American Journal of Critical Care最新文献

Background: Sound levels in the pediatric intensive care unit (PICU) are often above recommended levels, but few researchers have identified the sound sources contributing to high levels.

Objectives: To identify sources of PICU sound exposure.

Methods: This was a secondary analysis of continuous bedside video and dosimeter data (n = 220.7 hours). A reliable coding scheme developed to identify sound sources in the adult ICU was modified for pediatrics. Proportions of sound sources were compared between times of high (≥45 dB) and low (<45 dB) sound, during day (7 AM to 6:59 PM) and night (7 PM to 6:59 AM) shifts, and during sound peaks (≥70 dB).

Results: Overall, family vocalizations (38% of observation time, n = 83.9 hours), clinician vocalizations (32%, n = 70.6 hours), and child nonverbal vocalizations (29.4%, n = 64.9 hours) were the main human sound sources. Media sounds (57.7%, n = 127.3 hours), general activity (40.7%, n = 89.8 hours), and medical equipment (31.3%, n = 69.1 hours) were the main environmental sound sources. Media sounds occurred in more than half of video hours. Child nonverbal (71.6%, n = 10.2 hours) and family vocalizations (63.2%, n = 9 hours) were highly prevalent during sound peaks. General activity (32.1%, n = 33.2 hours), clinician vocalizations (22.5%, n = 23.3 hours), and medical equipment sounds (20.6, n = 21.3 hours) were prevalent during night shifts.

Conclusions: Clinicians should partner with families to limit nighttime PICU noise pollution. Large-scale studies using this reliable coding scheme are needed to understand the PICU sound environment.

Background: Family members and close friends of patients undergoing mechanical ventilation in the intensive care unit (ICU) often experience stress and a sense of helplessness. Participating in the care of their loved one may improve their adaptation to the ICU environment and better prepare them for caregiving after discharge.

Objectives: The primary aim of this study was to develop the Family Willingness for Caregiving Scale (FWCS) and test its psychometric properties. The secondary aim was to examine relationships between family members' demographic characteristics and caregiving willingness.

Methods: The process of scale development followed DeVellis's 8-step method, and the scale was tested in 3 phases. The first 2 phases examined content validity and face validity, respectively. In phase 3, the FWCS was administered to a sample of family members currently visiting an ICU patient.

Results: Content validity and face validity were confirmed. The internal consistency reliability of the scale was acceptable, and exploratory factor analysis revealed a 1-factor structure comprising both physical and emotional/supportive care tasks. Caregiving willingness differed significantly by sex, with women reporting greater willingness than men reported.

Conclusions: Further testing of the FWCS is needed. After refinement, the FWCS could be used to evaluate factors contributing to caregiving willingness of family members of ICU patients and advance the science related to family engagement in the ICU. Additionally, it could be used as a practical tool to suggest family caregiving activities in the ICU.

Background: It remains poorly understood why only some hemodynamically unstable patients who receive aggressive treatment with vasopressor medications develop limb necrosis.

Objective: To determine the incidence of limb necrosis and the factors associated with it following high-dose vasopressor therapy.

Methods: A retrospective case-control medical records review was performed of patients aged 18 to 89 years who received vasopressor therapy between 2012 and 2021 in a single academic medical center. The study population was stratified by the development of limb necrosis following vasopressor use. Patients who experienced necrosis were compared with age- and sex-matched controls who did not experience necrosis. Demographic information, comorbidities, and medication details were recorded.

Results: The incidence of limb necrosis following vasopressor administration was 0.25%. Neither baseline demographics nor medical comorbidities differed significantly between groups. Necrosis was present in the same limb as the arterial catheter most often for femoral catheters. The vasopressor dose administered was significantly higher in the necrosis group than in the control group for ephedrine (P = .02) but not for the other agents. The duration of therapy was significantly longer in the necrosis group than in the control group for norepinephrine (P = .001), epinephrine (P = .04), and ephedrine (P = .01). The duration of vasopressin administration did not differ significantly between groups.

Conclusion: The findings of this study suggest that medication-specific factors, rather than patient and disease characteristics, should guide clinical management of necrosis in the setting of vasopressor administration.

Background: Intensive care unit (ICU) patients experience hypoglycemia at nearly 4 times the rate seen in non-ICU counterparts. Although inpatient hypoglycemia management relies on nurse-driven protocols, protocol adherence varies between institutions and units.

Objective: To compare hypoglycemia management between ICU and non-ICU patients in an institution with high adherence to a hypoglycemia protocol.

Methods: This secondary analysis used retrospective medical record data. Cases were ICU patients aged 18 years or older with at least 1 hypoglycemic event (blood glucose level < 70 mg/dL); non-ICU controls were matched by age within 10 years, sex, and comorbidities. Time from initial hypoglycemic blood glucose level to subsequent blood glucose recheck, number of interventions, time to normoglycemia, and number of spontaneous hypoglycemic events were compared between groups.

Results: The sample included 140 ICU patients and 280 non-ICU controls. Median time to blood glucose recheck did not differ significantly between groups (19 minutes for both groups). Difference in mean number of interventions before normoglycemia was statistically but not clinically significant (ICU, 1.12; non-ICU, 1.35; P < .001). Eighty-four percent of ICU patients and 86% of non-ICU patients returned to normoglycemia within 1 hour. Median time to normoglycemia was lower in ICU patients than non-ICU patients (21.5 vs 26 minutes; P = .01). About 25% of patients in both groups experienced a spontaneous hypoglycemic event.

Conclusion: Adherence to nurse-driven hypoglycemia protocols can be equally effective in ICU and non-ICU patients. Further research is needed to determine protocol adherence barriers and patient characteristics that influence response to hypoglycemia interventions.

Background: Early mobility interventions in intensive care units (ICUs) are safe and improve outcomes in subsets of critically ill adults. However, implementation varies, and the optimal mobility dose remains unclear.

Objective: To test for associations between daily dose of out-of-bed mobility and patient outcomes in different ICUs.

Methods: In this retrospective cohort study of electronic records from 7 adult ICUs in an academic quarternary hospital, multivariable linear regression was used to examine the effects of out-of-bed events per mobility-eligible day on mechanical ventilation duration and length of ICU and hospital stays.

Results: In total, 8609 adults hospitalized in ICUs from 2015 through 2018 were included. Patients were mobilized out of bed on 46.5% of ICU days and were eligible for mobility interventions on a median (IQR) of 2.0 (1-3) of 2.7 (2-9) ICU days. Median (IQR) out-of-bed events per mobility-eligible day were 0.5 (0-1.2) among all patients. For every unit increase in out-of-bed events per mobility-eligible day before extubation, mechanical ventilation duration decreased by 10% (adjusted coefficient [95% CI], -0.10 [-0.18 to -0.01]). Daily mobility increased ICU stays by 4% (adjusted coefficient [95% CI], 0.04 [0.03-0.06]) and decreased hospital stays by 5% (adjusted coefficient [95% CI], -0.05 [-0.07 to -0.03]). Effect sizes differed among ICUs.

Conclusions: More daily out-of-bed mobility for ICU patients was associated with shorter mechanical ventilation duration and hospital stays, suggesting a dose-response relationship between daily mobility and patient outcomes. However, relationships differed across ICU subpopulations.