High PEEP/low FiO2 ventilation is associated with lower mortality in COVID-19.

RATIONALE: The positive end-expiratory pressure (PEEP) strategy in patients with coronavirus 2019 (COVID-19) acute respiratory distress syndrome (ARDS) remains debated. Most studies originate from the initial waves of the pandemic. Here we aimed to assess the impact of high PEEP/low FiO2 ventilation on outcomes during the second wave in the Netherlands. METHODS: Retrospective observational study of invasively ventilated COVID-19 patients during the second wave. Patients were categorized based on whether they received high PEEP or low PEEP ventilation according to the ARDS Network tables. The primary outcome was ICU mortality, and secondary outcomes included hospital and 90-day mortality, duration of ventilation and length of stay, and the occurrence of kidney injury. Propensity matching was performed to correct for factors with a known relationship to ICU mortality. RESULTS: This analysis included 790 COVID-ARDS patients. At ICU discharge, 32 (22.5%) out of 142 high PEEP patients and 254 (39.2%) out of 848 low PEEP patients had died (HR 0.66 [0.46-0.96]; P = 0.03). High PEEP was linked to improved secondary outcomes. Matched analysis did not change findings. CONCLUSIONS: High PEEP ventilation was associated with improved ICU survival in patients with COVID-ARDS.

Driving pressure during routine ventilation in the ICU: Is the ICU-team as driven as they should be?

PURPOSE: To evaluate the effect of structured staff training on the respiratory support provided. MATERIALS AND METHODS: Staff training with emphasis on the applied DP in mechanical ventilation was provided during one year. After completion of staff training, the effect was prospectively evaluated in patients who were continuously mechanically ventilated in a controlled mode for at least 6 h starting from admission. Pressure difference (Pdiff = Ppeak - PEEPtot) in the baseline period, as a derivative of the driving pressure, was compared with two evaluation periods from 0 to 6 months and 6-12 months (i.e. follow-up) after completion of the training. RESULTS: At analysis 248 patients met the inclusion criteria. In the baseline period Pdiff was not lung protective (> 15 cm H2O) in 39% of cases. In the first follow-up period this decreased to 25% of cases and further dropped to 17% in the second follow-up period. This was a relative decrease of 56% compared to the training period. At the end of evaluation the proportion of patients with a safe Pdiff had gradually increased from 58% during training to 82% (χ2 = p 0.005). CONCLUSIONS: These results suggest that ICU staff training could lead to more adequate respiratory support provided during controlled mechanical ventilation.

A Core Outcome Set for Research Evaluating Interventions to Enable Communication in Patients With an Artificial Airway: An International Delphi Consensus Study (Comm-COS).

OBJECTIVES: Critically ill adults requiring artificial airways experience profound communication deficits. Studies of interventions supporting communication report disparate outcomes, creating subsequent challenges in the interpretation of their effectiveness. Therefore, we aimed to develop international consensus for a communication core outcome set (Comm-COS) for future trials of communication interventions in this population. DESIGN: 1) Systematic review, 2) patient/family interviews, 3) two-round modified Delphi, and 4) virtual consensus meetings with a final voting round. A multidisciplinary expert steering committee oversaw all stages. SETTING: Interviews and consensus meetings were conducted via videoconferencing. Digital methods were used for Delphi and final Comm-COS voting. SUBJECTS: Three stakeholder groups: 1) patient and family members with lived experience within 3 years, 2) clinicians with experience working in critical care, and 3) researchers publishing in the field. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We identified 59 outcomes via our systematic review, 3 unique outcomes from qualitative interviews, and 2 outcomes from our steering committee. Following item reduction, 32 outcomes were presented in Delphi round 1; 134 participants voted; 15 patient/family (11%), 91 clinicians (68%), and 28 researchers (21%). Nine additional outcomes were generated and added to round 2; 106 (81%) participants voted. Following completion of the consensus processes, the Comm-COS includes seven outcomes: 1) changes in emotions and wellbeing associated with ability to communicate, 2) physical impact of communication aid use, 3) time to functional communication, 4) ability to communicate healthcare needs (comfort/care/safety/decisions), 5) conversation agency, 6) ability to establish a communication connection to develop and maintain relationships, and 7) acceptability of the communication intervention. CONCLUSIONS: This is the first COS to specifically focus on communication for critically ill adults. Limitations for operationalization include selection of measures to use with these outcomes. Identification of suitable measures and adoption of the Comm-COS in future trials will help establish effective interventions to ameliorate the highly prevalent and negative experience of communicative incapacity.

Whole blood thiamine, intravenous thiamine supplementation and delirium occurrence in the intensive care unit: retrospective cohort analyses.

BACKGROUND: Thiamine di-phosphate is an essential cofactor in glucose metabolism, glutamate transformation and acetylcholinesterase activity, pathways associated with delirium occurrence. We hypothesised that a deficiency in whole blood thiamine and intravenous thiamine supplementation could impact delirium occurrence. AIM: To establish whether a deficiency in whole blood thiamine and/or intravenous thiamine supplementation within 72 h of intensive care admission is associated with delirium occurrence. METHOD: The first dataset was secondary analysis of a previous study in an intensive care unit in the Netherlands, reported in 2017. The second dataset contained consecutive intensive care admissions 2 years before (period 1: October 2014 to October 2016) and after (period 2: April 2017 to April 2019) routine thiamine supplementation was introduced within 72 h of admission. Delirium was defined as a positive Confusion Assessment Method-Intensive Care Unit score(s) in 24 h. RESULTS: Analysis of the first dataset (n = 57) using logistic regression showed no relationship between delirium and sepsis or whole blood thiamine, but a significant association with age (p = 0.014). In the second dataset (n = 3074), 15.1% received IV thiamine in period 1 and 62.6% during period 2. Hierarchical regression analysis reported reduction in delirium occurrence in the second period; this did not reach statistical significance, OR = 0.81 (95% CI 0.652-1.002); p = 0.052. CONCLUSION: No relationship was detected between whole blood thiamine and delirium occurrence on admission, at 24 and 48 h. It remains unclear whether routine intravenous thiamine supplementation during intensive care admission impacts delirium occurrence. Further prospective randomised clinical trials are needed.

The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial.

BACKGROUND: Drug-drug interactions (DDIs) can harm patients admitted to the intensive care unit (ICU). Yet, clinical decision support systems (CDSSs) aimed at helping physicians prevent DDIs are plagued by low-yield alerts, causing alert fatigue and compromising patient safety. The aim of this multicentre study was to evaluate the effect of tailoring potential DDI alerts to the ICU setting on the frequency of administered high-risk drug combinations. METHODS: We implemented a cluster randomised stepped-wedge trial in nine ICUs in the Netherlands. Five ICUs already used potential DDI alerts. Patients aged 18 years or older admitted to the ICU with at least two drugs administered were included. Our intervention was an adapted CDSS, only providing alerts for potential DDIs considered as high risk. The intervention was delivered at the ICU level and targeted physicians. We hypothesised that showing only relevant alerts would improve CDSS effectiveness and lead to a decreased number of administered high-risk drug combinations. The order in which the intervention was implemented in the ICUs was randomised by an independent researcher. The primary outcome was the number of administered high-risk drug combinations per 1000 drug administrations per patient and was assessed in all included patients. This trial was registered in the Netherlands Trial Register (identifier NL6762) on Nov 26, 2018, and is now closed. FINDINGS: In total, 10 423 patients admitted to the ICU between Sept 1, 2018, and Sept 1, 2019, were assessed and 9887 patients were included. The mean number of administered high-risk drug combinations per 1000 drug administrations per patient was 26·2 (SD 53·4) in the intervention group (n=5534), compared with 35·6 (65·0) in the control group (n=4353). Tailoring potential DDI alerts to the ICU led to a 12% decrease (95% CI 5-18%; p=0·0008) in the number of administered high-risk drug combinations per 1000 drug administrations per patient, after adjusting for clustering and prognostic factors. INTERPRETATION: This cluster randomised stepped-wedge trial showed that tailoring potential DDI alerts to the ICU setting significantly reduced the number of administered high-risk drug combinations. Our list of high-risk drug combinations can be used in other ICUs, and our strategy of tailoring alerts based on clinical relevance could be applied to other clinical settings. FUNDING: ZonMw.

Thirst in adult patients in the intensive care unit: protocol for a scoping review.

INTRODUCTION: Thirst is one of the most bothersome symptoms experienced by intensive care unit (ICU) patients. Effective diagnosis and management of thirst in the ICU is essential, particularly as patients are less sedated than previously and more aware of this problem. Currently, no overview of publications on thirst identification and management in ICU patients exists. The scoping review will address the broad question 'What is known about thirst as a symptom in adult critically ill patients?' It aims to provide an overview of the causes and risk factors, diagnosis and measurement, the symptom dimensions and its interaction with other symptoms, and thirst management. METHODS AND ANALYSIS: The review will follow the Joanna Briggs Institute methodology framework to guide the process and will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Methods include: defining the review questions, eligibility criteria, concepts of interest and context; and outlining the search strategy, study selection process, data extraction and analysis. PubMed, MEDLINE, EMBASE and CINAHL will be searched from inception to April 2022. ETHICS AND DISSEMINATION: Ethical approval is not required, as the scoping review will synthesise information from available publications. The scoping review will be submitted for publication to a scientific journal, presented at relevant conferences and disseminated as part of future workshops with ICU support groups and the critical care professional community.

Mental health-related quality of life is related to delirium in intensive care patients.

PURPOSE: Delirium during intensive care unit (ICU) stay may be related to premorbid mental illness. In addition, delirium during ICU stay may also negatively affect long-term health-related quality of life. The aim of our study was to investigate if delirium in the ICU is related to premorbid mental quality of life and affects long-term mental quality of life after ICU stay. METHODS: We performed a prospective cohort study in 1021 patients admitted for longer than 48 h in a medical-surgical ICU. We evaluated mental and physical quality of life using the Short-form-12 before ICU admission, at hospital discharge, and 3, 6 and 12 months after hospital discharge. Mixed model and logistic regression models were used to analyze the data. RESULTS: Patients who experienced a delirium during ICU stay reported a worse pre-admission mental quality of life than those without delirium (p < 0.001). Furthermore, patients who suffered from delirium during their ICU stay exhibited a significant decrease in mental quality of life over time relative to patients without delirium (p = 0.035). CONCLUSION: In this large follow-up study, we demonstrated that ICU survivors who experienced a delirium during ICU stay reported a significantly worse pre-admission mental health-related quality of life and a significant decrease in mental health-related quality of life in the year after hospital discharge compared with patients without delirium.

Variation in communication and family visiting policies in intensive care within and between countries during the Covid-19 pandemic: The COVISIT international survey.

BACKGROUND: During the COVID-19 pandemic, intensive care units (ICU) introduced restrictions to in-person family visiting to safeguard patients, healthcare personnel, and visitors. METHODS: We conducted a web-based survey (March-July 2021) investigating ICU visiting practices before the pandemic, at peak COVID-19 ICU admissions, and at the time of survey response. We sought data on visiting policies and communication modes including use of virtual visiting (videoconferencing). RESULTS: We obtained 667 valid responses representing ICUs in all continents. Before the pandemic, 20% (106/525) had unrestricted visiting hours; 6% (30/525) did not allow in-person visiting. At peak, 84% (558/667) did not allow in-person visiting for patients with COVID-19; 66% for patients without COVID-19. This proportion had decreased to 55% (369/667) at time of survey reporting. A government mandate to restrict hospital visiting was reported by 53% (354/646). Most ICUs (55%, 353/615) used regular telephone updates; 50% (306/667) used telephone for formal meetings and discussions regarding prognosis or end-of-life. Virtual visiting was available in 63% (418/667) at time of survey. CONCLUSIONS: Highly restrictive visiting policies were introduced at the initial pandemic peaks, were subsequently liberalized, but without returning to pre-pandemic practices. Telephone became the primary communication mode in most ICUs, supplemented with virtual visits.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey.

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

Measuring thirst distress of patients in the intensive care unit.

BACKGROUND: Thirst is one of the most intense and distressing symptoms experienced by patients in the intensive care unit (ICU), and no validated measurement tools exist. Validating a thirst measurement tool for the ICU population could be a first step in gaining a better understanding of thirst in ICU patients and aid the development and implementation of strategies regarding the prevention and control of thirst. AIM: The objective of this study was to determine the validity and reliability of the "Thirst distress scale for patients with heart failure (TDS-HF)" in measuring thirst distress in adult ICU patients. METHODS: Content validity was established by an expert panel consisting of ICU nurses, intensivists and five ICU patients. Concurrent validity, known-groups validity and internal consistency were determined in a consecutive sample of 56 awake and oriented ICU patients with a median age of 70 years (IQR: 57-74). RESULTS: Content validity of the TDS-HF in the ICU population was low, with item-content validity indexes between 0.25 and 0.75. Concurrent validity was high as Spearman's correlation between TDS-HF and the numeric rating score (0-10) for thirst distress was 0.71. Internal consistency was high (Cronbach's alpha 0.78). When comparing groups, only higher blood urea nitrogen was significantly related to higher scores on the TDS-HF (P = .003). CONCLUSION: The TDS-HF has high concurrent validity and reliability in measuring thirst distress in ICU patients. Nevertheless, questions remain regarding the applicability and content validity of the scale, which should be further explored before the TDS-HF can be used in the ICU. RELEVANCE FOR CLINICAL PRACTICE: The TDS-HF can be used to explore thirst distress and to evaluate interventions. Individual items of the scale can be used to explore the nature of thirst distress in individual patients.

SICQ Coping and the Health-Related Quality of Life and Recovery of Critically Ill ICU Patients: A Prospective Cohort Study.

BACKGROUND: The coping styles of the Sickness Insight in Coping Questionnaire (SICQ; positivism, redefinition, toughness, fighting spirit, nonacceptance) may affect the health and recovery of hospitalized critically ill patients. RESEARCH QUESTION: Do the SICQ coping styles of hospitalized critically ill patients relate to the patients health-related quality of life (HRQoL) and recovery? STUDY DESIGN AND METHODS: A prospective cohort study was conducted in a single university-affiliated Dutch hospital. Participants were critically ill adult patients admitted to a mixed medical-surgical ICU (start: n = 417; pre-ICU: n = 391; hospital discharge: n = 350; 3-month follow-up: n = 318; 6-month follow-up: n = 308; 12-month follow-up: n = 285). Coping was recorded with the SICQ pre-ICU and at discharge. HRQoL was measured with the SF-12 pre-ICU, at discharge, and 3, 6, and 12 months after discharge. Indicators of recovery were ICU and hospital length of stay, discharge disposition, and mortality. Correlation and regression analyses were used for data analysis. RESULTS: Positivism (r = 0.28-0.51), fighting spirit (r = 0.14-0.35), and redefinition (r = 0.12-0.23) associated significantly (P < .05) with mental HRQoL after discharge. Furthermore, positivism associated positively (P < .01) with physical HRQoL (r = 0.17-0.26) after discharge. Increase in positivism (r = 0.13), redefinition (r = 0.13), and toughness (r = 0.13) across the period of hospitalization associated positively (P ≤ .05) with mental HRQoL at discharge. Pre-ICU positivism associated with hospital length of stay (ρ = -.21, P ≤ .05) and hazard for death (HR = 0.57, P < .01) and had a unidirectional effect on mental HRQoL (ß = .30, P < .001). INTERPRETATION: SICQ coping is associated with long-term mental HRQoL, hospital length of stay, and hazard for death among hospitalized critically ill patients.

Health-related quality of life in ICU survivors-10 years later.

Many Intensive Care (ICU) survivors experience long lasting impairments in physical and psychological health as well as social functioning. The objective of our study was to evaluate these effects up to 10 years after ICU discharge. We performed a long-term prospective cohort study in patients admitted for longer than 48 h in a medical-surgical ICU. We evaluated health-related quality of life (HRQOL) before ICU admission using the Short-form-36 (SF-36), at ICU discharge, at hospital discharge and at 1, 2, 5 and 10 years follow up (all by patients). Changes in HRQOL were assessed based on linear mixed modeling. We included a total of 749 patients (from 2000 to 2008). During 10 years 475 (63.4%) patients had died, 125 (16.7%) patients were lost to follow up and 149 (19.9%) patients could be evaluated. The mean scores of four HRQOL dimensions (i.e., physical functioning (p < 0.001; mean 54, SD 32, effect size 0.77, 95% CI [0.54-1.0]), role-physical (p < 0.001; mean 44, SD 47, effect size 0.65, 95% CI [0.41-0.68] general health (p < 0.001; mean 52, SD 27, effect size 0.48; 95% CI 0.25-0.71) and social functioning (p < 0.001; mean 72, SD 32, effect size 0.41, 95% CI [0.19-0.64]) were still lower 10 years after ICU discharge compared with pre-admission levels (n = 149) and with an age reference population. Almost all SF-36 dimensions changed significantly over time from ICU discharge up to 10 years after ICU discharge. Over the 10 year follow up physical functioning of medical-surgical ICU survivors remains impaired compared with their pre-admission values and an age reference population. However, effect sizes showed no significant differences suggesting that surviving patients largely regained their age-specific HRQOL at 10 years.

Tailored modulation of the inflammatory balance in COVID-19 patients admitted to the ICU?-a viewpoint.

A growing consensus seems to be emerging that dexamethasone is a crucial component in the treatment of COVID-19-associated oxygen-dependent respiratory failure. Although dexamethasone has an undeniably beneficial effect on the inflammatory response in a subgroup of patients, the potential negative effects of corticosteroids must also be considered. In view of these negative effects, we argue that a one-size-fits-all dexamethasone approach may be potentially harmful in specific subsets of patients with COVID-19-associated ARDS. We propose a different individually tailored treatment strategy based on the patient's inflammatory response.