Critical Care Explorations最新文献

Music has played a long and storied role in clinical healing. However, the integration of music into clinical practice has been slow to gain traction, despite a recent meta-analysis demonstrating association of music interventions with clinically meaningful improvements in health-related quality of life. There is growing evidence that music has an active role in reducing patient pain and anxiety as well as affecting physiologic parameters, such as heart rate and blood pressure, in an ICU setting. Past studies have shown that incorporation of music into procedures in the operating room, radiology suites, and catheterization labs has reduced concurrent pharmacologic sedation requirements. In the age of patient-centered personalized medicine, we propose a call to action to implement an easily accessible, attainable checklist item offering a personal choice of music for patients during standardized bedside procedural training, to reduce anxiety, pain, and pharmacologic sedation and potentially improve clinical outcomes.

Passive leg raise (PLR) during cardiopulmonary resuscitation (CPR) is simple and noninvasive maneuver, which can potentially improve patient-related outcomes. Initial CPR guidelines have previously advocated "elevation of the lower extremities to augment artificial circulation during CPR." There is lack of supporting evidence for this recommendation.

Design: This was a double cross-over physiologic efficacy randomized study.

Setting and patients: Study in 10 subjects with in-hospital cardiac arrest for whom CPR was undertaken.

Intervention: Subjects were randomized to receive two cycles of CPR with PLR followed by two cycles of CPR without PLR (Group I) or vice-versa (Group II). Subjects had their foreheads (right and left) fitted with near infrared spectroscopy (NIRS) electrodes (O3 System-Masimo, Masimo corporation Forty Parker, Irvine CA) while undergoing CPR during the study. NIRS readings, a measure of mixed venous, arterial, and capillary blood oxygen saturation, act as a surrogate measure of cerebral blood perfusion during CPR.

Measurement and main results: PLR was randomly used "first" in five of them, whereas it was used "second" in the remaining five subjects. In subjects in whom PLR was performed during first two cycles (Group I), NIRS values were initially significantly greater. The performance of PLR during CPR in Group II attenuated the decline in NIRS readings during CPR.

Conclusions: PLR during CPR is feasible and leads to augmentation of cerebral blood flow. Furthermore, the expected decline in cerebral blood flow over time during CPR may be attenuated by this maneuver. The clinical significance of these findings will require further investigations.

COVID-19 highlighted the need for use of real-world data (RWD) in critical care as a near real-time resource for clinical, research, and policy efforts. Analysis of RWD is gaining momentum and can generate important evidence for policy makers and regulators. Extracting high quality RWD from electronic health records (EHRs) requires sophisticated infrastructure and dedicated resources. We sought to customize freely available public tools, supporting all phases of data harmonization, from data quality assessments to de-identification procedures, and generation of robust, data science ready RWD from EHRs. These data are made available to clinicians and researchers through CURE ID, a free platform which facilitates access to case reports of challenging clinical cases and repurposed treatments hosted by the National Center for Advancing Translational Sciences/National Institutes of Health in partnership with the Food and Drug Administration. This commentary describes the partnership, rationale, process, use case, impact in critical care, and future directions for this collaborative effort.

To evaluate the efficacy and cost-effectiveness of high-flow nasal cannula (HFNC) when compared with noninvasive positive pressure ventilation (NIPPV) in patients with acute hypoxic respiratory failure (AHRF).

Data sources: We performed a comprehensive search of MEDLINE, Embase, CINAHL, the Cochrane library, and the international Health Technology Assessment database from inception to September 14, 2022.

Study selection: We included randomized control studies that compared HFNC to NIPPV in adult patients with AHRF. For clinical outcomes, we included only parallel group and crossover randomized control trials (RCTs). For economic outcomes, we included any study design that evaluated cost-effectiveness, cost-utility, or cost benefit analyses.

Data extraction: Clinical outcomes of interest included intubation, mortality, ICU and hospital length of stay (LOS), and patient-reported dyspnea. Economic outcomes of interest included costs, cost-effectiveness, and cost-utility.

Data synthesis: We included nine RCTs (n = 1,539 patients) and one cost-effectiveness study. Compared with NIPPV, HFNC may have no effect on the need for intubation (relative risk [RR], 0.93; 95% CI, 0.69-1.27; low certainty) and an uncertain effect on mortality (RR, 0.84; 95% CI, 0.59-1.21; very low certainty). In subgroup analysis, NIPPV delivered through the helmet interface-as opposed to the facemask interface-may reduce intubation compared with HFNC (p = 0.006; moderate credibility of subgroup effect). There was no difference in ICU or hospital LOS (both low certainty) and an uncertain effect on patient-reported dyspnea (very low certainty). We could make no conclusions regarding the cost-effectiveness of HFNC compared with NIPPV.

Conclusions: HFNC and NIPPV may be similarly effective at reducing the need for intubation with an uncertain effect on mortality in hospitalized patients with hypoxemic respiratory failure. More research evaluating different interfaces in varying clinical contexts is needed to improve generalizability and precision of findings.

To gain consensus on measurement methods for outcomes (delirium occurrence, severity, time to resolution, mortality, health-related quality of life [HrQoL], emotional distress including anxiety, depression, acute stress, and post-traumatic stress disorder, and cognition) of our Core Outcome Set (COS) for trials of interventions to prevent and/or treat delirium in critically ill adults.

Design: International consensus process.

Setting: Three virtual meetings (April 2021).

Patients/subjects: Critical illness survivors/family, clinicians, and researchers from six Countries.

Interventions: None.

Measurements and main results: Measures (selected based on instrument validity, existing recommendations, and feasibility) and measurement time horizons were discussed. Participants voted on instruments and measurement timing (a priori consensus threshold ≥ 70%). Eighteen stakeholders (28% ICU survivors/family members) participated. We achieved consensus on the Confusion Assessment Method-ICU or Intensive Care Delirium Screening Checklist to measure delirium occurrence and delirium resolution (100%), Hospital Anxiety and Depression Scale for emotional distress (71%), and Montreal Cognitive Assessment-Blind for cognition (83%). We did not achieve consensus on EQ-5D five-level for HrQoL (69%) or its measurement at 6 months. We also did not achieve consensus on the Impact of Event Scale (IES)-Revised or IES-6 for post-traumatic stress (65%) or on measurement instruments for delirium severity incorporating delirium-related emotional distress. We were unable to gain consensus on when to commence and when to discontinue assessing for delirium occurrence and time to resolution, when to determine mortality. We gained consensus that emotional distress and cognition should be measured up to 12 months from hospital discharge.

Conclusions: Consensus was reached on measurement instruments for four of seven outcomes in the COS for delirium prevention or treatment trials for critically ill adults. Further work is required to validate instruments for delirium severity that include delirium-related emotional distress.

In patients who require systemic anticoagulation, a reliable monitoring method is required to ensure anticoagulation is maintained within the correct therapeutic window and patients are treated appropriately. When titrating direct thrombin inhibitors (DTIs), dilute thrombin time (dTT) measurements have been demonstrated to be more reliable and accurate than activated partial thromboplastin time (aPTT) measurements and thus often the preferred DTI assessment. However, a clinical need arises when both dTT measurements are not readily available and aPTT measurements are unreliable.

Case summary: A 57-year-old woman with a history of antiphospholipid antibody syndrome, heparin-induced thrombocytopenia, and multiple prior deep venous thromboses and pulmonary emboli was admitted with COVID-19 pneumonia and intubated due to hypoxic respiratory failure. Argatroban was initiated in place of her home medication warfarin. However, the patient had a prolonged aPTT value at baseline and overnight dTT assay measurements were limited at our institution. A multidisciplinary team of hematology and pharmacy clinicians created a modified patient-specific aPTT target range and argatroban dosing was titrated accordingly. Subsequent aPTT values in the modified target range corresponded to therapeutic dTT values, indicating therapeutic anticoagulation was successfully achieved and maintained. Patient blood samples were additionally evaluated retrospectively using an investigational novel point-of-care test that detected and quantified the argatroban anticoagulant effect.

Conclusions: Therapeutic anticoagulation with a DTI in a patient with unreliable aPTT measurements can be achieved with use of a modified patient-specific aPTT target range. Early validation of an investigational rapid testing alternative for DTI monitoring is promising.

[This corrects the article DOI: 10.1097/CCE.0000000000000870.].

Outcomes for critically ill COVID-19 are well described; however, the impact of the pandemic on critically ill patients without COVID-19 infection is less clear.

Objectives: To demonstrate the characteristics and outcomes of non-COVID patients admitted to an ICU during the pandemic, compared with the previous year.

Design: A population-based study conducted using linked health administrative data comparing a cohort from March 1, 2020, to June 30, 2020 (pandemic) to a cohort from March 1, 2019, to June 30, 2019 (nonpandemic).

Setting and participants: Adult patients (18 yr old) admitted to an ICU in Ontario, Canada, without a diagnosis of COVID-19 during the pandemic and nonpandemic periods.

Main outcomes and measures: The primary outcome was all-cause in-hospital mortality. Secondary outcomes included hospital and ICU length of stay, discharge disposition, and receipt of resource intensive procedures (e.g., extracorporeal membrane oxygenation, mechanical ventilation, renal replacement therapy, bronchoscopy, feeding tube insertion, and cardiac device insertion). We identified 32,486 patients in the pandemic cohort and 41,128 in the nonpandemic cohort. Age, sex, and markers of disease severity were similar. Fewer patients in the pandemic cohort were from long-term care facilities and had fewer cardiovascular comorbidities. There was an increase in all-cause in-hospital mortality among the pandemic cohort (13.5% vs 12.5%; p < 0.001) representing a relative increase of 7.9% (adjusted odds ratio, 1.10; 95% CI, 1.05-1.56). Patients in the pandemic cohort admitted with chronic obstructive pulmonary disease exacerbation had an increase in all-cause mortality (17.0% vs 13.2%; p = 0.013), a relative increase of 29%. Mortality among recent immigrants was higher in the pandemic cohort compared with the nonpandemic cohort (13.0% vs 11.4%; p = 0.038), a relative increase of 14%. Length of stay and receipt of intensive procedures were similar.

Conclusions and relevance: We found a modest increase in mortality among non-COVID ICU patients during the pandemic compared with a nonpandemic cohort. Future pandemic responses should consider the impact of the pandemic on all patients to preserve quality of care.

Excessive noise is ubiquitous in the ICU, and there is growing evidence of the negative impact on work performance of caregivers. This study aims to determine the effectiveness of interventions to reduce noise in the ICU.

Data sources: Databases of PubMed, EMBASE, PsychINFO, CINAHL, and Web of Science were systematically searched from inception to September 14, 2022.

Study selection: Two independent reviewers assessed titles and abstracts against study eligibility criteria. Noise mitigating ICU studies were included when having at least one quantitative acoustic outcome measure expressed in A-weighted sound pressure level with an experimental, quasi-experimental, or observational design. Discrepancies were resolved by consensus, and a third independent reviewer adjudicated as necessary.

Data extraction: After title, abstract, and full-text selection, two reviewers independently assessed the quality of each study using the Cochrane's Risk Of Bias In Nonrandomized Studies of Interventions tool. Data were synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, and interventions were summarized.

Data synthesis: After screening 12,652 articles, 25 articles were included, comprising either a mixed group of healthcare professionals (n = 17) or only nurses (n = 8) from adult or PICU settings. Overall, the methodological quality of the studies was low. Noise reduction interventions were categorized into education (n = 4), warning devices (n = 3), multicomponent programs (n = 15), and architectural redesign (n = 3). Education, a noise warning device, and an architectural redesign significantly decreased the sound pressure levels.

Conclusions: Staff education and visual alert systems seem promising interventions to reduce noise with a short-term effect. The evidence of the studied multicomponent intervention studies, which may lead to the best results, is still low. Therefore, high-quality studies with a low risk of bias and a long-term follow-up are warranted. Embedding noise shielding within the ICU-redesign is supportive to reduce sound pressure levels.