Critical Care Research and Practice最新文献

Introduction: Mortality rate amongst critically ill patients admitted to the intensive care unit (ICU) is disproportionately high in sub-Saharan African countries such as Cameroon. Identifying factors associated with higher in-ICU mortality guides more aggressive resuscitative measures to curb mortality, but the dearth of data on predictors of in-ICU mortality precludes this action. We aimed to determine predictors of in-ICU mortality in a major referral ICU in Cameroon. Methodology. This was a retrospective cohort study of all patients admitted to the ICU of Douala Laquintinie Hospital from 1st of March 2021 to 28th February 2022. We performed a multivariable analysis of sociodemographic, vital signs on admission, and other clinical and laboratory variables of patients discharged alive and dead from the ICU to control for confounding factors. Significance level was set at p < 0.05.

Results: Overall, the in-ICU mortality rate was 59.4% out of 662 ICU admissions. Factors independently associated with in-ICU mortality were deep coma (aOR = 0.48 (0.23-0.96), 95% CI, p = 0.043), and hypernatremia (>145 meq/L) (aOR = 0.39 (0.17-0.84) 95% CI, p = 0.022).

Conclusion: The in-ICU mortality rate in this major referral Cameroonian ICU is high. Six in 10 patients admitted to the ICU die. Patients were more likely to die if admitted with deep coma and high sodium levels in the blood.

Flexible bronchoscopy (FB) is often performed in critically ill patients with suspected pneumonia. It is assumed that there will be an association with improved outcomes when bronchoalveolar lavage (BAL) data lead to a change in antimicrobial therapy. Methods. This study included a retrospective cohort of intensive care unit (ICU) patients who underwent FB for a diagnosis of suspected pneumonia. The study compared the outcome of patients in whom antimicrobial modification was carried out based on BAL reports versus those in whom it was not carried out. Cases where the procedure could not be completed or had incomplete records were excluded. The FB reports were accessed from the register maintained in the Department of Respiratory Medicine. The demographic details, clinical symptoms, laboratory investigations, and microbiological and radiology reports were recorded. Data on the antmicrobial therapy that the patients received during treatment and the outcome of the treatment were obtained from the case records and noted in the data collection form. Results. Data from a total of 150 patients admitted to the ICU, who underwent FB, were analyzed. The outcomes in the group where antimicrobial modification based on bronchoalveolar lavage (BAL) fluid reports was carried out versus the no-change group were as follows: expired 23, improved 82, unchanged 8 versus expired 12, improved 18, and unchanged 7 (p = 0.018); total duration of ICU stay 13.12 ± 10.61 versus 19.43 ± 13.4 days (p = 0.012); and duration from FB to discharge from ICU 6.33 ± 3.76 days versus 8.46 ± 5.99 (p = 0.047). The median total duration of ICU stay and clinical outcomes were significantly better in the nonintubated patients in whom BAL-directed antimicrobial modification was implemented. Distribution of microorganisms based on BAL reports was as follows: Acinetobacter baumanii 45 (30%), Klebsiella pneumoniae 37 (24.66%), Escherichia coli 9 (6%), and Pseudomonas aeruginosa 9 (6%). Conclusion. A change in antimicrobial therapy based on BAL data was associated with improved outcomes. The commonest bacterial isolate in the BAL fluid was Acinetobacter baumanii.

Objective: To investigate the effects of an early neuromuscular electrical stimulation (NMES) protocol on muscle quality and size as well as signaling mediators of muscle growth and systemic inflammation in patients with traumatic brain injury (TBI).

Design: Two-arm, single-blinded, parallel-group, randomized, controlled trial with a blinded assessment. Setting. Trauma intensive care unit at a university hospital. Participants. Forty consecutive patients on mechanical ventilation (MV) secondary to TBI were prospectively recruited within the first 24 hours following admission. Interventions. The intervention group (NMES; n = 20) received a daily session of NMES on the rectus femoris muscle for five consecutive days (55 min/each session). The control group (n = 20) received usual care. Main Outcome Measures. Muscle echogenicity and thickness were evaluated by ultrasonography. A daily blood sample was collected to assess circulating levels of insulin-like growth factor I (IGF-I), inflammatory cytokines, and matrix metalloproteinases (MMP).

Results: Both groups were similar at baseline. A smaller change in muscle echogenicity and thickness (difference between Day 1 and Day 7) was found in the control group compared to the NMES group (29.9 ± 2.1 vs. 3.0 ± 1.2, p < 0.001; -0.79 ± 0.12 vs. -0.01 ± 0.06, p < 0.001, respectively). Circulating levels of IGF-I, pro-inflammatory cytokines (IFN-y), and MMP were similar between groups.

Conclusion: An early NMES protocol can preserve muscle size and quality and maintain systemic levels of signaling mediators of muscle growth and inflammation in patients with TBI. This trial is registered with https://www.ensaiosclinicos.gov.br under number RBR-2db.

Background: Though vaccines have been reported as highly efficacious in preventing severe COVID-19 disease, there is emerging data of severe infections, albeit a small number, in vaccinated individuals. We have conducted a retrospective observational study to assess the clinical characteristics, immunological response, and disease outcomes among the vaccinated and unvaccinated patients admitted to the ICU with severe COVID-19 disease.

Methods: Study Design and Participants. We conducted a retrospective observational study in COVID ICU of a tertiary care hospital. Data were collected from the month of 1 April 2021 to 31 November 2021. All adult patients admitted to the ICU having severe COVID-19 disease were included in the study. Data were collected from the medical records database which included demographics, a clinical course in the ICU, laboratory and radiological parameters, and disease outcomes. In a subset of patients, cell-mediated immunity and S1S2-neutralising antibody assessment was done.

Results: A total of 419 patients with severe COVID-19 were included in the study. Of the 419 patients, 90 (21.5%) were vaccinated, and 329 (78.5%) were unvaccinated. There was a significantly higher mortality in unvaccinated severe COVID 19 patients as compared to vaccinated severe COVID patients (46.2% vs 34.4%; P < 0.0455). The neutralizing antibody titre was significantly higher in survivors as compared to nonsurvivors (2139.8, SE ± 713.3 vs 471, SE ± 154.4); P < 0.026.

Conclusion: Our study suggests the association of lower neutralizing antibody levels with mortality in ICU patients admitted with COVID-19 breakthrough infections.

Background: Respiratory monitoring of mechanical ventilation (MV) is relevant and challenging in COVID-19. Mechanical power (MP) is a novel and promising monitoring tool in acute distress respiratory syndrome (ARDS), representing the amount of energy transferred from the ventilator to the patient. It encompasses several setting parameters and patient-dependent variables that could cause lung injury. MP can therefore be an additional tool in the assessment of these patients.

Objective: This study aims to evaluate respiratory monitoring through MP and its relationship with mortality in patients with COVID-19-related ARDS (CARDS) under mechanical ventilation (MV) and prone position (PP) strategies.

Methods: Retrospective, unicentric, and cohort studies. We included patients with CARDS under invasive MV and PP strategies. Information regarding MP, ventilation, and gas exchange was collected at 3 moments: (1) prior to the first PP, (2) during the first PP, and (3) during the last PP. We tested the relationship between MP and VR with in-hospital mortality.

Results: We included 91 patients. There was a statistically significant difference in MP measurements between survivors and nonsurvivors only in the last prone position (p < 0.001). This is due to the significant increase in MP measurements in nonsurvivors (difference from the baseline: 3.63 J/min; 95% CI: 0.31 to 6.94), which was not observed in the group that survived (difference from the baseline: 0.02 J/min; 95% CI: -2.66 to 2.70). In multivariate analysis, MP (p=0.009) was associated with hospital death when corrected for confounder variables (SAPS 3 score, mechanical ventilation time, age, and number of prone sessions).

Conclusions: MP is an independent predictor of mortality in PP patients with CARDS.

Introduction: Mechanical ventilation (MV) is a backbone and major supportive modality in intensive care units (ICUs) even though it has side effects and complications. Knowledge of nurses about mechanical ventilators and good practice of nursing care for the ventilated patient plays a crucial role in improving the effectiveness of mechanical ventilation, preventing harm, and optimizing the patient outcome. This study intended to assess the knowledge regarding MV and the practice of ventilator care among nurses working in the ICU.

Method: A descriptive cross-sectional study design was conducted. All nurses working in the intensive care unit of selected governmental hospitals were included in the study. The data were collected from March 1 to 30, 2021 with structured and pretested self-administered questionnaires. The collected data were evaluated with SPSS version 26 software. The variables, which have an independent association with poor outcomes, were identified based on OR, with 95% CI and a p value less than 0.05.

Results: Of 146 nurses who participated in the study, 51.4% were males. About 71.4% had a BSc in nursing and 57.5% of them had training related to MV. More than half (51.4%) of nurses had poor knowledge regarding MV and the majority (58.9%) of them had poor practice in ventilatory care. The educational level (AOR, 5.1; 95% CI, 1.190-22.002) was positively associated with knowledge. Likewise, the educational level (AOR 5.0 (1.011-24.971)) and work experience (AOR 4.543 (1.430-14.435)) were positively associated with the practice of nurses.

Conclusions: Knowledge regarding mechanical ventilators and the practice of ventilatory care among nurses in the selected public hospitals was poor. The educational levels were found statistically associated with both the knowledge and practice of nurses. To improve nursing care offered for MV patients, upgrading the educational level of intensive care nurses plays a vital role.

Background: This systematic review and meta-analysis of randomized controlled trials (RCTs) was performed to compare the safety and efficacy of supine vs. nonsupine positions during intubation.

Methods: Based on the literature from inception to October 2020, 13 studies with nonemergent intubation in supine and nonsupine positions were chosen using PRISMA and MOOSE protocols. Pooled estimates were calculated using random-effects models with 95% confidence interval (CI). The primary outcome was a successful intubation, attempt, and duration of intubation. The secondary outcome was adverse events (trauma and hypoxia). Bias was evaluated qualitatively, by visual analysis, and quantitatively through the Egger test.

Results: The final analysis included 13 clinical trials with 1,916 patients. The pooled success rates in the supine vs. lateral positions were 99.21% and 98.82%. The supine vs. semierect positions were 99.21% and 98.82%. The 1st attempt success rate in the supine vs. lateral position was 85.35% and 88.56% compared to 91.38% and 90.76% for the supine vs. semierect position. The rate of total adverse events in the supine position was 3.73% vs. 6.74% in the lateral position, and the rate of total adverse events in the supine position was 0.44% vs. 0.93% in semierect position. Low to substantial heterogeneity was noted in our analysis. Discussion. There is no significant difference between total successful intubations and success from 1st intubation attempt between supine and nonsupine positions. However, there are slightly higher rates of adverse events in nonsupine position. Addition of more recent studies on supine vs. nonsupine intubations would improve this study. Given these findings, it is important to develop more studies regarding different intubation positions and techniques with the aim of improving efficacy and decreasing adverse outcomes. Other. This review is not registered in a public database. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Background: Adherence to ethical codes is a major pillar of nursing care that is affected by various factors. Identifying these factors can lead to better ethical performance. The present study was conducted to determine critical care nurses' adherence to ethical codes and its association with spiritual well-being (SWB) and moral sensitivity (MS).

Methods: In this descriptive-correlational study, data were collected using the moral sensitivity questionnaire (MSQ) by Lützén et al., Paloutzian and Ellison's spiritual well-being scale (SWBS), and the adherence to ethical codes questionnaire. The study was conducted on 298 nurses working in critical care units of hospitals affiliated with Shiraz University of Medical Sciences in southern Iran in 2019. This study was examined and approved by the Ethics Committee of Shiraz University of Medical Sciences.

Results: The majority of the participants were female (76.2%) and single (60.1%), with a mean age of 30.69 ± 5.74 years. The mean scores of adherence to ethical codes, SWB, and MS were 64.06 (good), 91.94 (moderate), and 134.08 (moderate), respectively. Adherence to ethical codes had a positive correlation with the total score of SWB (P < 0.001, r = 0.25) and MS (P < 0.001, r = 0.27). A positive correlation was also observed between MS and SWB (P < 0.001, r = 0.41). Meanwhile, MS (β = 0.21) had a greater effect than SWB (β = 0.157) on adherence to ethical codes.

Conclusion: Critical care nurses showed a good adherence to ethical codes. MS and SWB also positively affected their adherence to ethical codes. Nursing managers can use these findings to devise plans for the promotion of MS and SWB in nurses and thus help improve their ethical performance.

Background: The utility of the Sequential Organ Failure Assessment (SOFA) score in predicting mortality in the intensive care unit (ICU) has been demonstrated before, but serial testing in various settings is required to validate and improve the score. This study examined the utility of the SOFA score in predicting mortality in Jordanian ICU patients and aimed to find a modified score that required fewer laboratory tests.

Methods: A prospective observational study was conducted at Jordan University Hospital (JUH). All adult patients admitted to JUH ICUs between June and December 2020 were included in the study. SOFA scores were measured daily during the whole ICU stay. A modified SOFA score (mSOFA) was constructed from the available laboratory, clinical, and demographic data. The performance of the SOFA, mSOFA, qSOFA, and SIRS in predicting ICU mortality was assessed using the area under the receiver operating characteristic curve (AUROC).

Results: 194 patients were followed up. SOFA score (mean ± SD) at admission was significantly higher in non-survivors (7.5 ± 3.9) compared to survivors (2.4 ± 2.2) and performed the best in predicting ICU mortality (AUROC = 0.8756, 95% CI: 0.8117-0.9395) compared to qSOFA (AUROC = 0.746, 95% CI: 0.655-0.836) and SIRS (AUROC = 0.533, 95% CI: 0.425-0.641). The constructed mSOFA included points for the hepatic and CNS SOFA scores, in addition to one point each for the presence of chronic kidney disease or the use of breathing support; it performed as well as the SOFA score in this cohort or better than the SOFA score in a subgroup of patients with heart disease.

Conclusion: SOFA score was a good predictor of mortality in a Jordanian ICU population and better than qSOFA, while SIRS could not predict mortality. Furthermore, the proposed mSOFA score which employed fewer laboratory tests could be used after validation from larger studies.