Efetividade de um plano de metas fisioterapêuticas em pacientes internados em uma unidade de terapia intensiva: uma análise retrospectiva vs. prospectiva / Effectiveness of a plan of physiotherapy goals in patients hospitalized in an intensive care unit: a retrospective analysis vs. prospective

Introdução: A fisioterapia na unidade de terapia intensiva (UTI) apresenta como objetivo utilizar estratégias de mobilização precoce a fim de reduzir o impacto da fraqueza muscular adquirida na UTI. Logo, este estudo apresenta como objetivo avaliar a efetividade de um plano de metas fisioterapêuticas para pacientes internados em uma Unidade de Terapia Intensiva.Métodos: Estudo de coorte retrospectivo e prospectivo comparativo realizado em uma UTI de um hospital público de Porto Alegre. Foram incluídos pacientes internados entre os meses de janeiro e junho de 2019, maiores de 18 anos e que tiveram alta da UTI. A coleta de dados foi realizada através de informações e relatório que constam no prontuário eletrônico utilizado na Instituição. Foi analisado o desfecho das metas estabelecidas na admissão para sentar fora do leito e deambular.Resultados: A maioria dos pacientes foi do sexo masculino (57,5%). A média de idade foi de 60,52 ± 17,64 anos. A maioria das metas estabelecidas, tanto para sentar fora do leito como para deambular, foram atingidas (89% e 86,9%, respectivamente). Houve correlação significativa entre o alcance de meta para deambulação e ganho de força muscular pelo escore MRC (p = 0,041) e ganho de força muscular quando comparada admissão e alta da UTI (p = 0,004).Conclusão: Este estudo observou que estabelecer metas para sentar fora do leito e deambular para pacientes internados em UTI é efetivo.

Introduction: Physiotherapy in the intensive care unit (ICU) aims to use early mobilization strategies in order to reduce the impact of muscle acquired weakness in the ICU. Therefore, this study aims to evaluate the effectiveness of a physiotherapeutic goal plan for patients admitted to an Intensive Care Unit. Methods: Retrospective and comparative prospective cohort study carried out in an ICU of a public hospital in Porto Alegre. Patients hospitalized between January and June 2019, over 18 years old and discharged from the ICU were included. Data collection was carried out through information and report contained in the electronic medical record used in the Institution. The outcome of goals established at admission for sitting out of bed and walking was analyzed. Results: Most patients were male (57.5%). The mean age was 63.2 ± 16.2 years. Most established goals, both for sitting out of bed and walking, were achieved (89% and 86.9%, respectively). There was a significant correlation between reaching the ambulation goal and muscle strength gain by the MRC score (p= 0.041) and muscle strength gain when comparing admission and discharge from the ICU (p = 0.004). Conclusion: This study observed that establishing goals for sitting out of bed and walking for ICU patients is effective.

An analysis of pharmaceutical care for critical patients of an adult Intensive Care Unit

Abstract This work analyzed the pharmacotherapeutic problems identified by the clinical pharmacist in an intensive care unit (ICU) and the acceptance of pharmaceutical interventions in solving these problems. This is a descriptive cross-sectional retrospective study, carried out in the adult ICU of a public hospital. All patients hospitalized during the study period had their pharmacotherapy monitored and those whose stay at the ICU lasted less than 24 hours were excluded. The pharmacotherapeutic problems were classified according to type, cause, acceptability/implementation, mode of intervention, outcome and related pharmacotherapeutic group. 302 patients were followed up and 350 pharmacotherapeutic problems were identified. Most of them were classified as unnecessary drug-treatment (n=186; 53.1%). The most frequent causes were excessive drug administration (n=181; 97.3%), and antimicrobials was the main group of drugs associated to that type of problem. 350 pharmaceutical interventions were performed, highlighting "prescriber informed only" (n=178; 50.9%), with an average acceptability of 90.7%, with those carried out on site being more effective (93.4%). The number of pharmacotherapeutic problems that were totally solved was 282 (80.6%). Clinical pharmacy activities in the ICU identified, prevented and corrected pharmacotherapeutic problems, contributing to the optimization of pharmacotherapy in aspects related to the need, efficacy and safety of treatments.

Factores organizativos que influyen en el desempeño de una unidad de cuidados intensivos / Organizational Factors Influencing the Performance of An Intensive Care Unit

Algunas deficiencias vinculadas a la organización laboral en el proceso de atención médica repercuten en la supervivencia general, la del paciente crítico y en varias afecciones muy graves como la sepsis y el síndrome de distrés respiratorio agudo, entre otros indicadores importantes de las unidades de cuidados intensivos. Este trabajo tiene el objetivo de reflexionar y favorecer el debate sobre los factores organizativos determinantes intermediarios de la calidad de la atención en las terapias intensivas, porque suelen ser desestimados a pesar de ser modificables las fisuras que dichos factores producen en ella. El trabajo en equipo, la disciplina, el liderazgo, la labor investigativa, el humanismo, la docencia, el trabajo multidisciplinario, la superación profesional y el apoyo administrativo son factores fundamentales para que un grupo de trabajo de salud alcance un buen desempeño. A pesar del gran impacto que, en general, la tecnología y el grado de desarrollo socioeconómico ejercen a favor de la salud existen muchos aspectos no vinculados a estos que son decisivos para lograr buenos indicadores de calidad(AU)

Some deficiencies linked to the work organization in the medical care process have an impact on overall survival, that of the critical patient and on several very serious conditions such as sepsis and acute respiratory distress syndrome, among other important indicators of intensive care units. This work aims to reflect and promote the debate on the organizational factors that determine the quality of care in intensive care units, because they are usually dismissed despite the fissures that these factors produce in it are modifiable. Teamwork, discipline, leadership, research work, humanism, teaching, multidisciplinary work, professional improvement and administrative support are fundamental factors for a health work group to achieve good performance. Despite the great impact that, in general, technology and the degree of socioeconomic development exert in favor of health, there are many aspects not linked to them that are decisive to achieve good quality indicators(AU)

Un desafío sanitario en la gestión del servicio de medicina crítica de un hospital del Ecuador: Vivencias en la pandemia COVID-19 / A health challenge in the management of the critical medicine service of a hospital in Ecuador: Experiences in the COVID-19 pandemic

El SARS COV 2, tomó por sorpresa al mundo, con impacto en el sector salud, generándose una gran crisis sanitaria, golpeados por escasez de insumos, de equipos, de personal y capacidad instalada insuficiente para la atención de la contigencia. Ademas, la infodemia, el pánico y el miedo con sus respectivas consecuencias, se empodero de la sociedad civil, situación que no es ajena a sector salud, por ello, este relato de experiencia tuvo objetivo describir la gestión del servicio de medicina crítica de un hospital de Guayaquil- Ecuador durante la pandemia por el Coronavirus. En los centros asitenciales, el personal se enfrenta all desafío sanitario, principalmente en la gestión del servicio de medicina crítica. Al ser nombrado hospital centinela, con una capacidad instadala redujo de 494 a 200 camas, y se creó además el área de hospitalización de infectología; La interrelación de profesionales de la enfermería, médicos infectólogos, médicos neumólogos, servicios de terapia física y rehabilitación, servicios de nutrición, y los terapistas respiratorios, fue fundamental para afrontar la crisis, para vela por el bienestar del paciente, no solo en la parte física, sino psicología y de humanización. No obtante, el miedo a lo desconocido inherente a la especie humana, se transforma en pánico ante esta enfermedad provocando emociones, sentimientos, vivencias exacerbadas, y la inseguridad y desconfianza en que el sistema sanitario(AU)

SARS COV 2 took the world by surprise, with an impact on the health sector, generating a major health crisis, hit by a shortage of supplies, equipment, personnel and insufficient installed capacity for contingency care. In addition, the infodemic, panic and fear with their respective consequences, empowered civil society, a situation that is not unrelated to the health sector, therefore, this experience report aimed to describe the management of the critical medicine service of a Guayaquil-Ecuador hospital during the Coronavirus pandemic. In care centers, the staff faces the health challenge, mainly in the management of the critical medicine service. Being named a sentinel hospital, with an installed capacity it was reduced from 494 to 200 beds, and the infectious disease hospitalization area was also created; The interrelation of nursing professionals, infectious disease doctors, pulmonologists, physical therapy and rehabilitation services, nutrition services, and respiratory therapists, was essential to face the crisis, to ensure the well-being of the patient, not only in the physics, but psychology and humanization. However, the fear of the unknown inherent in the human species is transformed into panic in the face of this disease, causing emotions, feelings, exacerbated experiences, and insecurity and distrust in the health system(Au)

The Potential Cost-Effectiveness of a Machine Learning Tool That Can Prevent Untimely Intensive Care Unit Discharge.

OBJECTIVES: The machine learning prediction model Pacmed Critical (PC), currently under development, may guide intensivists in their decision-making process on the most appropriate time to discharge a patient from the intensive care unit (ICU). Given the financial pressure on healthcare budgets, this study assessed whether PC has the potential to be cost-effective compared with standard care, without the use of PC, for Dutch patients in the ICU from a societal perspective. METHODS: A 1-year, 7-state Markov model reflecting the ICU care pathway and incorporating the PC decision tool was developed. A hypothetical cohort of 1000 adult Dutch patients admitted in the ICU was entered in the model. We used the literature, expert opinion, and data from Amsterdam University Medical Center for model parameters. The uncertainty surrounding the incremental cost-effectiveness ratio was assessed using deterministic and probabilistic sensitivity analyses and scenario analyses. RESULTS: PC was a cost-effective strategy with an incremental cost-effectiveness ratio of €18 507 per quality-adjusted life-year. PC remained cost-effective over standard care in multiple scenarios and sensitivity analyses. The likelihood that PC will be cost-effective was 71% at a willingness-to-pay threshold of €30 000 per quality-adjusted life-year. The key driver of the results was the parameter "reduction in ICU length of stay." CONCLUSIONS: We showed that PC has the potential to be cost-effective for Dutch ICUs in a time horizon of 1 year. This study is one of the first cost-effectiveness analyses of a machine learning device. Further research is needed to validate the effectiveness of PC, thereby focusing on the key parameter "reduction in ICU length of stay" and potential spill-over effects.

Preparing for patients with high-consequence infectious diseases: Example of a high-level isolation unit.

INTRODUCTION: Patients with high-consequence infectious diseases (HCID) are rare in Western Europe. However, high-level isolation units (HLIU) must always be prepared for patient admission. Case fatality rates of HCID can be reduced by providing optimal intensive care management. We here describe a single centre's preparation, its embedding in the national context and the challenges we faced during the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic. METHODS: Ten team leaders organize monthly whole day trainings for a team of doctors and nurses from the HLIU focusing on intensive care medicine. Impact and relevance of training are assessed by a questionnaire and a perception survey, respectively. Furthermore, yearly exercises with several partner institutions are performed to cover different real-life scenarios. Exercises are evaluated by internal and external observers. Both training sessions and exercises are accompanied by intense feedback. RESULTS: From May 2017 monthly training sessions were held with a two-month and a seven-month break due to the first and second wave of the SARS-CoV-2 pandemic, respectively. Agreement with the statements of the questionnaire was higher after training compared to before training indicating a positive effect of training sessions on competence. Participants rated joint trainings for nurses and doctors at regular intervals as important. Numerous issues with potential for improvement were identified during post processing of exercises. Action plans for their improvement were drafted and as of now mostly implemented. The network of the permanent working group of competence and treatment centres for HCID (Ständiger Arbeitskreis der Kompetenz- und Behandlungszentren für Krankheiten durch hochpathogene Erreger (STAKOB)) at the Robert Koch-Institute (RKI) was strengthened throughout the SARS-CoV-2 pandemic. DISCUSSION: Adequate preparation for the admission of patients with HCID is challenging. We show that joint regular trainings of doctors and nurses are appreciated and that training sessions may improve perceived skills. We also show that real-life scenario exercises may reveal additional deficits, which cannot be easily disclosed in training sessions. Although the SARS-CoV-2 pandemic interfered with our activities the enhanced cooperation among German HLIU during the pandemic ensured constant readiness for the admission of HCID patients to our or to collaborating HLIU. This is a single centre's experience, which may not be generalized to other centres. However, we believe that our work may address aspects that should be considered when preparing a unit for the admission of patients with HCID. These may then be adapted to the local situations.

Lung- and Diaphragm-Protective Ventilation by Titrating Inspiratory Support to Diaphragm Effort: A Randomized Clinical Trial.

OBJECTIVES: Lung- and diaphragm-protective ventilation is a novel concept that aims to limit the detrimental effects of mechanical ventilation on the diaphragm while remaining within limits of lung-protective ventilation. The premise is that low breathing effort under mechanical ventilation causes diaphragm atrophy, whereas excessive breathing effort induces diaphragm and lung injury. In a proof-of-concept study, we aimed to assess whether titration of inspiratory support based on diaphragm effort increases the time that patients have effort in a predefined "diaphragm-protective" range, without compromising lung-protective ventilation. DESIGN: Randomized clinical trial. SETTING: Mixed medical-surgical ICU in a tertiary academic hospital in the Netherlands. PATIENTS: Patients (n = 40) with respiratory failure ventilated in a partially-supported mode. INTERVENTIONS: In the intervention group, inspiratory support was titrated hourly to obtain transdiaphragmatic pressure swings in the predefined "diaphragm-protective" range (3-12 cm H2O). The control group received standard-of-care. MEASUREMENTS AND MAIN RESULTS: Transdiaphragmatic pressure, transpulmonary pressure, and tidal volume were monitored continuously for 24 hours in both groups. In the intervention group, more breaths were within "diaphragm-protective" range compared with the control group (median 81%; interquartile range [64-86%] vs 35% [16-60%], respectively; p < 0.001). Dynamic transpulmonary pressures (20.5 ± 7.1 vs 18.5 ± 7.0 cm H2O; p = 0.321) and tidal volumes (7.56 ± 1.47 vs 7.54 ± 1.22 mL/kg; p = 0.961) were not different in the intervention and control group, respectively. CONCLUSIONS: Titration of inspiratory support based on patient breathing effort greatly increased the time that patients had diaphragm effort in the predefined "diaphragm-protective" range without compromising tidal volumes and transpulmonary pressures. This study provides a strong rationale for further studies powered on patient-centered outcomes.

RBC Transfusion in Venovenous Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study.

OBJECTIVES: In the general critical care patient population, restrictive transfusion regimen of RBCs has been shown to be safe and is yet implemented worldwide. However, in patients on venovenous extracorporeal membrane oxygenation, guidelines suggest liberal thresholds, and a clear overview of RBC transfusion practice is lacking. This study aims to create an overview of RBC transfusion in venovenous extracorporeal membrane oxygenation. DESIGN: Mixed method approach combining multicenter retrospective study and survey. SETTING: Sixteen ICUs worldwide. PATIENTS: Patients receiving venovenous extracorporeal membrane oxygenation between January 2018 and July 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the proportion receiving RBC, the amount of RBC units given daily and in total. Furthermore, the course of hemoglobin over time during extracorporeal membrane oxygenation was assessed. Demographics, extracorporeal membrane oxygenation characteristics, and patient outcome were collected. Two-hundred eight patients received venovenous extracorporeal membrane oxygenation, 63% male, with an age of 55 years (45-62 yr), mainly for acute respiratory distress syndrome. Extracorporeal membrane oxygenation duration was 9 days (5-14 d). Prior to extracorporeal membrane oxygenation, hemoglobin was 10.8 g/dL (8.9-13.0 g/dL), decreasing to 8.7 g/dL (7.7-9.8 g/dL) during extracorporeal membrane oxygenation. Nadir hemoglobin was lower on days when a transfusion was administered (8.1 g/dL [7.4-9.3 g/dL]). A vast majority of 88% patients received greater than or equal to 1 RBC transfusion, consisting of 1.6 U (1.3-2.3 U) on transfusion days. This high transfusion occurrence rate was also found in nonbleeding patients (81%). Patients with a liberal transfusion threshold (hemoglobin > 9 g/dL) received more RBC in total per transfusion day and extracorporeal membrane oxygenation day. No differences in survival, hemorrhagic and thrombotic complication rates were found between different transfusion thresholds. Also, 28-day mortality was equal in transfused and nontransfused patients. CONCLUSIONS: Transfusion of RBC has a high occurrence rate in patients on venovenous extracorporeal membrane oxygenation, even in nonbleeding patients. There is a need for future studies to find optimal transfusion thresholds and triggers in patients on extracorporeal membrane oxygenation.

Humanizing the intensive care unit experience in a comprehensive cancer center: A patient- and family-centered improvement study.

OBJECTIVES: Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center. METHODS: A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives' effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys. RESULTS: A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff. SIGNIFICANCE OF RESULTS: Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.

Learning lessons from the paediatric critical care response to the SARS-CoV-2 pandemic in England and Wales: a qualitative study.

OBJECTIVES: To explore the experiences of clinical leads in paediatric critical care units (PCCUs) in England and Wales during the reorganisation of services in the initial surge of the SARS-CoV-2 pandemic and to learn lessons for future surges and service planning. METHODS: A qualitative study design using semistructured interviews via virtual conferencing was conducted with consultant clinical leads and lead nurses covering 21 PCCUs. Interviews were conducted over a period of 2 weeks, 2 months after the initial SARS-CoV-2 surge. Interview notes underwent thematic analysis. RESULTS: Thematic analysis revealed six themes: leadership, management and planning; communication; workforce development and training; innovation; workforce experience; and infection prevention and control. Leadership was facilitated through clinician-led local autonomy for decision-making and services were better delivered when the workforce was empowered to be flexible in their response. Communication was preferred through collaborative management structures. Further lessons include recognising workforce competencies in surge preparations, the use of virtual technology in facilitating training and meetings, the importance of supporting the well-being of the workforce and the secondary consequences of personal protective equipment use. CONCLUSIONS: During the 2020 SARS-CoV-2 pandemic, an agile response to a rapidly changing situation was enabled through effective clinical leadership and an adaptive workforce. Open systems of communication across senior clinical and management teams facilitated service planning. Support for all members of the workforce through implementation of appropriate and innovative education and well-being solutions was vital in sustaining resilience. This learning supports planning for future surge capacity across paediatric critical care locally and nationally.

Prone-Positioning for Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation.

OBJECTIVES: To determine the characteristics and outcomes of patients prone-positioned during extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and lung CT pattern associated with improved respiratory system static compliance after that intervention. DESIGN: Retrospective, single-center study over 8 years. SETTINGS: Twenty-six bed ICU in a tertiary center. MEASUREMENTS AND MAIN RESULTS: A propensity score-matched analysis compared patients with prone-positioning during extracorporeal membrane oxygenation and those without. An increase of the static compliance greater than or equal to 3 mL/cm H2O after 16 hours of prone-positioning defined prone-positioning responders. The primary outcome was the time to successful extracorporeal membrane oxygenation weaning within 90 days of postextracorporeal membrane oxygenation start, with death as a competing risk. Among 298 venovenous extracorporeal membrane oxygenation-treated adults with severe acute respiratory distress syndrome, 64 were prone-positioning extracorporeal membrane oxygenation. Although both propensity score-matched groups had similar extracorporeal membrane oxygenation durations, prone-positioning extracorporeal membrane oxygenation patients' 90-day probability of being weaned-off extracorporeal membrane oxygenation and alive was higher (0.75 vs 0.54, p = 0.03; subdistribution hazard ratio [95% CI], 1.54 [1.05-2.58]) and 90-day mortality was lower (20% vs 42%, p < 0.01) than that for no prone-positioning extracorporeal membrane oxygenation patients. Extracorporeal membrane oxygenation-related complications were comparable for the two groups. Patients without improved static compliance had higher percentages of nonaerated or poorly aerated ventral and medial-ventral lung regions (p = 0.047). CONCLUSIONS: Prone-positioning during venovenous extracorporeal membrane oxygenation was safe and effective and was associated with a higher probability of surviving and being weaned-off extracorporeal membrane oxygenation at 90 days. Patients with greater normally aerated lung tissue in the ventral and medial-ventral regions on quantitative lung CT-scan performed before prone-positioning are more likely to improve their static compliance after that procedure during extracorporeal membrane oxygenation.

Incidence, Clinical Characteristics and Outcomes of Early Hyperbilirubinemia in Critically Ill Patients: Insights From the MARS Study.

OBJECTIVE: To investigate the incidence, clinical characteristics and outcomes of early hyperbilirubinemia in critically ill patients. DESIGN AND SETTING: This is a post hoc analysis of a prospective multicenter cohort study. PATIENTS: Patients with measured bilirubin levels within the first 2 days after ICU admission were eligible. Patients with liver cirrhosis were excluded. ENDPOINTS: The primary endpoint was the incidence of early hyperbilirubinemia, defined as bilirubin ≥33 µmol/L within 2 days after ICU admission. Secondary endpoints included clinical characteristics of patients with versus patients without early hyperbilirubinemia, and outcomes up to day 30. RESULTS: Of 4,836 patients, 559 (11.6%) patients had early hyperbilirubinemia. Compared to patients without early hyperbilirubinemia, patients with early hyperbilirubinemia presented with higher severity of illness scores, and higher incidences of sepsis and organ failure. After adjustment for confounding variables, early hyperbilirubinemia remained associated with mortality at day 30 (odds ratio, 1.31 [95%-confidence interval 1.06-1.60]; P = 0.018). Patients with early hyperbilirubinemia and thrombocytopenia (interaction P-value = 0.005) had a higher likelihood of death within 30 days (odds ratio, 2.61 [95%-confidence interval 2.08-3.27]; P < 0.001) than patients with early hyperbilirubinemia and a normal platelet count (odds ratio, 1.09 [95%-confidence interval 0.75-1.55]; P = 0.655). CONCLUSIONS: Early hyperbilirubinemia occurs frequently in the critically ill, and these patients present with higher disease severity and more often with sepsis and organ failures. Early hyperbilirubinemia has an association with mortality, albeit this association was only found in patients with concomitant thrombocytopenia.

Fluid Balance and Ventilator-Associated Events Among Patients Admitted to ICUs in China: A Nested Case-Control Study.

OBJECTIVES: Fluid therapy is an important component of intensive care management, however, optimal fluid management is unknown. The relationship between fluid balance and ventilator-associated events has not been well established. This study investigated the dose-response relationship between fluid balance and ventilator-associated events. DESIGN: Nested case-control study. SETTING: The study was based on a well-established, research-oriented registry of healthcare-associated infections at ICUs of West China Hospital system (Chengdu, China). PATIENTS: A total of 1,528 ventilator-associated event cases with 3,038 matched controls, who consistently underwent mechanical ventilation for at least 4 days from April 1, 2015, to December 31, 2018, were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We calculated cumulative fluid balance within 4 days prior to ventilator-associated event occurrence. A weighted Cox proportional hazards model with restricted cubic splines was used to evaluate the dose-response relationship. A nonlinear relationship between fluid balance and all three tiers of ventilator-associated events, patients with fluid balance between -1 and 0 L had the lowest risk (p < 0.05 for nonlinear test). The risk of ventilator-associated event was significantly higher in patients with positive fluid balance (4 d cumulative fluid balance: 1 L: 1.19; 3 L: 1.92; 5 L: 2.58; 7 L: 3.24), but not in those with negative fluid balance (-5 L: 1.34; -3 L: 1.14; -1 L: 0.98). CONCLUSIONS: There was nonlinear relationship between fluid balance and all three tiers of ventilator-associated event, with an fluid balance between -1 and 0 L corresponding to the lowest risk. Positive but not negative fluid balance increased the risk of ventilator-associated events, with higher positive fluid balance more likely to lead to ventilator-associated events.

Differences and Similarities Among COVID-19 Patients Treated in Seven ICUs in Three Countries Within One Region: An Observational Cohort Study.

OBJECTIVES: To investigate healthcare system-driven variation in general characteristics, interventions, and outcomes in coronavirus disease 2019 (COVID-19) patients admitted to the ICU within one Western European region across three countries. DESIGN: Multicenter observational cohort study. SETTING: Seven ICUs in the Euregio Meuse-Rhine, one region across Belgium, The Netherlands, and Germany. PATIENTS: Consecutive COVID-19 patients supported in the ICU during the first pandemic wave. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline demographic and clinical characteristics, laboratory values, and outcome data were retrieved after ethical approval and data-sharing agreements. Descriptive statistics were performed to investigate country-related practice variation. From March 2, 2020, to August 12, 2020, 551 patients were admitted. Mean age was 65.4 ± 11.2 years, and 29% were female. At admission, Acute Physiology and Chronic Health Evaluation II scores were 15.0 ± 5.5, 16.8 ± 5.5, and 15.8 ± 5.3 (p = 0.002), and Sequential Organ Failure Assessment scores were 4.4 ± 2.7, 7.4 ± 2.2, and 7.7 ± 3.2 (p < 0.001) in the Belgian, Dutch, and German parts of Euregio, respectively. The ICU mortality rate was 22%, 42%, and 44%, respectively (p < 0.001). Large differences were observed in the frequency of organ support, antimicrobial/inflammatory therapy application, and ICU capacity. Mixed-multivariable logistic regression analyses showed that differences in ICU mortality were independent of age, sex, disease severity, comorbidities, support strategies, therapies, and complications. CONCLUSIONS: COVID-19 patients admitted to ICUs within one region, the Euregio Meuse-Rhine, differed significantly in general characteristics, applied interventions, and outcomes despite presumed genetic and socioeconomic background, admission diagnosis, access to international literature, and data collection are similar. Variances in healthcare systems' organization, particularly ICU capacity and admission criteria, combined with a rapidly spreading pandemic might be important drivers for the observed differences. Heterogeneity between patient groups but also healthcare systems should be presumed to interfere with outcomes in coronavirus disease 2019.

Anisocoria and Poor Pupil Reactivity by Quantitative Pupillometry in Patients With Intracranial Pathology.

OBJECTIVES: To describe the prevalence and associated risk factors of new onset anisocoria (new pupil size difference of at least 1 mm) and its subtypes: new onset anisocoria accompanied by abnormal and normal pupil reactivities in patients with acute neurologic injuries. DESIGN: We tested the association of patients who experienced new onset anisocoria subtypes with degree of midline shift using linear regression. We further explored differences between quantitative pupil characteristics associated with first-time new onset anisocoria and nonnew onset anisocoria at preceding observations using mixed effects logistic regression, adjusting for possible confounders. SETTING: All quantitative pupil observations were collected at two neuro-ICUs by nursing staff as standard of care. PATIENTS: We conducted a retrospective two-center study of adult patients with intracranial pathology in the ICU with at least a 24-hour stay and three or more quantitative pupil measurements between 2016 and 2018. MEASUREMENTS AND MAIN RESULTS: We studied 221 patients (mean age 58, 41% women). Sixty-three percent experienced new onset anisocoria. New onset anisocoria accompanied by objective evidence of abnormal pupil reactivity occurring at any point during hospitalization was significantly associated with maximum midline shift (ß = 2.27 per mm; p = 0.01). The occurrence of new onset anisocoria accompanied by objective evidence of normal pupil reactivity was inversely associated with death (odds ratio, 0.34; 95% CI, 0.16-0.71; p = 0.01) in adjusted analyses. Subclinical continuous pupil size difference distinguished first-time new onset anisocoria from nonnew onset anisocoria in up to four preceding pupil observations (or up to 8 hr prior). Minimum pupil reactivity between eyes also distinguished new onset anisocoria accompanied by objective evidence of abnormal pupil reactivity from new onset anisocoria accompanied by objective evidence of normal pupil reactivity prior to first-time new onset anisocoria occurrence. CONCLUSIONS: New onset anisocoria occurs in over 60% of patients with neurologic emergencies. Pupil reactivity may be an important distinguishing characteristic of clinically relevant new onset anisocoria phenotypes. New onset anisocoria accompanied by objective evidence of abnormal pupil reactivity was associated with midline shift, and new onset anisocoria accompanied by objective evidence of normal pupil reactivity had an inverse relationship with death. Distinct quantitative pupil characteristics precede new onset anisocoria occurrence and may allow for earlier prediction of neurologic decline. Further work is needed to determine whether quantitative pupillometry sensitively/specifically predicts clinically relevant anisocoria, enabling possible earlier treatments.

Rapid Development and Deployment of an Intensivist-Led Venovenous Extracorporeal Membrane Oxygenation Cannulation Program.

OBJECTIVES: To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program. DESIGN: A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program. SETTING: An adult ICU in a tertiary academic medical center in Camden, NJ. PATIENTS: Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation. INTERVENTIONS: Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists. MEASUREMENTS AND MAIN RESULTS: Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1). CONCLUSIONS: There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.

Late Awakening Is Common in Settings Without Withdrawal of Life-Sustaining Therapy in Out-of-Hospital Cardiac Arrest Survivors Who Undergo Targeted Temperature Management.

OBJECTIVES: We investigated awakening time and characteristics of awakening compared nonawakening and factors contributing to poor neurologic outcomes in out-of-hospital cardiac arrest survivors in no withdrawal of life-sustaining therapy settings. DESIGN: Retrospective analysis of the Korean Hypothermia Network Pro registry. SETTING: Multicenter ICU. PATIENTS: Adult (≥ 18 yr) comatose out-of-hospital cardiac arrest survivors who underwent targeted temperature management at 33-36°C between October 2015 and December 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured the time from the end of rewarming to awakening, defined as a total Glasgow Coma Scale score greater than or equal to 9 or Glasgow Coma Scale motor score equals to 6. The primary outcome was awakening time. The secondary outcome was 6-month neurologic outcomes (poor outcome: Cerebral Performance Category 3-5). Among 1,145 out-of-hospital cardiac arrest survivors, 477 patients (41.7%) regained consciousness 30 hours (6-71 hr) later, and 116 patients (24.3%) awakened late (72 hr after the end of rewarming). Young age, witnessed arrest, shockable rhythm, cardiac etiology, shorter time to return of spontaneous circulation, lower serum lactate level, absence of seizures, and multisedative requirement were associated with awakening. Of the 477 who woke up, 74 (15.5%) had poor neurologic outcomes. Older age, liver cirrhosis, nonshockable rhythm, noncardiac etiology, a higher Sequential Organ Failure Assessment score, and higher serum lactate levels were associated with poor neurologic outcomes. Late awakeners were more common in the poor than in the good neurologic outcome group (38/74 [51.4%] vs 78/403 [19.4%]; p < 0.001). The awakening time (odds ratio, 1.005; 95% CIs, 1.003-1.008) and late awakening (odds ratio, 3.194; 95% CIs, 1.776-5.746) were independently associated with poor neurologic outcomes. CONCLUSIONS: Late awakening after out-of-hospital cardiac arrest was common in no withdrawal of life-sustaining therapy settings and the probability of awakening decreased over time.