Intensive & critical care nursing最新文献

Objective: To describe the practice of ventilator-associated pneumonia (VAP) prevention and control through the incremental introduction of prevention strategies and assess the effect on VAP incidence.

Design: Historical observational surveillance study conducted over 13 years.

Setting: A 12-bed adult intensive care unit (ICU) in a general hospital in Belgium.

Participants: Patients admitted between 2007 and 2019, with ICU stays of ≥48 h.

Interventions: Incremental introduction of VAP preventive measures from 2008, including head-of-bed elevation, cuff pressure control, endotracheal tubes with tapered cuffs, subglottic secretion drainage, chlorhexidine oral care, and daily sedation assessment.

Measurements and main results: A significant decline in VAP incidence density rates was observed, from 18.3 to 2.6 cases per 1000 ventilator days from the baseline to the final period.

Conclusions: Systematic implementation of VAP preventive measures significantly reduced VAP incidence. However, this reduction did not translate into decreased overall ICU mortality.

Implications for practice: The study underscores the importance of continuous VAP surveillance and preventive measures in reducing VAP incidence.

Objective: The relationship between ventilator-associated events (VAE) and microaspiration in intubated patients has not be studied. The objective of this study was to evaluate the relationship between abundant microaspiration of oropharyngeal secretions or gastric contents and the incidence of VAE.

Patients and methods: This was a post hoc analysis of the BESTCUFF study, which was a multicenter, cluster randomized, cross-over, controlled, open-label trial in adult patients ventilated for over 48 h. All tracheal aspirates were sampled for 48 h following enrollment, with quantitative measurement of pepsin and alpha-amylase. VAE were identified using National Healthcare Safety Network criteria, based on PEEP or FiO₂ variations compared to stable parameters in previous days. The primary objective was to assess the relationship between abundant global microaspiration and the incidence of VAE, adjusted for pre-specified confounding factors (sex, SAPS II score and Glasgow coma scale).

Results: 261 patients were included, of which 31 (11.9%) developed VAE, with an overall median age of 65 (interquartile range 52-74), a majority of male patients (164, 62.8%), a median SAPS II score of 50 [40-61], a median SOFA score of 8 [5-11], and acute respiratory failure as main reason for ICU admission (117, 44.8%).The incidence of VAE was not significantly associated with abundant global microaspiration (adjusted cause-specific hazard ratio (cHR): 1.55 [0.46-5.17), abundant gastric microaspiration (adjusted cHR: 1.24 [0.61-2.53), or with abundant oropharyngeal microaspiration (adjusted HR: 1.07 [0.47-2.42]).

Conclusions: Our results suggest no significant association between abundant global, gastric or oropharyngeal microaspiration and the incidence of VAE.

Implications for clinical practice: This study underscores that measuring microaspiration in intubated critically ill patients might not be useful to predict the diagnosis of VAE or to evaluate interventions aiming at preventing these complications.

Objectives: To investigate the correlation between varying doses of norepinephrine (NE) and the incidence of pressure injuries (PIs) in COVID-19 patients in intensive care units (ICUs).

Design: A retrospective multicenter study was conducted on 1,078 COVID-19 patients admitted to ICUs with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. The research spanned from March 2020 to April 2021 across five university-affiliated hospitals in Iran. Univariate and multivariate binary logistic regression analyses, along with linear and non-linear dose-response assessments, were utilized to evaluate the relationship between NE dosages and the probability of PI development.

Findings: The multivariate analysis revealed a significant association between higher doses of NE administered over 24 h (OR: 1.832, 95 % CI: 1.218-2.754, P=0.004) and cumulative doses (OR: 1.408, 95 % CI: 1.204-1.975, P=0.048) with the occurrence of PIs. Moreover, patients receiving high NE doses had a nearly fourfold increased risk of developing PIs, regardless of PIs stage, compared to those on low or moderate doses (>15 µg/min vs. ≤ 15 µg/min; OR: 4.401, 95 % CI: 3.339-5.801, P=0.001). Although the linear dose-response analysis did not show a significant correlation between NE doses and PI development (P>0.05), the non-linear analysis indicated that NE doses ≤ 9 µg/min were associated with a reduced risk of PI development.

Conclusion: Maintaining NE infusion within the range of 1-9 µg/min appears to be most effective in reducing the likelihood of PIs in ICU patients with COVID-19. Lower NE doses (≤9 µg/min) were associated with a lower risk of PI development, suggesting that factors beyond NE dosage or the use of other vasopressors may play a crucial role in PI formation in this patient cohort.

Implications for clinical practice: Rather than suggesting a specific threshold, clinicians should consider further studies to determine the optimal dose that balances microvascular perfusion and patient outcomes. It is crucial to comprehensively evaluate additional factors and selectively use vasopressors. Individualized care, including regular monitoring and personalized treatment plans, is essential for achieving the best outcomes in this patient population.

Objectives: To determine the incidence and risk factors of tracheostomy-related pressure injuries (TRPI) and examine the COVID-19 pandemic's impact on TRPI incidence.

Design: Secondary analysis of Global Tracheostomy Collaborative database and a multi-center hospital system's electronic medical records.

Setting: 27 hospitals, primarily in the United States, United Kingdom, and Australasia.

Patients: 6,400 adults and 2,405 pediatric patients hospitalized with tracheostomy between 1 January 2019 and 31 December 2021.

Measurement: TRPI as a binary outcome, reported as odds ratios.

Results: TRPI incidence was 4.69 % in adults and 5.65 % in children. For adults, associated risks were female sex (OR: 0.64), severe obesity (OR: 2.62), ICU admission (OR: 2.05), cuffed tracheostomy (OR: 1.49), fenestrated tracheostomy (OR: 15.37), percutaneous insertion (OR: 2.03) and COVID-19 infection (OR: 1.66). For children, associated risks were diabetes mellitus (OR: 4.31) and ICU admission (OR: 2.68). TRPI odds increased rapidly in the first 60 days of stay. Age was positively associated with TRPI in adults (OR: 1.014) and children (OR: 1.060). Black patients had higher TRPI incidence than white patients; no moderating effects of race were found. Hospital cluster effects (adults ICC: 0.227; children ICC: 0.138) indicated unmeasured hospital-level factors played a significant role.

Conclusions: Increasing age and length of stay up to 60 days are TRPI risk factors. Other risks for adults were female sex, severe obesity, cuffed/fenestrated tracheostomy, percutaneous insertion, and COVID-19; for children, diabetes mellitus and FlexTend devices were risks. Admission during the COVID-19 pandemic had contrasting effects for adults and children. Additional research is needed on unmeasured hospital-level factors.

Implications for clinical practice: These findings can guide targeted interventions to reduce TRPI incidence and inform tracheostomy care during public health crises. Hospital benchmarking of tracheostomy-related pressure injuries is needed.

Objective: To describe healthcare professionals' perception of current early rehabilitation practices and their preconditions, focusing on functional and cognitive stimulation facilitated by nurses and other healthcare professionals in Scandinavian intensive care units (ICUs).

Design: Cross-sectional electronic survey administered to healthcare professionals. The survey was developed in Danish, translated into Norwegian and Swedish, and delivered using Google Forms. The qualitative data were analysed using the framework method.

Setting: Scandinavian ICUs.

Results: Practices facilitated by nurses and other healthcare professionals in the ICU often began with weaning from the ventilator and reducing sedation. This was followed by increased mobilisation and building physical strength. There was attention to optimising nutrition, swallowing function, and oral intake. Enabling communication and employing cognitively stimulating activities and bodily stimulation to engage the patient's mind were also framed as rehabilitation. To avoid delirium and overexertion, it was important to balance rest and activity and to shield the patient from unnecessary stimulation. Furthermore, it was important to support the patient's will to live and to involve the family in rehabilitation. Post-discharge rehabilitation activities included reaching out to patients discharged to wards and homes.

Conclusion: Rehabilitation was described as progressing from passive to active as patients gained consciousness and strength. Weaning, balancing rest and activity, supporting the patient's life courage and will to recover, open visitation policies, and multi-professional collaboration were important prerequisites for rehabilitation.

Implications for practice: All aspects of patient care can function as important opportunities for physical and cognitive rehabilitation. Balancing rest and activity is important for conserving the patient's energy for rehabilitation.

Introduction: Antimicrobial resistance is a major public health challenge recognised by the WHO as an urgent global healthcare concern. Patients in Intensive Care Units (ICUs) are particularly prone to colonisation and/or infection by multidrug-resistant organisms (MDROs).

Objectives: Delineate the epidemiological characteristics and risk factors for MDROs colonisation in mixed ICUs and Resuscitation Units by focusing on initial and nosocomial colonisation.

Material and methods: A descriptive observational study with analytical elements. It uses the Zero-Resistance register from the Preventive Medicine Service of the Albacete General University Hospital (Spain) from April 2016 to December 2021. It identifies the risk factors for MDROs colonisation.

Results: Of 7,541 cases, 61.0 % with initial colonisation had risk factors for MDROs versus 34.0 % not colonised upon hospitalisation (p < 0.001). Significant risk factors for initial colonisation included hospitalisation for ≥ 5 days within the last 3 months, prior MDROs colonisation/infection and institutionalization. No significant risk factor differences were found for nosocomial colonisation. An association between longer ICU stays and nosocomial colonisation (p < 0.001) was noted.

Conclusions: Significant risk factors for initial MDROs colonisation were hospitalisation for ≥ 5 days in the last 3 months, prior MDROs colonisation/infection and institutionalisation. Longer ICU stays increased the nosocomial colonisation risk.

Implications for clinical practice: This study underscores the importance to early identify and manage patients at risk for MDROs colonisation in ICUs. By recognising factors (i.e. previous hospitalisations, existing colonisation or infection, impact of prolonged ICU stay), healthcare providers can implement targeted strategies to mitigate the spread of MDROs; e.g. enhanced surveillance, stringent infection control measures and judicious antibiotics use. Our findings highlight the need for a comprehensive approach to manage antimicrobial resistance in critical care settings to ultimately improve patient outcomes and reduce MDROs burden in hospitals.