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Objective: This study aimed to investigate the early, late, and total constipation frequency, related factors, and their effects on the hospitalization day, gastric residual volume, vomiting, distension, and diarrhea, the feeding type, white blood cells, and C-reactive protein levels, and body temperature. Method: Data from this observational cross-sectional study were collected in an anesthesia and reanimation intensive care unit of a public hospital in Bolu, Turkey. The sample included 116 patients who met the criteria of the study. The sample size was determined using power analysis according to the results of a pilot study. The patient information form, daily observation form, and Bristol stool consistency scale were used for collecting the data. Results: The constipation frequency was 63.8% in the unit. The early constipation frequency was 18.9%, and the late constipation frequency was 6.8%. The hospitalization day in these groups was longer than those without constipation. Also, the patients receiving mechanical ventilator support, enteral tube feeding, and diuretic medication had a higher risk for constipation. The enema/laxative was applied to half of the patients who developed constipation in the unit, after which more than half developed diarrhea. Distension and enteral feeding were more frequent in late-type constipation patients. The levels of white blood cells, C-reactive protein levels, and body temperature between all groups were not statistically different (p>0.05). Conclusion: The frequency of constipation was higher in the intensive care unit, even when the defecation period was considered four days. Receiving mechanical ventilator support, enteral tube feeding, and diuretics increased the risk of constipation. Amaç: Bu çalışma erken, geç ve toplam konstipasyon sıklığı, ilişkili faktörler ve bunların hastaneye yatış günü, mide rezidüel hacmi, kusma, distansiyon, diyare, beslenme şekli, beyaz kan hücreleri, C-reaktif protein seviyeleri ve vücut sıcaklığı üzerine etkilerinin incelenmesini amaçladı. Yöntem: Bu gözlemsel kesitsel çalışmanın verileri, Türkiye'de Bolu ilinde bulunan bir devlet hastanesinin anestezi ve reanimasyon yoğun bakım ünitesinde toplandı. Örneklem, çalışmanın kriterlerini karşılayan 116 hastayı içerdi. Örneklem büyüklüğü, pilot çalışmanın sonuçlarına göre güç analizi kullanılarak belirlendi. Verilerin toplanmasında hasta bilgi formu, günlük gözlem formu ve Bristol dışkı kıvam ölçeği kullanıldı. Bulgular: Yoğun bakımda konstipasyon sıklığı %63,8 idi. Erken konstipasyon sıklığı %18,9, geç konstipasyon sıklığı ise %6,8 olarak belirlendi. Bu gruplarda hastanede kalış günü konstipasyonu olmayanlara göre daha uzundu. Ayrıca mekanik ventilatör desteği, enteral tüple beslenme ve diüretik ilaç kullanan hastalarda konstipasyon riski daha yüksekti. Yoğun bakımda konstipasyon gelişen hastaların yarısına lavman/laksatif uygulandı, sonrasında yarısından fazlasında diyare gelişti. Geç tip konstipasyon hastalarında distansiyon ve enteral beslenme daha sık görüldü. Beyaz kan hücreleri, C-reaktif protein seviyeleri ve vücut sıcaklığı tüm gruplar arasında istatistiksel olarak anlamlı değildi (p>0,05). Sonuç: Yoğun bakım ünitesinde dışkılama süresi dört gün olarak kabul edildiğinde bile konstipasyon sıklığının daha yüksek olduğu görüldü. Mekanik ventilatör desteği almak, enteral tüple beslenmek ve diüretik kullanmak konstipasyon riskini artırmaktadır. [ABSTRACT FROM AUTHOR]

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901. [ABSTRACT FROM AUTHOR]

Objective: To establish and validate an individualized nomogram to predict mortality risk within 30 days in patients with sepsis from the emergency department. Methods: Data of 1205 sepsis patients who were admitted to the emergency department in a tertiary hospital between Jun 2013 and Sep 2021 were collected and divided into a training group and a validation group at a ratio of 7:3. The independent risk factors related to 30-day mortality were identified by univariate and multivariate analysis in the training group and used to construct the nomogram. The model was evaluated by receiver operating characteristic (ROC) curve, calibration chart and decision curve analysis. The model was validated in patients of the validation group and its performance was confirmed by comparing to other models based on SOFA score and machine learning methods. Results: The independent risk factors of 30-day mortality of sepsis patients included pro-brain natriuretic peptide, lactic acid, oxygenation index (PaO2/FiO2), mean arterial pressure, and hematocrit. The AUCs of the nomogram in the training and verification groups were 0.820 (95% CI: 0.780–0.860) and 0.849 (95% CI: 0.783–0.915), respectively, and the respective P-values of the calibration chart were 0.996 and 0.955. The DCA curves of both groups were above the two extreme curves, indicating high clinical efficacy. The AUC values were 0.847 for the model established by the random forest method and 0.835 for the model established by the stacking method. The AUCs of SOFA model in the model and validation groups were 0.761 and 0.753, respectively. Conclusion: The sepsis nomogram can predict the risk of death within 30 days in sepsis patients with high accuracy, which will be helpful for clinical decision-making. [ABSTRACT FROM AUTHOR]

Background: There is conflicting evidence on association between quick sequential organ failure assessment (qSOFA) and sepsis mortality in ICU patients. The primary aim of this study was to determine the association between qSOFA and 28-day mortality in ICU patients admitted for sepsis. Association of qSOFA with early (3-day), medium (28-day), late (90-day) mortality was assessed in low and lower middle income (LLMIC), upper middle income (UMIC) and high income (HIC) countries/regions. Methods: This was a secondary analysis of the MOSAICS II study, an international prospective observational study on sepsis epidemiology in Asian ICUs. Associations between qSOFA at ICU admission and mortality were separately assessed in LLMIC, UMIC and HIC countries/regions. Modified Poisson regression was used to determine the adjusted relative risk (RR) of qSOFA score on mortality at 28 days with adjustments for confounders identified in the MOSAICS II study. Results: Among the MOSAICS II study cohort of 4980 patients, 4826 patients from 343 ICUs and 22 countries were included in this secondary analysis. Higher qSOFA was associated with increasing 28-day mortality, but this was only observed in LLMIC (p < 0.001) and UMIC (p < 0.001) and not HIC (p = 0.220) countries/regions. Similarly, higher 90-day mortality was associated with increased qSOFA in LLMIC (p < 0.001) and UMIC (p < 0.001) only. In contrast, higher 3-day mortality with increasing qSOFA score was observed across all income countries/regions (p < 0.001). Multivariate analysis showed that qSOFA remained associated with 28-day mortality (adjusted RR 1.09 (1.00–1.18), p = 0.038) even after adjustments for covariates including APACHE II, SOFA, income country/region and administration of antibiotics within 3 h. Conclusions: qSOFA was independently associated with 28-day mortality in ICU patients admitted for sepsis. In LLMIC and UMIC countries/regions, qSOFA was associated with early to late mortality but only early mortality in HIC countries/regions. [ABSTRACT FROM AUTHOR]

Background: Standardized training for pain, agitation-sedation, and delirium (PAD) management is urgently needed for Chinese intensivists' continuing education. Since 2020, because of the COVID-19 pandemic, the Chinese Analgesia and Sedation Education and Research (CASER) group has used an online blended teaching mode based on a small private online course (SPOC) and case-based learning (CBL). This study evaluated whether an online blended teaching mode has similar effects on PAD management training when an offline mode cannot be used. Materials and methods: Since 2020, the CASER group has provided offline training and online SPOC&CBL training three times each, targeting intensivists and ICU nurses in China. All participants were divided into an offline group and SPOC&CBL group. A final examination was offered in each training session to assess the students' mastery of professional knowledge. Teachers' and students' perceptions regarding the online SPOC&CBL mode were evaluated through questionnaires. Results: Of all participants (n = 117), 106 completed all examinations and questionnaires. Most participants were aged 31–40 years (53, 50.0%), had an academic degree (60, 56.6%), and worked in a tertiary hospital (100, 94.34%). We assessed the learning effect on participants from two aspects: theory and clinical practice. There was no significant difference between the SPOC&CBL and offline groups in terms of theoretical, case analysis, and total scores (p > 0.05). In terms of the participants' perceptions regarding the SPOC&CBL mode, 91.5% considered the online mode to be a useful and accessible alternative to improve knowledge and skills. A total of 95.7% of the participants believed that they could interact well with group members, and 87.2% believed that they had a good degree of participation. Of these participants, 76.6% believed that they had received valuable learning resources. All instructors believed that the SPOC&CBL mode was more flexible than the offline mode in terms of teaching time and location, and they were all willing to carry out training with the SPOC&CBL mode. Conclusion: Compared to the offline mode, the SPOC&CBL mode can also enhance participants' knowledge and skills and meets their expectations. Therefore, an online mode can be considered a potential method in PAD management education in China. [ABSTRACT FROM AUTHOR]

Introduction: There are few reports describing the association of naldemedine with defecation in critically ill patients with opioid-induced constipation. The purpose of this study was to determine whether naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation. Methods: In this retrospective cohort study, patients admitted to the Intensive Care Unit (ICU) without defecation for 48 hours while receiving opioids were eligible for enrollment. The primary endpoint was the time of the first defecation within 96 hours after inclusion. Secondary endpoints included presence of diarrhea, duration of mechanical ventilation, ICU length of stay, ICU mortality, and in-hospital mortality. The Cox proportional hazard regression analysis with time-dependent covariates was used to evaluate the association naldemedine with earlier defecation. Results: A total of 875 patients were enrolled and were divided into 63 patients treated with naldemedine and 812 patients not treated. Defecation was observed in 58.7% of the naldemedine group and 48.8% of the no-naldemedine group during the study (p = 0.150). The naldemedine group had statistically significantly prolonged duration of mechanical ventilation (8.7 days vs 5.5 days, p < 0.001) and ICU length of stay (11.8 days vs 9.2 days, p = 0.001) compared to the no-naldemedine group. However, the administration of naldemedine was significantly associated with earlier defecation [hazard ratio:2.53; 95% confidence interval: 1.71–3.75, p < 0.001]. Conclusion: The present study shows that naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation. [ABSTRACT FROM AUTHOR]

Aims and background: Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal therapy to support oxygenation of patients with severe cardiac or respiratory failure. Studies have shown that acute kidney injury (AKI) can worsen the outcome in these patients. This study aims to assess the incidence and outcome of AKI in patients on ECMO support. Materials and methods: This retrospective study included 64 patients who underwent ECMO for more than 24 hours. Patients who died within 48 hours of initiation of ECMO and patients with end-stage renal disease (ESRD) on maintenance hemodialysis were excluded. Acute kidney injury was diagnosed and categorized according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Results: Of the 64 patients studied, 38 patients (59.38%) developed AKI and 17 patients (44.73%) among them developed AKI within 24 hours of initiation of ECMO. Age, Acute Physiology and Chronic Health Evaluation (APACHE-II) score, hypertension, use of nephrotoxic agents, inotropic support, and poor cardiac function were the risk factors associated with the development of AKI. Diabetes mellitus, type of ECMO used, and duration of ECMO were not found to be risk factors for AKI. Renal replacement therapy was initiated in 31 patients (81.58%). The overall mortality in the whole group was 67.19%, while it was 81.58% among the patients with AKI. Conclusion: Acute kidney injury was found to be an independent risk factor for mortality in patients on ECMO. Early identification of the risk factors for AKI and management may help to improve the survival rate. Clinical significance: The occurrence of AKI among patients on ECMO support increases the risk of mortality significantly. Hence, measures to prevent AKI, as well as early detection and appropriate management of AKI, would improve patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Shorter courses of antimicrobials have been shown to be non-inferior to longer, "traditional" duration of therapies, including for some severe healthcare-associated infections, with a few exceptions. However, evidence is lacking regarding shorter regimes against severe infections by multidrug-resistant Gram-negative bacteria (MDR-GNB), which are often caused by distinct strains and commonly treated with second-line antimicrobials. In the duratiOn of theraPy in severe infecTIons by MultIdrug-reSistant gram-nEgative bacteria (OPTIMISE) trial, we aim to assess the non-inferiority of 7-day versus 14-day antimicrobial therapy in critically ill patients with severe infections caused by MDR-GNB. Methods: This is a randomized, multicenter, open-label, parallel controlled trial to assess the non-inferiority of 7-day versus 14-day of adequate antimicrobial therapy for intensive care unit (ICU)-acquired severe infections by MDR-GNB. Adult patients with severe infections by MDR-GNB initiated after 48 h of ICU admission are screened for eligibility. Patients are eligible if they proved to be hemodynamically stable and without fever for at least 48 h on the 7th day of adequate antimicrobial therapy. After consenting, patients are 1:1 randomized to discontinue antimicrobial therapy on the 7th (± 1) day or to continue for a total of 14th (± 1) days. Planned Outcomes: The primary outcome is treatment failure, defined as death or relapse of infection within 28 days after randomization. Non-inferiority will be achieved if the upper edge of the two-tailed 95% confidence interval of the difference between the clinical failure rate in the 7-day and the 14-day group is not higher than 10%. Conclusion: The OPTIMISE trial is the first randomized controlled trial specifically designed to assess the duration of antimicrobial therapy in patients with severe infections by MDR-GNB. Trial Registration: ClinicalTrials.gov, NCT05210387. Registered on 27 January 2022. Seven Versus 14 Days of Antibiotic Therapy for Multidrug-resistant Gram-negative Bacilli Infections (OPTIMISE). [ABSTRACT FROM AUTHOR]

Using data from cardiovascular surgery patients with long and highly variable post-surgical lengths of stay (LOS), we develop a modeling framework to reduce recovery unit congestion. We estimate the LOS and its probability distribution using machine learning models, schedule procedures on a rolling basis using a variety of optimization models, and estimate performance with simulation. The machine learning models achieved only modest LOS prediction accuracy, despite access to a very rich set of patient characteristics. Compared to the current paper-based system used in the hospital, most optimization models failed to reduce congestion without increasing wait times for surgery. A conservative stochastic optimization with sufficient sampling to capture the long tail of the LOS distribution outperformed the current manual process and other stochastic and robust optimization approaches. These results highlight the perils of using oversimplified distributional models of LOS for scheduling procedures and the importance of using optimization methods well-suited to dealing with long-tailed behavior. [ABSTRACT FROM AUTHOR]

Background: Despite the extensive volume of research published on checklists in the intensive care unit (ICU), no review has been published on the broader role of checklists within the intensive care unit, their implementation and validation, and the recommended clinical context for their use. Accordingly, a scoping review was necessary to map the current literature and to guide future research on intensive care checklists. This review focuses on what checklists are currently used, how they are used, process of checklist development and implementation, and outcomes associated with checklist use. Methods: A systematic search of MEDLINE (Ovid), Embase, Scopus, and Google Scholar databases was conducted, followed by a grey literature search. The abstracts of the identified studies were screened. Full texts of relevant articles were reviewed, and the references of included studies were subsequently screened for additional relevant articles. Details of the study characteristics, study design, checklist intervention, and outcomes were extracted. Results: Our search yielded 2046 studies, of which 167 were selected for further analysis. Checklists identified in these studies were categorised into the following types: rounding checklists; delirium screening checklists; transfer and handover checklists; central line-associated bloodstream infection (CLABSI) prevention checklists; airway management checklists; and other. Of 72 significant clinical outcomes reported, 65 were positive, five were negative, and two were mixed. Of 122 significant process of care outcomes reported, 114 were positive and eight were negative. Conclusions: Checklists are commonly used in the intensive care unit and appear in many clinical guidelines. Delirium screening checklists and rounding checklists are well implemented and validated in the literature. Clinical and process of care outcomes associated with checklist use are predominantly positive. Future research on checklists in the intensive care unit should focus on establishing clinical guidelines for checklist types and processes for ongoing modification and improvements using post-intervention data. [ABSTRACT FROM AUTHOR]

Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients. [ABSTRACT FROM AUTHOR]

We compared Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), Quick Sepsis-related Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) for sepsis diagnosis and adverse outcomes prediction. Clinical studies that used SIRS, SOFA, qSOFA, and NEWS for sepsis diagnosis and prognosis assessment were included. Data were extracted, and meta-analysis was performed for outcome measures, including sepsis diagnosis, in-hospital mortality, 7/10/14-day mortality, 28/30-day mortality, and ICU admission. Fifty-seven included studies showed good overall quality. Regarding sepsis prediction, SIRS demonstrated high sensitivity (0.85) but low specificity (0.41), qSOFA showed low sensitivity (0.42) but high specificity (0.98), and NEWS exhibited high sensitivity (0.71) and specificity (0.85). For predicting in-hospital mortality, SOFA demonstrated the highest sensitivity (0.89) and specificity (0.69). In terms of predicting 7/10/14-day mortality, SIRS exhibited high sensitivity (0.87), while qSOFA had high specificity (0.75). For predicting 28/30-day mortality, SOFA showed high sensitivity (0.97) but low specificity (0.14), whereas qSOFA displayed low sensitivity (0.41) but high specificity (0.88). NEWS independently demonstrates good diagnostic capability for sepsis, especially in high-income countries. SOFA emerges as the optimal choice for predicting in-hospital mortality and can be employed as a screening tool for 28/30-day mortality in low-income countries. [ABSTRACT FROM AUTHOR]

Background: Prolonged length of stay (LOS) has been associated with increased morbidity and resource utilization in various surgical procedures. We aim to determine factors associated with increased hospital stay in patient undergoing tracheoplasty. Methods: The 2012–2018 National Surgical Quality Improvement Program (NSQIP) database was queried for patients undergoing tracheoplasty. Patient LOS was the primary clinical outcome. A LOS >75th percentile was considered as prolonged and was utilized for bivariate analysis of demographic, comorbidity, and operative characteristics. LOS was utilized as a continuous variable for multivariate linear regression analysis. Results: A total of 252 patients were queried. The majority of patients were female (67.5%), white (82.4%), and over the age of 65 (77.0%). Patients had a median LOS of 7 days with the 75th percentile cutoff being defined at 10 days. On bivariate analysis of associated comorbidities, patients with prolonged LOS were more commonly obese (72.4% vs. 53.1%, p = 0.009), diabetic (37.9% vs. 16.5%, p < 0.001), dyspneic (58.6% vs. 40.7%, p = 0.016), and had chronic steroid use (25.9% vs. 12.9%, p = 0.018). Multivariable logistic regression analysis demonstrated significant associations between prolonged LOS and both chronic obstructive pulmonary disorder (COPD) (OR: 3.43, p = 0.020) and chronic steroid use (OR: 3.81, p = 0.018). Conclusions: This study elucidates factors associated with prolonged LOS in patients undergoing tracheoplasty. Patients with COPD and chronic steroid use were significantly associated with prolonged LOS. Level of Evidence: 4 Laryngoscope, 133:1938–1942, 2023 [ABSTRACT FROM AUTHOR]

Successful aerosol therapy in mechanically ventilated patients depends on multiple factors. Among these, position of nebulizer in ventilator circuit and humidification of inhaled gases can strongly influence the amount of drug deposited in airways. Indeed, the main objective was to preclinically evaluate impact of gas humidification and nebulizer position during invasive mechanical ventilation on whole lung and regional aerosol deposition and losses. Ex vivo porcine respiratory tracts were ventilated in controlled volumetric mode. Two conditions of relative humidity and temperature of inhaled gases were investigated. For each condition, four different positions of vibrating mesh nebulizer were studied: (i) next to the ventilator, (ii) right before humidifier, (iii) 15 cm to the Y-piece adapter and (iv) right after the Y-piece. Aerosol size distribution were calculated using cascade impactor. Nebulized dose, lung regional deposition and losses were assessed by scintigraphy using 99mtechnetium-labeled diethylene-triamine-penta-acetic acid. Mean nebulized dose was 95% ± 6%. For dry conditions, the mean respiratory tract deposited fractions reached 18% (± 4%) next to ventilator and 53% (± 4%) for proximal position. For humidified conditions, it reached 25% (± 3%) prior humidifier, 57% (± 8%) before Y-piece and 43% (± 11%) after this latter. Optimal nebulizer position is proximal before the Y-piece adapter showing a more than two-fold higher lung dose than positions next to the ventilator. Dry conditions are more likely to cause peripheral deposition of aerosols in the lungs. But gas humidification appears hard to interrupt efficiently and safely in clinical use. Considering the impact of optimized positioning, this study argues to maintain humidification. [ABSTRACT FROM AUTHOR]

Objectives: To find the frequency of Acute Medical complications and their determinants in stroke patients admitted to a hospital in Peshawar. Materials and Methods: In this cross-sectional descriptive study in the Department of Medicine and Neurology at Hayat Abad Medical Complex, Peshawar, Pakistan from 1/10/2022 till 31/12/2022, a total of 180 patients who presented with Cerebrovascular events based on CT/MRI were included. Patients' data were collected through questionnaires, NIHSS and GCS scores were calculated at the presentation and patients were followed in the hospital to detect complications. Comparisons with p-values were then determined using SPSS. Results: The overall rate of stroke complications in 180 patients documented was 90%, the common being Aspiration Pneumonia (48.89%), Urinary Tract infections (30%), Bedsores (28.33%), Pyrexia illness (22.22%) and Seizures (12.78%). NIHSS scores had a direct relationship, with patients scoring >12 having a complications rate of 93% in contrast to 76.5% in patients with scores of =3 (p-value 0.032). GCS at presentation had similar predictive value with scores of 15/15 having 73% and =8 having a 91% complication rate. Duration of hospitalization (p-value 0.014) had a key impact as patients admitted for a month had higher percentages of complications primarily UTI (52.4%), Bedsores (71%), and Constipation (33.3%). Treatments like Dexamethasone (p-value 0.003) and antiplatelets (p-value 0.010) were found to increase the rate of complications. Conclusion: In-hospital post-stroke complications are common having a direct link with stroke severity, hospitalization duration, and treatment given. An active approach is needed to identify and treat any complications early, thereby, improving outcomes and decreasing morbidity. [ABSTRACT FROM AUTHOR]

Objectives: Chemotherapy‐induced neutropenia in acute myeloid leukaemia (AML) is a risk factor for life‐threatening infections. Early diagnosis and prompt interventions are associated with better outcomes, but the prediction of infection severity remains an open question. Recently, National Early Warning Score (NEWS) and quick sequential organ failure assessment (qSOFA) scores were proposed as warning clinical instruments predicting in‐hospital mortality, but their role in the haematological context is still unknown. Methods: We retrospectively assess the predictive role of NEWS and qSOFA in a large and homogeneous cohort of adult AML patients treated with intensive chemotherapy. In a total of 1048 neutropenic episodes recorded in 334 consecutive patients, the scores were applied to predict outcomes on the same day of fever onset, and after 24 and 48 h from score calculation. Results: Both NEWS and qSOFA significantly predicted death, with more accuracy on the same day (NEWS AUROC 0.984 and qSOFA AUROC 0.969) and after 24 h (NEWS AUROC 0.928 and qSOFA AUROC 0.887), while remained moderately accurate after 48 h. Furthermore, also ICU admission was accurately predicted at fever onset and after 24 h. Conclusions: Both scores were useful tools in the management of post chemotherapy neutropenic febrile AML patients. [ABSTRACT FROM AUTHOR]

Purpose: Although investigations are limited, adjunctive aerosolized antibiotics have been advised in the setting of gram‐negative ventilator‐associated pneumonia (VAP). This study aimed to compare the efficiency of inhaled colistin with inhaled fosfomycin/tobramycin in treating VAP due to extensively drug‐resistant (XDR) Acinetobacter baumannii. Methods: This single center open‐label randomized controlled trial included 60 patients who developed XDR A. bumannii VAP. Eligible participants were randomly assigned to two groups (no. 30). Regardless of the assignment, all participants received meropenem (2 g as a 3‐h extended infusion every 8 h) plus intravenous colistin (a loading dose of 9 million IU and then 4.5 million IU every 12 h). The control group was given inhaled colistin (1 million IU every 8 h), and the case group received inhaled tobramycin/fosfomycin (300 mg every 12 h/80 mg every 12 h) as adjunctive therapy. The primary outcome was treatment duration, and the secondary outcomes were Clinical Pulmonary Infection Score (CPIS) trend and mortality rate in the groups. The decision to stop treatment was made by the treating physician. Results: The mean treatment duration was 13.73 ± 3.22 days in the colistin group and 10.85 ± 2.84 days in the tobramycin/fosfomycin group; the mean treatment duration in the latter group was lower significantly (P = 0.001). CPIS was decreased in the groups significantly (P < 0.001), but the mean changes of CPIS were significantly different between the groups, and in the inhaled tobramycin/fosfomycin group, a greater reduction (P = 0.005) was observed. Two (6.67%) patients in the control group and three (10%) patients in the case group died. Conclusion: The use of inhaled tobramycin/fosfomycin in cases with XDR A. bumannii VAP was associated with a shorter treatment duration in this open‐label trial. [ABSTRACT FROM AUTHOR]

Background: Patients admitted to the hospital floor (non-intensive care (ICU) settings) from the emergency department (ED) are generally stable. Unfortunately, some will unexpectedly decompensate rapidly. This study explores these patients and their characteristics. Methods: This retrospective, observational study examined patients admitted to non-ICU settings at a community hospital. Patients were identified by rapid response team (RRT) activation, triggered by acute decompensation. ED chief complaint, reason for activation, and vital signs were compared between patients transferred to a higher level of care versus those who were not. Results: Throughout 2019, 424 episodes of acute decompensation were identified, 118 occurring within 24 h of admission. A higher rate of ICU transfers was seen in patients with initial ED chief complaints of general malaise (87.5% vs 12.5%, p = 0.023) and dyspnea (70.6% vs 29.4%, p = 0.050). Patients with sudden decompensation were more likely to need ICU transfer if the RRT reason was respiratory issues (47% vs 24%, p = 0.010) or hypertension (9.1% vs 0%, p = 0.019). Patients with syncope as a reason for decompensation were less likely to need transfer (0% vs 10.3%, p = 0.014). Patients requiring ICU transfer were significantly older (74.4 vs 71.8 years, p = 0.016). No differences in admission vital signs, APACHE score, or qSOFA score were found. Conclusions: Patients admitted to the floor with chief complaint of general malaise or dyspnea should be considered at higher risk of having a sudden decompensation requiring transfer to a higher level of care. Therefore, greater attention should be taken with disposition of these patients at the time of admission. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to assess whether the Acute Physiology, Age, Chronic Health Evaluation II (APACHE‐II) score is a reliable predictor of 30‐day mortality in the setting of adult patients with ventilator‐dependent respiratory failure (VDRF) who undergo tracheostomy. Methods: This is a retrospective, single‐institution study. Potential subjects were identified using the current procedural terminology codes for the tracheostomy procedure and International Classification of Diseases, 10th Revision, codes for VDRF. APACHE‐II scores were retrospectively calculated. Tracheostomies were performed in our population over an 18‐month period (November 2018 through April 2020). Our study population did not include patients with novel coronavirus. The primary outcome was mortality at 30 days after tracheostomy. Results: A total of 238 patients with VDRF who had a tracheostomy were included in this study. Twenty‐eight (11.8%) patients died within 30 days of tracheostomy. The mean (standard deviation) APACHE‐II score was 22.5 (10.2) for patients who died within 30 days of tracheostomy and 19.8 (7.4) for patients living within 30 days of tracheostomy (p = 0.30). Patients with APACHE‐II scores greater than or equal to 30 showed higher odds of death within 30 days of tracheostomy (odds ratio, 3.0; 95% CI, 1.14–7.89, p = 0.03). Conclusion: An APACHE‐II score of 30 and above is associated with mortality within 30 days of tracheostomy in patients with VDRF. APACHE‐II scores may be a promising tool for assessing risk of mortality in patients with VDRF after tracheostomy. Level of Evidence: 3 Laryngoscope, 133:273–278, 2023 [ABSTRACT FROM AUTHOR]

Background: Lung cancer (LC) is the most common solid tumor type in the intensive care unit (ICU). This study investigated the characteristics of LC patients admitted to the ICU, the major reasons for their admission, short-term mortality, and associated risk factors. Methods: Patients with LC were retrospectively identified in the publicly available, large-scale, single-center database Medical Information Mart for Intensive Care (MIMIC) III. Demographic and clinical characteristics, including age, sex, smoking history, comorbidities, type of admission to ICU, major diagnoses, illness severity score as assessed by the Simplified Acute Physiology Score (SAPS) II and the Sequential Organ Failure Assessment (SOFA), ICU length of stay (LOS), use of mechanic ventilation (MV) or vasopressors, the existence of do-not-resuscitate (DNR) orders, and metastatic status were collected. The major reasons for ICU admission were analyzed in subgroups. The multivariate logistic regression analysis was used to determine the factors associated with the 28-day and 6-month mortality. Results: A total of 1242 ICU admissions were included. Diseases of respiratory (42.7%), nervous (14.3%), and cardiovascular (11.9%) systems accounted for the top reasons for admission. Pneumonia/pneumonitis, respiratory failure, and sepsis were the primary reasons for ICU admission. The median survival was 2.93 (95% CI: 2.42–3.43) months. The 28-day inhospital and the 6-month mortality were 30.6% and 68.2%, respectively. Sepsis (63.9%), respiratory failure (47.0%), and pleural effusion (40.9%) accounted for the top three highest 28-day ICU mortality in all causes. An age ≥ 65 years, a SAPS II ≥ 37, a SOFA ≥ 3, metastasis, and MV use were independent risk factors for an inferior 28-day survival rate, while only metastatic status and SOFA score were associated with the 6-month mortality. SAPS II was accepatable and better than SOFA in predicting 28-day ICU [area under the curve (AUC): 0.714 and 0.658, respectively] or 28-day inhospital mortality (AUC: 0.717 and 0.660, respectively). Conclusion: The 6-month prognosis for LC patients admitted to ICU was dismal. Multidisciplinary collaboration between intensivists and oncologists to identify high-risk patients and to determine a risk-benefit ratio of ICU treatment may improve survival prospects. [ABSTRACT FROM AUTHOR]

Sepsis is a global medical issue owing to its unacceptably high mortality rate. Therefore, an effective approach to predicting patient outcomes is critically needed. We aimed to search for a novel 28-day sepsis mortality prediction model based on serial interleukin-6 (IL-6), lactate (LAC), and procalcitonin (PCT) measurements. We enrolled 367 septic patients based on Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock). Serum IL-6, LAC, and PCT levels were measured serially. Results collected within 24 and 48–72 h of admission were marked as D1 and D3 (e.g., IL-6D1/D3), respectively; the IL-6, LAC, and PCT clearance (IL-6c, LACc, PCTc) at D3 were calculated. Data were split into training and validation cohorts (7:3). Logistic regression analyses were used to select variables to develop models and choose the best one according to the Akaike information criterion (AIC). Receiver operating characteristic curves (ROC), calibration plots, and decision curve analysis (DCA) were used to test model performance. A nomogram was used to validate the model. There were 314 (85.56%) survivors and 53 (14.44%) non-survivors. Logistic regression analyses showed that IL-6D1, IL-6D3, PCTD1, PCTD3, and LACcD3 could be used to develop the best prediction model. The areas under the curves (AUC) of the training (0.849, 95% CI: 0.787–0.911) and validation cohorts (0.828, 95% CI: 0.727–0.929), calibration plot, and the DCA showed that the model performed well. Thus, the predictive value of the risk nomogram was verified. Combining IL-6D1, IL-6D3, PCTD1, PCTD3, and LACcD3 may create an accurate prediction model for 28-day sepsis mortality. Multiple-center research with a larger quantity of data is necessary to determine its clinical utility. [ABSTRACT FROM AUTHOR]

Background: In March 2020, rising numbers of COVID-19 infections contributed to changes in intensive care unit visitation policies, with some facilities allowing no visitors. Objective: To compare visitation policies of Magnet and Pathway to Excellence hospitals with prepandemic open visitation in adult intensive care units. Methods: A mixed-methods study was conducted from January through March 2021. Quantitative data on visitation policies were extracted from websites of 96 Magnet and Pathway to Excellence hospitals that had allowed unrestricted visits in adult intensive care units before the pandemic. Qualitative data were collected via semistructured interviews with 9 nurse leaders from these hospitals. Results: More than 1 year after the start of the pandemic, all of the hospitals had instituted restricted visitation policies. The policies varied, with little to no evidence-based justification. Restrictions included 83% of hospitals (n = 80) allowing just 1 visitor per day and 69% of hospitals (n = 50 of 72) allowing no visits at all for patients with COVID-19 in the intensive care unit. Five themes were found when nurse leaders' interviews were analyzed: visitors not welcome, doing harm, external decisions at system level, visiting within limits, and changes in critical care nursing work. Conclusion: Results of the study suggest that despite the vast amount of evidence supporting the benefits of visitation and the harms of restricted visitation and expert recommendations for returning safe visitation to hospitals, Magnet and Pathway to Excellence hospitals continue to enforce restricted visitation policies in intensive care units. Patients, families, and nursing and health care staff must partner to create pandemic-proof visitation policies. [ABSTRACT FROM AUTHOR]

Copyright of Fisioterapia e Pesquisa is the property of Universidade de Sao Paulo, Faculdade de Medicina and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Philip Alexander, MD, is a native Texan, retired physician, and accomplished musician and artist. After 41 years as an internal medicine physician, Dr. Phil retired from his practice in College Station in 2016. A lifelong musician and former music professor, he often performs as an oboe soloist for the Brazos Valley Symphony Orchestra. He began exploring visual art in 1980, evolving from pencil sketches—including an official White House portrait of President Ronald Reagan—to the computer-generated drawings featured in this journal. His images, which first appeared in this journal in the spring of 2012, are his own original creations. If you would like to see your art published in the Methodist DeBakey Cardiovascular Journal, submit your creation online at journal.houstonmethodist.org as a “Humanities” entry. [ABSTRACT FROM AUTHOR]

Background: The disturbance of sleep has been associated with intensive care unit (ICU) delirium. Monitoring of EEG slow‐wave activity (SWA) has potential in measuring sleep quality and quantity. We investigated the quantitative monitoring of nighttime SWA and its association with the clinical evaluation of sleep in patients with hyperactive ICU delirium treated with dexmedetomidine. Methods: We performed overnight EEG recordings in 15 patients diagnosed with hyperactive delirium during moderate dexmedetomidine sedation. SWA was evaluated by offline calculation of the C‐Trend Index, describing SWA in one parameter ranging 0 to 100 in values. Average and percentage of SWA values <50 were categorized as poor. The sleep quality and depth was clinically evaluated by the bedside nurse using the Richards‐Campbell Sleep Questionnaire (RCSQ) with scores <70 categorized as poor. Results: Nighttime SWA revealed individual sleep structures and fundamental variation between patients. SWA was poor in 67%, sleep quality (RCSQ) in 67%, and sleep depth (RCSQ) in 60% of the patients. The category of SWA aligned with that of RCSQ‐based sleep quality in 87% and RCSQ‐based sleep depth in 67% of the patients. Conclusion: Both, SWA and clinical evaluation suggested that the quality and depth of nighttime sleep were poor in most patients with hyperactive delirium despite dexmedetomidine infusion. Furthermore, the SWA and clinical evaluation classifications were not uniformly in agreement. An objective mode such as practical EEG‐based solution for sleep evaluation and individual drug dosing in the ICU setting could offer potential in improving sleep for patients with delirium. [ABSTRACT FROM AUTHOR]

Background: Nutritional status is associated with mortality. The modified Nutrition Risk in the Critically Ill (mNUTRIC) score is one of the most commonly used nutritional risk assessment tools in intensive care units (ICUs). The purpose of this study was to compare the mortality predictive ability of the mNUTRIC score to that of the mNUTRIC-S2 score, which uses the Simplified Acute Physiology Score (SAPS) II instead of the Acute Physiology and Chronic Health Evaluation (APACHE) II. Methods: This retrospective cohort analysis included patients admitted to the ICU between January and September 2020. Each patient's electronic medical records were reviewed. The model discrimination for predicting ICU mortality was assessed by the area under the receiver operating characteristic (ROC) curve, and a Cox regression model was performed to confirm the relationship between the groups and mortality. Results: In total, 220 patients were enrolled. The ROC curve for predicting ICU mortality was 0.64 for the mNUTRIC score versus 0.67 for the mNUTRIC-S2 score. The difference between the areas was 0.03 (95% confidence interval [CI], -0.01 to 0.06; P=0.09). Patients with mNUTRIC-S2 score =5 had a greater risk of ICU mortality (hazard ratio [HR], 3.64; 95% CI, 1.85-7.14; P<0.001); however, no such relationship was observed with mNUTRIC score (HR, 1.69; 95% CI, 0.62-4.62; P=0.31). Conclusions: The mNUTRIC-S2 score was significantly associated with ICU mortality. A cutoff score of 5 was selected as most appropriate. [ABSTRACT FROM AUTHOR]

Background: With adult patients, the measurement of [TIMP-2]*[IGFBP7] can predict the risk of moderate to severe AKI within 12 h of testing. In pediatrics, however, the performance of [TIMP-2]*[IGFBP7] as a predictor of AKI was less studied and yet to be widely utilized in clinical practice. This study was conducted to validate the utility of [TIMP-2]*[IGFBP7] as an earlier biomarker for AKI prediction in Chinese infants and small children. Methods: We measured urinary [TIMP-2]*[IGFBP7] using NEPHROCHECK® at eight perioperative time points in 230 patients undergoing complex cardiac surgery and evaluated the performance of [TIMP-2]*[IGFBP7] for predicting severe AKI within 72 h of surgery. Results: A total of 50 (22%) of 230 developed AKI stages 2–3 within 72 h after CPB initiation. In the AKI stage 2–3 patients, two patterns of serum creatinine (SCr) elevations were observed. The patients with only a transient increase in SCr within 24 h (< 24 h, early AKI 2–3) did not experience a worse outcome than patients in AKI stage 0–1. AKI stage 2–3 patients with SCr elevation after 24 h (24–72 h, late AKI 2–3), as well as AKI dialysis patients (together designated severe AKI), did experience worse outcomes. Compared to AKI stages 0–1, significant elevations of [TIMP-2]*[IGFBP7] values were observed in severe AKI patients at hours T2, T4, T12, and T24 following CPB initiation. The AUC for predicting severe AKI with [TIMP-2]*[IGFBP7] at T2 (AUC = 0.76) and maximum T2/T24 (AUC = 0.80) are higher than other time points. The addition of the NEPHROCHECK® test to the postoperative parameters improved the risk assessment of severe AKI. Conclusions: Multiple AKI phenotypes (early versus late AKI) were identified after pediatric complex cardiac surgery according to SCr-based AKI definition. Urinary [TIMP-2]*[IGFBP7] predicts late severe AKI (but not early AKI) as early as 2 h following CPB initiation. A higher resolution version of the Graphical abstract is available as Supplementary information [ABSTRACT FROM AUTHOR]

Copyright of Revista Brasileira de Terapia Intensiva is the property of Associacao de Medicina Intensiva Brasileira and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Constipation is frequent in critically ill patients, and potentially related to adverse outcomes. Peripherally-active mu-opioid receptor antagonists (PAMORAs) are approved for opioid-induced constipation, but information on their efficacy and safety in critically ill patients is limited. We present a single-center, retrospective, case-series of the use of naldemedine for opioid-associated constipation, and we systematically reviewed the use of PAMORAs in critically ill patients., Methods: Case-series included consecutive mechanically-ventilated patients; constipation was defined as absence of bowel movements for >3 days. Naldemedine was administered after failure of the local laxation protocol. Systematic review: PubMed was searched for studies of PAMORAs to treat opioid-induced constipation in adult critically ill patients., Primary Outcomes: time to laxation, and number of patients laxating at the shortest follow-up., Secondary Outcomes: gastric residual volumes and adverse events., Key Results: A total of 13 patients were included in the case-series; the most common diagnosis was COVID-19 ARDS. Patients had their first bowel movement 1 [0;2] day after naldemedine. Daily gastric residual volume was 725 [405;1805] before vs. 250 [45;1090] mL after naldemedine, p = 0.0078. Systematic review identified nine studies (two RCTs, one prospective case-series, three retrospective case-series and three case-reports). Outcomes were similar between groups, with a trend toward a lower gastric residual volume in PAMORAs group., Conclusions & Inferences: In a highly-selected case-series of patients with refractory, opioid-associated constipation, naldemedine was safe and associated to reduced gastric residuals and promoting laxation. In the systematic review and meta-analysis, the use of PAMORAs (mainly methylnaltrexone) was safe and associated with a reduced intolerance to enteral feeding but no difference in the time to laxation., (© 2023 John Wiley & Sons Ltd.)

Improving predictive models for intensive care unit (ICU) inpatients requires a new strategy that periodically includes the latest clinical data and can be updated to reflect local characteristics. We extracted data from all adult patients admitted to the ICUs of two university hospitals with different characteristics from 2006 to 2020, and a total of 85,146 patients were included in this study. Machine learning algorithms were trained to predict in-hospital mortality. The predictive performance of conventional scoring models and machine learning algorithms was assessed by the area under the receiver operating characteristic curve (AUROC). The conventional scoring models had various predictive powers, with the SAPS III (AUROC 0.773 [0.766–0.779] for hospital S) and APACHE III (AUROC 0.803 [0.795–0.810] for hospital G) showing the highest AUROC among them. The best performing machine learning models achieved an AUROC of 0.977 (0.973–0.980) in hospital S and 0.955 (0.950–0.961) in hospital G. The use of ML models in conjunction with conventional scoring systems can provide more useful information for predicting the prognosis of critically ill patients. In this study, we suggest that the predictive model can be made more robust by training with the individual data of each hospital. [ABSTRACT FROM AUTHOR]

Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery–Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium. [ABSTRACT FROM AUTHOR]

Background: Delirium is a common disorder affecting around 31% of patients in the intensive care unit (ICU). Delirium assessment scores such as the Confusion Assessment Method (CAM) are time-consuming, they cannot differentiate between different types of delirium and their etiologies, and they may have low sensitivities in the clinical setting. While today, electroencephalography (EEG) is increasingly being applied to delirious patients in the ICU, a lack of clear cut EEG signs, leads to inconsistent assessments.Methods: We therefore conducted a scoping review on EEG findings in delirium. One thousand two hundred thirty-six articles identified through database search on PubMed and Embase were reviewed. Finally, 33 original articles were included in the synthesis.Results: EEG seems to offer manifold possibilities in diagnosing delirium. All 33 studies showed a certain degree of qualitative or quantitative EEG alterations in delirium. Thus, normal routine (rEEG) and continuous EEG (cEEG) make presence of delirium very unlikely. All 33 studies used different research protocols to at least some extent. These include differences in time points, duration, conditions, and recording methods of EEG, as well as different patient populations, and diagnostic methods for delirium. Thus, a quantitative synthesis and common recommendations are so far elusive.Conclusion: Future studies should compare the different methods of EEG recording and evaluation to identify robust parameters for everyday use. Evidence for quantitative bi-electrode delirium detection based on increased relative delta power and decreased beta power is growing and should be further pursued. Additionally, EEG studies on the evolution of a delirium including patient outcomes are needed. [ABSTRACT FROM AUTHOR]

Copyright of Anaesthesiologie & Intensivmedizin is the property of DGAI e.V. - Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin e.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This study aimed to develop a new prognostic model for predicting 30-day mortality in solid tumor patients with suspected infection. This study is a retrospective cohort study and was conducted from August 2019 to December 2019 at a single center. Adult active solid tumor patients with suspected infection were enrolled among visitors to the emergency room (ER). Logistic regression analysis was used to identify potential predictors for a new model. A total of 899 patients were included; 450 in the development cohort and 449 in the validation cohort. Six independent variables predicted 30-day mortality: Eastern Cooperative Oncology Group (ECOG) performance status (PS), peripheral oxygen saturation (SpO2), creatinine, bilirubin, C-reactive protein (CRP), and lactate. The C-statistic of the new scoring system was 0.799 in the development cohort and 0.793 in the validation cohort. The C-statistics in the development cohort was significantly higher than those of SOFA [0.723 (95% CI: 0.663–0.783)], qSOFA [0.596 (95% CI: 0.537–0.655)], and SIRS [0.547 (95% CI: 0.483–0.612)]. The discriminative capability of the new cancer-specific risk scoring system was good in solid tumor patients with suspected infection. The new scoring model was superior to SOFA, qSOFA, and SIRS in predicting mortality. [ABSTRACT FROM AUTHOR]

Background: Hospital and ICU structural factors are key factors affecting the quality of care as well as ICU patient outcomes. However, the data from China are scarce. This study was designed to investigate how differences in patient outcomes are associated with differences in hospital and ICU structure variables in China throughout 2019. Methods: This was a multicenter observational study. Data from a total of 2820 hospitals were collected using the National Clinical Improvement System Data that reports ICU information in China. Data collection consisted of a) information on the hospital and ICU structural factors, including the hospital type, number of beds, staffing, among others, and b) ICU patient outcomes, including the mortality rate as well as the incidence of ventilator-associated pneumonia (VAP), catheter-related bloodstream infections (CRBSIs), and catheter-associated urinary tract infections (CAUTIs). Generalized linear mixed models were used to analyse the association between hospital and ICU structural factors and patient outcomes. Results: The median ICU patient mortality was 8.02% (3.78%, 14.35%), and the incidences of VAP, CRBSI, and CAUTI were 5.58 (1.55, 11.67) per 1000 ventilator days, 0.63 (0, 2.01) per 1000 catheter days, and 1.42 (0.37, 3.40) per 1000 catheter days, respectively. Mortality was significantly lower in public hospitals (β = − 0.018 (− 0.031, − 0.005), p = 0.006), hospitals with an ICU-to-hospital bed percentage of more than 2% (β = − 0.027 (− 0.034, -0.019), p < 0.001) and higher in hospitals with a bed-to-nurse ratio of more than 0.5:1 (β = 0.009 (0.001, 0.017), p = 0.027). The incidence of VAP was lower in public hospitals (β = − 0.036 (− 0.054, − 0.018), p < 0.001). The incidence of CRBSIs was lower in public hospitals (β = − 0.008 (− 0.014, − 0.002), p = 0.011) and higher in secondary hospitals (β = 0.005 (0.001, 0.009), p = 0.010), while the incidence of CAUTIs was higher in secondary hospitals (β = 0.010 (0.002, 0.018), p = 0.015). Conclusion: This study highlights the association between specific ICU structural factors and patient outcomes. Modifying structural factors is a potential opportunity that could improve patient outcomes in ICUs. [ABSTRACT FROM AUTHOR]

Background: Systemic colistin is often utilized for management of drug resistant lower respiratory tract infections (LRTI). Nebulized administration of colistin allows direct instillation of active agent to maximize concentrations and limit systemic toxicities. Current literature supports efficacy of nebulized colistin as adjunctive treatment for LRTI. However, there is a paucity of data surrounding safety of this administration technique. Methods: The electronic medical record (EMR) was queried to identify patients treated with nebulized colistin between January 1, 2016 and December 31, 2018. The data collected from the EMR and hospital adverse drug reaction (ADR) reporting systems included: demographics, dose, serum creatinine (SCr), concomitant nephrotoxins, infecting pathogen, treatment-emergent ADRs, and drug toxicities. The primary outcome was prevalence of renal, neurologic, or respiratory ADRs secondary to nebulized colistin. Results: Thirty-two patients were administered nebulized colistin during the study period. Approximately 19% of patients had baseline chronic kidney disease. Cultures were positive in 29 patients of which 11 organisms were resistant to all tested antimicrobials. Three patients experienced acute kidney injury (AKI), 1 patient experienced a neurologic reaction, and 1 patient experienced a respiratory reaction, though none were considered treatment-related. Conclusion: The results of our study signify localized administration of colistin results in a low incidence of systemic adverse events. Nebulized colistin is a safe adjunct for managing LRTI. [ABSTRACT FROM AUTHOR]