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Background: A non-invasive method of measuring cardiac output (CO) can be beneficial in the care of critically ill patients. HemoVista (BiLab Co., Ltd.) is a medical device that measures CO non-invasively using multi-channel impedance plethysmography technology. The purpose of this study was to exploratively evaluate the performance of HemoVista in critically ill patients undergoing CO monitoring with the FloTrac (Edwards Lifesciences)., Methods: After non-invasively installing the HemoVista sensor in critically ill patients whose CO was monitored with the FloTrac, CO values measured by both devices were collected for 30 minutes. Cardiac output measured by both devices was selected every 10 seconds, creating approximately 360 data pairs per patient. Linear correlation analysis with Pearson correlation coefficients, Bland-Altman analysis, and four-quadrant plot analysis were performed to evaluate the performance of HemoVista., Results: A total of 7,138 pairs of CO data from the 20 patients were included in the analysis. A significant correlation was observed between the two methods of measuring CO (Pearson's r=0.489, P<0.001). The mean bias was 1.03 L/min, the 95% CI for the limit of agreement was -1.83 L/min to 3.93 L/min and the percentage error was 55.8%. The concordance rate of time-dependent CO between the two devices was 14.6%., Conclusions: It was observed that the current version of HemoVista has unsuitable performance for use in intensive care units. To be used for critically ill patients, the algorithm must be improved and reevaluated with an enhanced version.

Objective: To compare glucose measurements from capillary and venous blood samples using a point-of-care (POC) glucometer with a standard laboratory (colorimetric, glucose oxidase) assay (LABGLU) in a population of hospitalized, neonatal foals., Design: Multicenter, prospective, experimental study, conducted between March 2019 and June 2020., Setting: Four university teaching hospitals and 1 private referral hospital., Animals: Fifty-four hospitalized neonatal (≤30 days of age) foals., Interventions: Simultaneous capillary (muzzle, POCMUZ) and venous (jugular, POCJUG) blood samples were obtained to determine POC glucose concentrations. Venous samples were also analyzed by LABGLU. Each foal was sampled at the time of enrollment or admission to the hospital and at 1 subsequent point during hospitalization. Indirect mean arterial pressure and hematocrit were concurrently recorded., Measurements and Main Results: Bland-Altman analysis showed a mean bias (95% limits of agreement) of -28.0 (-88.6 to 32.6) mg/dL for comparison of POCJUG with LABGLU, -8.2 (-94.3 to 78.0) mg/dL for POCMUZ and LABGLU, and 18.8 (-44.4 to 82.0) mg/dL for POCMUZ and POCJUG. A total of 63.5% of the POCJUG and 45.2% of the POCMUZ samples exceeded the reference value by ±15 mg/dL (for LABGLU samples <75 mg/dL) or ±15% (for LABGLU samples ≥75mg/dL). Concordance correlation coefficient (95% confidence interval [CI]) indicated a fair agreement between POCJUG and LABGLU (0.75, 95% CI: 0.66-0.82) and between POCMUZ and LABGLU (0.71, 95% CI: 0.58-0.80). Fifty percent (14/28) of hypoglycemic foals on the reference method were incorrectly classified as euglycemic by POCJUG, and 5 of 28 were incorrectly classified by POCMUZ., Conclusions: In the sampled population, the chosen POC glucometer lacked agreement with the standard laboratory measurement. Limits of agreement were wide for both POCJUG and POCMUZ. Inaccuracies in POC results could impact decision-making in the clinical management of glycemic control in hospitalized neonatal foals and, importantly, increase the risk of hypoglycemic events being underdiagnosed in critical patients., (© Veterinary Emergency and Critical Care Society 2024.)

Introduction: Sinks have been introduced near patients to improve hand hygiene as part of infection prevention and control measures. However, sinks are a known reservoir for gram-negative bacterial pathogens in particular and their removal to prevent bacterial infections in intensive care patients is currently recommended by several international guidelines., Methods: Healthcare workers (HCWs) in 15 intensive care units (ICUs) in Germany were given the opportunity to complete an anonymous survey on the use of sinks between August 2022 and January 2023. Observations were then made in three participating ICUs to determine the frequency and reason for contact with the sink., Results: 258 questionnaires were returned (nurses 87%). 90% found it useful to very useful to have a sink in the patient room, and 56% reported using it daily for hand hygiene. We observed 33 contacts between nurses and sinks over 17 h. In 20/33 (60%) cases, the sink was used for waste disposal. In 3/33 (10%) it was used for hand washing., Discussion: Sinks are still used for daily care in intensive care units. Educational Interventions in existing buildings to minimise risk through "sink hygiene" (i.e. separation of sinks for water disposal and uptake) can make an important contribution to infection prevention., Competing Interests: Declarations Competing interests The authors declare no competing interests. Ethical approval In the authors´ opinion, the survey was not subject to consultation by an ethics committee in accordance with Sect. 15 of the Berlin Medical Association’s professional code of conduct, as no personal data of patients or employees was collected and processed. Conflict of interest All authors report no conflicts of interest relevant to this article., (© 2024. The Author(s).)

Background: Prophylactic dressings are used to prevent sacral pressure injuries (PIs) in intensive care unit (ICU) patients. Bedside clinicians are responsible for selecting these dressings despite the lack of comparative evidence., Objectives: The objective of this study was to assess the feasibility of undertaking a larger multisite comparative effectiveness trial of two prophylactic sacral dressings in adult ICU patients., Methods: Using a two-arm pilot randomised feasibility trial design, we randomly allocated adult ICU patients to the Mepilex® Border Sacrum dressing or Allevyn™ Life Sacrum dressing plus usual PI prevention care. Our primary study outcomes were study eligibility, recruitment, retention, intervention fidelity, and missing data criteria. Participants were followed up for up to 14 days or a study endpoint: new sacral PI, ICU discharge, death, prone positioning, urine/faecal incontinence, or withdrawal. Daily clinical data were collected including a deidentified sacral photograph, sacral visual skin assessment, dressing failure rates (rolled edges, adhesion loss), and dressing-related harm (e.g., blisters). The blinded outcome assessor used these data to determine the presence of a new sacral PI., Results: From January to September 2023, 1069 ICU patients were screened; 77 (7.2%) were eligible, and 68 (88.3%) were recruited. Half of our feasibility criteria were met. One participant (1.5%) developed a sacral PI. Throughout the study, half (n = 54; 49.5%) of the dressing changes were due to dressing failure (rolled edges: n = 43; 79.5%, adhesion failure: n = 11; 20.5%)., Conclusions: Several prophylactic sacral dressings are available; however, comparative effective evidence between brands relative to performance, benefits, and harms is lacking. Following minor study criteria modifications, we found that a larger multisite comparative trial is feasible. Sacral prophylactic dressing failure and dressing-related harms are care quality and patient safety issues requiring further investigation regarding performance, harm, and costs., Trial Registration: Australian and New Zealand Clinical Trial Registration number: ACTRN12622000793718 and World Health Organization Universal Trial number: U1111-1278-6055., Competing Interests: Conflict of interest The authors have none to declare., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: International guidelines recommend maintenance of mean arterial pressure (MAP) > 85 mmHg to defend spinal cord perfusion pressure after acute traumatic spinal cord injury (SCI). Variation in practice has been demonstrated in the emergency department blood pressure management of SCI in New South Wales (NSW). It is unknown whether this variation exists in the phase of intensive care management of acute SCI., Objectives: The objective of this study was to describe and compare current blood pressure management in the intensive care unit (ICU) of patients with acute traumatic SCI in two SCI referral centres in NSW., Methods: Patients with acute traumatic SCI admitted to two SCI referral centres, Unit A and Unit B during 2018-2019 in NSW, were included. Data were summarised using descriptive statistics., Results: Ninety-eight patients were included, with 91 patients having been prescribed a blood pressure target, 81 (83%) having required vasopressors, and 18 (18%) of these having been documented to have complications associated with vasopressor use. The average prescribed MAP target was 78 (interquartile range [IQR]: 10) mmHg in Unit A and 76 (IQR: 12) mmHg in Unit B. Median durations of prescribed target were 120 (IQR: 72) hours and 120 (IQR: 120) hours in Unit A and Unit B, respectively. The average MAP over the first 7 d was 88 (standard deviation: 9.5) mmHg in Unit A and 85 (standard deviation: 7.5) mmHg in Unit B. Sixty-three patients (64%) had a documented systolic blood pressure <90 mmHg in the first 24 h. Median ICU length of stay (LOS) was 9.7 (IQR: 11) d in Unit A and 6 (IQR: 6.6) d in Unit B. Median hospital LOS was 27 (IQR: 56.2) d in Unit B and 34.7 (IQR: 32.3) d in Unit B. ICU LOS was longer in patients who had a MAP target than in those who did not., Conclusions: Current blood pressure management in acute SCI in NSW involves ICU admission and blood pressure support with vasopressors; however, prescribed blood pressure targets are not in line with international guidelines., Competing Interests: Conflict of interest The authors have none to declare., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Acute Respiratory Distress Syndrome (ARDS) has a high morbidity and mortality. One therapy that can decrease mortality is ventilation in the prone position (PP). Patients undergoing PP are amongst the sickest, and there is a need for early identification of patients at particularly high risk of death. These patients may benefit from an in-depth review of treatment or consideration of rescue therapies. We report the development of a machine learning model trained to predict early mortality in patients undergoing prone positioning as part of the management of their ARDS., Methods: Prospectively collected clinical data were analysed retrospectively from a single tertiary ICU. The records of patients who underwent an initial session of prone positioning whilst receiving invasive mechanical ventilation were identified (n = 131). The decision to perform prone positioning was based on the criteria in the PROSEVA study. A C5.0 classifier algorithm with adaptive boosting was trained on data gathered before, during, and after initial proning. Data was split between training (85% of data) and testing (15% of data). Hyperparameter tuning was achieved through a grid-search using a maximal entropy configuration. Predictions for 7-day mortality after initial proning session were made on the training and testing data., Results: The model demonstrated good performance in predicting 7-day mortality (AUROC: 0.89 training, 0.78 testing). Seven variables were used for prediction. Sensitivity was 0.80 and specificity was 0.67 on the testing data set. Patients predicted to survive had 13.3% mortality, while those predicted to die had 66.67% mortality. Among patients in whom the model predicted patient would survive to day 7 based on their response, mortality at day 7 was 13.3%. Conversely, if the model predicted the patient would not survive to day 7, mortality was 66.67%., Conclusions: This proof-of-concept study shows that with a limited data set, a C5.0 classifier can predict 7-day mortality from a number of variables, including the response to initial proning, and identify a cohort at significantly higher risk of death. This can help identify patients failing conventional therapies who may benefit from a thorough review of their management, including consideration of rescue treatments, such as extracorporeal membrane oxygenation. This study shows the potential of a machine learning model to identify ARDS patients at high risk of early mortality following PP. This information can guide clinicians in tailoring treatment strategies and considering rescue therapies. Further validation in larger cohorts is needed., Competing Interests: Declarations Ethics approval and consent to participate Approval for the study was obtained from the Galway Clinical Research Ethics Committee (ref C.A. 2506). Specific consent was not obtained as all data were fully anonymised upon collection, with any patient identifiers absent or removed and replaced with an unrelated identification number in the study. Consent for publication Specific consent was not obtained as all data were fully anonymised upon collection, with any patient identifiers absent or removed and replaced with an unrelated identification number in the study. Competing interests JL is a senior editor of Intensive Care Medicine Experimental. No other authors express any competing interests., (© 2024. The Author(s).)

Background: This study evaluated the effectiveness of the 28-item Therapeutic Intervention Scoring System (TISS-28) in detecting multiorgan dysfunction (MOD) among critically ill obstetric patients and compared its predictive potential to other severity models, such as Sequential Organ Failure Assessment (SOFA) and Mortality Probability Model II (MPM II)., Methods: A prospective multicentre cohort study was conducted including obstetric patients, pregnant and up to 42 days postpartum, admitted to the intensive care units of two referral hospitals in Colombia. A total of 93 patients were recruited between March 2016 and February 2017 and from September 2019 to November 2019. Scores from the MPM II, SOFA, and TISS-28 were calculated within the first 24 h post-intensive care unit admission. The primary outcome was to evaluate the effectiveness of TISS-28 in predicting MOD, as defined by the World Health Organization near-miss criteria. We compared the TISS-28 with SOFA and MPM II scores in identifying MOD using the positive predictive value, negative predictive value, and the area under the receiver operating characteristic curve., Results: Data from 93 patients were analysed, of whom 22 developed MOD. Hypertensive disorders were the predominant diagnosis (n = 62; 66.7%). Patients with sepsis exhibited the highest TISS-28 score, indicating more intensive therapeutic interventions. The areas under the receiver operating characteristic curve for TISS-28, SOFA, and MPM II were 0.83 (95% confidence interval: 0.73-0.92), 0.66 (0.51-0.80), and 0.59 (0.43-0.74), respectively (p = 0.001). The cut-off value of a TISS-28 score ≥21 was associated with an increased likelihood of MOD (sensitivity: 83.2%, specificity: 71.2%), a positive predictive value of 47.3%, and a negative predictive value) of 93.2%., Conclusions: TISS-28 demonstrated robust performance in identifying MOD among obstetric patients compared to other severity indexes. The TISS-28 score complements physiology-derived severity scores by reflecting the level of care required, making it a valuable tool in risk stratification and resource allocation for critically ill obstetric patients., Competing Interests: Conflict of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this manuscript., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: There is a considerable gap in the current evidence concerning the prevalence of superinfections among critically ill patients with SARS-CoV-2 infection in Saudi Arabia., Objectives: We sought to determine the prevalence of bacterial superinfections following the initiation of antibiotic therapy in critically ill patients with SARS-CoV-2 infection., Methods: A retrospective observational study that included patients with SARS-CoV-2 infection admitted to the intensive care unit (ICU) for at least 24 hours and received empirical antibiotic therapy. The primary outcome was the rate of bacterial superinfections occurring at least 48 hours after the initiation of antibiotics. ICU-related outcomes and complications were compared between subgroups with and without superinfections and amongst the two most frequently used antibiotic regimens., Results: A total of 230 patients were included in our study. Superinfections developed in 40 (17.4%) patients, with the median time from the first dose of antibiotic to the emergence of superinfection of 17.6 days (IQR 9.8-29.2). Patients with superinfections had longer median ICU stays [ 27.1 days(IQR 15.2-43.3) versus 7.1 days(IQR 3.8-11.8); P  < 0.001], developed more complications [92.5% versus 52.6%; P  < 0.001], and had higher ICU mortality [45.0% versus 22.1%; P  = 0.0034] compared to patients without superinfections. The two most frequently prescribed antibiotic regimens were piperacillin/tazobactam plus levofloxacin (53.9%) and meropenem plus levofloxacin (19.7%). Although there was no significant difference in the rate of superinfections [15.3% versus 26.7%; P  = 0.09] between the two groups, patients in the superinfections group who received piperacillin/tazobactam plus levofloxacin developed more complications [94.7% versus 91.7%; P  < 0.001] and had a higher ICU mortality [57.9% versus 50%; P  < 0.001]., Conclusion: Superinfections occurred at a higher rate in critically ill patients with SARS-CoV-2 infection post empirical antibiotics initiation. The use of piperacillin/tazobactam plus levofloxacin was associated with an increase in the rate of complications and higher ICU mortality. Larger multicenter studies are needed to confirm these results., Competing Interests: Declaration of Conflicting InterestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Understanding how preexisting comorbidities may interact with a critical illness is important for the assessment of long-term survival probability of older patients admitted to the ICU., Material and Methods: The mortality after a first ICU admission in patients ≥ 55 years old registered in the Swedish Intensive Care Registry was compared to age- and sex-matched individuals from the general population with a landmark after 1 year. The comparison was adjusted for age, sex, and baseline comorbidity using Cox regression., Results: The 7-year study period included 140 008 patients, of whom 23% were 80 years or older. Patients surviving the first year remained at an increased risk compared to the general population, but much of this difference was attenuated after adjustment for baseline comorbidity (HR, 1.03; 95% CI 1.02-1.04). Excluding cardio-thoracic ICU admissions, the increased risk remained slightly elevated (adjusted HR, 1.15; 95% CI 1.13-1.16). Also, the subgroup ≥ 75 years old surviving the first year returned to a mortality rate comparable to the general population (HR, 0.98; 95% CI 0.96-0.99). Stratified by admission diagnosis an increased mortality rate remained beyond the first year for acute-on-chronic respiratory failure (adjusted HR, 1.47; 95% CI 1.36-1.58) but not for other respiratory causes (adjusted HR, 1.03; 95% CI 0.99-1.07) or admission for septic shock (adjusted HR, 1.04; 95% CI 0.95-1.13). No substantial increased mortality rate was notable beyond the first year for other admission diagnoses., Conclusion: Older ICU patients that survive the first year after an ICU admission return to a mortality rate close to that of the general population having similar baseline comorbidity, but variability is seen depending on the ICU admission diagnosis. Trial registration ClinicalTrials.gov ID: NCT06234709, date 02/01/2024., Competing Interests: Declarations Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

The mechanism of thrombocytopenia during acute pulmonary hypertension (PH) decompensation may be partly due to platelet aggregation in the lung. Platelet aggregates in explanted lung from 16 lung transplant patients during acute PH decompensation with and without thrombocytopenia were identified by immunohistochemistry. Scanning electron microscopy (SEM) was performed. 7 explant lung controls without PH and thrombocytopenia were also examined. Compared with controls, the median number of platelet aggregates was higher in patients with acute PH decompensation with thrombocytopenia (19.4 [IQR 3.4-38.3] vs 147.5 [IQR 26.5-203.2]). SEM showed capillaries filled with platelet aggregates. Our study suggests that platelets may aggregate in the lungs during acute PH decompensation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Hospital-related dermatological conditions are well-studied and reported in human medicine. However, studies about these dermatological disorders in veterinary medicine are lacking., Objectives: To report the incidence, type and distribution of hospital-acquired skin lesions (HASL) in dogs, and to investigate risk factors that may be associated with their development., Animals: Hospitalised client-owned dogs with HASL and a control group of hospitalised dogs without skin lesions., Materials and Methods: Prospective clinical evaluation of all HASL and dermatological tests, when indicated, were performed, over 6 months. A variety of potentially predisposing factors also were recorded., Results: Thirty-one dogs with HASL and a matched control group of 60 hospitalised dogs without skin lesions were included. The incidence of HASL was 11.2% (31 of 278). The most common lesion was erythema in 74.2% of dogs (23 of 31) and the most affected area was the abdomen in 58.1% (18 of 31) of dogs. Faecal and/or urinary incontinence was identified as an important risk factor for the development of skin lesions during hospitalisation (odds ratio 14.445, 95% confidence interval 1.444-144.479, p = 0.023). Immobilisation and changes in body temperature also may play a role in the development of such lesions in dogs., Conclusions and Clinical Relevance: Faecal and/or urinary incontinence was found to be an important factor in the development of HASL. The impact of HASL on patient outcomes and the prevention of these lesions requires further investigation., (© 2024 ESVD and ACVD.)

Introduction: Severely burned patients exhibit increased nutritional requirements and are at high risk of developing sepsis. Selenium is an essential trace element supporting antioxidant and anti-inflammatory pathways, mediated by incorporation into selenoproteins. The selenium status may affect sepsis risk in burn injury., Methods: This prospective cohort study included 90 adult patients admitted to Zurich Burn Center, Switzerland. All patients received a continuous intravenous infusion of 1000 μg sodium selenite per day during the first week as part of local standard of care. Three complementary biomarkers of serum selenium status were determined at nine time-points up to six months postburn, namely total selenium, selenoprotein P, and glutathione peroxidase 3. The resulting data were correlated to clinical parameters and outcomes, with sepsis as the primary end point., Results: A high fraction of the patients displayed selenium deficiency already at admission, and developed sepsis during hospitalization (n = 55; 61 %). Selenium status at admission was inversely related to burn severity. Low baseline selenoprotein P was associated with sepsis incidence, irrespective of trauma severity (adjusted HR, 1.94; 95 % CI, 1.05-3.63; p = 0.035). Burn severity and baseline concentrations of selenoprotein P and white blood cells together predicted sepsis with an area under the curve of 0.84 (95 % CI, 0.75-0.93; p < 0.0001). Supplemental selenium was associated with a transient normalization of selenium status., Conclusion: Considering its rapid decline following severe burn injury, the assessment of serum selenoprotein P upon admission may contribute to an early prediction of sepsis risk., Competing Interests: Competing interests LS holds shares of selenOmed GmbH, a company involved in Se status assessment; no other relationships or activities that could appear to have influenced the submitted work are indicated., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aim: To identify factors protecting and hindering the well-being of critical care nurses during the COVID-19 pandemic., Background: The unique work challenges of critical care nurses can undermine their professional and mental well-being; as evidenced by the prevailing literature on burnout, compassion fatigue, and moral distress. The COVID-19 pandemic has seen these professionals on the front lines and has raised many questions about professional well-being. Identifying the factors that protect and hinder the well-being of critical care nurses would help to develop the strategies necessary to reduce worrying phenomena associated with professional malaise., Evaluation: A systematic review was conducted using electronic databases including PubMed, CINAHL, Scopus, Cochrane, PsycINFO, and Web on Science., Key Issues: After full text analysis, 25 papers were included in the current systematic review. Factors influencing the well-being of critical care nurses have been grouped into "Protective" and "Hindering.", Conclusions: This review shows that critical care nurses' well-being is influenced by factors like personal resilience and supportive work environments, which enhance their experience. Challenges include sociodemographic issues and the COVID-19 pandemic's impact. Addressing these factors is crucial for their well-being and the effectiveness of healthcare systems., Implications for Clinical Practice: The well-being of nurses is intricately linked to the quality and security of patient care, ultimately influencing clinical outcomes. This review delves deeply into the multifaceted factors that affect the professional well-being of critical care nurses during the COVID-19 pandemic. Recognizing these elements is critical for directing health policy toward the development of initiatives that bolster healthcare workers' welfare. Prioritizing the professional well-being of nurses is imperative, as it is fundamental in mitigating the increasing inclination towards job turnover, a challenge that is profoundly impacting the healthcare sector., (© 2024 The Author(s). Public Health Nursing published by Wiley Periodicals LLC.)

Introduction: Post-intensive care syndrome (PICS) seriously affects the quality of life of intensive care unit (ICU) survivors, their ability to return to work and society and the quality of life of their families, increasing overall care costs and healthcare expenditures. ICU follow-up services have important potential to improve PICS. However, the best clinical practice model of ICU follow-up service has not been fully defined and its benefits for ICU survivors are not clear. This review will synthesise and map the current types of follow-up services for ICU survivors and summarise the impact of follow-up services on PICS., Methods and Analysis: This scoping review will be conducted by applying the five-stage protocol proposed by Arksey and O'Malley in an updated version of the Joanna Briggs Institute. Eight academic databases including the Cochrane Library, MEDLINE, Web of Science, Embase, EBSCO Academic, CINAHL, PsycInfo and SinoMed (China Biology Medicine) will be systematically searched from inception to the present. Peer-reviewed literature and grey literature will be included. Qualitative, quantitative and mixed methods studies will be included. Studies published in English or Chinese will be included. There will be no time restriction. Two reviewers will screen and select the articles independently and if there is any disagreement, the two reviewers will discuss or invite a third reviewer to make decisions together. Descriptive analysis will be used to conduct an overview of the literature. The results will be presented in a descriptive format in response to the review questions accompanied by the necessary tables or charts., Ethics and Dissemination: Ethical approval is not required for this scoping review because data could be obtained by reviewing published primary study results and do not involve human participants. Findings should be disseminated at scientific meetings and published in peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To evaluate the safety and tolerance of elective extubations in preterm newborns (PNB) during skin-to-skin care (SSC) compared to those performed in an incubator., Methods: Retrospective observational study including 142 extubations in 93 PNB with gestational age (GA) <32 weeks and/or birth weight (BW) <1500 g performed during the first 2 months of life. Safety, tolerance and extubation success at 72 h were assessed., Results: The median GA was 25.4 weeks in the SSC group versus 26.6 weeks in the incubator group (p = 0.002). The median BW was 700 grams and 880 grams, respectively (p = 0.001). In total, 60 extubations (42.3%) were performed during SSC in 42 PNB and 82 in incubator in 69 PNB. No incidents related to extubation during SSC were recorded. The extubation success rate was 80% in SSC versus 79.3% in incubator (p = 0.915). Most failures occurred between 3 and 24 h after extubation. There were no observed differences in heart rate or FiO 2 variations between the groups, nor in the need to escalate respiratory support at 24 h after extubation (SSC 15% vs. incubator 12.2%, p = 0.628)., Conclusion: Extubation during SSC is a feasible, safe and well-tolerated practice, while allowing PNB to experience the benefits from SSC., (© 2024 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background/aim: Benign tracheal stenosis (TS) is a potentially life-threatening condition caused by iatrogenic events resulting from endotracheal intubation and tracheostomy. The study aimed to determine the clinical characteristics, management, and long-term outcomes of patients with simple or complex post-intubation tracheal stenosis (PITS) who were admitted to the intensive care unit (ICU)., Materials and Methods: Retrospective analysis of patients admitted to the ICU between June 2016 and June 2022 and diagnosed with PITS were performed until June 2023., Results: 76 patients (mean age 54.9 ± 17.3%, 63.2% male, 61.8% complex stenosis) admitted to the ICU were analysed. The diagnosis of PITS was made by fiberoptic bronchoscopy (FOB) in 53.9% and computed tomography (CT) in 46.1%. The most common location of stenosis was the upper trachea area (57.9%, n = 44). The median stenosis length of the TS was 1.9 cm (median 2 cm for complex stenosis, 1 cm for simple stenosis, p < 0.001). Complex stenosis was associated with longer intubation time and multiple intubation history (p = 0.011, p = 0.028). At the same; complex stenosis was associated with prolonged and high stenosis percentage (p < 0.001). While dilatation and cryotherapy were sufficient for treatment in all patients with simple stenosis, the stent was applied to 34% patients with complex stenosis. Recurrence was higher in complex stenosis after bronchoscopic procedure (complex stenosis 95.7%, simple stenosis 17.2%). 19 (25%) patients required surgical operation, and all of these patients had complex stenosis (p < 0.001). Median follow-up was 33 months for simple stenosis and 34 months for complex stenosis. ICU length of stay (LOS) was longer in patients with complex stenosis. There was no statistically significant difference between TS classes in terms of ICU mortality (p = 0.466), 1-year mortality (p = 0.951), and mortality during follow-up (p = 0.608)., Conclusion: PITS is a challenging situation in ICU patients. In patients with a preliminary diagnosis of PITS, bronchoscopy should be performed without delay, and it should be known that interventional bronchoscopy is not only a diagnostic tool but an effective strategy in treatment management after the diagnosis is finalised. The advantage of interventional bronchoscopy is that it alleviates symptoms that necessitate hospitalisation in the ICU and eliminates the need for ICU of patients., Competing Interests: Declarations Ethics approval and consent to participate Approval was obtained from the ethics committee at the University of Yıldırım Beyazıt, Yenimahalle Training and Research Hospital Clinical Research (protocol number E-2023-52; dated 11/10/2023). Yenimahalle Training and Research Hospital Clinical Research Ethics Committee waived the need for informed consent because the current study was retrospective. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration (as revised in 2013) and its later amendments or comparable ethical standards. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Online democratic deliberation (ODD) may foster public engagement in new health strategies by providing opportunities for knowledge exchange between experts, policy makers, and the public. It can favor decision-making by generating new points of view and solutions to existing problems. Deliberation experts recommend gathering feedback from participants to optimize future implementation. However, this online modality has not been frequently evaluated., Objective: This study aims to (1) assess the quality of an ODD held in Quebec and Ontario, Canada, on the topic of COVID-19 triage protocols for access to critical care in an extreme pandemic context and (2) determine its transformative aspect according to the perceptions of participants., Methods: We conducted a simultaneous ODD in Quebec and Ontario on May 28 and June 4, 2022, with a diversified target audience not working in the health care system. We used a thematic analysis for the transcripts of the deliberation and the written comments of the participants related to the quality of the process. Participants responded to a postdeliberation questionnaire to assess the quality of the ODD and identify changes in their perspectives on COVID-19 pandemic triage protocols after the deliberation exercise. Descriptive statistics were used. An index was calculated to determine equality of participation., Results: The ODD involved 47 diverse participants from the public (n=20, 43% from Quebec and n=27, 57% from Ontario). Five themes emerged: (1) process appreciation, (2) learning experience, (3) reflecting on the common good, (4) technological aspects, and (5) transformative aspects. A total of 46 participants responded to the questionnaire. Participants considered the quality of the ODD satisfactory in terms of process, information shared, reasoning, and videoconferencing. A total of 4 (80%) of 5 participants reported at least 1 change of perspective on some of the criteria and values discussed. Most participants reported that the online modality was accessible and user-friendly. We found low polarization when calculating equal participation. Improvements identified were measures to replace participants when unable to connect and optimization of time during discussions., Conclusions: Overall, the participants perceived the quality of ODD as satisfactory. Some participants self-reported a change of opinion after deliberation. The online modality may be an acceptable alternative for democratic deliberation but with some organizational adaptations., (©Claudia Lucrecia Calderon Ramirez, Yanick Farmer, James Downar, Andrea Frolic, Lucie Opatrny, Diane Poirier, Gina Bravo, Audrey L'Espérance, Nathalie Gaucher, Antoine Payot, Joseph Dahine, Peter Tanuseputro, Louis-Martin Rousseau, Vincent Dumez, Annie Descôteaux, Clara Dallaire, Karell Laporte, Marie-Eve Bouthillier. Originally published in Journal of Participatory Medicine (https://jopm.jmir.org), 11.11.2024.)

Objective: This study aimed to compare the prevalence of burnout, missed nursing care, and intention-to-leave the job among nurses working in general care units and intensive care units (ICUs), and to analyse the risk factors for these outcomes between the two groups., Design: This was a cross-sectional study involving online surveys of nurses at participating hospitals conducted between November 2020 and July 2021 as part of the Magnet4Europe initiative., Setting and Participants: A convenience sample was recruited, consisting of 67 acute care hospitals in 6 countries: Belgium, England, Germany, Ireland, Norway, and Sweden. In total, data for 1,150 ICU nurses and 5,145 general ward nurses (1,901 from surgical wards and 3,250 from medical wards) were analysed., Results: The prevalence of burnout was significantly lower among nurses in ICUs (27.1 % vs. 30.3 %), missed care from care was significantly less frequent (65.5 % vs. 75.4 %), while intention-to-leave was similar (28.1 % vs. 29.2 %) compared with nurses in general wards. Nurses working in a better work environment and with lower workloads had statistically significant lower rates of burnout and intention-to-leave their job compared to those working in a poorer work environment and with higher workloads. Country-specific analysis showed a higher burnout rate and the intention-to-leave the job for nurses working in Germany, Ireland, Scandinavia, and the England compared to Belgium., Conclusions: ICU nurses did not have a higher risk of burnout and had significantly lower risks of missing care and intention-to-leave, compared to nurses in general wards. A better work environment and lower perceived workload were consistently associated with reduced risks for all outcomes studied., Implications for Clinical Practice: National policies should prioritize creating healthy work environments, reducing workloads, and addressing country-specific challenges to lower burnout rates, minimize missed care, and decrease the intention to leave the job among ICU and general ward nurses., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

To determine the prevalence of functional, respiratory and renal impairments and of post-intensive-care-syndrome (PICS) among patients who had attended a post-ICU multidisciplinary consultation (post-ICU-MC) around 3 months after ICU discharge, we performed a retrospective, monocentric observational study, at Clermont Ferrand University hospital, France. We included patients who had attended a post-ICU-MC. Their characteristics during ICU stay and at the post-ICU-MC were collected. Functional status was assessed by the 6-min-walking test, handgrip test and peak inspiratory pressure, respiratory function by exploratory functional outcomes, mental status by SF-36 score, and quality of life by SF-36 score and European Quality of Life 5 Dimensions questionnaire. Overall, we enrolled 67 patients, of whom 70%, 74%, and 68% had functional, respiratory, and renal impairments, respectively, at the post-ICU-MC. Additionally, 40%, 28%, 19%, and 2.5% had three, two, one, and none of these impairments, respectively. All patients experienced mental disorders and a decline in quality of life. Functional impairment correlated with frailty score and sex, and respiratory function with age. To conclude, the prevalence of PICS in our cohort was high, as was that of functional, respiratory and renal failure., (© 2024. The Author(s).)

Given the limited capacity to accurately determine the necessity for intubation in intensive care unit settings, this study aimed to develop and externally validate an interpretable machine learning model capable of predicting the need for intubation among ICU patients. Seven widely used machine learning (ML) algorithms were employed to construct the prediction models. Adult patients from the Medical Information Mart for Intensive Care IV database who stayed in the ICU for longer than 24 h were included in the development and internal validation. The model was subsequently externally validated using the eICU-CRD database. In addition, the SHapley Additive exPlanations method was employed to interpret the influence of individual parameters on the predictions made by the model. A total of 11,988 patients were included in the final cohort for this study. The CatBoost model demonstrated the best performance (AUC: 0.881). In the external validation set, the efficacy of our model was also confirmed (AUC: 0.750), which suggests robust generalization capabilities. The Glasgow Coma Scale (GCS), body mass index (BMI), arterial partial pressure of oxygen (PaO 2 ), respiratory rate (RR) and length of stay (LOS) before ICU were the top 5 features of the CatBoost model with the greatest impact. We developed an externally validated CatBoost model that accurately predicts the need for intubation in ICU patients within 24 to 96 h of admission, facilitating clinical decision-making and has the potential to improve patient outcomes. The prediction model utilizes readily obtainable monitoring parameters and integrates the SHAP method to enhance interpretability, providing clinicians with clear insights into the factors influencing predictions., (© 2024. The Author(s).)

Purpose: The optimal anticoagulation regimen for atrial fibrillation (AF) in critically ill patients is challenging as these patients may be at an increased risk for bleeding and clotting despite an absence or presence of anticoagulation. The purpose of this study was to compare bleeding and thrombotic rates in critically-ill adults with pre-existing AF receiving therapeutic anticoagulation versus chemical or mechanical venous thromboembolism prophylaxis. Methods: A retrospective, observational study was conducted. The primary outcome identified rate of International Society of Thrombosis and Hemostasis bleeding, and secondarily assessed all venous or arterial thromboembolic events. To determine risk-factors associated with bleeding and to account for differences in baseline characteristics, a multivariable logistic regression model was used. Results: A total of 199 patients were included, 100 receiving therapeutic anticoagulation and 99 receiving venous thromboembolism prophylaxis. Patients receiving therapeutic anticoagulation compared to chemical or mechanical prophylaxis had a median (IQR) CHA 2 DS 2 VASc score of 4 (3-5) versus 4 (2-5) ( P  = .5499) and HAS-BLED score of 3 (3-4) versus 3 (2-4) ( P  = .0013); respectively. There was almost a threefold adjusted increased risk of bleeding in patients receiving therapeutic anticoagulation compared to venous thromboembolism prophylaxis (adjusted odds ratio [aOR] 2.7 [95% CI 1.1-9.9]; P  = .0349). One stroke occurred in a patient receiving therapeutic anticoagulation, and none occurred in patients in the prophylaxis group ( P  = 1.000). Conclusion: Use of therapeutic anticoagulation in critically ill patients with pre-existing AF may increase bleed rates without protecting against stroke development., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background While some studies have suggested better outcomes for critically ill patients with balanced solutions over normal saline, the best type of intravenous fluid to use for stroke patients remains unknown.Objective To determine if balanced solutions or normal saline are associated with risk of hemorrhagic transformation or 90-day disability in patients with acute ischemic stroke treated with intravenous thrombolysis.Methods This was a retrospective review of the 2015-2019 Get with the Guidelines® data at a single academic medical center. Exposure was type of intravenous fluid and outcomes were modified Rankin scale (mRS) ≤2 at 90 days and hemorrhagic transformation. Multivariate analysis controlled for age, demographics, medical history, time to tPA, and admission stroke scale.Results We included 302 patients who received thrombolysis, of which 166 patients had mRS data at 90 days. In univariate analysis, exposure to any balanced solution was associated with increased 90-day disability (OR 4.3, 95% CI 3.8-4.9) and hemorrhagic transformation (OR 2.0, 95% CI 1.3-2.2). In multivariate analysis, exposure to a balanced solution at any time was associated with increased 90-day disability (OR 6.3, 95% CI 2.4-17.0, p<0.01), but not hemorrhagic transformation.Conclusion This observational trial demonstrated that exposure to balanced solutions is associated with increased risk of disability at 90 days and possibly hemorrhagic transformation in patients with acute ischemic stroke treated with intravenous thrombolysis. This data would suggest that normal saline is a preferred solution in these patients, though larger future trials are needed.

Background: Pediatric acute liver failure (PALF) is a clinical diagnosis in which previously asymptomatic children exhibit a rapid loss of liver function., Objectives: To describe the clinical and nutrition conditions at admission and during hospitalization in patients with PALF who underwent liver transplantation (LT) at a referral center and establish a possible association between nutrition status and prognosis in this population., Methods: A prospective study was conducted on children underwent LT because of PALF. Nutrition assessment was performed at admission and repeated weekly until hospital discharge, and their relationships with clinical outcomes were tested., Results: The study population consisted of 23 patients with a median age of 60 months and, in most cases, the etiology of acute liver failure (ALF) was indeterminate (69.6%). The majority of the patients were well nourished according to the z score body mass index-for-age (82.6%) and z arm circumference-for-age (zAC/A) (82.6%). A decline in nutrition status was observed in 47.6% of the patients, as indicated by a decrease in zAC. Clinical and nutrition improvement was demonstrated by the progressive increase in zAC, serum albumin levels, and phase angle (PA) values and by the reduction in C-reactive protein levels. There was no statistically significant relationship between nutrition status and clinical outcomes., Conclusion: Most children and adolescents with ALF presented adequate nutrition status at the time of LT, and some patients worsened their nutrition status during hospitalization, suggesting that post-LT is a period of high nutrition risk, and early nutrition therapy (NT) must be a priority in these patients., (© 2024 American Society for Parenteral and Enteral Nutrition.)

Background: Evidence on the benefits of fiber-supplemented enteral nutrition (EN) in critically ill patients is inconsistent, and critical care nutrition guidelines lack recommendations based on high-quality evidence. This systematic review and meta-analysis (SRMA) aims to provide a current synthesis of the literature on this topic., Methods: For this SRMA of randomized controlled trials (RCT), electronic databases (MEDLINE, EMBASE, CENTRAL) were searched systematically from inception to January 2024 and updated in June 2024. Trials investigating clinical effects of fiber-supplemented EN versus placebo or usual care in adult critically ill patients were selected. Two independent reviewers extracted data and assessed the risk of bias of the included studies. Random-effect meta-analysis and trial sequential analysis (TSA) were conducted. The primary outcome was overall mortality, and one of the secondary outcomes was diarrhea incidence. Subgroup analyses were also performed for both outcomes., Results: Twenty studies with 1405 critically ill patients were included. In conventional meta-analysis, fiber-supplemented EN was associated with a significant reduction of overall mortality (RR 0.66, 95% CI 0.47, 0.92, p = 0.01, I 2  = 0%; 12 studies) and diarrhea incidence (RR 0.70, 95% CI 0.51, 0.96, p = 0.03, I 2  = 51%; 11 studies). However, both outcomes were assessed to have very serious risk of bias, and, according to TSA, a type-1 error cannot be ruled out. No subgroup differences were found for the primary outcome., Conclusion: Very low-certainty evidence suggests that fiber-supplemented EN has clinical benefits. High-quality multicenter RCTs with large sample sizes are needed to substantiate any firm recommendation for its routine use in this group of patients. PROSPERO registration number: CRD42023492829., (© 2024. The Author(s).)

The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has developed a good clinical practice to address the challenges of treating critically ill patients in resource-limited austere environments, exacerbated by recent pandemics, natural disasters, and conflicts. The methodological approach was based on a literature review and a modified Delphi method, which involved blind voting and consensus evaluation using a Likert scale. This process was conducted over two rounds of online voting. The document covers six critical topics: the overall impact of austere conditions on critical care, airway management, analgesia, bleeding control, vascular access, and medical devices and equipment. In these settings, it is vital to apply basic care techniques flexibly, focusing on immediate bleeding control, airway management, and hypothermia treatment to reduce mortality. For airway management, rapid sequence intubation with ketamine for sedation and muscle relaxation is suggested. Effective pain management involves a multimodal approach, including patient-controlled analgesia by quickly acting safe drugs, with an emphasis on ethical palliative care when other options are unavailable. Regarding hemorrhage, military-derived protocols like Tactical Combat Casualty Care significantly reduced mortality and influenced the development of civilian bleeding control devices. Establishing venous access is crucial, with intraosseous access as a swift option and central venous access for complex cases, ensuring aseptic conditions. Lastly, selecting medical equipment that matches the specific logistical and medical needs is essential, maintaining monitoring standards and considering advanced diagnostic tools like point-of-care ultrasounds. Finally, effective communication tools for coordination and telemedicine are also vital., (© 2024. The Author(s).)

Large pharmacokinetic (PK) variability of fluconazole has been reported in critically ill patients, but the implications for fluconazole dosing remain unclear. The objectives of this study were to evaluate the population PK of fluconazole and identify appropriate dosage regimens by simulations. This was a retrospective analysis of fluconazole PK data from patients hospitalized in critical care and infectious disease departments. Both parametric and nonparametric population approaches were used. Various loading and maintenance fluconazole doses were evaluated by simulations, with computation of the probabilities of PK/pharmacodynamic (PD) target attainment (PTA) and cumulative fractions of response (CFR) based on international and local minimum inhibitory concentration (MIC) distributions of Candida sp. Data from 36 critically ill patients and 16 non-critically ill patients were available for model building ( n = 202 concentrations). The final model adequately described the data, including the external data set (13 patients). After 24 h of therapy, 65% and 74% of patients had trough and area under the concentration-time curve values below the usual targets. Standard dosages were associated with low PTA for MIC >1 mg/L at 24 h. Higher loading doses administered two times daily improved PTA. CFR were >90% for C. albicans with standard dosages, while they were very low for C. glabrata , even with high dosages. Candida species and associated MIC distributions strongly influence fluconazole dosage requirements. Higher loading doses may be necessary for the achievement of PK/PD targets up to MIC breakpoints. The use of fluconazole for invasive C. glabrata infection should be discouraged because of poor PK/PD target attainment., Competing Interests: The authors declare no conflict of interest.

Background: The introduction of Emergency Medicine in Rwanda in 2015 has been associated with a mortality reduction in patients presenting to Kigali University Teaching Hospital (KUTH). In the context of increasing numbers of critically ill patients presenting to Emergency Departments (ED) globally, the aim of this study was to describe the characteristics of critically ill patients, the critical care interventions performed, and the outcomes of critically ill patients presenting to the KUTH ED with the goal of informing future research into the root causes of mortality of critically ill ED patients and of identifying high yield topics for didactic and procedural training., Methods: A descriptive observational prospective cohort pilot study analyzed all patients ≥15 years who presented to KUTH between April and June 2022 with modified South African Triage Scores of Red with alarm, Red without alarm, and Orange., Results: Of 320 patients, 66.9% were male and median age was 40 years. Patients were triaged as Orange (65.3%), Red without alarm (22.8%), and Red with alarm (11.9%). Presentations were categorized as: medical emergencies (48.0%), traumatic injury (44.5%), and surgical emergencies (7.6%). Median length of stay was 31 h (IQR 28, 56) and boarding was 23 h (IQR 8, 48). Overall mortality was 12.2% and highest among medical emergencies (16.5%, p = 0.048) and increased significantly with triage color: Red with alarm (47.4%), Red without alarm (16.4%), and Orange (4.3%, p < 0.0001). Cardiopulmonary resuscitation (CPR) (10.3%), endotracheal intubation (8.8%), and vasopressor administration (3.1%) were the most frequent critical interventions performed. Survival after cardiac arrest was 9.1% and 32.1% after intubation. Mortality was associated with the following interventions: CPR, intubation, and use of vasopressors (p < 0.05)., Conclusions: This pilot study identified the most common critical care interventions performed and a high mortality among patients who required these interventions in the ED of a tertiary teaching hospital in Rwanda. These findings will inform didactics and procedural training for emergency care providers. Future research should focus on the root causes of mortality in these specific patient populations and identify areas of system strengthening to reduce mortality., (© 2024. The Author(s).)

Background: Pneumothorax is a little known and reported complication of COVID-19. These patients have poorer general outcomes and greater respiratory support requirements, longer hospitalization times, and higher mortality rates. The purpose of this study was to determine which factors predict mortality in patients with tube thoracostomy diagnosed with COVID-19, admitted to the COVID-19 intensive care unit (ICU), and developing pneumothorax., Methods: This respective, observational study was conducted in all COVID-19 ICUs at the Marmara University Pendik Training and Research Hospital, Türkiye. Patients admitted to the ICU with diagnoses of COVID-19 pneumonia and with chest tubes inserted due to pneumothorax were investigated retrospectively., Results: One hundred patients with tube thoracostomy were included in the study. Their median age was 68 (57-78), and 63% were men. The median follow-up time was 20 [10-29] days, and the median time from initial reverse transcriptase polymerase chain reaction (RT-PCR) results to tube thoracostomy was 17 [9-23] days. Initial RT-PCR results were positive in 90% of the patients, while 8% were negative, and 2% were unknown. Half the patients exhibited pulmonary involvement at thoracic computed tomography (CT) (n = 50), while 22 patients had COVID-19 reporting and data system (CO-RADS) scores of 5 (22%). Sixty-two patients underwent right tube thoracostomy, 24 left side placement, and 14 bilateral placement. The patients' mean positive end expiratory pressure (PEEP) level was 10.31 (4.48) cm H 2 O, with a mean peak inspiratory pressure (PIP) level of 26.69 (5.95) cm H 2 O, a mean fraction of inspired oxygen (FiO2) level of 80.06 (21.11) %, a mean respiratory rate of 23.71 (5.62) breaths/min, and a mean high flow nasal cannula (HFNC) flow rate of 70 (8.17) L/min. Eighty-seven patients were intubated (87%), six used non-rebreathable reservoir masks, four HFNC, two non-invasive mechanical ventilation (NIV), and one a simple face mask. Comorbidity was present in 70 patients, 25 had no comorbidity, and the comorbidity status of five was unknown. Comorbidities included hypertension (38%), diabetes mellitus (23%), cardiovascular disease (12%), chronic obstructive pulmonary disease (5%), malignancy (3%), rheumatological diseases (3%), dementia (2%) and other diseases (9%). Twelve of the 100 patients survived. The median survival time was 20 (17.82-22.18) days, and the median 28-day overall survival rate was 29% (20-38%). The multivariate Cox proportional hazards model indicated that age over 68 (HR = 2.23 [95% CI: 1.39-3.56]; p = 0.001), oxygenation status other than by intubation (HR = 2.24 [95% CI: 1.11-4.52]; p = 0.024), and HCO3- below 22 compared with a normal range of 22 to 26 (HR = 1.95 [95% CI: 1.08-3.50]; p = 0.026) were risk factors associated with mortality in patients in the ICU., Conclusions: Age over 68, receipt of oxygenation other than by intubation, and HCO3- values lower than 22 in patients with COVID-19 pneumonia emerged as prognostic factors associated with mortality in terms of pneumothorax., (© 2024. The Author(s).)

The Full Outline of UnResponsiveness (FOUR) score was developed to overcome the limitations of the Glasgow Coma Scale (GCS) when assessing individuals with impaired consciousness. We sought to review the evidence regarding the predictive validity of the GCS and FOUR score in intensive care unit (ICU) settings. This review was prospectively registered in PROSPERO (CRD42023420528). Systematic searches of CINAHL, MEDLINE, and Embase were undertaken. Prospective observational studies were included if both GCS and FOUR score were assessed in adults during ICU admission and if mortality and/or validated functional outcome measure scores were collected. Studies were excluded if they exclusively investigated patients with traumatic brain injury. Screening, data extraction, and quality assessment using the Quality in Prognosis Studies tool were conducted by two reviewers. Twenty studies of poor to moderate quality were included. Many studies only included patients with neurological illness and excluded sedated patients, despite high proportions of intubated patients. The FOUR score achieved higher area under the receiver operating characteristic curve values for mortality prediction compared with the GCS, and the FOUR score achieved significantly higher area under the receiver operating characteristic curve values for predictions of ICU mortality. Both coma scales showed similar accuracy in predicting "unfavorable" functional outcome. The FOUR score appeared to be more responsive than the GCS in the ICU, as most patients with a GCS score of 3 obtained FOUR scores between 1 and 8 due to preserved brainstem function. The FOUR score may be superior to the GCS for predicting mortality in ICU settings. Further adequately powered studies with clear, reliable methods for assessment of index and outcome scores are required to clarify the predictive performance of both coma scales in ICUs. Inclusion of sedated patients may improve generalizability of findings in general ICU populations., (© 2024. The Author(s).)

Competing Interests: Drs Bohula and Morrow are members of the TIMI Study Group, which has received institutional research grant support through Brigham and Women’s Hospital from Abbott, Abiomed, Amgen, Anthos Therapeutics, AstraZeneca, Bayer, Daiichi-Sankyo, Eisai, Intarcia, Merck, Novartis, Pfizer, Quark Pharmaceuticals, Regeneron, Roche, Siemens Healthcare, and Zora Biosciences. Dr Morrow has received consulting fees from Abbott Laboratories, ARCA Biopharma, InCarda, Merck and Co, Novartis, Regeneron, and Roche Diagnostics.

Breaking bad news is a challenging yet essential part of the role of healthcare professionals who care for major trauma patients and their families. This service evaluation investigated healthcare professionals' attitudes and experiences regarding breaking bad news in the context of major trauma. Healthcare professionals were recruited from the South Wales Trauma Network and their views collected via an online survey based on the Breaking Bad News Attitudes Scale. The survey was completed by 149 healthcare professionals and the responses demonstrated a range of experiences of breaking bad news in major trauma care, with challenges such as the environment, building rapport and setting expectations., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

There are instances where hospitals may experience a relative shortage of oxygen, for example, future pandemics, natural disasters or wartime. We developed a modification to a domiciliary ventilator that captures oxygen normally vented during expiration into the atmosphere, delivering it to the patient. The modification significantly increases PaO 2 in mechanically ventilated patients at their baseline FiO 2 and baseline FiO 2 +1, +2 and +3 L/min compared to no modification. The modification reduces walled oxygen consumption by median (IQR) -1.0 (-1.25 to -1.00) L/min whilst maintaining PaO 2 . This modification may be a valuable in circumstances where there is a relative shortage of oxygen., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MIP is a paid consultant for Philips Respironics; however, Philips had no role in this study. TOJ, PG, TMS, YM declare no conflicts of interest., (© The Intensive Care Society 2024.)

Background: Establishing a positive safety-culture environment is essential in healthcare settings to enhance patient care. This study aimed to determine the relationship between critical care nurses' perceptions of patient safety culture and adverse events., Methods: A cross-sectional study was conducted among 200 nurses working in critical care units in the Damanhour Governorate in Egypt. Data were collected using a self-administered questionnaire, including the Hospital Survey of Patients' Safety Culture (HSOPSC) and information on adverse events (AEs)., Results: The study revealed areas for improvement in patient safety culture, with low positive response rates in staffing (26.6%), non-punitive response to errors (38%), handoffs and transitions (39.4%), teamwork across and within units (42.3%), and overall perception of patient safety (49.3%). The majority of critical care nurses had a moderate to high level of overall perception of patient safety at 42.5% and 42.0%, respectively. The most frequent adverse events reported daily were complaints from patients or their families (65.5%). Adverse drug events and patient falls occurred several times per week in 56.5% and 57.0% of patients, respectively. A significant association was found between low safety culture perception and higher rates of patient falls ( p  = .008), adverse drug events (p = .005), and patient/family complaints (p = .030)., Conclusion: The findings of the study indicate that nurses' perceptions of patient safety culture are moderate. Adverse medication responses, falls, and complaints from patients or their families were noted. Female nurses aged 31 to 40, especially divorced nurses, had more experience, worked fewer than 8 h daily, and had a higher education level, which appeared to influence overall safety culture perceptions. Furthermore, there was a correlation between the prevalence of adverse events and patient safety culture, with cooperation being the key factor., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

This narrative review explores the implementation and impact of sepsis code protocols, an urgent intervention strategy designed to improve clinical outcomes in patients with sepsis. We examined the degree of implementation, activation criteria, areas of implementation, personnel involved, responses after activation, goals and targets, impact on clinical indicators, and challenges in implementation. The reviewed evidence suggests that sepsis codes can significantly reduce sepsis-related mortality and enhance early administration of treatments. However, variability in activation criteria and inconsistent application present ongoing challenges. The review considers the incorporation of newer scoring systems, such as NEWS and MEWS, and the potential integration of machine learning tools for early sepsis detection. It highlights the importance of tailoring implementation to specific healthcare contexts and the value of ongoing training to optimize sepsis response. Limitations include the ongoing controversy surrounding sepsis definitions and the need for standardized, feasible quality indicators. Future research should focus on standardizing activation criteria, improving protocol adherence, and exploring emerging technologies to enhance early sepsis detection and management. Despite challenges, sepsis codes show promise in improving patient outcomes when implemented thoughtfully and consistently across healthcare settings., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Acute brain injury due to conditions such as subarachnoid haemorrhage and traumatic brain injury are associated with physical, psychological, cognitive, emotional, and social deficits. Despite reductions in morbidity and mortality, there have been few significant changes in clinical practice. It has been suggested that heterogeneity in outcome assessment in studies has contributed to this limited progress., Objectives: The objectives of this study were to describe current methods of outcome assessment in aneurysmal subarachnoid haemorrhage and traumatic brain injury studies and to examine the relationship between methods of outcome assessment and reported outcomes., Methods: We performed a systematic review and meta-analysis of randomised controlled trials and cohort studies enrolling an adult aneurysmal subarachnoid haemorrhage or traumatic brain injury population and reporting at least one functional outcome measure., Results: We identified 176 studies, including 60 494 participants. The Glasgow Outcome Scale or the Glasgow Outcome Scale Extended was used in 68% (N = 120) of studies and the Modified Rankin Scale in 38% (N = 67) of studies. Outcome assessment was reported at different timepoints, using different methods of application, and often dichotomised using different ranges. Many studies did not report key details on methods of outcome assessment. Outcome assessment using the Modified Rankin Scale was associated with a higher proportion of patients reported as having a favourable outcome 0.62 (95% confidence interval [CI]: 0.58-0.67) than the Glasgow Outcome Scale 0.48 (95% CI: 0.43-0.53) or the Glasgow Outcome Scale Extended 0.42 (95% CI: 0.37-0.48, p < 0.01). In-person assessment was associated with an increased proportion of patients achieving a favourable outcome 0.55 (95% CI: 0.55-0.45) compared to telephone assessment 0.46 (95% CI: 0.40-0.52)., Conclusion: There is significant heterogeneity and incomplete reporting of methods of outcome assessment in critical care studies enrolling aneurysmal subarachnoid haemorrhage and traumatic brain injury patient populations. Our study identified an association between the methods of outcome assessment and reported outcomes. Our study supports initiatives to standardise outcome assessment in neurocritical care research to ensure the quality of outcome data., Registration: The International Prospective Register of Systematic Reviews (CRD42023072206)., Competing Interests: Conflict of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this manuscript., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Objective: Protocol to explore what is known about communication between critical care providers and patients and families from culturally and linguistically diverse backgrounds (defined as people who are either from minority ethnic groups, non-English-speaking backgrounds who may have diverse cultural, linguistic, spiritual and religious affiliations and opinions) about death, dying, end-of-life care and organ donation in the intensive care unit (ICU)., Introduction: Patients from culturally and linguistically diverse backgrounds experience barriers to optimised care when admitted to the ICU. These barriers appear to derive from differences in language, cultural, societal and ethical expectations between patients, their families and healthcare professionals. These barriers may significantly impact the delivery of end-of-life care to patients from culturally and linguistically diverse backgrounds. Therefore, this has the potential for inadequate management of medical, psychological and existential distress., Inclusion Criteria: Studies of all designs reporting for adult (age ≥18 years) patients and family members from culturally and linguistically diverse backgrounds at end-of-life in the ICU setting will be included. Studies that report results for patients aged <18 years or that are based outside the ICU will be excluded., Methods: Relevant sources will be retrieved, and their citation details will be imported into the Joanna Briggs Institute (JBI) System for the Unified Management, Assessment and Review of Information. This scoping review was guided by the JBI methodology for scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A systematic search was conducted in EBSCOhost, Web of Science, PubMed Central and SciELO, OVID Medline, CINAHL, and Scopus, limited to English-language publications, without date limitation. Key study characteristics and findings will be extracted using a data extraction tool developed by the reviewers. Anticipating heterogeneous study designs, findings will be presented as a thematic synthesis., Ethics and Dissemination: This is a protocol for a scoping review, formal ethics approval from the Human Research Ethics Committee (HREC) of the Local Health Network will be obtained for research projects that could potentially stem from this review and will then be subsequently disseminated through proper channels., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: This systematic review and meta-analysis aim to systematically assess the diagnostic accuracy of lung ultrasound in predicting weaning failure from mechanical ventilation in critically ill patients., Methods: We searched the relevant literature up to January 2024 in the databases Web of Science, Cochrane Library, Embase, and PubMed. Two researchers independently screened eligible studies and extracted data; disagreements, if any, were resolved through discussion or consultation with a third-party expert. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Statistical analyses were performed using Review Manager version 5.3 and Stata version 18.0, applying bivariate random-effects models to estimate sensitivity, specificity, diagnostic odds ratios, and their 95% confidence intervals, as well as to summarize receiver operating characteristic curves. Inter-study heterogeneity was assessed using the I-squared statistic, and potential sources of heterogeneity were explored by meta-regression analysis. The study follows the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses in reporting., Results: Fourteen studies were included in the systematic review, of which 13 studies (totaling 988 patients) were included in the meta-analysis. The meta-analysis revealed an overall sensitivity of 0.86 (95% confidence interval: 0.77-0.91) and a specificity of 0.75 (95% confidence interval: 0.66-0.83) for lung ultrasound in predicting extubation failure. The area under the receiver operating characteristic curve was 0.87 (95% confidence interval: 0.84-0.89). Meta-regression analysis identified lung ultrasound thresholds, reference standards (extubation outcomes), and study flow and time bias as significant factors influencing diagnostic accuracy., Conclusion: This systematic review and meta-analysis demonstrated that lung ultrasound has high diagnostic accuracy in predicting extubation failure in mechanically ventilated critically ill patients. Despite some study heterogeneity, lung ultrasound proved to be a reliable predictive tool for extubation failure. Future research should focus on standardizing the definition of extubation failure, exploring the impact of different thresholds on the predictive ability of lung ultrasound, and validating its application in various clinical settings to enhance its utility and accuracy in clinical practice., Systematic Review Registration: This systematic review and meta-analysis was registered with PROSPERO (registration number: CRD42024555909). The study adhered to the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Details of the PROSPERO protocol can be found in Supplementary Table 1., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zhang, Guo, Wang, Zhang, Shen and Zhao.)

Background: Current knowledge of the impact of socioeconomic factors on the risk of admission to the pediatric intensive care unit (PICU) for asthma is limited. Using composite measures of social vulnerability-Social Vulnerability Index (SVI) and Child Opportunity Index (COI) 2.0-we compared patients admitted for status asthmaticus to the PICU and pediatric ward at Children's Hospital Los Angeles (CHLA). We hypothesized patients with a high SVI and low COI are at higher risk for PICU admission., Methods: Patients were identified using ICD-10 codes for asthma. Primary outcome was admission to PICU versus ward for status asthmaticus. Patient-registered residential street addresses were geocoded and spatially joined to SVI and COI 2.0 data at the census tract level. Univariate and regression analyses using the patient's SVI, COI 2.0, and admission location were conducted., Results: From January 2017 to March 2022, there were 2458 admissions matched to addresses from 1983 distinct patients. The overall median SVI for all patients was 0.86 (IQR 0.6, 0.9). Overall median COI was 25.0 (IQR 10, 50). There was no difference in SVI or COI for admission to the PICU versus the ward. However, children requiring multiple hospital admissions for asthma were associated with higher SVI and lower COI., Conclusions: Children admitted to CHLA for asthma had an elevated SVI and low COI. There was no difference between admission locations based on SVI or COI scores. This indicates we care for children at increased socioeconomic risk, but this did not increase PICU use for asthma., (© 2024 European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

An effective patient handover is a core element of high-quality patient care. Communication during patient handover in the intensive care unit is particularly challenging due to the clinical complexity and rapid changes in patient trajectories, complex interdisciplinary and interprofessional interfaces, linguistic barriers, situational and structural disruptive factors, personnel stress factors as well as the communication and error culture of the teams. In addition to avoiding disruptive factors and creating optimal communication conditions and human resources, the use of standardized and structured handovers with the help of protocols and checklists, as recommended in the literature, plays a decisive role as part of a bundle of measures for effective and safe patient care., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Structured procedures have been established internationally for the initial clinical care of patients with traumatic injuries. Comparable concepts have not yet been applied to the initial clinical care of life-threatening nontraumatic emergencies. In 2022, a working group of the German Society for Acute and Emergency Medicine (DGINA) presented the Advanced Critical Illness Life Support (ACiLS) concept for the care of nontraumatic emergencies and offers corresponding training courses., Objective: To present systematic clinical first aid for patients with the leading symptom of shock according to the ACiLS concept., Result: The (PR&#95;E-)AUD 2 IT basic algorithm used in the ACiLS concept divides the initial care of a critically ill patient into the elements of preparation, resources, initial care, medical history, examination, differential diagnosis, diagnostics, interpretation and to do, interrupted by three team time-out elements for structured communication. The use of this concept is demonstrated here using the example of shock., Conclusion: The ACiLS concept has the potential to improve the quality of initial care of nontraumatic emergencies in emergency department shock rooms and intensive care units. Further evaluations in practice and training capacities are essential., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Frailty is strongly correlated with mortality in intensive care unit patients, yet routine screening among intensive care patients is rarely performed. The aim of this study is to assess frailty and health-related quality of life (HRQoL) in patients before intensive care admission and to compare this with outcomes after 3 and 12-months. The Clinical Frailty Scale and EQ-5D-5L will be used to assess frailty and HRQoL, respectively., Methods: This is an ongoing, prospective observational study including patients from five Norwegian ICU's. Inclusion criteria are patients aged ≥65 years requiring invasive mechanical ventilation for ≥24 h. The Clinical Frailty Scale and EQ-5D-5L are administered at baseline (before critical illness) and at 3- and 12-months post-inclusion. Additional data collected includes patient characteristics, ICU treatment details, illness severity and mortality. The EQ-5D-5L will be compared to Norwegian population norms and assessed for measurement properties., Results: Inclusion started July 2022 and will be stopped at 350 patients. The study will be completed in 2025., Conclusion: The study will assess the feasibility and measurement properties of the Clinical Frailty Scale and EQ-5D-5L in ICU survivors by telephone at long-term follow-up study and will give additional information on the frailty and HRQoL of intensive care survivors., Clinical Trial Registration: The study is registered in ClinicalTrials.gov NCT06012942. Protocol version 2.7.1, 19.05.2023., (© 2024 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

The management of patients in shock or arrest is a critical aspect of emergency medicine and critical care. Rapid and accurate assessment is paramount in determining the underlying causes and initiating timely interventions. This article provides a summary of essential ultrasound protocols for the critically ill patient including the extended focused assessment with sonography for trauma (EFAST), rapid ultrasound for shock and hypotension (RUSH), and sonography in hypotension and cardiac arrest in the emergency department (SHoC-ED)., Competing Interests: Disclosure Dr J. Rosario has no financial disclosures. Dr J. Lin has no financial disclosures. Dr N. Saltarelli has no financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Critical care beds are a limited resource, yet research indicates that recommendations for postoperative critical care admission based on patient-level risk stratification are not followed. It is unclear how prioritisation decisions are made in real-world settings and the effect of this prioritisation on outcomes., Methods: This was a prespecified analysis of an observational cohort study of adult patients undergoing inpatient surgery, conducted in 274 hospitals across the UK and Australasia during 2017. The primary outcome was postoperative morbidity at day 7. Logistic regression models were used to evaluate the relationship between critical care admission and patient and health system factors. The causal effect of critical care admission on outcome was estimated using variation in critical care occupancy as a natural experiment in an instrumental variable analysis., Results: A total of 19,491 patients from 248 hospitals were eligible for analysis, of whom 2107 were directly admitted to critical care postoperatively. Postoperative morbidity occurred in 2829/19,491 (15%) patients. Increasing surgical risk was associated with critical care admission, as was increased availability of critical care beds (odds ratio (95%CI) 1.04 (1.01-1.06), p = 0.002) per available bed; however, the probability of admission varied significantly between hospitals (median odds ratio 3.05). There was no evidence of a difference in postoperative morbidity with critical care admission (odds ratio (95%CI) 0.91 (0.57-1.45), p = 0.710)., Discussion: Postoperative critical care admission is variable and related to bed availability. Statistical methods that adjust for unobserved confounding lowered the estimates of harm previously reported to have been associated with postoperative critical care admission. Our findings provide a rationale for a clinical trial which would evaluate any potential benefits for postoperative critical care admission for patients in whom there is no absolute indication for admission., (© 2024 The Author(s). Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Objective: Effective communication about serious illness is pivotal in delivering surgical palliative care-a crucial component of comprehensive surgical critical care (SCC). However, limited educational strategies exist for fellow-level trainees, who are often directing clinical decision-making and building mutual trust with patients and families. This pilot study assess implications of a novel serious illness communication training opportunity tailored specifically for SCC fellows., Design: Prospective implementation of a multimodal training session (1 hour-didactic lecture, 2 hours-live-action simulation), using pre- and postcourse surveys to assess self-perceived confidence., Setting: University of Michigan in Ann Arbor, Michigan., Participants: Eleven ACGME-accredited SCC fellows during the 2023 to 2024 academic year participated and completed all 3 survey assessments., Results: Following the course, 6 of 7 confidence domains showed improvement, with 2 reaching statistical significance-communication skills to discuss goals of care and/or code status (3.73 vs. 4.36, p = 0.018) and end-of-life care or transition to comfort-focused care (3.36 vs. 4.18, p = 0.023) with a patient or family member. At 6-month follow up, fellows reported further increases in all queried domains, though changes were nonsignificant. Greatest absolute increases were noted in delivering serious news (4.18 vs. 4.55, p = 0.143) and expressing nonverbal empathy (4.09 vs. 4.50, p = 0.197). The majority (91%) of respondents felt more comfortable having serious illness conversations with patients and families due to their training course experience., Conclusion: Implementation of a 3-hour training course tailored for SCC fellows significantly boosted both the immediate and long-term confidence in their serious illness communication skills and ability to manage complex care scenarios., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Moral sensitivity may play a role in dealing with ethical issues in ICUs. However, the moral sensitivity of adult ICU nurses in China and its predictors have not been well investigated., Aim: To analyse the moral sensitivity of intensive care unit (ICU) nurses and its predictors., Study Design: A cross-sectional study through convenience sampling was conducted in the ICUs of five hospitals in China between November and December 2022. A total of 331 ICU nurses were recruited. Data were obtained using a self-developed socio-demographic characteristic questionnaire, the Moral Sensitivity Questionnaire, the Jefferson Scale of Empathy-Health Professionals and the Organizational Climate Scale for Nursing. The participating institutions received a link to the tools used for online data collection, which they then forwarded to nursing staff., Results: The valid response rate was 96.98% (n = 321). The total mean moral sensitivity score of nurses was 43.04 ± 5.95. The mean scores for empathic ability and organizational climate for nursing were 91.97 ± 17.88 and 101.28 ± 14.77, respectively. Regression analyses revealed that the primary factors associated with moral sensitivity among critical care nurses included work tenure (p < .05), empathic ability (p < .001) and organizational climate (p < .001)., Conclusions: High levels of moral sensitivity were found in critical care nurses in China. Work tenure, empathic ability and organizational climate were significant predictors of moral sensitivity in critical care nurses., Relevance to Clinical Practice: To enhance the ethical sensitivity of ICU nurses, we suggest to strengthen the training of novice nurses so that they can better face the moral dilemma in clinical practice. In addition, organizational managers should also take measures to create a positive and harmonious working atmosphere, promote the application of moral knowledge in nursing practice and enhance their moral sensitivity., (© 2024 British Association of Critical Care Nurses.)