American Journal of Critical Care最新文献

Background: Delirium is a common complication of critical illness, but the epidemiology of delirium among stroke patients with critical illness is uncertain.

Objectives: To assess the prevalence, severity, and short-term outcomes of delirium in adults admitted to a neurocritical care unit with acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage.

Methods: A prospective, observational cohort study was conducted in a neurocritical care unit in the United States. Patients were enrolled within 48 hours of stroke symptom onset. Delirium was assessed daily until study day 7 (or until transfer out of the neurocritical care unit) with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the CAM-ICU-7 delirium severity score.

Results: Overall, 44.4% of patients in the cohort had delirium. Prevalence was higher among patients with intracerebral hemorrhage (38%, 60%, and 32% in patients with acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage, respectively). Mean CAM-ICU-7 score for patients who had delirium was 5.64. Regression analyses showed patients with delirium had more ventilator days (point estimate, 2.59; 95% CI, 0.73-4.44), longer ICU and hospital lengths of stay (point estimates, 3.33 [95% CI, 1.36-5.31] and 6.76 [3.43-10.09], respectively), lower odds of discharge home (odds ratio, 0.42; 95% CI, 0.19-0.94), and higher odds of worse modified Rankin score of 3 or higher at discharge (odds ratio, 2.58; 95% CI, 1.04-6.36). Higher delirium severity resulted in worse outcomes.

Conclusions: Delirium is common among critically ill stroke patients, especially those with intracerebral hemorrhage, and patients who experience delirium have worse outcomes. Increasing severity of delirium is associated with adverse outcomes.

Family presence during resuscitation and invasive procedures emerged as a practice innovation in the early 1980s in response to family needs during critical health care situations. By the 1990s, the American Association of Critical-Care Nurses, along with numerous other organizations, had formally supported this intervention and developed practice alerts, position statements, and other evidence-based guidelines. As the practice spread, researchers stepped up to investigate patient, family, and health care team outcomes. Today, family presence is practiced and studied across the globe. This article describes an empirical "Being There" model of the family presence intervention based on more than 125 pieces of external evidence. Using a logic model framework, it outlines the components of a family presence program, including the situation and priorities, inputs, outputs, outcomes/impact, assumptions, and external factors. This model can be used by units and organizations interested in revitalizing or initiating a family presence program in pediatric or adult emergency, high-acuity, or critical care settings. Program development and evaluation suggestions are offered, as well as recommendations for implementation science research to identify the most effective strategies for helping health care teams adopt and sustain family presence programs to meet patient and family needs in vulnerable health care moments.

Background: Critical care nurses are at high risk for anxiety, depression, and posttraumatic stress disorder, leading to poor professional quality of life.

Objectives: To explore the current state of cardiothoracic critical care nurses' mental health and professional quality of life as restrictions related to the COVID-19 pandemic were lifted, specifically (1) to explore nurses' levels of posttraumatic stress disorder, anxiety and depression, and professional quality of life; and (2) to determine relationships between demographic characteristics, supportive factors, and intent to leave the profession and dependent variables.

Methods: A cross-sectional, descriptive survey was administered to cardiothoracic intensive care nurses in a tertiary care, Magnet-designated academic medical center in the northeastern United States. The survey incorporated established measures of mental health and perceptions of professional quality of life.

Results: The sample consisted of 34 mostly female nurses with a bachelor's degree or higher. Participants had a mean (SD) of 10.7 (10.3) years of experience. Severity scores for mental health and professional quality of life ranged from mild to moderate. Significant relationships were found among mental health variables, intent to leave the profession, and evidence-based supportive factors. Supportive factors influenced scores on measures of mental health and burnout. Support from friends and family was related to anxiety and depression scores. Intent to leave the profession was significantly related to all mental health variables. The incidence of burnout was higher among younger nurses.

Conclusions: The findings point to the critical need to identify innovative strategies to increase support, particularly from peers and organizational leadership.

Background: How advanced practice providers (APPs) are deployed in adult US intensive care units (ICUs) is understudied. Further, whether state-level restrictions on practice affect the availability of these providers is unknown.

Objectives: To describe staffing patterns of ICU APPs (nurse practitioners, physician assistants) in the context of physicians-in-training (interns, residents, fellows) and to explore the association between state-level APP practice restrictions and employment.

Methods: Data from a national survey of pre-COVID-19 (steady-state) ICU staffing linked to the 2020 American Hospital Association survey were used to examine staffing patterns (via descriptive statistics) and to explore the association of state-level practice restrictions with the presence of APPs in ICUs (via multivariable regression).

Results: The cohort included 588 adult ICUs, of which 336 (57.1%) reported both APPs and physicians-in-training, 124 (21.1%) APPs only, 73 (12.4%) physicians-in-training only, and 55 (9.4%) neither. Units with both provider types were more commonly surgical ICUs (17.6% vs ≤9.6%; P < .001), whereas those with neither were 98.2% mixed units. Those units with neither were smaller and more often in smaller, nonteaching, for-profit hospitals in nonmetropolitan areas. Two hundred twenty-five ICUs (38.3%) were in states allowing full APP practice scope. After adjustment, the odds of employing APPs were nonsignificantly higher in ICUs in full-practice states.

Conclusions: Both APPs and physicians-in-training are commonly deployed in US adult ICUs, often together. Laws limiting practice scope may impede deployment of these providers in ICUs.

Background: Acute respiratory distress syndrome (ARDS), a common condition among intensive care patients, is characterized by severe hypoxemia that may lead to acute brain injury. Although prone positioning has emerged as a lifesaving strategy in the management of ARDS, its effects on cerebral oxygenation remain insufficiently explored.

Objective: To evaluate the evolution of cerebral oxygenation during prone positioning in patients with ARDS.

Methods: This prospective, single-center study was done in the intensive care unit of a community hospital. Consecutive patients with moderate or severe ARDS were prospectively enrolled during a 12-month period. Cerebral oxygenation was assessed by near-infrared spectroscopy before and during an 18-hour period of prone positioning. Continuous variables were compared before and during prone positioning using the Wilcoxon signed rank test. Correlations were assessed using the Spearman rank test.

Results: Ten patients were included in the study, with 2 patients exiting at hours 6 and 12 after the start of prone positioning because of hemodynamic instability. Evidence of oxygenation improvement during prone positioning was indicated by an increase in regional cerebral oxygen saturation (rSo2) and the ratio of Pao2 to fraction of inspired oxygen (Fio2). The rSo2/Fio2 ratio was significantly increased from hour 3 to 12 (P = .049 at hour 3, P = .02 at hour 8, and P = .02 at hour 12). Also, rSo2 was significantly correlated with oxygen delivery (ρ = 0.811, P < .001) and cardiac index (ρ = 0.463, P < .001).

Conclusion: Prone positioning in patients with ARDS seems to be associated with improved cerebral oxygenation based on rSo2/Fio2 ratio.