Critical care explorations最新文献

Importance: Viral bronchiolitis is the leading cause of nonelective admission to the PICU. Guidelines recommend management that focuses on supportive care. Evidence suggests that inhaled epinephrine may reduce lower airways resistance and work of breathing in critical bronchiolitis. It has been demonstrated at one institution that it is feasible to administer continuous inhaled epinephrine (CIE) via heated high-flow nasal cannula (HFNC).

Objectives: To describe the demographic and clinical characteristics of patients with bronchiolitis who received CIE and assess their physiologic response to treatment compared with patients who received conventional therapy.

Design setting and participants: We performed a single-center retrospective cohort study of previously healthy children 0-2 years old admitted to the PICU with diagnosis of bronchiolitis from 2017 to 2023.

Main outcomes and measures: Physiologic response to treatment was assessed via analysis of vital signs and use of respiratory rate, oxygenation, heart rate (ROX-HR) index.

Results: One hundred ninety-three patients were included in the study. Patients who received CIE were younger (median age, 4 vs. 7 mo old; p = 0.01) and smaller (7.0 vs. 8.4 kg; p = 0.06), presented with higher initial peak respiratory rates (70 vs. 50 beats/min; p < 0.0001), and had longer ICU stays (3.4 vs. 1.8 d; p < 0.001). Patients treated with CIE exhibited overall higher respiratory rates and lower ROX-HR indices, indicating more severe illness. Within the first 48 hours of treatment, patients receiving CIE demonstrated a more rapid improvement in both respiratory rate and ROX-HR index compared with those receiving conventional therapy.

Conclusions and relevance: In this cohort, CIE was used as novel therapy for younger, smaller patients with more severe bronchiolitis on presentation to the PICU. The physiologic changes suggest potential benefit of this therapy for patients who are not improving with conventional HFNC therapy.

Objectives: Given significant harms of awake paralysis, guidelines recommend combination sedation and analgesia during neuromuscular blockade. In this study, we sought to describe guideline-concordant use of parenteral sedation and analgesia during sustained neuromuscular blockade among adults with critical illness.

Design: Multicenter, retrospective cohort study.

Setting: ICUs in 871 hospitals across the United States.

Patients: Adult patients admitted to an ICU between 2016 and 2022 who received invasive mechanical ventilation and at least one neuromuscular blocking agent (NMBA) on the same calendar day.

Interventions: None.

Measurements and main results: We used charge codes to identify use of parenteral sedatives (propofol, fospropofol, lorazepam, midazolam, diazepam, etomidate, phenobarbital, pentobarbital, and ketamine), and analgesics (fentanyl, hydromorphone, morphine, and ketamine) for each patient-day with neuromuscular blockade, and then categorized patient-days as guideline concordant or not. A total of 363,382 patient-days (among 104,984 hospitalizations) were included in the final cohort. Guideline-concordant sedation and analgesia were used concurrently in 345,660 patient-days (95.1%); only sedation was used in 15,618 patient-days (4.3%), only analgesia was used in 1,348 patient-days (0.4%), and neither sedation nor analgesia was used in 756 patient-days (0.2%). Most included hospitals (856 [98.3%]) used both sedation and analgesia on greater than or equal to 50% of patient-days; however, ten hospitals (1.1%) used only sedation on greater than or equal to 50% of patient-days, and 4 (0.6%) had no predominant sedation and analgesia strategy; however, 42.3% of the variation in guideline-concordant practice was attributable to residual unexplained clustering by hospital after accounting for demographics, severity of illness, and hospital characteristics.

Conclusions: Our findings suggest sedation and analgesia practices with NMBA use in adult ICUs are generally guideline-concordant but require corroboration using more precise, quantitative medication data. Practice variation between hospitals is potentially concerning and warrants further investigation targeting adequacy of sedation and analgesia during NMBA use and assessing the clinical impact of guideline-discordant practices.

Importance: Black and Hispanic/Latino patients are underrepresented in pediatric mode of death (MOD) studies. Although significant disparities have been reported, the associations of MOD with patient-level social determinants of health (SDOH) and the Child Opportunity Index (COI) are unknown.

Objectives: To investigate associations between PICU MOD, race and ethnicity, SDOH, and COI.

Design, setting, and participants: Retrospective, single-center cohort study at a twenty-four-bed PICU within a large safety-net, public hospital, including all PICU deaths between January 2010 and December 2019.

Main outcomes and measures: We examined MOD by race and ethnicity, COI, and SDOH, including preferred language, health insurance, single-parent household status, parental occupation, and healthcare barriers abstracted from medical records. MOD was categorized as limitation of artificial life-sustaining therapies/technology (LOT) or withdrawal of artificial life-sustaining therapies/technology (WOT), failed resuscitation (FR), and death by neurologic criteria (DNC).

Results: Of 238 deaths, Black non-Hispanic/Latino patients comprised 42% (n = 100), Hispanic/Latino patients of all races 35% (n = 83), and White non-Hispanic/Latino patients 19% (n = 46). LOT/WOT was the predominant MOD (75%, n = 174; LOT = 109, WOT = 65). Racial and ethnic groups showed significant differences in COI, SDOH, and healthcare barriers. Despite this, there were no significant differences in MOD by Race and Ethnicity, SDOH, or healthcare barriers. Median COI was lower for DNC compared to LOT and WOT, and for FR compared with WOT. However, when examined within individual racial and ethnic groups, there was no difference in median COI between FR, LOT, and WOT.

Conclusion and relevance: We found no differences in MOD by Race and Ethnicity, SDOH, or barriers. Median COI was lower for FR compared with WOT. This suggests that COI, as opposed to race and ethnicity, may play a role in pursuing or forgoing resuscitation at end-of-life. This study adds to the examination of pediatric healthcare disparities at end-of-life by including SDOH and COI data in MOD analysis.

This study aimed to evaluate ventilator requirements, gas exchange, and safety outcomes before and after initiation of continuous infusion ketamine in intubated patients with severe asthma exacerbations (SAEs) in ICUs. This retrospective observational study included 38 intubated patients 18 years old or older experiencing an SAE who received a continuous infusion of ketamine for greater than or equal to 1 hour. The primary outcome was change in Pco2 before and after ketamine initiation. The median Pco2 before ketamine initiation was 67.65 mm Hg (56-81 mm Hg) and 64 mm Hg (56-77 mm Hg) after. The median pH before and after ketamine initiation was 7.21 (7.12-7.3) and 7.24 (7.14-7.3), respectively. The median maximum rate of ketamine was 1.2 mg/kg/hr (0.7-1.5 mg/kg/hr). Mortality occurred in 15.8% of patients. Tachycardia occurred in 52.6% of patients, and hypotension occurred in 50% of patients. The rate of emergence reactions was 13.2%. In this study, continuous infusion ketamine was not associated with an improvement in Pco2.

Importance: Professional societies recommend interprofessional collaboration to support ICU surrogate decision-makers, yet little is known about how to operationalize it.

Objectives: Determine clinicians' perceived acceptability of interprofessional collaboration to support surrogates of ICU patients facing goals-of-care (GOC) decisions and identify barriers/facilitators to implementing a proposed interprofessional collaboration intervention.

Design, setting, and participants: Mixed-methods study with ICU clinicians from four hospitals in Pennsylvania and Ohio. Surveys assessed acceptability across three domains: perceived effectiveness, self-efficacy, and attitudes. Clinicians from two ICUs without an interprofessional collaboration program also answered interview questions eliciting barriers/facilitators to implementing a proposed interprofessional collaboration intervention.

Analysis: Descriptive statistics for survey data and content analysis of interview transcripts.

Results: We surveyed 56 clinicians: 25 physicians and advanced practice providers (APPs), and 31 other healthcare professionals (22 nurses, 3 social workers, 6 others), and interviewed 24. Ninety-eight percent agreed that enhanced interprofessional collaboration improves surrogate support. Among other healthcare professionals, 61% wanted a larger role in GOC decisions, 97% felt confident providing emotional support, and more than 74% were confident in reinforcing prognostic information and discussing values/preferences and GOC. ICU physicians/APPs were all comfortable with nurses and social workers providing emotional support, and most were comfortable with nurses (> 80%) and social workers (> 60%) reinforcing prognostic information and discussing values/preferences, and GOC. Although more than 95% of nurses and others were confident discussing physician-proposed treatment options, only 33% of social workers were, and less than or equal to 50% ICU physicians/APPs were comfortable with nurses/social workers doing so. 94% of ICU physicians/APPs supported adopting an interprofessional collaboration intervention with shared mental models, defined roles, and training. Barriers included team turnover, time constraints, evolving care plans, and training feasibility. Facilitators included specialized training, clear roles, and knowledge of the evidence base for interprofessional collaboration.

Conclusions: Most clinicians across roles found interprofessional collaboration for GOC decisions acceptable, with clear responsibilities, specialized training, workflow fit, and education on its value as key facilitators for implementation.

Objectives background: Families play an important role in the care of ICU patients, yet their potential to contribute to the detection of delirium-a common and harmful complication-is often underutilized. This study aimed to adapt the Sour Seven to create the Family ICU Delirium Detection Instrument (FIDDI) and to assess its usability, reliability, and construct validity for delirium detection in ICU patients.

Design: Cross-sectional.

Setting: Canadian closed 34-bed general systems adult ICU providing tertiary level care.

Participants: Patient-family pairs (dyads) were included. Eligible patients had no primary brain injury, a Richmond Agitation-Sedation Scale score of greater than or equal to -3 and were expected to remain in the ICU for at least 24 hours to complete all study assessments.

Interventions: Not applicable.

Measurements and main results: The Sour Seven underwent adaptation using data from the Family ICU Delirium Detection Study and input from a multidisciplinary working group. The FIDDI was then tested for internal consistency using Cronbach's alpha and construct validity through confirmatory factor analysis. Family members provided feedback through surveys on the tool's usability and their experience with delirium detection. We enrolled 51 patient and family member pairs. Most family members were women (n = 38, 75%), including spouses (n = 17, 33%), adult children (n = 16, 31%), or siblings (n = 10, 20%). The FIDDI showed strong internal consistency (Cronbach's alpha = 0.858). The model fit indices indicated acceptable structure validity (Tucker-Lewis index [TLI] = 1.015, comparative fit index = 1.000, root mean square error of approximation = 0.000, and standardized root mean residual = 0.044). Family members reported that the tool was easy to use and helpful for understanding delirium, although some attributed behavioral changes to medical treatments or clinical conditions, highlighting the need for further education on delirium.

Conclusions: The Sour Seven was successfully adapted for the ICU environment (FIDDI) and pre-tested, demonstrating reliability and construct validity for detecting delirium in the ICU. These findings support its potential as a family-engaged assessment tool. Further research is needed to test the value of the FIDDI relative to current delirium detection strategies.

Background: Immune-related adverse events (irAEs) induced by immune checkpoint inhibitors vary widely, raising diagnostic challenges. The management of suspected irAEs requires close collaboration between oncologists and organ specialists. Rarely, irAEs can occur as overlap syndromes and may require intensive care.

Case summary: A 69-year-old man required intensive care for severe overlap syndrome induced by a programmed death-ligand 1 inhibitor. The presentation as recurrent hypercapnic coma complicated the diagnosis of polyradiculoneuritis combined with myocarditis. The finding of anti-titin autoantibodies assisted in the diagnosis. The patient was successfully treated with corticosteroids, polyvalent immunoglobulins, abatacept, and ruxolitinib. The irAEs abated but the polypharmacy contributed to the development of fatal hemorrhagic shock.

Conclusions: This is the first reported case of seropositive, overlap irAEs consisting of myocarditis and polyradiculoneuritis. Early immunosuppressive therapy can alleviate irAEs but can also lead to serious complications in frail patients. This underscores the importance of carefully balancing expected therapeutic benefits against potential risks.

Importance: This study provides nationally representative data on critical care advanced practice provider (APP) workforce structure and practice, addressing gaps in onboarding, productivity assessment, and administrative roles that influence workforce sustainability.

Objectives: To analyze the composition of the clinical practice and workforce demographics of critical care medicine APPs.

Design, setting, and participants: We utilized a cross-sectional survey, which was distributed via email through the Society of Critical Care Medicine email list, targeting critical care APPs.

Main outcomes and measures: A total of 518 critical care APPs participated in the survey, comprising 63.2% advanced practice registered nurses, 28.8% physician assistants, and 8% clinical nurse specialists. The majority of the sample APPs worked 12-hour shifts covering days, nights, and weekends, with over 50% managing 6-10 patients per day shift. Common billing practices included critical care time (60.6%) and bedside invasive procedures (64.3%). Formal onboarding was reported by 68.6% of respondents, with academic hospitals more likely to offer such programs than community hospitals (72.3% vs. 27.7%; p < 0.001). Administrative APP roles were more prevalent in academic centers (p < 0.001) and were associated with greater access to professional development opportunities (p < 0.001). A significant proportion of respondents (41.5%) reported that their productivity was not formally measured. Notably, 22% of respondents reported an intent to leave the profession, particularly those lacking leadership or professional growth opportunities (p < 0.01).

Conclusions and relevance: This study captures practice trends and demographics of the critical care APP workforce. Day-to-day tasks among all respondents were globally clinically focused, but there were disparities in workload distribution, onboarding, productivity measurement, and administrative roles across types of centers. Additionally, there was significant association between limited professional growth opportunities and intent to leave critical care. These findings underscore the need for healthcare systems to invest in structured support, leadership development, and professional growth to enhance APP retention, engagement, and productivity. Further research is needed to identify efficient workload and staffing models.

Objectives: Current research does not address the existence and impact of structured tele-critical care (TCC) training on the delivery of care in the ICU. This pilot study aimed to evaluate the association between on boarding elements focused on training and clinicians perceptions of delivery of care.

Design: Cross-sectional survey study.

Setting and participants: Critical Care professionals at four U.S. hospitals, professional meetings and Society of Critical Care Medicine's International Membership base. Participants were active clinicians who practice in the TCC setting.

Interventions: None.

Measurements and main results: A total of 432 participants responded to the survey, 227 met the eligibility criteria (52.5%) and were included in the analysis. Respondents were a multi-professional group of TCC clinicians aged between 35-55 years of age (56.4%). Seventy-four percent of respondents reported having orientation before providing TCC, 46% reported having formal mentorship, and 66% reported formal training on their institutional platform. Provision of orientation before participating in a TCC program was associated with higher ratings of feeling prepared (odds ratio [OR], 3.52; p < 0.001) and feeling accepted as part of the ICU team (OR, 2.21; p = 0.008). Mentorship was associated with feeling more prepared (OR, 8.2; p < 0.001) and higher comfort in delivering care (OR, 2.78; p = 0.016). Platform training was associated with feeling more prepared (OR, 4.66; p < 0.001), comfortable in delivering care (OR, 3.6; p = 0.002), feeling accepted as part of the team (OR, 3.18; p < 0.001), and more likely to participate in quality improvement (OR, 2.51; p = 0.001). A site visit also made a positive impact in feeling prepared (OR, 2.86; p < 0.001), comfortable (OR, 4.95; p = 0.002), feeling like recommendations were accepted (OR, 3.73; p < 0.001), more likely to recommend TCC (OR, 3.18; p = 0.001), and participating in quality improvement (OR, 3.24; p < 0.001).

Conclusions: In this pilot study, structured training utilizing orientation, mentorship, and platform training as surrogates, along with a site visit before beginning delivery of care in a TCC setting, were associated with more positive perceptions in the delivery of care domains assessed. We highlight potentially important factors that warrant further evaluation and assessment of the need for standardization across TCC programs.

Importance: Communication failures during patient handoffs from the ICU to the ward are common and negatively impact patients. Structured handoff communication tools may improve these transitions yet remain infrequently used.

Objectives: Characterize local determinants of ICU-PAUSE handoff program perceived implementation success and describe adaptations made to the ICU-PAUSE tool and its implementation strategies during multicenter implementation.

Design, setting, and participants: Qualitative study in 11 academic hospitals' medical ICUs. Participants were intensive care physicians who volunteered to champion ICU-PAUSE implementation at their respective institutions.

Analysis: Thematic analysis of semi-structured interviews to understand determinants, artifact analysis to characterize adaptations, and retrospective post-implementation chart review of ICU-to-ward transfer notes to evaluate uptake and sustainability of the intervention.

Results: Participants reported fewer perceived implementation barriers than expected, with many anticipated barriers ultimately functioning as important facilitators. Eight sites (73%) modified the ICU-PAUSE electronic template and/or its implementation strategies; most of the 29 unique adaptations described by participants involved adding new content to the standard template. Noncontent adaptations were largely contextual to fit site-specific needs and facilitate tool adoption. One year after implementation, the ICU-PAUSE template was used in 75% of ICU-to-ward transfer notes analyzed.

Conclusions: ICU-PAUSE is a low-barrier intervention to improve ICU-ward handoff communication. This study highlights the importance of adaptability in the success of nationally scalable implementation efforts for bundled interventions like ICU-PAUSE.