis and ANCA vasculitis were excluded. We analyzed every admission chest CT-scan using two different approaches: a visual analysis (grading the extent of traction bronchiectasis, ground glass and honeycomb) and an automated analysis (grading the extent of ground glass and consolidation with a dedicated software). The primary outcome was ICU mortality. RESULTS: Between January 2014 and October 2020, 81 patients presented an acute respiratory failure with ILD on the admission chest CT-scan. In univariate analysis, only the main pulmonary artery diameter differed between patients who survived and those who died in ICU (30 vs 32 mm, p = 0.021). In multivariate analysis, none of the radiological funding was associated with ICU mortality. Visual and automated analyses did not yield different results, with a strong correlation between the two methods. However, the identification of an UIP pattern (and the presence of honeycomb) was associated with a poorer response to corticosteroid therapy. CONCLUSION: Our study showed that the extent of radiological findings and the severity of fibrosis indices on admission chest CT scans of ILD patients admitted to the ICU for ARF were not associated with subsequent deterioration.

Near-fatal pheochromocytoma crisis after beta-blocker and tumour haemorrhage.

Pheochromocytomas are rare neuroendocrine tumors characterised by the secretion of catecholamines and their metabolites. While some patients may be asymptomatic, they can also present with various symptoms including hypertensive crisis, headaches, palpitations, diaphoresis or other signs of catecholamine toxicity. Adrenal haemorrhage, though rare, is a potentially fatal complication that is often diagnosed during autopsy. In all patients with suspected pheochromocytoma, regardless of whether haemorrhagic conversion has occurred, prompt diagnosis is imperative. Early identification allows for the timely initiation of treatment, preventing potentially life-threatening complications. This case report details the haemorrhagic conversion of an undiagnosed pheochromocytoma in a female patient in her 30s.

Contemporary Training in American Critical Care Cardiology: Minnesota Critical Care Cardiology Education Summit: JACC Scientific Expert Panel.

This consensus statement emerges from collaborative efforts among leading figures in critical care cardiology throughout the United States, who met to share their collective expertise on issues faced by those active in or pursuing contemporary critical care cardiology education. The panel applied fundamentals of adult education and curriculum design, reviewed requisite training necessary to provide high-quality care to critically ill patients with cardiac pathology, and devoted attention to a purposeful approach emphasizing diversity, equity, and inclusion in developing this nascent field. The resulting paper offers a comprehensive guide for current trainees, with insights about the present landscape of critical care cardiology while highlighting issues that need to be addressed for continued advancement. By delineating future directions with careful consideration and intentionality, this Expert Panel aims to facilitate the continued growth and maturation of critical care cardiology education and practice.

Ability of the SMART-COP score to predict the need for intensive care unit admission and mortality in older patients with non-ventilator-associated hospital-acquired pneumonia: A retrospective observational study.

AIM: To evaluate the ability of SMART-COP (systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen and pH) score to predict the need for intensive care unit (ICU) admission and mortality among patients with non-ventilator-associated hospital-acquired pneumonia (NV-HAP) and to compare ICU-hospitalized patients with those followed-up in the clinic, as well as the patients who survived with those who died in the ICU, in terms of clinical and laboratory parameters. METHODS: A total of 203 patients (aged > 65 years) who were diagnosed with NV-HAP while staying in the geriatric clinic were enrolled in this retrospective observational study. Patient information was retrieved from hospital files. RESULTS: In a total of 203 patients with NV-HAP, the rate of ICU admission was 77.3% and the rate of mortality was 40.9%. The SMART-COP score was significantly higher in those admitted to the ICU and those died in the ICU (ICU nonsurvivors). The rate of ICU mortality was 52.9%. The SMART-COP score had significantly poor to moderate ability to predict the need for ICU admission (area under the curve [AUC] = 0.583) and both in-hospital mortality (AUC = 0.633) and ICU mortality (AUC = 0.617) with low sensitivity. The regression analysis revealed that a one-unit increase in SMART-COP score resulted in a 1.2-fold increase in both the hospital and ICU mortality (P < 0.05 for both) and 1.1-fold increase in ICU admission (P = 0.154). CONCLUSION: The SMART-COP score has poor to moderate ability to predict the need for ICU admission, in-hospital mortality and ICU mortality, and a one-unit increase in the SMART-COP score significantly increases the risk of both hospital and ICU mortality. Geriatr Gerontol Int 2024; ••: ••-••.

Critical care nurses' experiences on environmental sustainability: A qualitative content analysis.

BACKGROUND: Intensive care units (ICUs) are the primary producers of greenhouse gas emissions within hospitals, due to the use of several invasive materials. Nurses represent a large portion of the healthcare workforce and can be pivotal in promoting sustainability practices. Several international reports have suggested that nursing can help achieve the sustainable development objectives set by the United Nations. AIMS: The purpose is to explore behaviour related to environmental sustainability in intensive care nurses. STUDY DESIGN: A qualitative content analysis comprised of in-depth interviews involving 27 ICU nurses, who were each asked the same open-ended question. The transcripts collected were then analyzed and organized by a team of independently-working researchers. The analysis of the extrapolated concepts was carried out following the Neem M. (2022) method. The study is supported by a grant from the Centre of Excellence for Nursing Scholarship, Rome, July 2024. FINDINGS: The main recurring themes are as follows: (1) concepts of environmental sustainability in ICUs, (2) critical issues related to sustainable intervention in the ICUs (3) proactive environmental sustainability attitudes in ICUs. Time to know, define criticality, and improve is the conceptualization of sustainable behaviors experienced by ICU nurses. CONCLUSIONS: Taking the time to know and define the critical issues for implementing sustainable behaviours in the ICU, turned out to be the key to enforce the mindset of green nursing thinking. IMPLICATIONS TO CLINICAL PRACTICE: Sustainability behaviours need to be proposed and verified by ICU managers by creating sustainability teams and promoting a good working environment, founding the progression to green ICUs by focusing on health impact education and mindfulness.

[Toward optimizing AML treatment in the elderly].

Traditionally, the goal of AML therapy has been to induce remission with intensive chemotherapy, reduce tumor volume as much as possible with consolidation therapy, and achieve cure by allogeneic transplantation in patients with a poor prognosis. However, in elderly patients and patients with co-morbidities, toxicity often outweighs the therapeutic benefit of intensive chemotherapy. Now that low-intensity chemotherapy, such as methylation inhibitors and venetoclax, has emerged as a promising treatment option for elderly patients, it is more important than ever to consider age and comorbidities in treatment selection. The recently proposed comorbidity-based risk stratification system for AML enables prognostic stratification in not only patients who received intensive chemotherapy, but also those who received low-intensity chemotherapy. Optimization of treatment intensity based on such risk stratification should improve both treatment efficacy and safety, and ultimately improve the prognosis of AML.

Prospective Evaluation of Extubation Failure in Neonates and Infants After Cardiac Surgery.

Background: Extubation failure and its associated complications are not uncommon after pediatric cardiac surgery, especially in neonates and young infants. We aimed to identify the frequency, etiologies, and clinical characteristics associated with extubation failure after cardiac surgery in neonates and young infants. Methods: We conducted a single center prospective observational study of patients ≤180 days undergoing cardiac surgery between June 2022 and May 2023 with at least one extubation attempt. Patients who failed extubation, defined as reintubation within 72 h of first extubation attempt, were compared with patients extubated successfully using χ2, Fisher exact, or Wilcoxon rank-sum tests as appropriate. Results: We prospectively enrolled 132 patients who met inclusion criteria, of which 11 (8.3%) failed extubation. Median time to reintubation was 25.5 h (range 0.4-55.8). Extubation failures occurring within 12 h (n = 4) were attributed to upper airway obstruction or apnea, whereas extubation failures occurring between 12 and 72 h (n = 7) were more likely to be due to intrinsic lung disease or cardiac dysfunction. Underlying genetic anomalies, greater weight relative to baseline at extubation, or receiving positive end expiratory pressure (PEEP) > 5 cmH2O at extubation were significantly associated with extubation failure. Conclusions: In this study of neonates and young infants recovering from cardiac surgery, etiologies of early versus later extubation failure involved different pathophysiology. We also identified weight relative to baseline and PEEP at extubation as possible modifiable targets for future investigations of extubation failure in this patient population.

Characteristics and outcomes of children and young adults with sickle cell disease supported with extracorporeal membrane oxygenation (ECMO): An updated analysis of the ELSO registry.

BACKGROUND: Sickle cell disease (SCD) is a global hemoglobinopathy; approximately 300 000 individuals are diagnosed annually. Acute chest syndrome (ACS), a common complication, leads to significant hospitalization and mortality, particularly in cases of severe respiratory distress. ECMO outcomes in this specific population are poorly described. METHODS: This retrospective observational study, utilizing data from the Extracorporeal Life Support Organization (ELSO) registry, focuses on children and young adults (<40 years) with SCD undergoing ECMO from 1998 to 2022. RESULTS: We observed a growing trend in ECMO cases over the last 15 years, with 210 SCD patients identified in the registry (five neonates, 95 children, 110 adults). ECMO was predominantly initiated for pulmonary support (62%), and most of the primary diagnoses were related to SCD (reported as "SCD" or "acute chest syndrome"). The global survival rate was 55.8% (59% for children and 52.7% for adults). None of the children supported for extracorporeal cardiopulmonary resuscitation survived, and only 2/18 (11%) of adults cannulated for ECPR survived. Complication rates, including acute renal failure (33.8%) neurological events (13%), thrombotic (23.3%), or bleeding events (22.9%) were not noticeably different from reported outcomes in the ELSO registry. CONCLUSION: Our findings suggest that ECMO outcomes in SCD patients align with general ECMO trends and may not be limited by suspected unfavorable results in children and young adults. Despite limitations, our study contributes valuable insights into using ECMO in SCD, emphasizing the need for further research and understanding in this underexplored domain.