Asociación entre Glucemia inestable, tiempo de estancia y mortalidad de pacientes en estado críticos: Estudio de cohorte / Associação Entre Glicemia Instável, Tempo de Permanência e Mortalidade de Pacientes Críticos: Estudo de Coorte / Relationships between unstable Glycemia, Hospital Length Of Stay, and mortality In Critically Ill patients: A cohort study

Resumen Introducción: El control y la evaluación de los niveles glucémicos de pacientes en estado críticos es un desafío y una competencia del equipo de enfermería. Por lo que, determinar las consecuencias de esta durante la hospitalización es clave para evidenciar la importancia del oportuno manejo. Objetivo: Determinar la asociación entre la glucemia inestable (hiperglucemia e hipoglucemia), el resultado de la hospitalización y la duración de la estancia de los pacientes en una unidad de cuidados intensivos. Metodología: Estudio de cohorte prospectivo realizado con 62 pacientes a conveniencia en estado crítico entre marzo y julio de 2017. Se recogieron muestras diarias de sangre para medir la glucemia. Se evaluó la asociación de la glucemia inestable con la duración de la estancia y el resultado de la hospitalización mediante ji al cuadrado de Pearson. El valor de p<0.05 fue considerado significativo. Resultados: De las 62 personas participantes, 50 % eran hombres y 50 % mujeres. La edad media fue de 63.3 años (±21.4 años). La incidencia de glucemia inestable fue del 45.2 % y se asoció con una mayor duración de la estancia en la UCI (p<0.001) y una progresión a la muerte como resultado de la hospitalización (p=0.03). Conclusión: Entre quienes participaron, la glucemia inestable se asoció con una mayor duración de la estancia más prolongada y con progresión hacia la muerte, lo que refuerza la importancia de la actuación de enfermería para prevenir su aparición.

Resumo Introdução: O controle e avaliação dos níveis glicêmicos em pacientes críticos é um desafio e uma competência da equipe de enfermagem. Portanto, determinar as consequências da glicemia instável durante a hospitalização é chave para evidenciar a importância da gestão oportuna. Objetivo: Determinar a associação entre glicemia instável (hiperglicemia e hipoglicemia), os desfechos hospitalares e o tempo de permanência dos pacientes em uma unidade de terapia intensiva. Métodos: Um estudo de coorte prospectivo realizado com 62 pacientes a conveniência em estado crítico entre março e julho de 2017. Foram coletadas amostras diariamente de sangue para medir a glicemia. A associação entre a glicemia instável com o tempo de permanência e o desfecho da hospitalização foi avaliada pelo teste qui-quadrado de Pearson. O valor de p <0,05 foi considerado significativo. Resultados: Das 62 pessoas participantes, 50% eram homens e 50% mulheres. A idade média foi de 63,3 anos (±21,4 anos). A incidência de glicemia instável foi de 45,2% e se associou a um tempo de permanência mais prolongado na UTI (p <0,001) e uma progressão para óbito como desfecho da hospitalização (p = 0,03). Conclusão: Entre os participantes, a glicemia instável se associou a um tempo mais longo de permanência e com progressão para óbito, enfatizando a importância da actuação da equipe de enfermagem para prevenir sua ocorrência.

Abstract Introduction: The control and evaluation of glycemic levels in critically ill patients is a challenge and a responsibility of the nursing team; therefore, determining the consequences of this during hospitalization is key to demonstrate the importance of timely management. Objective: To determine the relationship between unstable glycemia (hyperglycemia and hypoglycemia), hospital length of stay, and the hospitalization outcome of patients in an Intensive Care Unit (ICU). Methods: A prospective cohort study conducted with 62 critically ill patients by convenience sampling between March and July 2017. Daily blood samples were collected to measure glycemia. The correlation of unstable glycemia with the hospital length of stay and the hospitalization outcome was assessed using Pearson's chi-square. A p-value <0.05 was considered significant. Results: Among the 62 patients, 50% were male and 50% were female. The mean age was 63.3 years (±21.4 years). The incidence of unstable glycemia was 45.2% and was associated with a longer ICU stay (p<0.001) and a progression to death as a hospitalization outcome (p=0.03). Conclusion: Among critically ill patients, unstable glycemia was associated with an extended hospital length of stay and a progression to death, emphasizing the importance of nursing intervention to prevent its occurrence.

Cultura de segurança em unidades de terapia intensiva na perspectiva da equipe multiprofissional: Estudo multicêntrico / Cultura de seguridad en unidades de terapia intensiva en la perspectiva del equipo multiprofesional: Estudio multicéntrico / Safety Culture in intensive care units from multiprofessional team perspective: A multicenter study

Resumo Introdução: A Cultura de Segurança do Paciente é considerada um importante componente estrutural dos serviços, que favorece a implantação de práticas seguras e a diminuição da ocorrência de eventos adversos. Objetivo: Identificar os fatores associados à cultura de segurança do paciente nas unidades de terapia intensiva adulto em hospitais de grande porte da região Sudeste do Brasil. Método: Estudo transversal do tipo survey e multicêntrico. Participaram 168 profissionais de saúde de quatro unidades (A, B, C e D) de terapia intensiva adulto. Foi utilizado o questionário "Hospital Survey on Patient Safety Culture". Considerou-se como variável dependente o nível de cultura de segurança do paciente e variáveis independentes aspectos sociodemográficos e laborais. Foram usadas estatísticas descritivas e para a análise dos fatores associados foi elaborado um modelo de regressão logística múltipla. Resultados: Identificou-se associação entre tipo de hospital com onze dimensões da cultura de segurança, quanto à função a categoria profissional médico, técnico de enfermagem e enfermeiro foram relacionadas com três dimensões; o gênero com duas dimensões e tempo de atuação no setor com uma dimensão. Conclusão: Evidenciou-se que o tipo de hospital, categoria profissional, tempo de atuação no setor e gênero foram associados às dimensões de cultura de segurança do paciente.

Resumen Introducción: La cultura de seguridad del paciente se considera un componente estructural importante de los servicios, que favorece la aplicación de prácticas seguras y la reducción de la aparición de acontecimientos adversos. Objetivo: Identificar los factores asociados a la cultura de seguridad del paciente en unidades de terapia intensiva adulto en hospitales de la región Sudeste del Brasil. Metodología: Estudio transversal de tipo encuesta y multicéntrico. Participaron 168 profesionales de salud de cuatro unidades (A, B, C y D) de terapia intensiva adulto. Se utilizó el cuestionario "Hospital Survey on Patient Safety Culture". Se consideró como variable dependiente el nivel de cultura de seguridad del paciente y variables independientes los aspectos sociodemográficos y laborales. Fueron usadas estadísticas descriptivas y, para analizar los factores asociados, fue elaborado un modelo de regresión logística múltiple. Resultados: Se identificó asociación entre tipo de hospital con once dimensiones de cultura de seguridad del paciente. En relación a la función, personal médico, técnicos de enfermería y personal de enfermería fueron asociados con tres dimensiones, el género con dos dimensiones y tiempo de actuación con una dimensión en el modelo de regresión. Conclusión: Se evidenció que el tipo de hospital, función, tiempo de actuación en el sector y género fueron asociados a las dimensiones de la cultura de seguridad del paciente.

Abstract Introduction: Patient safety culture is considered an important structural component of the services, which promotes the implementation of safe practices and the reduction of adverse events. Objective: To identify the factors associated with patient safety culture in adult intensive care units in large hospitals in Belo Horizonte. Method: Cross-sectional survey and multicenter study. A total of 168 health professionals from four units (A, B, C and D) of adult intensive care participated. The questionnaire "Hospital Survey on Patient Safety Culture" was used. The patient's level of safety culture was considered as a dependent variable, and sociodemographic and labor aspects were the independent variables. Descriptive statistics were used and a multiple logistic regression model was developed to analyze the associated factors. Results: An association was identified between the type of hospital and eleven dimensions of the safety culture. In terms of function, the doctors, nursing technicians, and nurse were related to three dimensions; gender with two dimensions, and time working in the sector with one dimension. Conclusion: It was evidenced that the type of hospital, function, time working in the sector, and gender were associated with the dimensions of patient safety culture.

Optimizing Early Recovery Through Timely Mobilization in Nephrectomy Patients: A Case Report.

Nephrectomy, a surgical method involving the partial or complete removal of one or both kidneys, is performed if there is the presence of a tumor or many other reasons. In the above case, a 60-year-old female patient with a history of recurring symptoms, stomach pain, and fever, as well as a previous history of tuberculosis was brought to a tertiary care hospital. The patient underwent a left-sided nephrectomy. An X-ray and a complete blood count (CBC) were done during the investigations. Patients experienced various post-operative complications like respiratory discomfort, secretions, early fatigue, and intensive care unit-acquired weakness (ICUAW). The patient was referred for physiotherapy. Throughout the intervention, outcome assessments showed progressive improvement in lung capacity, inspiratory pressure, and quality of life scores. Goal-oriented physiotherapy was planned according to the severity of the symptoms of the patient. The physical therapy rehabilitation program in the above case was planned for six weeks focusing on symptoms like shortness of breath, early fatigue, secretions, respiratory discomfort, difficulty in maintaining good posture because of pain at the incision site, reduced mobility, and various post-operative complications. The study focuses on the efficacy of an integrated physiotherapy strategy in increasing lung compliance, secretion clearance, and overall respiratory health. Early mobilization strategies were crucial in reducing post-surgery problems, hastening functional recovery, and shortening hospital stays.

Ethics in disaster, mass casualty care, and critical care.

The primary ethical principle guiding general medical practice is autonomy. However, in mass casualty (MASCAL) or disaster scenarios, the principles of beneficence and justice become of foremost concern. Despite multiple reviews, publications, and training courses available to prepare for a MASCAL incident, a minority of physicians and healthcare providers are abreast of these. In this review, we describe several MASCAL scenarios and their associated ethical, moral, and medicolegal quandaries in attempts to curb potential future misadventures.

Development of Prediction Model for Intensive Care Unit Admission Based on Heart Rate Variability: A Case-Control Matched Analysis.

This study aimed to develop a predictive model for intensive care unit (ICU) admission by using heart rate variability (HRV) data. This retrospective case-control study used two datasets (emergency department [ED] patients admitted to the ICU, and patients in the operating room without ICU admission) from a single academic tertiary hospital. HRV metrics were measured every 5 min using R-peak-to-R-peak (R-R) intervals. We developed a generalized linear mixed model to predict ICU admission and assessed the area under the receiver operating characteristic curve (AUC). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated from the coefficients. We analyzed 610 (ICU: 122; non-ICU: 488) patients, and the factors influencing the odds of ICU admission included a history of diabetes mellitus (OR [95% CI]: 3.33 [1.71-6.48]); a higher heart rate (OR [95% CI]: 3.40 [2.97-3.90] per 10-unit increase); a higher root mean square of successive R-R interval differences (RMSSD; OR [95% CI]: 1.36 [1.22-1.51] per 10-unit increase); and a lower standard deviation of R-R intervals (SDRR; OR [95% CI], 0.68 [0.60-0.78] per 10-unit increase). The final model achieved an AUC of 0.947 (95% CI: 0.906-0.987). The developed model effectively predicted ICU admission among a mixed population from the ED and operating room.

Dengue-Associated Hemophagocytic Lymphohistiocytosis: A Narrative Review of Its Identification and Treatment.

Dengue's lack of specific treatments beyond supportive care prompts a focus on uncovering additional pathophysiological factors. Dengue-associated hemophagocytic lymphohistiocytosis (HLH), characterized by dysregulated macrophage activation and cytokine storm, remains underexplored despite its potential to worsen disease severity and mortality. While rare, dengue-associated HLH disproportionately affects severe cases, significantly impacting mortality rates. To mitigate high mortality, early identification and familiarity with dengue-associated HLH are imperative for prompt treatment by clinicians. This narrative review therefore aims to examine the current clinical and therapeutic knowledge on dengue-associated HLH, and act as a resource for clinicians to improve their management of HLH associated with severe dengue. Dengue-associated HLH should be considered for all cases of severe dengue and may be suspected based on the presence of prolonged or recurrent fever for >7 days, or anemia without intravascular hemolysis or massive bleeding. Diagnosis relies on fulfilling at least five of the eight HLH-2004 criteria. Treatment predominantly involves short courses (3-4 days) of high-dose steroids (e.g., dexamethasone 10 mg/m2), with additional therapies considered in more severe presentations. Notably, outcomes can be favorable with steroid therapy alone.

Effect of early mobilization on the development of pneumonia in patients with traumatic brain injury in the neurosurgical intensive care unit: A historical controls study.

BACKGROUND: Pneumonia has a high incidence in traumatic brain injury (TBI) patients and lacks effective treatments. Early mobilization (EM) may be a potentially effective treatment. AIM: To explore the impact of EM on TBI-related pneumonia in the neurosurgical intensive care unit (NICU). METHOD: This study was a historical control study. 100 TBI patients who received EM intervention were prospectively included as the experimental group (EM cohort), and 250 TBI patients were retrospectively included as the control group. The propensity score matching (PSM) method was employed to balance baseline and minimize potential bias. The relationship between EM and TBI-related pneumonia was investigated by univariate and multivariate logistic regression, then further determined by subgroup analysis. The influence of other variables was excluded by interaction analyses. Finally, the effect of EM on the prognosis of TBI patients was analysed by comparing the Glasgow Coma Scale (GCS) and the hospital stay. RESULTS: After screening, 86 patients were included in the EM cohort and 199 patients were included in the control cohort. There were obvious differences between the two cohorts at baseline, and these differences were eliminated after PSM, when the incidence of pneumonia was significantly lower in the EM cohort than in the control cohort (35.0% vs. 61.9%, p < .001). Multivariate logistic regression showed that EM was an independent risk factor for TBI-related pneumonia and was significantly associated with a decreased incidence of pneumonia. This correlation was present in most subgroups and was not affected by other variables (p for interaction >.05). Patients in the EM cohort had shorter length of ICU stay (6 vs. 7 days, p = .017) and higher GCS at discharge (12 vs. 11, p = .010). CONCLUSION: EM is a safe and effective treatment for TBI patients in NICU, which can reduce the incidence of pneumonia, help to improve prognosis and shorten the length of ICU stay. RELEVANCE TO CLINICAL PRACTICE: Although the utilization rate of EM is low in TBI patients for various reasons, EM is still an effective method to prevent complications. Our study confirms that a scientific and detailed EM strategy can effectively reduce the incidence of pneumonia while ensuring the safety of TBI patients, which is worthy of further research and clinical application.

Parents' perceptions of factors influencing sleep in pediatric intensive care units: A qualitative study.

PURPOSE: The purpose of this study is to explore factors influencing sleep in pediatric intensive care units as perceived by parents of critically ill children. DESIGN AND METHODS: This descriptive qualitative study used individual semistructured interviews. Parents were recruited through purposive sampling from two pediatric intensive care units at two locations in one university hospital in Norway. Ten parents were interviewed. The interviews were analyzed using a six-phase reflexive thematic analysis. FINDINGS: The analysis produced 17 subthemes under four main themes: environmental factors in the pediatric intensive care unit disturb children's sleep, children need trust and safety to sleep, nurses' cooperation with parents influences children's sleep, and nurses' structuring of their practices is fundamental to sleep promotion. CONCLUSION: The parents found that the environment disturbed their children's sleep, and environmental factors were easier to control in single rooms than in multibed rooms. Children slept better when they felt safe and trusted the nurses, and parents desired more cooperation in promoting sleep for their children, which may be an essential and overlooked part of sleep promotion. Nurses varied considerably in how they prioritized sleep and structured their practices to promote sleep. PRACTICE IMPLICATIONS: Nurses should take parents' experiences into account to better promote sleep for patients. By limiting environmental disturbances, building relationships with children to make them feel safe, including parents in sleep promotion, and prioritizing sleep in their practices, nurses could improve sleep quality and limit the consequences of sleep disturbance.

Coping strategies of intensive care unit nurses reducing moral distress: A content analysis study.

BACKGROUND: Moral distress has negative effects on physical and mental health. However, there is little information about nurses' coping strategies reducing moral distress. AIM: The purpose of this study was to investigate the coping strategies of intensive care unit nurses reducing moral distress in Iran. STUDY DESIGN: This is a qualitative study with a content analysis approach. PARTICIPANTS AND RESEARCH CONTEXT: The research sample consisted of nurses working in intensive care units of teaching hospitals affiliated to Tehran University of Medical Sciences. Samples were selected among eligible nurses by purposive sampling. Data were obtained through 17 in-depth, individual, and semi-structured interviews with 17 nurses. Graneheim and Lundman's (2004) 6-step content analysis method was used to analyze the data. Data management was also performed by MAXQDA software version 20. The COREQ checklist was used to report the study. ETHICAL CONSIDERATIONS: This project was approved by the Ethics Committee of Tehran University of Medical Sciences. All ethical guidelines in research were followed. FINDING: The data analysis resulted in the formation of two main categories of desirable coping strategies (with two subcategories of compensation and rejuvenation) and less desirable coping strategies (with three subclasses of indifference over time, escape and concealment). DISCUSSION: The intensive care unit nurses in dealing with ethical problems first try to solve the problem through discussion, but when they fail to resolve it peacefully, they resort to several coping strategies. Factors, such as increasing experience, lack of support from hospital managers and officials, poor communication between colleagues, the need to maintain hierarchy, fear of reprimand, and a sense of powerlessness, changed the nurses' preferred strategies. It is important for managers to provide a blame/punishment-free atmosphere for expression of ethical experiences; a supportive atmosphere in which staff can engage in ethical discussions without fear of punishment. They should also provide opportunities for rest, rejuvenation, and adequate training for their employees.

"Life-Sustaining Treatment and Advance Care Documentation among Chinese American ICU Decedents".

CONTEXT: Despite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings. OBJECTIVES: To compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents. METHODS: In this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis. RESULTS: We identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99-3.40) and DNI completion (OR 1.81; 95%CI, 1.07-1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55-1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03-41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%). CONCLUSIONS: During terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.

Understanding and Practices of Oral Hygiene in the Intensive Care Units: Perspectives of Medical Staff at Two University Hospital Centers.

Objective: This study assesses the knowledge, practices, and attitudes of medical staff in intensive care units (ICUs) regarding oral hygiene care for critically ill, bedridden patients. Material and methods: A cross-sectional study included 65 employees from the Intensive Care Units of the Sestre Milosrdnice Clinical Hospital Centre (CHC SM) and the Clinic for Anesthesiology and Intensive Care at the University Clinical Hospital Centre Zagreb (CHC ZG). A self-administered questionnaire was used to assess knowledge, methods, frequency, and attitudes towards oral care for mechanically ventilated patients. The data were examined through descriptive statistical methods, presented in terms of proportions (percentages). For the purpose of comparing the feedback across the two hospital centers and different educational backgrounds, the Chi-square and Fisher's exact tests were employed. Results: Results of a survey of 65 participants (18 from CHC SM and 47 from CHC ZG) revealed a notable disparity in oral hygiene knowledge, with graduate nurses displaying the highest proportion of adequate knowledge (100%) and regular nurses showing the least (30.3%) (p<.001). Although the execution of oral care practices did not vary significantly among the groups, graduate nurses performed oral care more frequently (80% vs. baccalaureate technicians 33.33% and nurses 57.6%, three or more times a day) and demonstrated better proficiency in both mechanical (p=.005) and chemical (p<.001) biofilm management compared to their counterparts. No significant difference was observed in the delivery of oral care to orotracheally intubated patients across different educational levels (p=.127). However, a marked difference was noted in the perception of being adequately trained for such care, with nurses feeling less prepared (12.1%, p<.001). Despite these variances, all respondents recognized the importance of oral hygiene, thus showing a strong dedication to oral health care. Conclusions: This study highlights variability in ICU oral hygiene practices and points to the importance of standardized care protocols and improved training for healthcare staff.

Contextual design requirements for decision-support tools involved in weaning patients from mechanical ventilation in intensive care units.

Weaning patients from ventilation in intensive care units (ICU) is a complex task. There is a growing desire to build decision-support tools to help clinicians during this process, especially those employing Artificial Intelligence (AI). However, tools built for this purpose should fit within and ideally improve the current work environment, to ensure they can successfully integrate into clinical practice. To do so, it is important to identify areas where decision-support tools may aid clinicians, and associated design requirements for such tools. This study analysed the work context surrounding the weaning process from mechanical ventilation in ICU environments, via cognitive task and work domain analyses. In doing so, both what cognitive processes clinicians perform during weaning, and the constraints and affordances of the work environment itself, were described. This study found a number of weaning process tasks where decision-support tools may prove beneficial, and from these a set of contextual design requirements were created. This work benefits researchers interested in creating human-centred decision-support tools for mechanical ventilation that are sensitive to the wider work system.

Upskill training and preparedness of non-critical-care registered nurses deployed to intensive care units during the COVID-19 pandemic: A scoping review.

BACKGROUND: The increase in intensive care unit (ICU) capacity compelled by the COVID-19 pandemic required the rapid deployment of non-critical-care registered nurses to the ICU setting. The upskill training needed to prepare these registered nurses for deployment was rapidly assembled due to the limited timeframe associated with the escalating pandemic. Scoping the literature to identify the content, structure, and effectiveness of the upskill education provided is necessary to identify lessons learnt during the COVID-19 pandemic response so that they may guide workforce preparation for future surge planning. AIM: The aim of this scoping review was to map the literature to identify the available information regarding upskill training and preparedness of non-critical-care registered nurses deployed to the ICU during the COVID-19 pandemic. METHODS: This scoping review was conducted in accordance with JBI methodology. A protocol outlined the review questions and used the participants, concept, and context framework to define the inclusion and exclusion criteria. A search of healthcare databases MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane, and Scopus was supplemented with a grey literature search via Google. RESULTS: Screening and review found 32 manuscripts that met the inclusion criterion for examination. Analysis revealed variation in duration of programs, theoretical versus practical content, face-to-face or online mode of delivery, and duration of preparation time at the bedside in the ICU setting. Data on contributors to preparedness for deployment were sparse but included training, support, peer education, buddy time, and clarity around responsibilities and communication. DISCUSSION: Evaluation of upskill education was mostly limited to post-training surveys. Few studies explored the preparedness of deployed registered nurses as an outcome of their upskill training or described measures of effectiveness of ICU deployment. CONCLUSION: There is limited evidence describing preparedness of non-critical-care registered nurses on deployment to the ICU. Further research is needed to identify what elements of upskill education led to preparedness and effective deployment to the ICU setting.

Hyperlacticaemia in children with status asthmaticus. The Stewart approach.

BACKGROUND: Patients with status asthmaticus (SA) frequently present with lactic acidosis (LA). Our goal is to identify the nature of this LA using the Stewart physicochemical model and to identify the independent factors associated with LA in children with SA. METHODS: Analytical study of a retrospective cohort using a nested case-control design. Twenty-eight episodes of SA in 24 children were included. Patients admitted to a paediatric intensive care unit (PICU) for SA over a 9-year period were recruited consecutively. Data were analysed using the Stewart model and the Strong Ion Calculator. Data were analysed using descriptive statistics and regression models were fitted within the general linear model. RESULTS: Hyperlacticaemia (Lact[mM/L] = 3.905 [95% CI = 3.018-4.792]) and acidosis (pH = 7.294 [95% CI = 7.241-7.339]) were observed in 18 episodes (15 patients; 62.5%). According to the Stewart model, acidosis was caused by a decrease in strong ion difference. Initially, pCO2 was high (pCO2[mmHg] = 45.806 [95% CI = 37.314-54.298]) but the net unmeasured ion (NUI) component was normal (NUI=-4,461 [95% CI=-3.51 - -5.412]), and neither changed significantly over the clinical course. There was no need to determine pyruvate, as the NUI was normal and the LA was type B (non-hypoxic, lactate / pyruvate < 25). We observed a correlation (p = 0.023) between LA and intramuscular epinephrine administered on arrival at hospital, but not between LA and the cumulative dose of nebulized salbutamol. CONCLUSIONS: Most patients with SA presented LA. The Stewart model confirmed that LA is not hypoxic, probably due to sympathomimetic-related glycolysis.

Gastrointestinal effects of caffeine in preterm infants: a systematic review and Bayesian meta-analysis.

OBJECTIVE: Caffeine is widely used in preterm infants to prevent or treat apnoea of prematurity. Adverse gastrointestinal effects of caffeine have not been thoroughly researched in preterm infants. With this systematic review and meta-analysis, we aim to summarise the results of trials on the gastrointestinal effects of caffeine in preterm infants. DESIGN: We searched MEDLINE, Web of Science, Scopus and ClinicalTrials.gov up to 21 April 2023. We included randomised controlled trials assessing caffeine versus placebo in preterm neonates and reporting gastrointestinal side effects. Risk of bias was assessed using the Cochrane Risk of Bias tool. A Bayesian meta-analysis was performed to estimate the pooled OR of gastrointestinal side effects. RESULTS: Nine trials involving 2746 preterm infants were analysed. Seven trials assessing necrotising enterocolitis and four trials assessing feeding intolerance in our meta-analysis found no differences between caffeine and placebo (OR=1.007 (95% credible interval 0.021, 5.462), I2=97.4%, and OR=1.266 (95% credible interval 0.064, 28.326), I2=84.8%, respectively). Four trials assessed the outcomes spontaneous intestinal perforation, constipation, gastrointestinal disorder (composite outcome: gastro-oesophageal regurgitation or dilated bowel loops), age at oral feeding and cholestasis syndrome and found no differences between groups. One trial assessed the outcomes gastro-oesophageal symptoms and duration of tube feeding and found that caffeine was associated with a reduced burden of gastro-oesophageal reflux symptoms at 2 weeks (p<0.05), but not at term. CONCLUSIONS: According to this systematic review and meta-analysis, the use of caffeine at usual doses in preterm infants does not seem to be associated with significant gastrointestinal adverse effects.

[Withdrawal of Life-Sustaining Treatment in the PICU From the Nursing Staff's Perspective: Integrative Review]. / Beendigung lebenserhaltender Maßnahmen auf der Kinderintensivstation aus Perspektive der Pflegefachpersonen.

Withdrawal of Life-Sustaining Treatment in the PICU From the Nursing Staff's Perspective: Integrative Review Abstract: Background: Withdrawal of life sustaining measures is a common mode of treatment prior to the death of a critically ill child and has implications for all involved. The perspective of nurses has not yet been considered in this context. Aim: How do nurses experience the termination of life-sustaining measures in the paediatric intensive care unit? What is their role in this process? Methods: An integrative review was conducted to answer the research question. The literature search was performed in October 2022 in the CINAHL, Medline and PsycINFO databases. Results: Three qualitative and five quantitative studies were included. The confrontation with emotions, uncertainties in the decision-making process, challenges and conflicts in collaboration, in interacting with those involved and in the provision of care determine the experience of nurses during treatment withdrawal. The nurses as involved in the decision-making process and representative of interests are influenced by intrarole conflicts. Conclusion: Nursing professionals need support to cope with their experiences in the context of treatment withdrawal in children. In addition to surveying the type and scope of support measures, interprofessional guidelines must be developed when life-sustaining measures are withdrawn. This includes future research to specify the role of nurses in treatment withdrawal and includes, for example, the description of specific tasks, necessary skills or the extent of involvement in decision-making.

A novel nomogram for the prediction of subsyndromal delirium in patients in intensive care units: A prospective, nested case-controlled study.

BACKGROUND: Subsyndromal delirium is a dynamic, recognizable condition commonly observed in intensive care unit (ICU) patients that can lead to poor patient prognosis, and its prompt recognition and management can prevent disease progression. However, no evidence-based predictive tool has been developed specifically to assess the occurrence of subsyndromal delirium in the ICU. OBJECTIVE: To develop and validate a novel, simple and effective tool for estimating the risk of subsyndromal delirium among ICU patients. DESIGN: A prospective, nested case-controlled study. DATA SOURCES: A total of 731 patients were recruited from the central ICU of a tertiary hospital in southwestern China from August 2021 to November 2022. METHODS: The least absolute shrinkage and selection operator was applied to screen potential features for univariate and multivariate logistic regression. A nomogram was constructed using the selected variables. The performance of the nomogram was evaluated by combining the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). RESULTS: The prevalence of subsyndromal delirium among ICU patients was 23.06 %. Multiple logistic regression analysis revealed that the independent predictive factors for subsyndromal delirium among ICU patients were vision impairment, a history of falls, the use of restraint, blood transfusion, the use of antibiotics, surgery, the Caprini score, and the Braden score, all of which were used to construct the nomogram. The AUCs for the model were 0.710 (95 % CI, 0.654-0.766, P < 0.001) and 0.825 (95 % CI, 0.732-0.917, P < 0.001) in the training and validation cohorts, respectively, indicating that the model had high accuracy in distinguishing patients with and without subsyndromal delirium. The calibration curve of the nomogram showed good consistency between the predicted and actual probabilities. The DCA indicated that the nomogram has clinical application for patients in the ICU. CONCLUSIONS: We developed an easy-to-use nomogram for identifying subsyndromal delirium in ICU patients with satisfactory predictive ability based on simple and easily accessible clinical features. The nomogram can identify ICU patients at high-risk for subsyndromal delirium and may be a useful subsyndromal delirium tool for current ICU physicians.

Predicting adverse long-term neurocognitive outcomes after pediatric intensive care unit admission.

BACKGROUND AND OBJECTIVE: Critically ill children may suffer from impaired neurocognitive functions years after ICU (intensive care unit) discharge. To assess neurocognitive functions, these children are subjected to a fixed sequence of tests. Undergoing all tests is, however, arduous for former pediatric ICU patients, resulting in interrupted evaluations where several neurocognitive deficiencies remain undetected. As a solution, we propose using machine learning to predict the optimal order of tests for each child, reducing the number of tests required to identify the most severe neurocognitive deficiencies. METHODS: We have compared the current clinical approach against several machine learning methods, mainly multi-target regression and label ranking methods. We have also proposed a new method that builds several multi-target predictive models and combines the outputs into a ranking that prioritizes the worse neurocognitive outcomes. We used data available at discharge, from children who participated in the PEPaNIC-RCT trial (ClinicalTrials.gov-NCT01536275), as well as data from a 2-year follow-up study. The institutional review boards at each participating site have also approved this follow-up study (ML8052; NL49708.078; Pro00038098). RESULTS: Our proposed method managed to outperform other machine learning methods and also the current clinical practice. Precisely, our method reaches approximately 80% precision when considering top-4 outcomes, in comparison to 65% and 78% obtained by the current clinical practice and the state-of-the-art method in label ranking, respectively. CONCLUSIONS: Our experiments demonstrated that machine learning can be competitive or even superior to the current testing order employed in clinical practice, suggesting that our model can be used to severely reduce the number of tests necessary for each child. Moreover, the results indicate that possible long-term adverse outcomes are already predictable as early as at ICU discharge. Thus, our work can be seen as the first step to allow more personalized follow-up after ICU discharge leading to preventive care rather than curative.

Inter-rater agreement between patient- and proxy-reported cognitive functioning in intensive care unit patients: A cohort study.

BACKGROUND: Health status, including cognitive functioning before critical illness, is associated with long-term outcomes in intensive care unit survivors. Premorbid data are therefore of importance in longitudinal studies. Few patients can self-report at intensive care admission. Consequently, proxy assessments of patients' health status are used. However, it remains unclear how accurately proxies can report on an intensive care patient's cognitive status. OBJECTIVES: The aim of this study was to examine the agreement between patient- and proxy-reporting of the Cognitive Failures Questionnaire and to compare the agreement between proxy reports using the latter questionnaire and the Informant Questionnaire of Cognitive Decline in the Elderly as a reference. METHODS: The present cohort study is part of a longitudinal multicentre study collecting both patient and proxy data using questionnaires and clinical data from medical records during intensive care unit stays. Agreement on patient and proxy pairs was examined using intraclass correlation coefficient (ICC), Spearman's correlation, percentage agreement, and Gwet's AC1 statistics. Agreement between the proxy-reported questionnaires was examined using percentage agreement and Gwet's AC1 statistics. RESULTS: In total, we collected 99 pairs of patient-proxy assessments and 158 proxy-proxy assessments. The ICC for the sum scores revealed moderate agreement (n = 99; ICC = 0.59; 99% confidence interval [CI]: [0.30-0.76]) between patient and proxy. Agreement on items was poor (AC1 = 0.13; 99% CI: [0.01-0.24]) to moderate (AC1 = 0.55; 99% CI: [0.43-0.68]). Agreement using cut-off scores (>43) to indicate cognitive impairment was very good (89.9%, AC1 = 0.87; 99% CI: [0.79-0.95]). Agreement between the proxy-reported Cognitive Failures Questionnaire (>43) and the reference questionnaire (≥3.5) was also very good (n = 158; 85%, AC1 = 0.82; 99% CI: [0.74-0.90]). CONCLUSIONS: Proxy assessments of the Cognitive Failures Questionnaire (>43) may be used to indicate cognitive impairment if patients are unable to self-report. Agreement was high between the two questionnaires determined by proxies, showing that these can be used interchangeably to assess cognitive functioning if proxy reporting is needed.