[Expert consensus on clinical practice of parenteral nutrition therapy for critically ill patients in China (2024)].

Critical patients have a high incidence of malnutrition, which can lead to adverse outcomes such as infections and ICU-acquired weakness. Improving the nutritional status of critically ill patients is currently an important challenge. Parenteral nutrition (PN) is an important component of medical nutrition, but there is still much controversy over how to implement a reasonable and standardized PN for critically ill patients. To further standardize the PN strategy for critically ill patients, the Critical Care Medicine Branch of the Zhejiang Medical Association convened experts in the field of critical care medicine and formulated the Expert consensus on clinical practice of parenteral nutrition therapy for critically ill patients in China (2024). This consensus is based on the GRADE evidence quality grading standard, problem oriented, and summarizes evidence-based medicine evidence from multiple aspects such as PN timing, suitable population, nutritional plan, and ingredient ratio, providing professional suggestions for the standardization and implementation of PN in clinical nutrition practice.

Update on the Epimed Monitor Adult ICU Database: 15 years of its use in national registries, quality improvement initiatives and clinical research.

In recent decades, several databases of critically ill patients have become available in both low-, middle-, and high-income countries from all continents. These databases are also rich sources of data for the surveillance of emerging diseases, intensive care unit performance evaluation and benchmarking, quality improvement projects and clinical research. The Epimed Monitor database is turning 15 years old in 2024 and has become one of the largest of these databases. In recent years, there has been rapid geographical expansion, an increase in the number of participating intensive care units and hospitals, and the addition of several new variables and scores, allowing a more complete characterization of patients to facilitate multicenter clinical studies. As of December 2023, the database was being used regularly for 23,852 beds in 1,723 intensive care units and 763 hospitals from ten countries, totaling more than 5.6 million admissions. In addition, critical care societies have adopted the system and its database to establish national registries and international collaborations. In the present review, we provide an updated description of the database; report experiences of its use in critical care for quality improvement initiatives, national registries and clinical research; and explore other potential future perspectives and developments.

Cultivating Diversity, Equity, and Inclusion in Pulmonary and Critical Care Training: A Path Toward Health Care Excellence.

Pulmonary and Critical Care Medicine (PCCM) fellowship training faces increasing competition but lacks diversity, hindering health care excellence. Despite a growing interest in the field, programs lack diverse representation. Addressing this issue is crucial to combat health disparities and bias, benefiting trainees, practitioners, and patients. Sustainable solutions are vital for achieving diversity, equity, and inclusion in PCCM. Strategies for achieving equity among training programs include adopting inclusive recruitment practices, recognizing differential attainment, addressing bias, fostering an equitable academic climate, and implementing multifaceted strategic processes to enhance diversity in mentorship including recognition and compensation for diversity and equity work.

A Clinician's Guide to Understanding Bias in Critical Clinical Prediction Models.

This narrative review focuses on the role of clinical prediction models in supporting informed decision-making in critical care, emphasizing their 2 forms: traditional scores and artificial intelligence (AI)-based models. Acknowledging the potential for both types to embed biases, the authors underscore the importance of critical appraisal to increase our trust in models. The authors outline recommendations and critical care examples to manage risk of bias in AI models. The authors advocate for enhanced interdisciplinary training for clinicians, who are encouraged to explore various resources (books, journals, news Web sites, and social media) and events (Datathons) to deepen their understanding of risk of bias.

Clinician perspectives and recommendations regarding design of clinical prediction models for deteriorating patients in acute care.

BACKGROUND: Successful deployment of clinical prediction models for clinical deterioration relates not only to predictive performance but to integration into the decision making process. Models may demonstrate good discrimination and calibration, but fail to match the needs of practising acute care clinicians who receive, interpret, and act upon model outputs or alerts. We sought to understand how prediction models for clinical deterioration, also known as early warning scores (EWS), influence the decision-making of clinicians who regularly use them and elicit their perspectives on model design to guide future deterioration model development and implementation. METHODS: Nurses and doctors who regularly receive or respond to EWS alerts in two digital metropolitan hospitals were interviewed for up to one hour between February 2022 and March 2023 using semi-structured formats. We grouped interview data into sub-themes and then into general themes using reflexive thematic analysis. Themes were then mapped to a model of clinical decision making using deductive framework mapping to develop a set of practical recommendations for future deterioration model development and deployment. RESULTS: Fifteen nurses (n = 8) and doctors (n = 7) were interviewed for a mean duration of 42 min. Participants emphasised the importance of using predictive tools for supporting rather than supplanting critical thinking, avoiding over-protocolising care, incorporating important contextual information and focusing on how clinicians generate, test, and select diagnostic hypotheses when managing deteriorating patients. These themes were incorporated into a conceptual model which informed recommendations that clinical deterioration prediction models demonstrate transparency and interactivity, generate outputs tailored to the tasks and responsibilities of end-users, avoid priming clinicians with potential diagnoses before patients were physically assessed, and support the process of deciding upon subsequent management. CONCLUSIONS: Prediction models for deteriorating inpatients may be more impactful if they are designed in accordance with the decision-making processes of acute care clinicians. Models should produce actionable outputs that assist with, rather than supplant, critical thinking.

How to Accurately Detect Renal Replacement Therapy Weaning in Intensive Care: Data Quality and Standardization Considerations for the OMOP Common Data Model.

This study assesses the effectiveness of the Observational Medical Outcomes Partnership common data model (OMOP CDM) in standardising Continuous Renal Replacement Therapy (CRRT) data from intensive care units (ICU) of two French university hospitals. Our objective was to extract and standardise data from various sources, enabling the development of predictive models for CRRT weaning that are agnostic to the data's origin. Data for 1,696 ICU stays from the two data sources were extracted, transformed, and loaded into the OMOP format after semantic alignment of 46 CRRT standard concepts. Although the OMOP CDM demonstrated potential in harmonising CRRT data, we encountered challenges related to data variability and the lack of standard concepts. Despite these challenges, our study supports the promise of the OMOP CDM for ICU data standardization, suggesting that further refinement and adaptation could significantly improve clinical decision making and patient outcomes in critical care settings.

Intensive Care Quality Indicators Dashboard Using Observational Medical Outcomes Partnership Common Data Model.

This paper presents the development of a visualization dashboard for quality indicators in intensive care units (ICUs), using the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). The dashboard enables the user to visualize quality indicator data using histograms, pie charts and tables. Our project uses the OMOP CDM, ensuring a seamless implementation of our dashboard across various hospitals. Future directions for our research include expanding the dashboard to incorporate additional quality indicators and evaluating clinicians' feedback on its effectiveness.

Intensive care unit guidelines for admission and discharge, 2023.

The Directorate General of Health Services (DGHS), India, has released guidelines for intensive care unit (ICU) admission and discharge [1] to guide intensivists and registered medical practitioners (RMPs) in an Expert Consensus Statement (ECS). This is based on the recommendations of 24 experts working in different ICU settings. This team deserves applause for their efforts in creating guidelines for clinicians working in ICU settings. The Delphi method [2], considered one of the most scientific methods for such statements, has been used for this ECS.

Reliability and Safety Testing of a Ventilator Remote Control System Against Communication Failures and Network Disruptions.

INTRODUCTION: The need for remote ventilator control has been highlighted by the COVID-19 Public Health Emergency. Remote ventilator control from outside a patient's room can improve response time to patient needs, protect health care workers, and reduce personal protective equipment (PPE) consumption. Extending remote control to distant locations can expand the capabilities of frontline health care workers by delivering specialized clinical expertise to the point of care, which is much needed in diverse health care settings, such as tele-critical care and military medicine. However, the safety and effectiveness of remote ventilator control can be affected by many risk factors, including communication failures and network disruptions. Consensus safety requirements and test methods are needed to assess the resilience and safety of remote ventilator control under communication failures and network disruptions. MATERIALS AND METHODS: We designed two test methods to assess the robustness, usability, and safety of a remote ventilator control prototype system jointly developed by Nihon Kohden OrangeMed, Inc. and DocBox, Inc. ("the NK-DocBox system") to control the operation of an NKV-550 critical care ventilator under communication failures and network disruptions. First, the robustness of the NKV-550 ventilator was tested using a remote-control application developed on OpenICE - an open-source medical device interoperability platform - to transmit customized high-frequency and erroneous remote-control commands that could be caused by communication failures in a real-world environment. The second method utilized a network emulator to create different types and severity of network quality of service (QoS) degradation, including bandwidth throttling, network delay and jitter, packet drop and reordering, and bit errors, in the NKV-DocBox system to quantitatively assess the impact on system usability and safety. RESULTS: The NKV-550 ventilator operated as expected when remote-control commands arrived as fast as once per second. It ignored erroneous commands attempting to adjust invalid ventilation parameters. When facing commands that set the ventilation mode and parameters to invalid values, it reset the ventilation mode or parameters to default values, the safety implication of which may merit further evaluation. When any network QoS attribute (except for packet reordering) started to degrade, the NK-DocBox System experienced interference to its remote-control function, such as delays in the transmission of ventilator data and remote-control commands within the system. When the network QoS was worse than 500 ms network delay, 100 ms network jitter, 1% data drop rate, 12 Mbps minimal bandwidth, or 1e-6 bit error rate, the system became unsafe to use. For example, ventilator waveforms visualized on the remote-control application demonstrated freezes, out-of-synchronization, and moving backwards; and the connection between the ventilator and the remote-control application became unstable. CONCLUSION: The presented test methods confirmed the robustness of the NKV-550 ventilator against high-frequency and erroneous remote control, quantified the impact of network disruptions on the usability, reliability, and safety of the NK-DocBox system and identified the minimum network QoS requirements for it to function safely. These generalizable test methods can be customized to evaluate other remote ventilator control technologies and remote control of other types of medical devices against communication failures and network disruptions.

Impact of En Route Critical Care Provider Experience on Lung Protective Ventilation Compliance During Air Transport of Combat Wounded.

INTRODUCTION: The primary objective of this study was to evaluate the association between the U.S. Air Force Critical Care Air Transport (CCAT) provider operational experience with compliance for lung protective ventilation (LPV) volumes recommended by Acute Respiratory Distress Syndrome Clinical Network guidelines. MATERIALS AND METHODS: We performed a retrospective cohort study of CCAT providers transporting combat casualties requiring mechanical ventilation from the Middle East to Germany from 2007 to 2012. We reviewed CCAT medical records from 2007 to 2012 for the total number of patient transports by CCAT physicians and respiratory care practitioners (RCPs). Center for Sustainment of Trauma and Readiness Skills Cincinnati process improvement questionnaire data described provider demographics and clinical backgrounds. We linked these data to patient demographics and in-flight ventilation management from a prior CCAT cohort study. Patient inclusion criteria included transport by CCAT from the Middle East to Germany for traumatic injury requiring mechanical ventilation between 2007 and 2012. We excluded patients with no documented height or tidal volume. LPV compliance was defined as tidal volumes ≤8 mL/kg of predicted body weight during en route critical care transport. We performed a logistic regression analysis. This study was reviewed and approved by the 59th Medical Wing institutional review board (IRB). RESULTS: We analyzed 491 patient transports conducted by 71 (RCPs and 84 physicians. Patients had a median age of 25 years (IQR 22-30), 98% were male, median injury severity score was 24 (IQR 17-34), and median preflight PaO2/FiO2 was 285 (IQR 220-365). Median experience was 26 missions (IQR 13-40) for RCPs and 23 missions (IQR 12-38) for physicians. All in-flight tidal volumes were LPV compliant in 58.3% of missions. Unadjusted analysis showed higher LPV compliance for RCPs with in-garrison critical care experience. Multivariate models did not find an association between missions flown and LPV compliance but did demonstrate a positive association with physician specialty of medical intensivist (OR 3.0, 95% CI 1.6-5.7) and a negative association with flights in 2008 (OR 0.4, 95% CI 0.2-0.7) for LPV compliance. CONCLUSION: No association was found between number of missions flown by CCAT providers and lung protective tidal volume compliance. Linkage of multiple data sources enabled investigation of clinical and operational currency associations with a care quality metric compliance in the combat en route care environment. Future studies should evaluate the impact of ongoing CCAT training and quality improvement interventions on LPV compliance.

[Intensive care after cardiac arrest - Swedish Resuscitation Council summarizes the new guidelines]. / Intensivvård efter hjärtstopp.

In Sweden 1600 patients/year survive cardiac arrest (30-day survival). Post-resuscitation care is complex and aims to stabilize organ function with focus on preventing secondary brain injury. In 2021 The European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) published joint guidelines on post-resuscitation care. In this article the Swedish Resuscitation Council summarizes the new guidelines with addition of more recent evidence to guide post-resuscitation care.

Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults.

RATIONALE: Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB). OBJECTIVES: The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. DESIGN: A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. METHODS: The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance. RESULTS: The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing. CONCLUSIONS: The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.

Core socioDemographic data variables in ICU Trials (CoDe-IT): a protocol for generating core data variables using a Delphi consensus process.

INTRODUCTION: Sociodemographic variables influence health outcomes, either directly (ie, gender identity) or indirectly (eg, structural/systemic racism based on ethnoracial group). Identification of how sociodemographic variables can impact the health of critically ill adults is important to guide care and research design for this population. However, despite the growing recognition of the importance of collecting sociodemographic measures that influence health outcomes, insufficient and inconsistent data collection of sociodemographic variables persists in critical care studies. We aim to develop a set of core data variables (CoDaV) for social determinants of health specific to studies involving critically ill adults. METHODS AND ANALYSIS: We will conduct a scoping review to generate a list of possible sociodemographic measures to be used for round 1 of the modified Delphi processes. We will engage relevant knowledge users (previous intensive care unit patients and family members, critical care researchers, critical care clinicians and research co-ordinators) to participate in the modified Delphi consensus survey to identify the CoDaV. A final consensus meeting will be held with knowledge user representatives to discuss the final CoDaV, how each sociodemographic variable will be collected (eg, level of granularity) and how to disseminate the CoDaV for use in critical care studies. ETHICS AND DISSEMINATION: The University of Calgary conjoint health research ethics board has approved this study protocol (REB22-1648).

How and when post intensive care syndrome-family is measured: A scoping review.

OBJECTIVES: Family members of Intensive Care Unit (ICU) patients can experience mental health difficulties. These are collectively described as Post Intensive Care Syndrome-Family (PICS-F). There are no standardised outcome measures to benchmark the impact of PICS-F. This scoping review aimed to map and characterise interventions, outcomes, and outcome instruments related to PICS-F. METHODS: Eight databases were searched in June 2023: Pubmed, CINAHL, Ovid Medline, EMBASE, PsycInfo, AMED, Emcare and Cochrane. The grey literature was also searched. Studies published after 2012 related to PICS-F were included. Search strategy included: (Population) family members of adult ICU patients, (Concept) PICS-F, (Context) ICU settings. Frequency analysis of outcomes was performed, and instruments were mapped to describe the characteristics. RESULTS: Of the identified 4848 records, 46 papers representing 44 unique studies met the inclusion criteria and were retained for analysis. In total, 8008 family members were represented across 15 countries in four continents worldwide. The number of studies reporting PICS-F interventions increased rapidly over the past 12 years and were performed in ICUs treating mixed conditions. Studies were randomised control trials (n = 33), before-and-after design (n = 6) and non-randomised trials (n = 5). A total of 18 outcome instruments were used measuring predominantly anxiety, with complicated grief measured only once. The identified instruments were mostly validated for clinical and disease specific populations but not validated among relatives of ICU patients. CONCLUSION: There is a plethora of instruments measuring PICS-F outcomes. No core outcome set is currently available for PICS-F. To reduce heterogeneity of how PICS-F is measured, a core outcome set with validated measurements is recommended to allow benchmarking and to document the impact of PICS-F interventions. IMPLICATIONS FOR CLINICAL PRACTICE: Recognising PICS-F symptoms and understanding how to assess them could help clinicians to develop interventions to improve family outcomes. Validated instruments are needed to evaluate these interventions.

Strategies to Improve Sleep Quality in Intensive Care Unit Patients.

BACKGROUND: Patients in intensive care units are exposed to many factors that can negatively affect the quality of their sleep. OBJECTIVE: To describe the latest findings regarding sleep quality improvement in intensive care unit patients. METHODS: An integrative literature review was conducted in the CINAHL, PubMed, Cochrane Library, and MEDLINE databases in April and May 2023. The following keywords were used: intensive care units, promotion, sleep quality, and sleep. The Critical Appraisal Skills Programme tool was used to assess the quality of individual studies. RESULTS: Of 159 articles identified, 10 were included in the final analysis. The findings were grouped into 4 thematic categories: consequences of poor sleep quality, factors affecting sleep quality, pharmacologic ways to improve sleep quality, and nonpharmacologic ways to improve sleep quality. DISCUSSION: Various pharmacologic and nonpharmacologic treatments are used in clinical settings. Nonpharmacologic interventions include sleep masks, earplugs, reductions in alarm volume, and reductions in nighttime interventions. Relaxation techniques include aromatherapy, music therapy, and acupressure. CONCLUSIONS: The most effective way to improve sleep for intensive care unit patients is to use a combination of pharmacologic and nonpharmacologic interventions. Among the latter, the use of earplugs and sleep masks is simplest.

Reigniting Intensive Care Unit Liberation.

BACKGROUND: The Society of Critical Care Medicine has established guidelines to manage pain, sedation, delirium, immobility, family participation, and sleep disruption in the intensive care unit, a set of interventions known as the intensive care unit liberation (ABCDEF) bundle. Adherence to these guidelines has shown positive results. LOCAL PROBLEM: In the intensive care units of a level I trauma academic teaching hospital in central Texas, the rate of bedside nursing staff adherence to the ABCDEF bundle was only 67.1% in January 2022. The aim of this quality improvement project was to improve adherence to the bundle. METHODS: Knowledge gaps were found to be the driver of the low adherence rate. Two primary needs were identified: (1) education on the elements of the ABCDEF bundle and (2) increased awareness and recognition of incomplete and incorrect documentation. Interventions included focused education on intensive care unit liberation. RESULTS: From February to June 2022, overall adherence to the ABCDEF bundle increased from 67.1% to 95.3%, ventilator use decreased by approximately 10%, and restraint use dropped by about 9%. The incidence of delirium increased, but this increase was due to incorrect patient assessment before the interventions. CONCLUSION: The results of this project are consistent with literature demonstrating that a multifaceted approach to improving ABCDEF bundle adherence can produce sustainable improvement in patient outcomes. This report may help other organizations facing similar challenges improve adherence to the bundle in a postpandemic environment.