American Journal of Critical Care最新文献

Background: Patients undergoing medical procedures benefit from preprocedural education.

Objective: To evaluate a multisensory virtual reality preoperative educational program for patients undergoing elective cardiovascular surgical procedures with postoperative recovery in the intensive care unit (ICU) and assess its impact on patients' outcomes and experience.

Methods: Patients scheduled for elective cardiovascular surgical procedures with expected recovery in the ICU were enrolled. A multidisciplinary team designed the virtual reality simulation. Educational objectives focused on patient safety, family presence, ICU machinery and activities, reorientation, and communication with the care team. Historical control patients (n = 94) underwent medical record review and were contacted to complete surveys. Virtual reality simulation patients (n = 44) underwent medical record review, viewed the simulation at a preoperative appointment, and completed surveys. The study included patients admitted from June 4, 2019, to May 12, 2022.

Results: Durations of postoperative sedation and mechanical ventilation were lower in patients receiving virtual reality simulation. Most patients in the virtual reality simulation group (92%) said the simulation alleviated their anxiety and helped them understand what to expect in the ICU. The simulation improved their feeling of safety and decreased their fear of the unknown. Delirium incidence was not different in the 2 groups.

Conclusions: Preprocedural education via virtual reality simulation can improve the experience and outcomes of patients undergoing elective cardiothoracic surgery with recovery in the ICU.

Background: COVID-19 can cause severe acute respiratory distress syndrome or myocardial dysfunction requiring extracorporeal membrane oxygenation (ECMO). Whether comorbidities or sociodemographic factors influence outcomes in these patients is unclear.

Methods: Adult patients from the National Inpatient Sample dataset with COVID-19 pneumonia or non-COVID-19 pneumonia who underwent ECMO between 2016 and 2021 were included. Cohorts were matched in a 1:5 ratio using propensity scores. The primary outcome of interest was inpatient mortality; secondary outcomes included length of stay, total hospitalization costs, need for dialysis, rate of vascular complications, and discharge disposition.

Results: Weighted patient groups (COVID-19 pneumonia, 5680 patients; non-COVID-19 pneumonia, 430 patients) were identified. Mean (SD) age was 46.0 (11.2) years in the COVID-19 group, 45.1 (12.5) years in the non-COVID-19 group. After matching, unweighted groups (COVID-19 pneumonia, 1136 patients; non-COVID-19 pneumonia, 86 patients) were compared. Patients with COVID-19 pneumonia had higher mortality risk (odds ratio [OR], 1.98; 95% CI, 1.11-3.53; P = .02), longer stays (38.0 vs 28.5 days, P < .001), higher costs ($1 278 270 vs $967 866, P = .002), and less likelihood of discharge home (OR, 0.42; 95% CI, 0.21-0.85; P = .02) than patients with non-COVID-19 pneumonia. Vascular complication rate (OR, 0.77; 95% CI, 0.27-2.26; P = .64) and need for dialysis (OR, 1.01; 95% CI, 0.49-2.08; P = .97) did not differ between groups.

Conclusions: Among patients undergoing ECMO, those with COVID-19 pneumonia had worse outcomes than those with non-COVID-19 pneumonia after adjustment for sociodemographic factors and comorbidities.

Background: Critically ill patients and their families commonly experience financial hardship, yet this experience is inadequately addressed by clinicians providing care in the intensive care unit. Understanding clinicians' perspectives on the barriers to addressing financial hardship provides an opportunity to identify and mitigate those barriers and improve patient outcomes.

Objective: To characterize intensive care unit clinicians' experiences with and perceived barriers to addressing financial hardship with their patients.

Methods: The study entailed a thematic analysis of semistructured interviews of 17 physicians, nurses, and social workers providing care to critically ill patients in a large academic health care system in the US Pacific Northwest.

Results: Participants recognized the importance of addressing financial hardship as an integral part of patient-centered care but identified barriers influencing their comfort with and capacity to address financial hardship. Barriers fit into 2 themes: "(dis)comfort addressing financial hardship" and "values-based concerns." (Dis)comfort addressing financial hardship was influenced by systems- and practice-based barriers. Participants discussed concerns about real and perceived conflicts of interest when patient, family, clinician, and institutional priorities were not aligned.

Conclusions: Participants recognized financial hardship as an important consequence of critical illness that negatively affected patient and family outcomes, yet they described barriers to adequately addressing this topic. Normalizing discussions about the financial impacts of critical illness and systematically screening for financial hardship may be a first step in mitigating these barriers.

Background: Because the death of a loved one is distressing for families, bereavement support is recommended for high-quality end-of-life care. Although health care professionals provide support during the death, many do not routinely follow up with bereaved families.

Objectives: To describe and compare how health care professionals view and provide bereavement support.

Methods: This prospective, cross-sectional study assessed registered nurses, physicians, social workers, respiratory therapists, and unlicensed assistive personnel working in the intensive care unit, step-down unit, and emergency department. Health care professionals completed a survey assessing their views, practices, and training in providing bereavement support to families. Descriptive statistics and the Kruskal-Wallis test were used to describe and compare the groups.

Results: Among 123 health care professionals, 67.5% were registered nurses and 78% were female. Most (64.2%) supported families at the time of death; however, only 6.5% followed up with bereaved families in the weeks after the death. Physicians, social workers, and registered nurses provided bereavement support more often than unlicensed assistive personnel and respiratory therapists did (P = .001). Only 29.3% were very comfortable providing support to bereaved families. Respiratory therapists were less comfortable than other health care professionals (P = .002). Most health care professionals (54.5%) wanted formal training on providing bereavement support. The main barriers to providing bereavement support included lack of training, time, and resources.

Conclusions: Understanding health care professionals' views and practices on providing bereavement support may help inform the development of appropriate educational materials, interventions, and protocols around bereavement support.

Background: Consensus is lacking on best practices regarding treatment of elevated intracranial pressure. One method is placement of an external ventricular drain to divert cerebrospinal fluid via continuous or intermittent drainage.

Objective: To explore the time required for fluid to finish draining at various pressure gradients under high- and low-compliance conditions.

Methods: An ex vivo model filled with 6200 mL saline and minimal air (low compliance) or 6050 mL saline and 150 mL air (high compliance) was attached to an external ventricular drain and transducer and then calibrated. The initial pressure in the chamber was set by adding or removing saline, and the buretrol was positioned to the set threshold. The external ventricular drain was then opened. Using different pressure gradients, 84 observations (42 low compliance, 42 high compliance) were obtained to identify the time to the second-to-last drop and the last drop (end of drainage).

Results: The overall mean (SD) time from stopcock opening to last drop was 100.80 (65.84) seconds. The mean low-compliance time was 40.57 (15.83) seconds, and the mean high-compliance time was 161.00 (33.14) seconds (P < .001). Pressure gradient was a predictor of drainage time in both high-compliance (P < .001) and low-compliance (P < .001) conditions. In all 84 trials, fluid diversion was complete within 4.5 minutes (second-to-last drop, 2 minutes 48 seconds).

Conclusions: The results of this study highlight the need to standardize intracranial pressure monitoring practice and further scientific knowledge about the best drainage techniques for patients with acquired brain injury.

Background: High-flow nasal cannula oxygen therapy is commonly used in acute respiratory failure. Despite this therapy's benefits, it also has risks, with therapy failure and intubation delay cited most frequently. Awareness of these risks is important to ensure optimal patient care and guide future research.

Objective: To explore risk representation in the literature for acutely ill adult patients receiving high-flow nasal cannula therapy.

Methods: A scoping review was performed using the Joanna Briggs Institute method of evidence synthesis. An a priori search strategy and protocol were carried out using the PubMed, Embase, CINAHL Complete, and medRxiv databases. After primary screening, data were collected using the REDCap (Research Electronic Data Capture) tool. Data were prepared, analyzed, and presented using Jupyter Notebook (Python 3.9.7). An online data repository was created to host the associated datasets for future work.

Results: Primary screening of the 2975 results led to exclusion of 2272 records. After duplicate and redundant articles were removed, articles underwent full-text review, yielding 343 included articles. The most frequently implicated disease in high-flow nasal cannula research was COVID-19 (n = 145), with publication frequency peaking in 2022 (n = 110). All risks fell under 8 categories: deterioration, death, device-related events, delay, disposition, debility, distress, and dysphagia (the "8 D's").

Conclusion: Acutely ill patients receiving high-flow nasal cannula therapy encounter 8 categories of risk. Deterioration and death are the most often discussed. Device-related events, delay, disposition, debility, and distress warrant further study.

Background: Mechanical ventilation and prone positioning are high-risk procedures for patients and health care team members, increasing patients' risk of secondary infection and pressure injuries, as well as increasing staff workload and risk of injury or contracting infectious diseases. Verticalization therapy is the practice of controlled, in-bed, upright positioning. Previous research showed increases in oxygenation during verticalization therapy, which suggests that verticalization therapy may be beneficial in patients with respiratory failure.

Objectives: To investigate the safety and feasibility of verticalization therapy in patients experiencing respiratory distress, including patients with COVID-19.

Methods: A convenience sample of adult patients in the medical respiratory intensive care unit at a mid-Atlantic urban academic medical center received up to 2 verticalization therapy sessions daily for a goal of 30 to 120 minutes each.

Results: The study aimed to enroll 15 participants, but suspended recruitment after 6 because of clinical team concerns that some participants were experiencing hypotension and decreases in oxygen saturation during verticalization, as well as lack of adequate nursing staff time. Most participants tolerated verticalization therapy, but one participant's initial verticalization therapy session was stopped at 30° because of hypotension and desaturation. The unit lacked nursing staff needed to consistently verticalize participants.

Conclusions: The small number of participants limits interpretation of study findings. Future studies should consider baseline critical illness severity and a slower rate of verticalization. Although it is unclear whether verticalization therapy decreases demands on physicians, advanced practice providers, and respiratory therapists, it clearly increased nursing workload in this study.