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Purpose of Review: Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear., Recent Findings: The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Enrollment into critical care clinical trials is often hampered by the need to rely on surrogate decision-makers. To identify potential interventions facilitating enrollment into critical care clinical trials, a better understanding of surrogate decision-making for critical care clinical trial enrollment is needed., Research Question: What are the barriers and facilitators of critical care trial enrollment? What are surrogate decision-makers' perspectives on proposed interventions to facilitate trial enrollment?, Study Design and Methods: We conducted semistructured interviews with 20 surrogate decision-makers of critically ill patients receiving mechanical ventilation. The interviews were recorded and transcribed verbatim, and analyzed for themes using an inductive approach., Results: Thematic analysis confirmed previous research showing that trust in the system, assessing the risks and benefits of trial participation, the desire to help others, and building medical knowledge as important motivating factors for trial enrollment. Two previously undescribed concerns among surrogate decision-makers of critically ill patients were identified, including the potential to interfere with clinical treatment decisions and negative sentiment about placebos. Surrogates viewed public recognition and charitable donations for participation as favorable potential interventions to encourage trial enrollment. However, participants viewed direct financial incentives and prioritizing research participants during medical rounds negatively., Interpretation: This study confirms and extends previous findings that health system trust, study risks and benefits, altruism, knowledge generation, interference with clinical care, and placebos are key concerns and barriers for surrogate decision-makers to enroll patients in critical care trials. Future studies are needed to evaluate if charitable giving on the patient's behalf and public recognition are effective strategies to promote enrollment into critical care trials., Competing Interests: Financial/Nonfinancial Disclosures None declared., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU., (Copyright © 2024 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.)

Objectives: The evidence for tocilizumab in the treatment of COVID-19 is contradictory, with some clinical trials showing benefits in regard to progression to mechanical ventilation (MV) and/or mortality. The aim of this study is to evaluate in real clinical practice the effectiveness of tocilizumab in treating COVID-19 and to identify prognostic factors for patient outcomes., Methods: This was an observational, retrospective study of COVID-19 patients treated with tocilizumab between March 2020 and February 2021 in a tertiary hospital. Variables were demographics, comorbidities, vital signs, analytical parameters, COVID-19 treatment, progression to MV, intensive care unit (ICU) admission, hospital stay, and mortality., Results: A total of 685 patients (64.7% men, median 68 years) were included. Overall mortality was 23.4% (14.2% in the first 14 days post-tocilizumab) and 93.3% in patients with MV and/or in the ICU at 14 days post-tocilizumab. In addition, 61.5% of discharges occurred during the same period. In patients who died, statistically significant differences were observed in the baseline analytical parameters of C-reactive protein (CRP), D-dimer and higher lactate dehydrogenase (LDH) (p<0.05)., Conclusions: In most patients the clinical results of tocilizumab were observed at 14 days post-administration and could benefit from earlier administration of treatment. Baseline levels of CRP, D-dimer and LDH could be prognostic factors for the evolution of the COVID-19 patient., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Awakening, Breathing Coordination, Delirium monitoring and Early mobility bundle (ABCDE) is associated with lower mortality for intensive care unit (ICU) patients. However, efforts to improve ABCDE are variably successful, possibly due to lack of clarity about who are the team members interacting when caring for each patient, each shift. Lack of patient shift-level information regarding who is interacting with whom limits the ability to tailor interventions to the specific ICU team to improve ABCDE., Objective: Determine the number and types of individuals (i.e., clinicians and family members) interacting in the care of mechanically ventilated (MV) patients, as reported by the patients' assigned physician, nurse, and respiratory therapist (RT) each shift, using a network science lens., Methods: We conducted a prospective, patient-shift-level survey in 2 medical ICUs. For each patient, we surveyed the assigned physician, nurse, and RT each day and night shift about who they interacted with when providing ABCDE for each patient-shift. We determined the number and types of interactions, reported by physicians, nurses, and RTs and day versus night shift., Results: From 1558 surveys from 404 clinicians who cared for 169 patients over 166 shifts (65% response rate), clinicians reported interacting with 2.6 individuals each shift (physicians: 2.65, nurses: 3.33, RTs: 1.86); this was fewer on night shift compared to day shift (1.99 versus 3.02). Most frequent interactions were with the bedside nurse, attending, resident, intern, and RT; family member interactions were reported in less than 1 in 5 surveys (12.2% of physician surveys, 19.7% of nurse surveys, 4.9% of RT surveys)., Interpretation: Clinicians reported interacting with 3-4 clinicians each shift, and fewer on nights. Nurses interacted with the most clincians and family members. Interventions targeting shift-level teams, focusing on nurses and family members, may be a way to improve ABCDE delivery and ICU teamwork., Competing Interests: Authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: The initiation of invasive long-term ventilation (I-LTV) for an adolescent with Rett Syndrome (RTT) involves many serious bioethical considerations. In moving towards a more inclusive model of patient participation, transparency surrounding the main influencing factors around this decision is important., Objective: We aimed to identify the main drivers influencing a clinician's decision to support initiation of I-LTV for an adolescent with RTT., Method: We used an anonymous online vignette-based factorial survey. The survey was distributed internationally through eight professional multi-disciplinary organisations to reach clinicians working in paediatrics., Results: We analysed 504 RTT vignettes completed by 246 clinicians using mixed effect regression modelling. The main three significant influencing factors identified were: parental agreement with the decision to support initiation, the family's support network, and proximity to a tertiary care centre. Additional comments from participants focused on family support, and the importance of on-going communication with the family., Conclusion: As the rights of those with disabilities improve and participation of adolescents in decision-making becomes more established, effective communications with the family around goals of care and particular sensitivity and reflective practice around methods of consensus building will likely contribute to a positive decision-making process at this difficult time., Competing Interests: Declaration of competing interest All authors declare no conflict of interest., (© 2024 Published by Elsevier Ltd on behalf of European Paediatric Neurology Society.)

To effectively use data from intensive care unit patient information systems at multiple hospitals, it is necessary to standardize the data into a well-ordered form. However, terms often vary between devices. We designed a mechanical ventilation concept model and applied data to that model using existing tools and expert opinions. The JSICM glossary was revised based on this study.

Objectives: Patients requiring mechanical ventilation in the intensive care unit (ICU) have diminished respiratory defences and are at high risk of respiratory compromise, leading to an increased risk of pulmonary infection and prolonged ventilation. Ventilator hyperinflation (VHI) is an airway clearance technique used by physiotherapists and is suggested to improve respiratory mechanics. The objective of this study was to review the evidence for the benefits and risks of VHI in intubated and mechanically ventilated patients in the ICU., Review Method Used: We conducted a systematic review., Data Sources: We searched PubMed, Embase, CINAHL, CENTRAL, and Scopus from inception to 31st May 2022 for all randomised control trials evaluating VHI in intubated and mechanically ventilated adults in the ICU., Review Methods: Two authors independently performed study selection and data extraction. Individual study risk of bias was assessed using the Physiotherapy Evidence Database scale, and certainty in outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluations framework., Results: We included 10 studies enrolling 394 patients. Compared to standard care, VHI had significant effects on sputum clearance (Standardise mean difference: 0.36, 95% confidence interval [CI]: 0.12 to 0.61; very low certainty), static pulmonary compliance (mean difference [MD]: 4.77, 95% CI: 2.40 to 7.14; low certainty), dynamic pulmonary compliance (MD: 1.59, 95% CI: 0.82 to 2.36; low certainty) and oxygenation (MD: 0.28, 95% CI: 0.01 to 0.55; low certainty). No significant adverse events or immediate side effects relating to VHI were reported. There is a paucity of data available on the effects of VHI on clinical outcomes including mechanical ventilation duration, ICU length of stay, and mortality., Conclusions: Our findings suggest VHI has potential short-term respiratory benefits including increased secretion clearance, pulmonary compliance, and oxygenation, with no immediate adverse effects in intubated and mechanically ventilated ICU patients. However, there remains limited data on the longer term influence of VHI on clinical outcomes, and further research to inform clinical practice is needed., Registration: This study is registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022341421)., 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 © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Patient communication is profoundly impacted during the intensive care unit (ICU) stay. While the impacts of altered communication are recognised, there is a paucity of data on the prevalence of communication attempts as well as modes utilised by patients and unit practices to manage communication function., Objective: The objectives of this study were to describe the prevalence and characteristics of observed communication attempts (nonverbal, verbal, and use of the staff call bell) in adult ICU patients and report on unit-level practices on communication management., Methods: A prospective, binational, cross-sectional point-prevalence study was conducted across 44 Australia and New Zealand adult ICUs. Data on communication attempts, modes, ICU-level guidelines, training, and resources were collected in June 2019., Results: Across 44 ICUs, 470 of 623 (75%) participants, including ventilated and nonventilated patients, were attempting to communicate on the study day. Of those invasively ventilated via an endotracheal tube for the entire study day, 42 of 172 (24%) were attempting to communicate and 39 of 45 (87%) patients with a tracheostomy were attempting to communicate. Across the cohort, the primary mode of communication was verbal communication, with 395 of 470 (84%) patients using speech; of those 371 of 395 (94%) spoke English and 24 of 395 (6%) spoke a language other than English. Participants attempting to communicate on the study day had a shorter length of stay (LOS), a mean difference of 3.8 days (95% confidence interval: 0.2; 5.1) shorter LOS in the ICU than those not attempting to communicate, and a mean difference 7.9 days (95% confidence interval: 3.1; 12.6) shorter LOS in hospital overall. Unit-level practices and supports were collected. Six of 44 (14%) ICUs had a protocol for communication management, training was available in 11 of 44 (25%) ICUs, and communication resources were available in 37 of 44 (84%) ICUs., Conclusion: Three-quarters of patients admitted to the ICU were attempting to communicate on the study day, with multiple methods used to support verbal and nonverbal communication regardless of ventilation status. Guidance and training were absent from the majority of ICUs, indicating a need for development and implementation of policies, training, and resources., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: Using a system, which accuracy is equivalent to the gold standard Douglas Bag (DB) technique for measuring oxygen consumption (VO 2 ), carbon dioxide generation (VCO 2 ), and respiratory quotient (RQ), we aimed to continuously measure these metabolic indicators and compare the values between post-cardiothoracic surgery and critical care patients., Methods: This was a prospective, observational study conducted at a suburban, quaternary care teaching hospital. Age 18 years or older patients who underwent mechanical ventilation were enrolled., Results: We included 4 post-surgery and 6 critical care patients. Of those, 3 critical care patients died. The longest measurement reached to 12 h and 15 min and 50 cycles of repeat measurements were performed. VO 2 of the post-surgery patients were 234 ± 14, 262 ± 27, 212 ± 16, and 192 ± 20 mL/min, and those of critical care patients were 122 ± 20, 189 ± 9, 191 ± 7, 191 ± 24, 212 ± 12, and 135 ± 21 mL/min, respectively. The value of VO 2 was more variable in the post-surgery patients and the range of each patient was 44, 126, 71, and 67, respectively. SOFA scores were higher in non-survivors and there were negative correlations of RQ with SOFA., Conclusions: We developed an accurate system that enables continuous and repeat measurements of VO 2 , VCO 2 , and RQ. Critical care patients may have less activity in metabolism represented by less variable values of VO 2 and VCO 2 over time as compared to those of post-cardiothoracic surgery patients. Additionally, an alteration of these values may mean a systemic distinction of the metabolism of critically ill patients., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objectives: The objective was to compare specific data from the 2020 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report "Balancing the Pressures" with two previous U.K. studies and to examine changes in the pediatric population requiring long-term ventilation (LTV) as well as the types delivered. We believe that the new data presented will facilitate future service planning., Design: A subset of confidential enquiry data derived from a study by a nationally funded quality improvement organization (NCEPOD: www.ncepod.org.uk ) was compared with two previous U.K. datasets., Setting: Healthcare providers across England, Wales, and Northern Ireland-inpatient and community settings., Patients: Children and young people (CAYP) 0-16 years old receiving LTV between April 1, 2016, and March 31, 2018., Interventions: None., Measurements and Main Results: When comparing the NCEPOD data with that last published in the United Kingdom, the number of CAYP requiring LTV more than doubled between 2008 and 2018 (933-2,093). There has also been a particular increase in the proportion of children that were under two when they were commenced on LTV (26-39.2%). Children are now more likely than previously to be receiving LTV to manage upper airway obstruction and CNS conditions. There has also been an approximate doubling of those receiving LTV over the whole 24-hour period (9.4-18.4%)., Conclusions: The increased numbers and changing characteristics of babies and children requiring LTV over the last 3 decades in the United Kingdom have implications for all healthcare sectors but particularly for providers of critical care services., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Ventilator-free days (VFDs) are a composite endpoint increasingly used as the primary outcome in critical care trials. However, because of the skewed distribution and competitive risk between components, sample size estimation remains challenging. This systematic review was conducted to systematically assess whether the sample size was congruent, as calculated to evaluate VFDs in trials, with VFDs' distribution and the impact of alternative methods on sample size estimation., Methods: A systematic literature search was conducted within the PubMed and Embase databases for randomized clinical trials in adults with VFDs as the primary outcome until December 2021. We focused on peer-reviewed journals with 2021 impact factors greater than five. After reviewing definitions of VFDs, we extracted the sample size and methods used for its estimation. The data were collected by two independent investigators and recorded in a standardized, pilot-tested forms tool. Sample sizes were calculated using alternative statistical approaches, and risks of bias were assessed with the Cochrane risk-of-bias tool., Results: Of the 26 clinical trials included, 19 (73%) raised "some concerns" when assessing risks of bias. Twenty-four (92%) trials were two-arm superiority trials, and 23 (89%) were conducted at multiple sites. Almost all the trials (96%) were unable to consider the unique distribution of VFDs and death as a competitive risk. Moreover, significant heterogeneity was found in the definitions of VFDs, especially regarding varying start time and type of respiratory support. Methods for sample size estimation were also heterogeneous, and simple models, such as the Mann-Whitney-Wilcoxon rank-sum test, were used in 14 (54%) trials. Finally, the sample sizes calculated varied by a factor of 1.6 to 17.4., Conclusions: A standardized definition and methodology for VFDs, including the use of a core outcome set, seems to be required. Indeed, this could facilitate the interpretation of findings in clinical trials, as well as their construction, especially the sample size estimation which is a trade-off between cost, ethics, and statistical power. Systematic review registration PROSPERO ID: CRD42021282304. Registered 15 December 2021 ( https://www.crd.york.ac.uk/prospero/display&#95;record.php?ID=CRD42021282304 )., (© 2023. The Author(s).)

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI., Competing Interests: The authors declare that they have no conflicts of interest in connection with this article. Potential conflicts of interest for QI development are indicated in Attachment 2., (Copyright © 2023 Kumpf et al.)

Falls in the ICU are multifaceted, affecting patients of all ages. Historically, falls have been associated with patients in the hospital environment, but fall rates after discharge and readmission rates following a fall are now areas of concern. Recent innovations to prevent risks related to sedation and immobility in the hospital have revealed their impact on ICU patients and fall risk. Risk factors for falls in the ICU relate to length of stay and acuity-related care requirements, such as mechanical ventilation, sedation, and prolonged immobilization. Evidence-based fall prevention includes screening tools, prevention bundles/programs, and implementing clinical practice guidelines., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: On the basis of low-quality evidence, international critical care nutrition guidelines recommend a wide range of protein doses. The effect of delivering high-dose protein during critical illness is unknown. We aimed to test the hypothesis that a higher dose of protein provided to critically ill patients would improve their clinical outcomes., Methods: This international, investigator-initiated, pragmatic, registry-based, single-blinded, randomised trial was undertaken in 85 intensive care units (ICUs) across 16 countries. We enrolled nutritionally high-risk adults (≥18 years) undergoing mechanical ventilation to compare prescribing high-dose protein (≥2·2 g/kg per day) with usual dose protein (≤1·2 g/kg per day) started within 96 h of ICU admission and continued for up to 28 days or death or transition to oral feeding. Participants were randomly allocated (1:1) to high-dose protein or usual dose protein, stratified by site. As site personnel were involved in both prescribing and delivering protein dose, it was not possible to blind clinicians, but patients were not made aware of the treatment assignment. The primary efficacy outcome was time-to-discharge-alive from hospital up to 60 days after ICU admission and the secondary outcome was 60-day morality. Patients were analysed in the group to which they were randomly assigned regardless of study compliance, although patients who dropped out of the study before receiving the study intervention were excluded. This study is registered with ClinicalTrials.gov, NCT03160547., Findings: Between Jan 17, 2018, and Dec 3, 2021, 1329 patients were randomised and 1301 (97·9%) were included in the analysis (645 in the high-dose protein group and 656 in usual dose group). By 60 days after randomisation, the cumulative incidence of alive hospital discharge was 46·1% (95 CI 42·0%-50·1%) in the high-dose compared with 50·2% (46·0%-54·3%) in the usual dose protein group (hazard ratio 0·91, 95% CI 0·77-1·07; p=0·27). The 60-day mortality rate was 34·6% (222 of 642) in the high dose protein group compared with 32·1% (208 of 648) in the usual dose protein group (relative risk 1·08, 95% CI 0·92-1·26). There appeared to be a subgroup effect with higher protein provision being particularly harmful in patients with acute kidney injury and higher organ failure scores at baseline., Interpretation: Delivery of higher doses of protein to mechanically ventilated critically ill patients did not improve the time-to-discharge-alive from hospital and might have worsened outcomes for patients with acute kidney injury and high organ failure scores., Funding: None., Competing Interests: Declaration of interests The UK sites received support in the form of protein supplement supply from Nutrinovo (prosource tube feed [TF]) and Stanningly Pharma (Renapro Shot), and CA$20 000 from Nutricia to cover insurance and project management costs locally. Those that provided financial and product support for the trial had no role in designing the protocol, conducting the trial, or analysing the data, and did not have access to the data nor influence the content of the publication. We declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Intensive care unit (ICU)-acquired weakness often develops in patients who are undergoing invasive mechanical ventilation. Early active mobilization may mitigate ICU-acquired weakness, increase survival, and reduce disability., Methods: We randomly assigned 750 adult patients in the ICU who were undergoing invasive mechanical ventilation to receive increased early mobilization (sedation minimization and daily physiotherapy) or usual care (the level of mobilization that was normally provided in each ICU). The primary outcome was the number of days that the patients were alive and out of the hospital at 180 days after randomization., Results: The median number of days that patients were alive and out of the hospital was 143 (interquartile range, 21 to 161) in the early-mobilization group and 145 days (interquartile range, 51 to 164) in the usual-care group (absolute difference, -2.0 days; 95% confidence interval [CI], -10 to 6; P = 0.62). The mean (±SD) daily duration of active mobilization was 20.8±14.6 minutes and 8.8±9.0 minutes in the two groups, respectively (difference, 12.0 minutes per day; 95% CI, 10.4 to 13.6). A total of 77% of the patients in both groups were able to stand by a median interval of 3 days and 5 days, respectively (difference, -2 days; 95% CI, -3.4 to -0.6). By day 180, death had occurred in 22.5% of the patients in the early-mobilization group and in 19.5% of those in the usual-care group (odds ratio, 1.15; 95% CI, 0.81 to 1.65). Among survivors, quality of life, activities of daily living, disability, cognitive function, and psychological function were similar in the two groups. Serious adverse events were reported in 7 patients in the early-mobilization group and in 1 patient in the usual-care group. Adverse events that were potentially due to mobilization (arrhythmias, altered blood pressure, and desaturation) were reported in 34 of 371 patients (9.2%) in the early-mobilization group and in 15 of 370 patients (4.1%) in the usual-care group (P = 0.005)., Conclusions: Among adults undergoing mechanical ventilation in the ICU, an increase in early active mobilization did not result in a significantly greater number of days that patients were alive and out of the hospital than did the usual level of mobilization in the ICU. The intervention was associated with increased adverse events. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; TEAM ClinicalTrials.gov number, NCT03133377.)., (Copyright © 2022 Massachusetts Medical Society.)

Hemodynamic and respiratory complications are the main causes of morbidity and mortality in in critical care units (CCU). Imaging techniques are a key tool in differential diagnosis and treatment. In the last decade, ultrasound has shown great potential for bedside diagnosis of respiratory disease, as well as for the hemodynamic assessment of critically ill patients. Ultrasound has proven to be a useful guide for identifying the type of shock, estimating cardiac output, guiding fluid therapy and vasoactive drugs, providing security in the performance of percutaneous techniques (thoracentesis, pericardiocentesis, evacuation of abscesses/hematomas), detecting dynamically in real time pulmonary atelectasis and its response to alveolar recruitment maneuvers, and predicting weaning failure from mechanical ventilation. Due to its dynamic nature, simple learning curve and absence of ionizing radiation, it has been incorporated as an essential tool in daily clinical practice in CCUs. The objective of this review is to offer a global vision of the role of ultrasound and its applications in the critically ill patient., (Copyright © 2022 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: With ICU mortality rates decreasing, it is increasingly important to identify interventions to minimize functional impairments and improve outcomes for survivors. Simultaneously, we must identify robust patient-centered functional outcomes for our trials. Our objective was to investigate the clinimetric properties of a progression of three outcome measures, from strength to function., Methods: Adults (≥ 18 years) enrolled in five international ICU rehabilitation studies. Participants required ICU admission were mechanically ventilated and previously independent. Outcomes included two components of the Physical Function in ICU Test-scored (PFIT-s): knee extensor strength and assistance required to move from sit to stand (STS); the 30-s STS (30 s STS) test was the third outcome. We analyzed survivors at ICU and hospital discharge. We report participant demographics, baseline characteristics, and outcome data using descriptive statistics. Floor effects represented ≥ 15% of participants with minimum score and ceiling effects ≥ 15% with maximum score. We calculated the overall group difference score (hospital discharge score minus ICU discharge) for participants with paired assessments., Results: Of 451 participants, most were male (n = 278, 61.6%) with a median age between 60 and 66 years, a mean APACHE II score between 19 and 24, a median duration of mechanical ventilation between 4 and 8 days, ICU length of stay (LOS) between 7 and 11 days, and hospital LOS between 22 and 31 days. For knee extension, we observed a ceiling effect in 48.5% (160/330) of participants at ICU discharge and in 74.7% (115/154) at hospital discharge; the median [1st, 3rd quartile] PFIT-s difference score (n = 139) was 0 [0,1] (p < 0.05). For STS assistance, we observed a ceiling effect in 45.9% (150/327) at ICU discharge and in 77.5% (79/102) at hospital discharge; the median PFIT-s difference score (n = 87) was 1 [0, 2] (p < 0.05). For 30 s STS, we observed a floor effect in 15.0% (12/80) at ICU discharge but did not observe a floor or ceiling effect at hospital discharge. The median 30 s STS difference score (n = 54) was 3 [1, 6] (p < 0.05)., Conclusion: Among three progressive outcome measures evaluated in this study, the 30 s STS test appears to have the most favorable clinimetric properties to assess function at ICU and hospital discharge in moderate to severely ill participants., (© 2022. The Author(s).)

Background: Intensive care unit (ICU) sedation guidelines recommend targeting a light sedation level, but light sedation has no accepted definition, and inconsistent levels have been proposed., Objective: To determine Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores that best describe patients' ability to follow voice commands., Methods: This prospective, observational pilot study enrolled a convenience sample of ICU patients receiving mechanical ventilation. Pairs of trained investigators evaluated scores on the Sedation-Agitation Scale and Richmond Agitation-Sedation Scale and ability to follow commands before and up to 2 hours after sedation lightening in a blind, independent, simultaneous fashion. Positive predictive values (PPVs) and likelihood ratios (LRs) of Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores associated with light sedation (ability to follow at least 3 commands) were calculated., Results: Ninety-six assessments (50 before and 46 after lightening of sedation) were performed in medical ICU patients. Scores best associated with ability to follow at least 3 commands were Sedation-Agitation Scale score of 4 (PPV, 0.88; 95% CI, 0.70-0.98; LR, 14.0) and Richmond Agitation-Sedation Scale score of -1 (PPV, 0.81; 95% CI, 0.61-0.93; LR, 10.7), superior to previously recommended thresholds of Sedation-Agitation Scale score of 3 (PPV, 0.62; 95% CI, 0.48-0.75; LR, 3.1) and Richmond Agitation-Sedation Scale score of -3 (PPV, 0.52; 95% CI, 0.39-0.64; LR, 2.0)., Conclusions: The level of sedation most associated with the ability to follow commands appears higher than previously recommended. Further study is needed regarding the effects of sedation level on ICU patients' ability to follow commands and assessment of delirium, pain, and patient preferences., (©2022 American Association of Critical-Care Nurses.)

Competing Interests: Competing interests: All of the authors of this manuscript are investigators for the NIHR Health Technology Assessment funded UK-ROX (Intensive Care Unit Randomised Trial Comparing Two Approaches to OXygen Therapy) trial (https://www.icnarc.org/Our-Research/Studies/Uk-Rox/About)DM: lecture and consultancy fees from Siemens Healthineers and Edwards Lifesciences. Director of Oxygen Control Systems. MG served as chair of the NHSE guidance on the management of critical care for adults with COVID-19. MG serves on the medical advisory board of Sphere Medical and is a director of Oxygen Control Systems. He has received honoraria for speaking and/or travel expenses from BOC Medical (Linde Group), Edwards Lifesciences and Cortex.

Introduction: Intoxications are common in intensive care units (ICUs). The number of causative substances is large, mortality usually low. This retrospective cohort study aims to characterize differences of intoxicated compared to general ICU patients, point out variations according to causative agents, as well as to highlight differences between survivors and non-survivors among intoxicated individuals in a large-scale multi-center analysis., Methods: A total of 105,998 general ICU patients and 4,267 individuals with the admission diagnoses "overdose" and "drug toxicity" from the years 2014 and 2015 where included from the eICU Collaborative Research Database. In addition to comparing these groups with respect to baseline characteristics, intensive care measures and outcome parameters, differences between survivors and non-survivors from the intoxication group, as well as the individual groups of causative substances were investigated., Results: Intoxicated patients were younger (median 41 vs. 66 years; p<0.001), more often female (55 vs. 45%; p<0.001), and normal weighted (36% vs. 30%; p<0.001), whereas more obese individuals where observed in the other group (37 vs. 31%; p<0.001). Intoxicated individuals had a significantly lower mortality compared to general ICU patients (1% vs. 10%; aOR 0.07 95%CI 0.05-0.11; p<0.001), a finding which persisted after multivariable adjustment (aOR 0.17 95%CI 0.12-0.24; p<0.001) and persisted in all subgroups. Markers of disease severity (SOFA-score: 3 (1-5) vs. 4 (2-6) pts.; p<0.001) and frequency of vasopressor use (5 vs. 15%; p<0.001) where lower, whereas rates of mechanical ventilation where higher (24 vs. 26%; p<0.001) in intoxicated individuals. There were no differences with regard to renal replacement therapy in the first three days (3 vs. 4%; p=0.26). In sensitivity analysis (interactions for age, sex, ethnicity, hospital category, maximum initial lactate, mechanical ventilation, and vasopressor use), a trend towards lower mortality in intoxicated patients persisted in all subgroups., Conclusion: This large-scale retrospective analysis indicates a significantly lower mortality of intoxicated individuals compared to general ICU patients., (© 2022. The Author(s).)

Background: We sought to identify factors that influence surrogate decision makers' decisions to enroll patients into a critical care randomized controlled trial., Methods: We conducted a qualitative study embedded within a randomized controlled trial testing the effect of a behavioral nudge intervention for surrogate decision makers on enrollment rate in a sham ventilatory weaning trial among patients with acute respiratory failure. Participants were adult surrogate decision makers of patients receiving mechanical ventilation for acute respiratory failure. The study was conducted in 10 ICUs across 2 urban hospitals within an academic medical center in Philadelphia, Pennsylvanaia, United States. Immediately following their trial enrollment decision, surrogate decision makers were asked to enter free-text responses about the factors that influenced their decision. Responses were analyzed using content analysis., Results: Of the 90 (49%) participants who provided free-text responses, the mean age was 54.9 years (SD 14.3), 69 (79%) were Caucasian, and 48 (53%) were the spouse of the eligible patient. We identified 5 themes influencing enrollment decisions: (i) trial characteristics, (ii) patient clinical condition, (iii) decision making processes, (iv) altruism, and (v) enrollment attempt. Among surrogates who enrolled the patient in the trial (n = 40), the most commonly cited factors were helping future patients (n = 24, 60%) and following the patient's wishes (n = 11, 28%). In contrast, those who declined enrollment (n = 50) most commonly reported that the patient was too sick (n = 27, 54%) and that they feared complicating the patient's condition (n = 11, 22%)., Conclusions: Surrogates who enroll patients into trials most often cite altruistic motivations, while those who decline enrollment are most often concerned with the severity of the patients' condition.

Background: Tracheostomy is performed in patients expected to require prolonged mechanical ventilation, but to date optimal timing of tracheostomy has not been established. The evidence concerning tracheostomy in COVID-19 patients is particularly scarce. We aimed to describe the relationship between early tracheostomy (≤10 days since intubation) and outcomes for patients with COVID-19., Methods: This was a prospective cohort study performed in 152 centres across 16 European countries from February to December 2020. We included patients aged ≥70 yr with confirmed COVID-19 infection admitted to an intensive care unit, requiring invasive mechanical ventilation. Multivariable analyses were performed to evaluate the association between early tracheostomy and clinical outcomes including 3-month mortality, intensive care length of stay, and duration of mechanical ventilation., Results: The final analysis included 1740 patients with a mean age of 74 yr. Tracheostomy was performed in 461 (26.5%) patients. The tracheostomy rate varied across countries, from 8.3% to 52.9%. Early tracheostomy was performed in 135 (29.3%) patients. There was no difference in 3-month mortality between early and late tracheostomy in either our primary analysis (hazard ratio [HR]=0.96; 95% confidence interval [CI], 0.70-1.33) or a secondary landmark analysis (HR=0.78; 95% CI, 0.57-1.06)., Conclusions: There is a wide variation across Europe in the timing of tracheostomy for critically ill patients with COVID-19. However, we found no evidence that early tracheostomy is associated with any effect on survival amongst older critically ill patients with COVID-19., Clinical Trial Registration: ClinicalTrials.gov NCT04321265., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Oxygen therapy is a widely used intervention in acutely ill patients in the intensive care unit (ICU). It is established that not only hypoxia, but also prolonged hyperoxia is associated with poor patient-centered outcomes. Nevertheless, a fundamental knowledge gap remains regarding optimal oxygenation for critically ill patients. In this randomized clinical trial, we aim to compare ventilation that uses conservative oxygenation targets with ventilation that uses conventional oxygen targets with respect to mortality in ICU patients., Methods: The "ConservatIve versus CONventional oxygenation targets in Intensive Care patients" trial (ICONIC) is an investigator-initiated, international, multicenter, randomized clinical two-arm trial in ventilated adult ICU patients. The ICONIC trial will run in multiple ICUs in The Netherlands and Italy to enroll 1512 ventilated patients. ICU patients with an expected mechanical ventilation time of more than 24 h are randomized to a ventilation strategy that uses conservative (PaO 2 55-80 mmHg (7.3-10.7 kPa)) or conventional (PaO 2 110-150 mmHg (14.7-20 kPa)) oxygenation targets. The primary endpoint is 28-day mortality. Secondary endpoints are ventilator-free days at day 28, ICU mortality, in-hospital mortality, 90-day mortality, ICU- and hospital length of stay, ischemic events, quality of life, and patient opinion of research and consent in the emergency setting., Discussion: The ICONIC trial is expected to provide evidence on the effects of conservative versus conventional oxygenation targets in the ICU population. This study may guide targeted oxygen therapy in the future., Trial Registration: Trialregister.nl NTR7376 . Registered on 20 July, 2018., (© 2022. The Author(s).)

Despite high prevalence of asthma in children in the UK, there were no prior report on asthma admissions in paediatric intensive care units (PICU). We investigated the epidemiology and healthcare resource utilisation in children with asthma presenting to PICUs in England. PICANet, a UK national PICU database, was queried for asthma as the primary reason for admission, of children resident in England from April 2006 until March 2013. There were 2195 admissions to PICU for a median stay of 1.4 days. 59% were males and 51% aged 0-4 years. The fourth and fifth most deprived quintiles represented 61% (1329) admissions and 73% (11) of the 15 deaths. Deaths were most frequent in 10-14 years age (n = 11, 73%), with no deaths in less than 5 years age. 38% of admissions (828/2193) received invasive ventilation, which was more frequent with increasing deprivation (13% (108/828) in least deprived to 31% (260/828) in most deprived) and with decreasing age (0-4-year-olds: 49%, 409/828). This first multi-centre PICU study in England found that children from more deprived neighbourhoods represented the majority of asthma admissions, invasive ventilation and deaths in PICU. Children experiencing socioeconomic deprivation could benefit from enhanced asthma support in the community., (© 2022. The Author(s).)

Introduction: Obstetric intensive care unit admission (ICU) suggests severe morbidity. However, there is no available data on the subject in Ghana. This retrospective review was conducted to determine the indications for obstetric ICU admission, their outcomes and factors influencing these outcomes to aid continuous quality improvement in obstetric care., Methods: This was a retrospective review conducted in a tertiary hospital in Ghana. Data on participant characteristics including age and whether participant was intubated were collected from patient records for all obstetric ICU admissions from 1st January 2010 to 31st December 2019. Descriptive statistics were presented as frequencies, proportions and charts. Hazard ratios were generated for relations between obstetric ICU admission outcome and participant characteristics. A p-value <0.05 was deemed statistically significant., Results: There were 443 obstetric ICU admissions over the review period making up 25.7% of all ICU admissions. The commonest indications for obstetric ICU admissions were hypertensive disorders of pregnancy (70.4%, n = 312/443), hemorrhage (14.4%, n = 64/443) and sepsis (9.3%, n = 41/443). The case fatality rates for hypertension, hemorrhage, and sepsis were 17.6%, 37.5%, and 63.4% respectively. The obstetric ICU mortality rate was 26% (115/443) over the review period. Age ≥25 years and a need for mechanical ventilation carried increased mortality risks following ICU admission while surgery in the index pregnancy was associated with a reduced risk of death., Conclusion: Hypertension, haemorrhage and sepsis are the leading indications for obstetric ICU admissions. Thus, preeclampsia screening and prevention, as well as intensifying antenatal education on the danger signs of pregnancy can minimize obstetric complications. The establishment of an obstetric HDU in CCTH and the strengthening of communication between specialists and the healthcare providers in the lower facilities, are also essential for improved pregnancy outcomes. Further studies are needed to better appreciate the wider issues underlying obstetric ICU admission outcomes., Plain Language Summary: This was a review of the reasons for admitting severely-ill pregnant women and women who had delivered within the past 42 days to the intensive care unit (ICU), the admission outcomes and risk factors associated with ICU mortality in a tertiary hospital in a low-resource country. High blood pressure and its complications, bleeding and severe infections were observed as the three most significant reasons for ICU admissions in decreasing order of significance. Pre-existing medical conditions and those arising as a result of, or aggravated by pregnancy; obstructed labour and post-operative monitoring were the other reasons for ICU admission over the study period. Overall, 26% of the admitted patients died at the ICU and maternal age of at least 25 years and the need for intubation were identified as risk factors for ICU deaths. Attention must be paid to high blood pressure during pregnancy., Competing Interests: The authors have declared that no competing interests exist.

Background and Aim: Pain assessment in pediatric intensive care unit (PICU) is a demanding challenge. The COMFORT-B scale is recognized as the gold standard in such patients. However, the use of this instrument in PICU setting is disputed. The Behavioral Pain Scale (BPS), instead, is considered to be the gold standard for pain assessment in deeply sedated, mechanically ventilated adult patients. The BPS has been validated in Italian, requires a short observation time compared to the COMFORT-B and does not increase workloads. A first evaluation of BPS was made in PICU with good results regarding face validity and content validity, however suggesting further studies given the small sample on which it was tested. The aim of this study was the validation of the BPS in sedated, intubated, and mechanically ventilated pediatric patients., Methods: A descriptive, comparative design was used. A convenience sample of 84 non-verbal, sedated and mechanically ventilated critical care pediatric patients was included. Patient pain was assessed concurrently with three observational scales (BPS, COMFORT-B, NRS) before, during and after routine procedures that are considered painful and non-painful., Results: Internal consistency was α = .86. Correlations between BPS and the other instruments were high, demonstrating a good concurrent validity of the BPS. T test and assessment of ROC curves demonstrated a good discriminant validity of the BPS., Conclusions: The BPS proved to be valid and reliable for the assessment of pain also in the use with pediatric patients.

Given the dramatic increase in critically ill patients who present to the emergency department for care, along with the persistence of boarding of critically ill patients, it is imperative for the emergency physician to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2020 that pertain to the resuscitation and care of select critically ill patients. These articles have been selected based on the authors annual review of key critical care, emergency medicine and medicine journals and their opinion of the importance of study findings as it pertains to the care of critically ill ED patients. Several key findings from the studies discussed in this paper include the administration of dexamethasone to patients with COVID-19 infection who require mechanical ventilation or supplemental oxygen, the use of lower levels of positive end-expiratory pressure for patients without acute respiratory distress syndrome, and early initiation of extracorporeal membrane oxygenation for out-of-hospital cardiac arrest patients with refractory ventricular fibrillation if resources are available. Furthermore, the emergency physician should not administer tranexamic acid to patients with acute gastrointestinal bleeding or administer the combination of vitamin C, thiamine, and hydrocortisone for patients with septic shock. Finally, the emergency physician should titrate vasopressor medications to more closely match a patient's chronic perfusion pressure rather than target a mean arterial blood pressure of 65 mmHg for all critically ill patients., Competing Interests: Declaration of Competing Interest The authors do not have any financial conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: This study aimed to evaluate the accuracy of pulse oximetry-derived oxygen saturation (SpO 2 ) on room air, determined at hospital admission, as a predictor for the need for mechanical ventilatory support in patients with Coronavirus Disease-2019 (COVID-19)., Methods: In this retrospective observational study, demographic and clinical details of the patients were obtained during ICU admission. SpO 2 and respiratory rate (RR) on room air were determined within the first 6 h of hospital admission. As all measurements were obtained on room air, we calculated the simplified respiratory rate‑oxygenation (ROX) index by dividing the SpO 2 by the RR. Based on the use of any assistance of mechanical ventilator (invasive or noninvasive), patients were divided into mechanical ventilation (MV) group and oxygen therapy group. The accuracy of the SpO 2 , CT score, and ROX index to predict the need to MV were determined using the Area under receiver operating curve (AUC)., Results: We included 72 critically ill patients who tested COVID-19-positive. SpO 2 on the room air could predict any MV requirement (AUC [95% confidence interval]: 0.9 [0.8-0.96], sensitivity: 70%, specificity 100%, cut-off value ≤78%, P < 0.001). Within the MV group, the use of noninvasive ventilation (NIV) was successful in 37 (74%) patients, whereas 13 patients (26%) required endotracheal intubation. The cut-off ROX value for predicting early NIV failure was ≤1.4, with a sensitivity of 85%, a specificity of 86%, and an AUC of 0.86 (95% confidence interval of 0.73-0.94, P < 0.0001)., Conclusions: A baseline SpO 2 ≤78% is an excellent predictor of MV requirement with a positive predictive value of 100%. Moreover, the ROX index measured within the first 6 h of hospital admission is a good indicator of early NIV failure., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Delirium is a serious and complex problem facing critically ill patients, their families, and the health care system. When delirium develops, it is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. This article uses a clinical case to discuss our approach to delirium prevention and treatment in the ICU. We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on nonpharmacologic care strategies, including reorientation, early mobility, and incorporating family into care when possible. At present, the evidence does not support the routine administration of medications to prevent or treat delirium. A pharmacologic approach may be needed for agitated delirium, and we discuss our evaluation of the evidence for and against particular medications. Although delirium can be a distressing problem, there is evidence that it can be addressed through careful attention to prevention, detection, and minimizing the long-term impact on patients and their families., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The current COVID-19 pandemic has placed enormous strain on healthcare systems worldwide. Understanding of COVID-19 is rapidly evolving. Pneumonia associated with COVID-19 may lead to respiratory failure requiring mechanical ventilation. The rise in patients requiring mechanical ventilation may lead to an increase in tracheostomies being performed in patients with COVID-19. Performing tracheostomy in patients with active SARS-CoV-2 infection poses a number of challenges., Methods: These guidelines were written following multidisciplinary agreement between Otolaryngology, Head and Neck Surgery, Respiratory Medicine and the Department of Anaesthetics and Critical Care Medicine in the Royal College of Surgeons in Ireland. A literature review was performed and a guideline for elective tracheostomy insertion in patients with COVID-19 proposed., Conclusion: The decision to perform tracheostomy in patients with COVID-19 should be undertaken by senior members of the multidisciplinary team. Steps should be taken to minimise risks to healthcare workers., Competing Interests: Declaration of competing interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment., Objective: To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting., Design: A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR)., Methods: The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting., Results: The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency., Conclusion: Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines., Competing Interests: Conflict of interest Professor Gavin Lambert has acted as a consultant for Medtronic, has received research grant support from Medtronic and has received honoraria or travel support for presentations from Pfizer, Wyeth Pharmaceuticals, Servier, and Medtronic. The other 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 © 2021. Published by Elsevier Ltd.)

Background: In the context of the COVID-19 pandemic, prone position (PP) has been frequently used in the intensive care units to improve the prognosis in patients with respiratory distress. However, turning patients to prone imply important complications such as pressure ulcers. The aim of this paper is to describe the prevalence and characteristics of prone-positioning pressure sores (PPPS) and analyze the related risk factors., Methods: A case-control study was performed in Gregorio Maranon hospital in Madrid during the COVID-19 pandemic between April and May 2020. We enrolled 74 confirmed COVID-19 patients in critical care units with invasive mechanical ventilation who were treated with pronation therapy. There were 57 cases and 17 controls. Demographic data, pronation maneuver characteristics and PPPS features were analyzed., Results: In the case group, a total number of 136 PPPS were recorded. The face was the most affected region (69%). Regarding the severity, stage II was the most frequent. The main variables associated with an increased risk of PPPS were the total number of days under pronation cycles, and PP maintained for more than 24 h. The prealbumin level at admission was significantly lower in the case group. All of the ulcers were treated with dressings. The most frequent acute complication was bleeding (5%)., Conclusions: According to our study, PPPS are related to the characteristics of the maneuver and the previous nutritional state. The implementation of improved positioning protocols may enhance results in critical patient caring, to avoid the scars and social stigma that these injuries entail., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The coronavirus pandemic has resulted in an increased number of interhospital transfers of patients with artificial airways. The transfer of these patients is associated with risks and has been experienced as highly challenging, which needs to be further explored., Aims and Objectives: To describe critical care nurses' experiences of caring for critically ill patients with artificial airways during interhospital transfers., Design: A cross-sectional study using a qualitative approach was conducted during spring 2020. Participants were critical care nurses (n = 7) from different hospitals (n = 2)., Methods: The data were collected through semi-structured interviews based on an interview guide. A qualitative content analysis using an inductive approach was performed., Results: The analysis resulted in one main theme, "Preserving the safety in an unknown environment," and three sub-themes, "Being adequately prepared is essential to feel secure," "Feeling abandoned and overwhelmingly responsible," and "Being challenged in an unfamiliar and risky environment.", Conclusions: Critical care nurses experienced interhospital transfers of critically ill patients with artificial airways as complex and risky. It is essential to have an overall plan in order to prevent any unpredictable and acute events. Adequate communication and good teamwork are key to the safe transfer of a critically ill patient in that potential complications and dangers to the patient can be prevented., Relevance to Clinical Practice: Standardized checklists need to be created to guide the transfers of critically ill patients with different conditions. This would prevent failures based on human or system factors, such as lack of experience and lack of good teamwork., (© 2021 The Authors. Nursing in Critical Care published by John Wiley & Sons, Ltd on behalf of British Association of Critical Care Nurses.)

OBJECTIVES: Recent reviews demonstrated discordant effects of ICU-based physical rehabilitation on physical function. These inconsistencies may be related to differences in treatment fidelity—the extent to which a protocol is delivered as planned. Before evaluating the association of fidelity with outcomes, we must first understand the extent of treatment fidelity reporting in ICU-based physical rehabilitation randomized controlled trials (RCTs). DATA SOURCES: Six electronic databases from inception to December 2022. STUDY SELECTION: We included RCTs enrolling adults or children admitted to the ICU, if greater than or equal to 50% were invasively mechanically ventilated greater than 24 hours, and underwent an ICU-based physical rehabilitation intervention, with no limitation to comparators or outcomes. DATA EXTRACTION: We screened and extracted data independently and in duplicate, with a third reviewer as needed. Extracted data included study characteristics, treatment descriptions, and the presence of National Institutes of Health Behaviour Change Consortium (NIH-BCC) treatment fidelity tool components. Treatment fidelity scores were calculated as the proportion of reported (numerator) out of total NIH-BCC components (denominator). We calculated scores across studies and by treatment group (intervention vs. comparator). We used linear regression to assess for a time trend in study treatment fidelity scores. DATA SYNTHESIS: Of 20,433 citations, 94 studies met inclusion criteria. Authors reported a median (first–third quartiles) of 19% (14–26%) of treatment fidelity components across studies. Intervention group scores were higher than comparator groups (24% [19–33%] vs. 14% [5–24%], p < 0.01). We found a mean increase in study treatment fidelity scores by 0.7% (0.3 points) per year. CONCLUSIONS: Only 19% of treatment fidelity components were reported across studies, with comparator groups more poorly reported. Future research could investigate ways to optimize treatment fidelity reporting and determine characteristics associated with treatment fidelity conduct in ICU-based physical rehabilitation RCTs. [ABSTRACT FROM AUTHOR]

Objective: To explore swallowing function and risk factors associated with delayed recovery of swallowing in patients with COVID-19 post–invasive mechanical ventilation using the Functional Oral Intake Scale (FOIS). Design: Longitudinal cohort study. Setting: Three secondary-level hospitals. Participants: Invasively ventilated patients (N=28) who were hospitalized with severe COVID-19 and referred to the hospitals’ speech and language pathology (SLP) departments after mechanical ventilation between March 5 and July 5, 2020 for an evaluation of swallowing function before commencing oral diet. Interventions: SLP assessment, advice, and therapy for dysphagia. Main Outcome Measures: Oral intake levels at baseline and hospital discharge according to the FOIS. Patients were stratified according to FOIS (1-5, dysphagia; 6-7, functional oral intake). Data regarding comorbidities, frailty, intubation and tracheostomy, proning, and SLP evaluation were collected. Results: Dysphagia was found in 71% of the patients at baseline (79% men; age, 61±12y; body mass index, 30±8 kg/m2). The median FOIS score at baseline was 2 (interquartile range [IQR], 1) vs 5 (IQR, 2.5) at hospital discharge. Patients with dysphagia were older (64±8.5y vs 53±16y; P=.019), had a higher incidence of hypertension (70% vs 12%; P=.006), and were ventilated invasively longer (16±7d vs 10±2d; P=.017) or had a tracheostomy (9±9d vs 1±2d; P=.03) longer. A negative association was found between swallowing dysfunction at bedside and days hospitalized (r=–0.471, P=.01), and number of days in the intensive care unit (ICU) (r=–0.48, P=.01). Conclusion: Dysphagia is prevalent in COVID-19 patients after invasive mechanical ventilation and is associated with number of days in hospital and number of days in the ICU. Swallowing function and tolerance of oral diet improved at discharge (P

Purpose: Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients. Methods: A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors. Results: A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period. Conclusion: Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health. [ABSTRACT FROM AUTHOR]