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OBJECTIVES: Serum creatinine (SCr) is the primary biomarker for assessing kidney function; however, it may lag behind true kidney function, especially in instances of acute kidney injury (AKI). The objective of the work is to develop Nephrocast, a deep-learning model to predict next-day SCr in adult patients treated in the intensive care unit (ICU). MATERIALS AND METHODS: Nephrocast was trained and validated, temporally and prospectively, using electronic health record data of adult patients admitted to the ICU in the University of California San Diego Health (UCSDH) between January 1, 2016 and June 22, 2024. The model features consisted of demographics, comorbidities, vital signs and laboratory measurements, and medications. Model performance was evaluated by mean absolute error (MAE) and root-mean-square error (RMSE) and compared against the prediction days SCr as a reference. RESULTS: A total of 28 191 encounters met the eligibility criteria, corresponding to 105 718 patient-days. The median (interquartile range [IQR]) MAE and RMSE in the internal test set were 0.09 (0.085-0.09) mg/dL and 0.15 (0.146-0.152) mg/dL, respectively. In the prospective validation, the MAE and RMSE were 0.09 mg/dL and 0.14 mg/dL, respectively. The models performance was superior to the reference SCr. DISCUSSION AND CONCLUSION: Our model demonstrated good performance in predicting next-day SCr by leveraging clinical data routinely collected in the ICU. The model could aid clinicians in in identifying high-risk patients for AKI, predicting AKI trajectory, and informing the dosing of renally eliminated drugs.

BACKGROUND: An association between driving pressure (∆P) and the outcomes of invasive mechanical ventilation (IMV) may exist. However, the effect of a sustained limitation of ∆P on mortality in patients with acute respiratory distress syndrome (ARDS), including patients with COVID-19 (COVID-19-related acute respiratory distress syndrome (C-ARDS)) undergoing IMV, has not been rigorously evaluated. The use of emulations of a target trial in intensive care unit research remains in its infancy. To inform future, large ARDS target trials, we explored using a target trial emulation approach to analyse data from a cohort of IMV adults with C-ARDS to determine whether maintaining daily ∆p24 hours of IMV were considered to be assigned to limited ∆P or LTVV. Lung mechanics were measured twice daily after ventilator setting adjustments were made. To evaluate the effect of each lung-protective ventilation (LPV) strategy on the 28-day mortality, we fit a stabilised inverse probability weighted marginal structural model that adjusted for baseline and time-varying confounders known to affect protection strategy use/adherence or survival. RESULTS: Among the 92 patients included, 27 (29.3%) followed limited ∆P ventilation, 23 (25.0%) the LTVV strategy and 42 (45.7%) received no LPV strategy. The adjusted estimated 28-day survival was 47.0% (95% CI 23%, 76%) in the limited ∆P group, 70.3% in the LTVV group (95% CI 37.6%, 100%) and 37.6% (95% CI 20.8%, 58.0%) in the no LPV strategy group. INTERPRETATION: Limiting ∆P may not provide additional survival benefits for patients with C-ARDS over LTVV. Our results help inform the development of future target trial emulations focused on evaluating LPV strategies, including reduced ∆P, in adults with ARDS.

Video laryngoscopy outperforms direct laryngoscopy for successful orotracheal intubation in the emergency department. When performing video laryngoscopy, emergency physicians may use a standard geometry blade or a hyperangulated blade. Hyperangulated video laryngoscopy is easier when using a rigid hyperangulated stylet instead of a standard malleable stylet. The angulation of the hyperangulated blade makes it difficult to use an endotracheal tube (ETT) introducer (bougie). We describe a case report using a DuCanto suction catheter (SSCOR) with a preloaded bougie to perform orotracheal intubation during hyperangulated video laryngoscopy. An adult patient presented to the emergency department in status epilepticus and was intubated for airway protection. Hyperangulated video laryngoscopy was performed with a LoPro S4 (GlideScope) blade; a DuCanto suction catheter was used to deliver a bougie through the vocal cords. The bougie was advanced down the trachea, and the DuCanto suction catheter was removed. The bougie successfully delivered a size 8.0 ETT. Visualization of the larynx with hyperangulated video laryngoscopy is usually easy, but ETT delivery into the trachea can be challenging. Rigid hyperangulated stylets were created to facilitate ETT delivery, but these stylets are expensive and often not available. Traditional teaching says that a bougie cannot be used while intubating with a hyperangulated blade. This case report describes a method to deliver a bougie via a DuCanto suction catheter during hyperangulated video laryngoscopy. It allows for the use of a bougie with a hyperangulated blade and offers a technique to perform hyperangulated video laryngoscopy without a rigid stylet.

Introduction: The use of push-dose vasopressors to treat anesthesia-induced hypotension is a common evidence-based practice among anesthesiologists. In more recent years, the use of push-dose vasopressors has transitioned to the emergency department (ED) and critical care setting. There is debate on the best choice of a push-dose vasopressor, with push-dose epinephrine or phenylephrine being more commonly used. This scoping review evaluated publications regarding the clinical use of push-dose norepinephrine.Methods: We queried research studies in both PubMed and Google Scholar on the use of push-dose norepinephrine in human subjects, with numerous randomized controlled trials that compare norepinephrine to other vasopressors including phenylephrine, ephedrine, and epinephrine.Results: A large majority of the studies were performed in the setting of spinal anesthesia prior to cesarean section, while several involved the administration of general anesthesia, with limited-to-no literature in the emergency and critical care setting. Of the 27 studies that we included in the review, 17 were randomized controlled trials. These studies demonstrated that norepinephrine was safe and effective.Conclusion: Prior research has demonstrated the superiority of norepinephrine as a pressor of choice for various shock states. In this review, the safety and efficacy of push-dose norepinephrine is demonstrated, and favorable hemodynamic markers are shown in comparison to other agents. In addition, there are some safety and efficiency benefits to using push-dose norepinephrine from an administration standpoint, as well as clinically in decreased need for repeat doses. Further high-quality studies in the emergency and critical care realm would be beneficial to confirm these findings.

ObjectiveAfter the 2012 Reassessment Campaign on Veterinary Resuscitation (RECOVER) CPR Guidelines, this is an update of evidence-based consensus guidelines for Basic Life Support (BLS), advanced life support (ALS), and periarrest monitoring.DesignThese RECOVER CPR Guidelines were generated using a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for evidence evaluation and translation of this evidence into clear and actionable clinical instructions. Prioritized clinical questions in the Population, Intervention, Comparator, and Outcome (PICO) format were used as the basis to conduct systematic literature searches by information specialists, to extract information from relevant publications, to assess this evidence for quality, and finally to translate the findings into treatment recommendations. These recommendations were reviewed by the RECOVER writing group and opened for comment by veterinary professionals for 4 weeks.SettingTransdisciplinary, international collaboration in university, specialty, and emergency practice.ResultsA total of 40 worksheets were prepared to evaluate questions across the 3 domains of BLS, ALS and Monitoring, resulting in 90 individual treatment recommendations. High-dose epinephrine is no longer recommended, and atropine, if used, is only administered once. Bag-mask ventilation is prioritized over mouth-to-nose ventilation in nonintubated animals. In addition, an algorithm for initial assessment, an updated CPR algorithm, a rhythm diagnosis tool, and an updated drug dosing table are provided.ConclusionsWhile the majority of the BLS and ALS recommendations remain unchanged, some noteworthy changes were made due to new evidence that emerged over the past 10 years. Indirectness of evidence remains the largest impediment to the certainty of guidelines formulation and underscores an urgent need for more studies in the target species of dogs and cats.

ObjectiveTo describe the methodology used by the Reassessment Campaign on Veterinary Resuscitation (RECOVER) to re-evaluate the scientific evidence relevant to CPR in small and large animals, to newborn resuscitation, and to first aid and to formulate the respective consensus-based clinical guidelines.DesignThis report describes the evidence-to-guidelines process employed by RECOVER that is based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and includes Information Specialist-driven systematic literature search, evidence evaluation conducted by more than 200 veterinary professionals, and provision of clinical guidelines in the domains of Preparedness and Prevention, Basic Life Support, Advanced Life Support, Post-cardiac Arrest Care, Newborn Resuscitation, First Aid, and Large Animal CPR.SettingTransdisciplinary, international collaboration in academia, referral practice, and general practice.ResultsFor this update to the RECOVER 2012 CPR guidelines, we answered 135 Population, Intervention, Comparator, and Outcome (PICO) questions with the help of a team of Domain Chairs, Information Specialists, and more than 200 Evidence Evaluators. Most primary contributors were veterinary specialists or veterinary technician specialists. The RECOVER 2024 Guidelines represent the first veterinary application of the GRADE approach to clinical guideline development. We employed an iterative process that follows a predefined sequence of steps designed to reduce bias of Evidence Evaluators and to increase the repeatability of the quality of evidence assessments and ultimately the treatment recommendations. The process also allowed numerous important knowledge gaps to emerge that form the foundation for prioritizing research efforts in veterinary resuscitation science.ConclusionsLarge collaborative, volunteer-based development of evidence- and consensus-based clinical guidelines is challenging and complex but feasible. The experience gained will help refine the process for future veterinary guidelines initiatives.

ObjectiveTo systematically review evidence and devise treatment recommendations for basic life support (BLS) in dogs and cats and to identify critical knowledge gaps.DesignStandardized, systematic evaluation of literature pertinent to BLS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by 2 Evidence Evaluators, and findings were reconciled by BLS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk to benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.SettingTransdisciplinary, international collaboration in university, specialty, and emergency practice.ResultsTwenty questions regarding animal position, chest compression point and technique, ventilation strategies, as well as the duration of CPR cycles and chest compression pauses were examined, and 32 treatment recommendations were formulated. Out of these, 25 addressed chest compressions and 7 informed ventilation during CPR. The recommendations were founded predominantly on very low quality of evidence and expert opinion. These new treatment recommendations continue to emphasize the critical importance of high-quality, uninterrupted chest compressions, with a modification suggested for the chest compression technique in wide-chested dogs. When intubation is not possible, bag-mask ventilation using a tight-fitting facemask with oxygen supplementation is recommended rather than mouth-to-nose ventilation.ConclusionsThese updated RECOVER BLS treatment recommendations emphasize continuous chest compressions, conformation-specific chest compression techniques, and ventilation for all animals. Very low quality of evidence due to absence of clinical data in dogs and cats consistently compromised the certainty of recommendations, emphasizing the need for more veterinary research in this area.

ObjectiveTo systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps.DesignStandardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.SettingTransdisciplinary, international collaboration in university, specialty, and emergency practice.ResultsSeventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats.ConclusionsThese updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.

Introduction: Standard of care for patients with acute ischemic stroke from large vessel occlusion (AISLVO) includes prompt evaluation for urgent mechanical thrombectomy (MT) at a comprehensive stroke center (CSC). During the start of the coronavirus 2019 pandemic (COVID-19), there were reports about disruption to emergency department (ED) operations and delays in management of patients with AIS-LVO. In this study we investigate the outcome and operations for patients who were transferred from different EDs to an academic CSC’s critical care resuscitation unit (CCRU), which specializes in expeditious transfer of time-sensitive disease.Methods: This was a pre-post retrospective study using prospectively collected clinical data from our CSC’s stroke registry. Adult patientswho were transferred fromany ED to the CCRUand underwent MT were eligible. We compared time intervals in the pre-pandemic (PP) period between January 2018– February 2020, such as ED in-out and CCRU arrival-angiography, to those during the pandemic (DP) between March 2020–May 31, 2021. We used classification and regression tree (CART) analysis to identify which time intervals, besides clinical factors, were associated with good neurological outcome (90-day modified Rankin scale 0–2).Results: We analyzed 203 patients: 135 (66.5%) in the PP group and 68 (33.5%) in the DP group. Time from ED triage to computed tomography (difference 7 minutes, 95% confidence interval [CI] −12 to −1, P < 0.01) for the DP group was statistically longer, but ED in-out was similar for both groups. Time from CCRU arrival to angiography (difference 9 minutes, 95% CI 4–13, P < 0.01) for the DP group was shorter. Forty-nine percent of the DP group achieved mRS ≤ 2 vs 32% for the PP group (difference −17%, 95% CI −0.32 to −0.03, P < 0.01). The CART identified initial National Institutes of Health Stroke Scale, age, ED in-and-out time, and CCRU arrival-to-angiography time as important predictors of good outcome.Conclusion: Overall, the care process in EDs and at this single CSC for patients requiring MT were not heavily affected by the pandemic, as certain time metrics during the pandemic were statistically shorter than pre-pandemic intervals. Time intervals such as ED in-and-out and CCRU arrival-to-angiography were important factors in achieving good neurologic outcomes. Further study is necessary to confirm our observation and improve operational efficiency in the future.

BACKGROUND: Language in nonmedical data sets is known to transmit human-like biases when used in natural language processing (NLP) algorithms that can reinforce disparities. It is unclear if NLP algorithms of medical notes could lead to similar transmissions of biases. RESEARCH QUESTION: Can we identify implicit bias in clinical notes, and are biases stable across time and geography? STUDY DESIGN AND METHODS: To determine whether different racial and ethnic descriptors are similar contextually to stigmatizing language in ICU notes and whether these relationships are stable across time and geography, we identified notes on critically ill adults admitted to the University of California, San Francisco (UCSF), from 2012 through 2022 and to Beth Israel Deaconess Hospital (BIDMC) from 2001 through 2012. Because word meaning is derived largely from context, we trained unsupervised word-embedding algorithms to measure the similarity (cosine similarity) quantitatively of the context between a racial or ethnic descriptor (eg, African-American) and a stigmatizing target word (eg, nonco-operative) or group of words (violence, passivity, noncompliance, nonadherence). RESULTS: In UCSF notes, Black descriptors were less likely to be similar contextually to violent words compared with White descriptors. Contrastingly, in BIDMC notes, Black descriptors were more likely to be similar contextually to violent words compared with White descriptors. The UCSF data set also showed that Black descriptors were more similar contextually to passivity and noncompliance words compared with Latinx descriptors. INTERPRETATION: Implicit bias is identifiable in ICU notes. Racial and ethnic group descriptors carry different contextual relationships to stigmatizing words, depending on when and where notes were written. Because NLP models seem able to transmit implicit bias from training data, use of NLP algorithms in clinical prediction could reinforce disparities. Active debiasing strategies may be necessary to achieve algorithmic fairness when using language models in clinical research.

OBJECTIVE: Recent clinical guidelines for sepsis management emphasize immediate antibiotic initiation for suspected septic shock. Though hypotension is a high-risk marker of sepsis severity, prior studies have not considered the precise timing of hypotension in relation to antibiotic initiation and how clinical characteristics and outcomes may differ. Our objective was to evaluate antibiotic initiation in relation to hypotension to characterize differences in sepsis presentation and outcomes in patients with suspected septic shock. METHODS: Adults presenting to the emergency department (ED) June 2012-December 2018 diagnosed with sepsis (Sepsis-III electronic health record [EHR] criteria) and hypotension (non-resolving for ≥30 min, systolic blood pressure 60 min after (late) treatment. RESULTS: Among 2219 patients, 55% received early treatment, 13% immediate, and 32% late. The late subgroup often presented to the ED with hypotension (median 0 min) but received antibiotics a median of 191 min post-ED presentation. Clinical characteristics notable for this subgroup included higher prevalence of heart failure and liver disease (p

Introduction: Unlicensed cosmetic procedures, which come at increased risk of infection and potential surgical complications, have introduced new challenges in healthcare. Physicians should be aware of presentations that may arise secondary to these procedures.Case Report: We describe a case in which a previously healthy, 28-year-old female presented with new-onset seizures and acute respiratory distress syndrome (ARDS) in the setting of a recent cosmetic procedure with silicone injections to the gluteal region. The patient’s hospital course was complicated by altered mental status, respiratory failure, rapid hemodynamic compromise, and eventual death.Conclusion: In rare cases, one possible complication of cosmetic procedures is silicone embolism syndrome, which is characterized by pneumonitis, alveolar hemorrhage, and ARDS. The patient described in this report also experienced neurologic symptoms including seizure and altered mental status. This is a clinical diagnosis that relies upon thorough history-taking and detailed physical exam. Documentation on this phenomenon is limited, and medical management has not yet been standardized for this condition. Morbidity and mortality remain high.

Allogeneic hematopoietic cell transplantation (HCT) can be complicated by life-threatening organ toxicity and infection necessitating intensive care. Epidemiologic data have been limited by single-center studies, poor database granularity, and a lack of long-term survivors. To identify contemporary trends in intensive care unit (ICU) use and long-term outcomes, we merged data from the Center for International Blood and Marrow Transplant Research and the Virtual Pediatric Systems databases. We identified 6995 pediatric patients with HCT aged ≤21 years who underwent first allogeneic HCT between 2008 and 2014 across 69 centers in the United States or Canada and followed patients until the year 2020. ICU admission was required for 1067 patients (8.3% by day +100, 12.8% by 1 year, and 15.3% by 5 years after HCT), and was linked to demographic background, pretransplant organ toxicity, allograft type and HLA-match, and the development of graft-versus-host disease or malignancy relapse. Survival to ICU discharge was 85.7%, but more than half of ICU survivors required ICU readmission, leading to 52.5% and 42.6% survival at 1- and 5-years post-ICU transfer, respectively. ICU survival was worse among patients with malignant disease, poor pretransplant organ function, and alloreactivity risk factors. Among 1-year HCT survivors, those who required ICU in the first year had 10% lower survival at 5 years and developed new dialysis-dependent renal failure at a greater rate (P

Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.

In critical care, the specific, structured approach to patient care known as a time-limited trial has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patients response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trials duration. The plans 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.

INTRODUCTION: Patients experience high symptom burden during critical care hospitalization and mechanical ventilation. Medications are of limited effectiveness and are associated with increased morbidity such as delirium and long-term cognitive and psychological impairments. Music-based interventions have been used for pain and anxiety management in critical care but remain understudied in terms of music selection and range of symptoms. This study aimed to describe the ways in which a diverse sample of critically ill adults used personalized music listening and their perceptions of the effects of music listening on symptom experience after critical injury. METHODS: Semi-structured interviews (N = 14) of adult patients, families and friends who were provided with personalized music in an urban, academic, neurotrauma intensive care unit were collected and analyzed with grounded theory methodology. Open coding of transcripts, field notes and memos was performed using Atlas.ti.9.1. Recruitment and data collection were deemed complete once thematic saturation was achieved. RESULTS: We identified 6 uses of personalized music listening in critical care: 1) Restoring consciousness; 2) Maintaining cognition; 3) Humanizing the hospital experience; 4) Providing a source of connection; 5) Improving psychological wellbeing; and 6) Resolving the problems of silence. Patients used music to address psychological experiences of loneliness, fear, confusion, and loss of control. Personalized music helped patients maintain their identity and process their trauma. Additional benefits of music included experiencing pleasure, hope, resilience, and feelings of normalcy. Patients disliked being sedated and used music to wake up. Findings also highlighted the problem of the lack of meaningful stimulation in critical care. CONCLUSION: Critically injured adults used personalized music to achieve psychological and cognitive homeostasis during critical care hospitalization. These results can inform future studies designed to explore the use of music-based interventions to prevent and treat the cognitive and emotional morbidity of critical care.

BackgroundPrediction-based strategies for physiologic deterioration offer the potential for earlier clinical interventions that improve patient outcomes. Current strategies are limited because they operate on inconsistent definitions of deterioration, attempt to dichotomize a dynamic and progressive phenomenon, and offer poor performance.ObjectiveCan a deep learning deterioration prediction model (Deep Learning Enhanced Triage and Emergency Response for Inpatient Optimization [DETERIO]) based on a consensus definition of deterioration (the Adult Inpatient Decompensation Event [AIDE] criteria) and that approaches deterioration as a state "value-estimation" problem outperform a commercially available deterioration score?Derivation cohortThe derivation cohort contained retrospective patient data collected from both inpatient services (inpatient) and emergency departments (EDs) of two hospitals within the University of California San Diego Health System. There were 330,729 total patients; 71,735 were inpatient and 258,994 were ED. Of these data, 20% were randomly sampled as a retrospective "testing set."Validation cohortThe validation cohort contained temporal patient data. There were 65,898 total patients; 13,750 were inpatient and 52,148 were ED.Prediction modelDETERIO was developed and validated on these data, using the AIDE criteria to generate a composite score. DETERIO's architecture builds upon previous work. DETERIO's prediction performance up to 12 hours before T0 was compared against Epic Deterioration Index (EDI).ResultsIn the retrospective testing set, DETERIO's area under the receiver operating characteristic curve (AUC) was 0.797 and 0.874 for inpatient and ED subsets, respectively. In the temporal validation cohort, the corresponding AUC were 0.775 and 0.856, respectively. DETERIO outperformed EDI in the inpatient validation cohort (AUC, 0.775 vs. 0.721; p < 0.01) while maintaining superior sensitivity and a comparable rate of false alarms (sensitivity, 45.50% vs. 30.00%; positive predictive value, 20.50% vs. 16.11%).ConclusionsDETERIO demonstrates promise in the viability of a state value-estimation approach for predicting adult physiologic deterioration. It may outperform EDI while offering additional clinical utility in triage and clinician interaction with prediction confidence and explanations. Additional studies are needed to assess generalizability and real-world clinical impact.

INTRODUCTION: Sepsis is a major cause of morbidity and mortality worldwide. In the updated, 2016 Sepsis-3 criteria, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, where organ dysfunction can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score of 2 points or more. We sought to apply the Sepsis-3 criteria to characterise the septic cohort in the Amsterdam University Medical Centres database (Amsterdam UMCdb). METHODS: We examined adult intensive care unit (ICU) admissions in the Amsterdam UMCdb, which contains de-identified data for patients admitted to a mixed surgical-medical ICU at a tertiary academic medical centre in the Netherlands. We operationalised the Sepsis-3 criteria, defining organ dysfunction as an increase in the SOFA score of 2 points or more, while infection was defined as a new course of antibiotics or an escalation in antibiotic therapy, with at least one antibiotic given intravenously. Patients with sepsis were determined to be in septic shock if they additionally required the use of vasopressors and had a lactate level >2 mmol/L. RESULTS: We identified 18,221 ICU admissions from 16,408 patients in our cohort. There were 6,312 unique sepsis episodes, of which 30.2% met the criteria for septic shock. A total of 4,911/6,312 sepsis (77.8%) episodes occurred on ICU admission. Forty-seven percent of emergency medical admissions and 36.7% of emergency surgical admissions were for sepsis. Overall, there was a 12.5% ICU mortality rate; patients with septic shock had a higher ICU mortality rate (38.4%) than those without shock (11.4%). CONCLUSIONS: We successfully operationalised the Sepsis-3 criteria to the Amsterdam UMCdb, allowing the characterization and comparison of sepsis epidemiology across different centres.

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.

INTRODUCTION: Direct oral anticoagulant (DOAC) use is becoming more prevalent in patients presenting after trauma. We sought to identify the prevalence and predictors of subtherapeutic and therapeutic DOAC concentrations and hypothesized that increased anti-Xa levels would correlate with increased risk of bleeding and other poor outcomes. METHODS: A retrospective cohort study of all trauma patients on apixaban or rivaroxaban admitted to a level 1 trauma center between January 2015 and July 2021 was performed. Patients were excluded if they did not have a DOAC-specific anti-Xa level at presentation. Therapeutic levels were defined as an anti-Xa of 50 ng/mL to 250 ng/mL for rivaroxaban and 75 ng/mL to 250 ng/mL for apixaban. Linear regression was used to identify correlations between study variables and anti-Xa level, and binomial logistic regression was used to test the association of anti-Xa level with outcomes. RESULTS: There were 364 trauma patients admitted during the study period who were documented to be on apixaban or rivaroxaban. Of these, 245 patients had anti-Xa levels measured at admission. The population was 53% woman, with median age of 78 years, and median Injury Severity Score of 5. In total, 39% of patients had therapeutic and 20% had supratherapeutic anti-Xa levels. Female sex, increased age, decreased height and weight, and lower estimated creatinine clearance were associated with higher anti-Xa levels at admission. There was no correlation between anti-Xa level and the need for transfusion or reversal agent administration, admission diagnosis of intracranial hemorrhage (ICH), progression of ICH, hospital length of stay, or mortality. CONCLUSIONS: Anti-Xa levels in trauma patients on DOACs vary widely; female patients who are older, smaller, and have decreased kidney function present with higher DOAC-specific anti-Xa levels after trauma. We were unable to detect an association between anti-Xa levels and clinical outcomes. LEVEL OF EVIDENCE: III-Prognostic and Epidemiological.

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

Background: Acute Respiratory Distress Syndrome (ARDS) has a high morbidity and mortality. One therapy that can decrease mortality is ventilation in the prone position (PP). Patients undergoing PP are amongst the sickest, and there is a need for early identification of patients at particularly high risk of death. These patients may benefit from an in-depth review of treatment or consideration of rescue therapies. We report the development of a machine learning model trained to predict early mortality in patients undergoing prone positioning as part of the management of their ARDS. Methods: Prospectively collected clinical data were analysed retrospectively from a single tertiary ICU. The records of patients who underwent an initial session of prone positioning whilst receiving invasive mechanical ventilation were identified (n = 131). The decision to perform prone positioning was based on the criteria in the PROSEVA study. A C5.0 classifier algorithm with adaptive boosting was trained on data gathered before, during, and after initial proning. Data was split between training (85% of data) and testing (15% of data). Hyperparameter tuning was achieved through a grid-search using a maximal entropy configuration. Predictions for 7-day mortality after initial proning session were made on the training and testing data. Results: The model demonstrated good performance in predicting 7-day mortality (AUROC: 0.89 training, 0.78 testing). Seven variables were used for prediction. Sensitivity was 0.80 and specificity was 0.67 on the testing data set. Patients predicted to survive had 13.3% mortality, while those predicted to die had 66.67% mortality. Among patients in whom the model predicted patient would survive to day 7 based on their response, mortality at day 7 was 13.3%. Conversely, if the model predicted the patient would not survive to day 7, mortality was 66.67%. Conclusions: This proof-of-concept study shows that with a limited data set, a C5.0 classifier can predict 7-day mortality from a number of variables, including the response to initial proning, and identify a cohort at significantly higher risk of death. This can help identify patients failing conventional therapies who may benefit from a thorough review of their management, including consideration of rescue treatments, such as extracorporeal membrane oxygenation. This study shows the potential of a machine learning model to identify ARDS patients at high risk of early mortality following PP. This information can guide clinicians in tailoring treatment strategies and considering rescue therapies. Further validation in larger cohorts is needed. [ABSTRACT FROM AUTHOR]

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

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

With the large volume of data coming from implemented technologies and monitoring systems, intensive care units (ICUs) represent a key area for artificial intelligence (AI) application. Despite the last decade has been marked by studies focused on the use of AI in medicine, its application in mechanical ventilation management is still limited. Optimizing mechanical ventilation is a complex and high-stake intervention, which requires a deep understanding of respiratory pathophysiology. Therefore, this complex task might be supported by AI and machine learning. Most of the studies already published involve the use of AI to predict outcomes for mechanically ventilated patients, including the need for intubation, the respiratory complications, and the weaning readiness and success. In conclusion, the application of AI for the management of mechanical ventilation is still at an early stage and requires a cautious and much less enthusiastic approach. Future research should be focused on AI progressive introduction in the everyday management of mechanically ventilated patients, with the aim to explore the great potentiality of this tool. Plain Language Summary: The use of artificial intelligence for mechanical ventilation Artificial Intelligence (AI) could help the management of patients treated with mechanical ventilation in critical care practice. Current guidelines are based on data coming from the general population, without considering the individual patients' characteristics. With the use of AI for mechanical ventilation, critical care practice could be improved by offering personalized treatments, reducing complications, and assisting clinicians in decision-making to improve patient outcomes and reduce mortality rates. Despite AI in medicine has progressed in the last decade, little is known about its use in critical care and in ventilation management. In order to improve its everyday use, future research should be performed in intensive care settings. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusion To evaluate the safety and tolerance of elective extubations in preterm newborns (PNB) during skin‐to‐skin care (SSC) compared to those performed in an incubator.Retrospective observational study including 142 extubations in 93 PNB with gestational age (GA) <32 weeks and/or birth weight (BW) <1500 g performed during the first 2 months of life. Safety, tolerance and extubation success at 72 h were assessed.The median GA was 25.4 weeks in the SSC group versus 26.6 weeks in the incubator group (p = 0.002). The median BW was 700 grams and 880 grams, respectively (p = 0.001). In total, 60 extubations (42.3%) were performed during SSC in 42 PNB and 82 in incubator in 69 PNB. No incidents related to extubation during SSC were recorded. The extubation success rate was 80% in SSC versus 79.3% in incubator (p = 0.915). Most failures occurred between 3 and 24 h after extubation. There were no observed differences in heart rate or FiO2 variations between the groups, nor in the need to escalate respiratory support at 24 h after extubation (SSC 15% vs. incubator 12.2%, p = 0.628).Extubation during SSC is a feasible, safe and well‐tolerated practice, while allowing PNB to experience the benefits from SSC. [ABSTRACT FROM AUTHOR]

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

The article delves into the topic of safety in critical care nursing, particularly in intensive care units (ICUs), through interviews with nurses and nurse leaders in Sweden. It highlights the importance of maintaining a safety mindset, fostering commitment to patient safety, and continuous learning to ensure safe care practices. The document also includes research articles on patient safety culture, qualitative research methods, and the impact of the COVID-19 pandemic on ICUs, offering insights for enhancing healthcare practices and quality of care. [Extracted from the article]

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

Background: Evidence on the benefits of fiber-supplemented enteral nutrition (EN) in critically ill patients is inconsistent, and critical care nutrition guidelines lack recommendations based on high-quality evidence. This systematic review and meta-analysis (SRMA) aims to provide a current synthesis of the literature on this topic. Methods: For this SRMA of randomized controlled trials (RCT), electronic databases (MEDLINE, EMBASE, CENTRAL) were searched systematically from inception to January 2024 and updated in June 2024. Trials investigating clinical effects of fiber-supplemented EN versus placebo or usual care in adult critically ill patients were selected. Two independent reviewers extracted data and assessed the risk of bias of the included studies. Random-effect meta-analysis and trial sequential analysis (TSA) were conducted. The primary outcome was overall mortality, and one of the secondary outcomes was diarrhea incidence. Subgroup analyses were also performed for both outcomes. Results: Twenty studies with 1405 critically ill patients were included. In conventional meta-analysis, fiber-supplemented EN was associated with a significant reduction of overall mortality (RR 0.66, 95% CI 0.47, 0.92, p = 0.01, I2 = 0%; 12 studies) and diarrhea incidence (RR 0.70, 95% CI 0.51, 0.96, p = 0.03, I2 = 51%; 11 studies). However, both outcomes were assessed to have very serious risk of bias, and, according to TSA, a type-1 error cannot be ruled out. No subgroup differences were found for the primary outcome. Conclusion: Very low-certainty evidence suggests that fiber-supplemented EN has clinical benefits. High-quality multicenter RCTs with large sample sizes are needed to substantiate any firm recommendation for its routine use in this group of patients. PROSPERO registration number: CRD42023492829. [ABSTRACT FROM AUTHOR]

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

Background: The mechanisms underlying the state of systemic immune suppression that develops following major trauma are poorly understood. A post-injury increase in circulating levels of prostaglandin E2 (PGE2) has been proposed as a contributory factor, yet few studies have addressed how trauma influences PGE2 biology. Methods: Blood samples from 95 traumatically-injured patients (injury severity score ≥8) were collected across the pre-hospital (≤2 hours), acute (4-12 hours) and subacute (48-72 hours) post-injury settings. Alongside ex vivo assessments of lipopolysaccharide (LPS)-induced cytokine production by monocytes, neutrophil reactive oxygen species production and phagocytosis, serum concentrations of PGE2 and its scavenger albumin were measured, and the expression of enzymes and receptors involved in PGE2 synthesis and signalling analysed. Leukocytes from trauma patients were treated with cyclooxygenase (COX) inhibitors (indomethacin or NS-398), or the protein kinase A inhibitor H89, to determine whether injury-induced immune suppression could be reversed by targeting the PGE2 pathway. The effect that trauma relevant concentrations of PGE2 had on the anti-microbial functions of neutrophils, monocytes and monocyte-derived macrophages (MDMs) from healthy controls (HC) was examined, as was the effect of PGE2 on efferocytosis. To identify factors that may trigger PGE2 production post-trauma, leukocytes from HC were treated with mitochondrial-derived damage associated molecular patterns (mtDAMPs) and COX-2 expression and PGE2 generation measured. Results: PGE2 concentrations peaked in blood samples acquired ≤2 hours post-injury and coincided with significantly reduced levels of albumin and impaired LPS-induced cytokine production by monocytes. Significantly higher COX-2 and phospholipase A2 expression was detected in neutrophils and/or peripheral blood mononuclear cells isolated from trauma patients. Treatment of patient leukocytes with indomethacin, NS-398 or H89 enhanced LPS-induced cytokine production and neutrophil extracellular trap generation. Exposure to physiological concentrations of PGE2 suppressed the anti-microbial activity of monocytes, neutrophils and MDMs of HC, but did not influence efferocytosis. In a formyl-peptide receptor-1 dependent manner, mtDAMP treatment significantly increased COX-2 protein expression in neutrophils and monocytes, which resulted in increased PGE2 production. Conclusions: Physiological concentrations of PGE2 suppress the anti-microbial activities of neutrophils, monocytes and MDMs. Targeting the PGE2 pathway could be a therapeutic approach by which to enhance innate immune function post-injury. [ABSTRACT FROM AUTHOR]

Background andAims: Guidelines now recommend inpatient continuous glucose monitor (CGM) use with confirmatory blood glucose measurements. However, the Food and Drug Administration has not yet officially approved CGM for inpatient use in large part because its accuracy has not been established in this setting. We tested the accuracy of the Dexcom G6 (G6) in 28 adults on an insulin infusion in a medical–surgical intensive care unit with 1064 matched CGM and arterial point-of-care pairs. Methods: The participants were on average 57.29 (SD 2.39) years, of whom 13 had a prior diagnosis of diabetes and 14 were admitted for a surgical diagnosis. The first 19 participants received the G6 without calibration and had a mean absolute relative difference (MARD) of 13.19% (IQR 5.11, 19.03) across 659 matched pairs, which just meets the critical care expert recommendation of MARD <14%. We then aimed to improve accuracy for the subsequent 9 participants using a calibration protocol. Results: The MARD for calibrated participants was 9.65% (3.03, 13.33), significantly lower than for uncalibrated participants (P < 0.001). Calibration also demonstrated excellent safety with 100% of values within the Clarke Error Grid zones A and B compared with 99.07% without calibration. Our protocol achieved the lowest MARD and safest CEG profile in the critical care setting and well exceeds the critical care expert recommendations. Our large sample of heterogenous critically ill patients also reached comparable accuracy to the MARD of 9% for G6 in outpatients. We believe our calibration protocol will allow G6 to be used with sufficient accuracy in inpatients. [ABSTRACT FROM AUTHOR]

Acute hypercapnic respiratory failure is a life-threatening condition caused by alveolar hypoventilation. It is mostly caused by an acute exacerbation of chronic obstructive pulmonary disease or conditions yielding muscle dysfunction. Noninvasive ventilation through a facemask is the cornerstone first-line strategy to support hypercapnic patients with acidemia, and current guidelines strongly recommend this intervention to improve survival and long-term clinical outcomes. Because of its benefits related to carbon dioxide washout from the upper airways and the enhanced comfort, high-flow nasal oxygen has been proposed as a respiratory support strategy in patients with hypercapnic respiratory failure, both as an alternative to and in combination with noninvasive ventilation. When compared to noninvasive ventilation as a first-line intervention, high-flow nasal oxygen shows a higher rate of failure. Hence, if not contraindicated, the use of noninvasive ventilation should be preferred. After the resolution of acidemia with noninvasive ventilation, high-flow nasal oxygen showed promising physiological effects compared to conventional oxygen. During weaning from mechanical ventilation in patients with or at risk of developing hypercapnia, high-flow nasal oxygen showed encouraging results, especially when applied alternating with sessions of noninvasive ventilation. Optimal settings of high-flow nasal oxygen in hypercapnic patients include the use of a smaller-size cannula, flows ranging between 30 and 40 L/min, and FiO2 adjusted to obtain SpO2 between 88% and 92%. Specific interfaces, such as asymmetric cannulas, may further enhance the benefits of a high flow in terms of carbon dioxide clearance. In this narrative review, we provide an updated overview of the physiological rationale and clinical evidence concerning the use of high-flow nasal oxygen in patients with acute hypercapnic respiratory failure. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your knowledge of tools commonly used for breaking bad news to patients and families • To read about the challenges of breaking bad news to patients and families in major trauma care • To reflect on your own experiences of breaking bad news to patients and families. Breaking bad news is a challenging yet essential part of the role of healthcare professionals who care for major trauma patients and their families. This service evaluation investigated healthcare professionals’ attitudes and experiences regarding breaking bad news in the context of major trauma. Healthcare professionals were recruited from the South Wales Trauma Network and their views collected via an online survey based on the Breaking Bad News Attitudes Scale. The survey was completed by 149 healthcare professionals and the responses demonstrated a range of experiences of breaking bad news in major trauma care, with challenges such as the environment, building rapport and setting expectations. [ABSTRACT FROM AUTHOR]

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

Background: Intensive care unit (ICU) patients are at an increased risk of ocular surface injuries because of various factors such as reduced tear production and impaired protective mechanisms. Despite the significance of ocular care in ICU settings, there is a lack of consensus on effective interventions, leading to inadequate prevention of ocular surface disease (OSD). Aim: This systematic review aimed to assess the effectiveness of nursing eye care in preventing OSD in ICU patients. Secondary objectives included identifying primary risk factors for ocular injuries and examining the most effective preventive methods. Study Design: A systematic review following PRISMA guidelines was conducted, encompassing a literature search, article selection, quality assessment and data synthesis. Studies meeting inclusion criteria were observational studies and clinical trials, focusing on adults admitted to ICUs under sedation and receiving mechanical ventilation. Results: Of 3545 initially identified articles, 12 studies met inclusion criteria. These studies involved a total of 1853 participants. Various interventions were assessed, including saline rinsing, lubricating drops, gel lubricants, occlusion with polyethylene dressing, passive blinking and eyelid closure with tape. Moist chamber occlusion every 6 h combined with gel lubrication emerged as the most effective method in preventing OSD. Conclusions: Gel lubrication along with moist chamber occlusion proved to be the most effective strategy in preventing ocular injuries in ICU patients. Conversely, the routine use of physiological saline was associated with increased severity of corneal lesions. Properly defined protocols and well‐trained nursing teams are crucial for reducing ocular injuries in ICU settings. Relevance to Clinical Practice: The findings underscore the importance of implementing evidence‐based eye care protocols in ICUs, emphasizing the use of gel lubrication and ocular surface protection to mitigate the risk of OSD. This highlights the need for comprehensive training programmes for ICU nursing staff to ensure optimal ocular care delivery. [ABSTRACT FROM AUTHOR]

Background: The surge in critically ill COVID‐19 patients caused a shortage of intensive care unit (ICU) beds. Some hospitals temporarily transformed general wards into ICUs to meet this pressing health care demand. Aim: This study aims to evaluate and analyse the risk factors in temporary ICU from the perspective of nurses. By identifying these factors, the goal is to provide actionable insights and recommendations for effectively establishing and managing temporary ICUs in similar crisis scenarios in the future. Study Design: The study was conducted in China within a public hospital. Specifically, it focused on examining 62 nurses working in a temporary ICU that was converted from an infectious disease ward. The research utilized the Hazard Vulnerability Analysis (HVA) scoring method to identify potential threats, evaluate their probability, estimate their impact on specific organizations or regions and calculate the relative risk associated with such occurrences. Results: Staff demonstrated the highest risk percentage (32.74%), with Stuff (16.11%), Space (15.19%) and System (11.30%) following suit. The most critical risk factors included insufficient knowledge and decision‐making competence in critical care (56.14%), lacking decision‐making abilities and skills in renal replacement therapy care (55.37%), inadequate decision‐making capacity and relevant skills in respiratory support care (50.64%), limited decision‐making capability in circulatory support care (45.73%) and unfamiliarity with work procedures or systems (42.09%). Conclusions: Urgent implementation of tailored training and support for temporary ICU nurses is paramount. Addressing capability and skill‐related issues among these nurses supersedes resource availability, infrastructure, equipment and system considerations. Essential interventions must target challenges encompassing nurses' inability to perform critical treatment techniques autonomously and ensure standardized care. These measures are designed to heighten patient safety and elevate care quality during emergencies. These findings offer a viable avenue to mitigate potential moral distress, anxiety and depression among nurses, particularly those transitioning from non‐critical care backgrounds. These nurses swiftly assimilate into temporary ICUs, and the study's insights offer practical guidance to alleviate their specific challenges. Relevance to Clinical Practice: The study on risk factors for converting traditional wards into temporary ICU during the COVID‐19 pandemic, especially from the perspective of nurses, provides crucial insights into the challenges and requirements for effectively establishing and managing these emergency settings. The findings highlight several key areas of concern and opportunities for improvement directly related to clinical practice, particularly in situations where there is a rapid need to adapt to increased demands for critical care. By addressing the identified risk factors through enhanced training, support systems, resource management, process improvements and cultivating a culture of adaptability, not only can the quality of care in temporary ICUs be improved, but also can the health care system be better prepared for future emergencies. These actions will help mitigate the risks associated with such conversions, ultimately benefiting patient safety, staff well‐being and the overall effectiveness of health care services in crises. [ABSTRACT FROM AUTHOR]

Background: Multiple risk assessment scales are available for predicting the development of pressure injuries (PIs) in patients in the intensive care unit (ICU). Most PI risk assessment tools have been validated at the time of admission; however, another time point during treatment could better reflect clinical changes and therefore, the risk of PIs. Aim: The study aimed to examine the predictive validity of PI risk assessment scale designed for ICU patients, the conscious level, mobility, haemodynamic, oxygenation and nutrition (COMHON) index, at several time points or intervals during ICU stay. Study Design: This was an observational prospective study undertaken over a period of 1 year (July 2021–June 2022). Patients admitted to ICU for >3 days were included. The number, location and degree of the PIs were recorded. The level of risk for developing PIs during the stay was determined by calculating the COMHON scores at admission, and 72 h, as well as the highest and mean score. Predictive validity was studied using accuracy parameters and areas under the receiver operating characteristic curve (AUC). The best cutoff point was also determined and used to compare risk between categories. Results: Of the 286 patients included in the study, 160 (59%) were male. The level of severity evaluated using the APACHE II scale was 18.4 ± 5.8 points. Invasive mechanical ventilation was used in 32.1% (n = 92) of the patients and 20.6% (n = 59) received high flow oxygen therapy. The incidence of PI was 15.4% (n = 44), with sacral location in 47.7% (n = 21) and grade II in 75% (n = 33) of the patients. The AUC was 0.907 (0.872–0.942); 0.881 (0.842–0.920); 0.877 (0.835–0.920) and 0.749 (0.667–0.831) at the mean, the highest, 72 h and ICU admission scores, respectively. The best cutoff point was 13 in all patients. The risk of developing a PI was 6.4 times higher in the high‐risk group (>13 points). Conclusions: The best predictive capacity for the COMHON index risk assessment was the mean and highest scores. The predictive accuracy was higher on the third day of the patient's stay than on admission, and this was attributed to the clinical changes observed in some patients over the course of their critical illness. Relevance for Clinical Practice: Patients in ICU are at high risk of developing PIs, therefore, preventive measures should be maximized. Risk assessment should be carried out sequentially owing to the changes that patients present throughout their ICU stay and preventive measures should be used according to the risk level. [ABSTRACT FROM AUTHOR]

Background: Deep sedation may be indicated in the intensive care unit (ICU) for the management of acute organ failure, but leads to sedative‐induced delirium. Whether processed electroencephalography (p‐EEG) is useful in this setting is unclear. Aim: To describe the PSI index in deeply sedated critically ill patients with acute organ failure, and to examine a potential association between low PSI values and ICU delirium. [Correction added on 16 October 2024, after first online publication: Aim subsection in Abstract has been added on this version.] Methods: We conducted a single‐centre observational study of non‐neurological ICU patients sedated according to a standardized guideline of deep sedation (Richmond Agitation Sedation Scale [RASS] between −5 and −4) during the acute phase of respiratory and/or cardio‐circulatory failure. The SedLine (Masimo Incorporated, Irvine, California) was used to monitor the Patient State Index (PSI) (ranging from 0 to 100, <25 = very deep sedation and >50 = light sedation to full awareness) during the first 72 h of care. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU). Results: The median duration of PSI monitoring was 43 h. Patients spent 49% in median of the total PSI monitoring duration with a PSI <25. Patients with delirium (n = 41/97, 42%) spent a higher percentage of total monitored time with PSI <25 (median 67% [19–91] vs. 47% [12.2–78.9]) in non‐delirious patients (p.047). After adjusting for the cumulative dose of analgesia and sedation, increased time spent with PSI <25 was associated with higher delirium (odds ratio 1.014; 95% CI 1.001–1.027, p =.036). Conclusions: A clinical protocol of deep sedation targeted to RASS at the acute ICU phase may be associated with prolonged EEG suppression and increased delirium. Whether PSI‐targeted sedation may help reducing sedative dose and delirium deserves further clinical investigation. Relevance to Clinical Practice: Patients requiring deep sedation are at high risk of being over‐sedated and developing delirium despite the application of an evidence‐based sedation guideline. Development of early objective measures are essential to improve sedation management in these critically ill patients. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injuries (TBIs) are one of the leading causes of death or long‐term disability around the world. As a result of improvements in supportive care, patients are surviving more severe insults with more pronounced dependency on their families, hospitals, and long‐term care facilities. The introduction of brain tissue oxygenation (PbtO2) monitoring aims to recognize episodes of reduced cerebral perfusion with and without associated increased intracranial pressure (ICP). Aim: The aim of this review is to determine the impact of PbtO2 on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended (GOS/GOSE) in patients with moderate to severe TBI. Study Design: Systematic review with narrative and meta‐analysis. All original research in which adult patients undergoing PbtO2 were compared with a control group of traditional ICP/cerebral perfusion pressure (CPP) monitoring. Both randomized controlled trials and observational studies were included in this review. Methods: Databases were searched in September 2022. The primary outcome of the review was the impact of PbtO2 monitoring on GOS/GOSE, while secondary outcomes were mortality and length of stay (LOS) in the intensive care unit (ICU). Results: Seven studies with a combined number of 770 patients were included in the review. These patients were adults ≥16 years of age. Only two of the studies included found a statistically significant association between PbtO2 monitoring and improved long‐term neurological outcomes in patients with TBI (p =.01, p <.01). A meta‐analysis of the secondary outcomes identified an associated reduction of mortality in favour of the group treated with PbtO2 monitoring (p <.0001). Results from studies examining LOS in ICU have demonstrated an associated increase of LOS in ICU in patients treated with PbtO2‐guided therapy. Conclusion: From the studies included in this review, only two found a statistically significant association between PbtO2 monitoring and long‐term outcomes. It is unclear whether PbtO2 goal‐directed therapy has a positive impact on the long‐term neurological functions and mortality of patients suffering from TBI. A multicentre randomized controlled trial may provide further evidence, but not necessarily conclusive. Relevance to Clinical Practice: Further research is warranted to determine the efficacy of the introduction of this new monitoring system to guide local policy change. [ABSTRACT FROM AUTHOR]

The invasive intra‐arterial approach is the gold standard for measuring blood pressure in intensive care units where accuracy is crucial. However, invasive procedures increase the risk of infections and mortality. This evidence‐based review aimed to determine whether continuous non‐invasive blood pressure (CNIBP) monitoring, using Radial Artery Applanation Tonometry (RAAT) devices, is as accurate as invasive methods. Six papers were included: three prospective cohort studies and three comparative studies. Most studies showed that mean arterial pressure is accurately recorded through RAAT monitoring; however, more research is needed to assess the accuracy of non‐invasive readings of systolic and diastolic blood pressures, as data are not always concordant. [ABSTRACT FROM AUTHOR]

To manage a clinical emergency effectively, physicians need well-developed leadership skills, yet limited structured leadership training is available for critical care trainees. To develop an effective curriculum, leadership competencies must first be defined. During clinical emergencies, what leadership behaviors do followers value? We conducted qualitative interviews with members of multidisciplinary critical care teams at a large academic health system, with participants including resident physicians, nurses, and respiratory therapists (N = 15). Thematic analysis was used to categorize leadership behaviors that followers perceived to be effective. We identified three themes related to leadership during clinical emergencies: control, collaboration, and common understanding. Participants described behaviors they believed resulted in both effective and ineffective leadership. For effective leaders, control, the most dominant theme, included behaviors that clearly established roles for the leader and followers, allowing the leader to guide care during a clinical emergency. Collaboration referenced the ability of a leader to maintain a collegial environment. Finally, common understanding reflected a leader's ability to manage communication in a way that fostered a shared mental model across team members. During clinical emergencies, followers value leaders who assert themselves while also maintaining positive team interaction and encouraging an organized flow of information. Our findings provide a potential framework to develop a leadership curriculum for critical care trainees. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Sleep promotion bundles being tested in PICUs use elements adapted from adult bundles. As children may react differently than adults in ICU environments, this study investigated what parents report disrupted the sleep of their child in a PICU. DESIGN: Secondary analysis of a multicenter validation study of the Survey of Sleep quality in the PICU. SETTING: Four Northeastern U.S. PICUs, one hospital-based pediatric sleep laboratory. PATIENTS: Parents sleeping at the bedside of a child in the PICU or hospitalbased sleep laboratory. INTERVENTIONS: Anonymous one-time survey eliciting parts of hospital or ICU environments that have been described as disruptive to sleep in validated adult ICU and pediatric inpatient questionnaires. MEASUREMENTS AND MAIN RESULTS: Level of sleep disruption was scored by Likert scale, with higher scores indicating more disruption. Age, demographics, baseline sleep, and PICU exposures were used to describe causes of sleep disruption in a PICU. Of 152 PICU parents, 71% of their children's sleep was disrupted significantly by at least one aspect of being in the PICU. The most prevalent were "being in pain or uncomfortable because they are sick" (38%), "not sleeping at home" (30%), "alarms on machines" (28%), and "not sleeping on their home schedule" (26%). Only 5% were disrupted by excessive nocturnal light exposure. Overall sleep disruption was not different across four PICUs or in those receiving sedation. The validation study control group, healthy children undergoing polysomnography, had less sleep disruption than those in a PICU despite sleeping in a hospital-based sleep laboratory. CONCLUSIONS: There are multiple aspects of critical care environments that affect the sleep of children, which are different from that of adults, such as disruption to home schedules. Future interventional sleep promotion bundles should include sedated children and could be applicable in multicenter settings. [ABSTRACT FROM AUTHOR]

The article discusses the burden of sepsis hospitalization for children and families, highlighting the various trajectories survivors may experience. It emphasizes the need for further research to understand when patients are truly out of danger. The text also touches on the global impact of sepsis, particularly in resource-limited settings, and the significant healthcare costs associated with sepsis care and recovery, both before and after the COVID-19 pandemic. [Extracted from the article]

The article "Video Laryngoscopy in Critically Ill Adults: Nascent, Evolving, or Established?" discusses the use of video laryngoscopy in tracheal intubation procedures for critically ill patients. The study compared video laryngoscopy (VL) with direct laryngoscopy (DL) in critically ill adults and found that VL was associated with a higher rate of first pass success. However, the study also noted limitations in outcome reporting and emphasized the need for further research to fully demonstrate the superiority of VL over DL. The article highlights the importance of considering factors such as operator experience, patient outcomes, and the need for additional data to inform clinical practice in airway management. [Extracted from the article]

OBJECTIVE: To determine the impact of point-of-care ultrasound (POCUS)- guided resuscitation on clinical outcomes in adult patients with shock. DATA SOURCE: We searched MEDLINE, Embase, and unpublished sources from inception to December 2023. STUDY SELECTION: We included randomized controlled trials (RCTs) that examined the use of POCUS to guide resuscitation in patients with shock. DATA EXTRACTION: We collected data regarding study and patient characteristics, POCUS protocol, control group interventions, and outcomes. DATA SYNTHESIS: We identified 18 eligible RCTs. POCUS slightly influences physicians' plans for IV fluid (IVF) and vasoactive medication prescription (moderate certainty), but results in little to no changes in the administration of IVF (low to high certainty) or inotropes (high certainty). POCUS may result in no change in the number of CT scans performed (low certainty) but probably reduces the number of diagnostic echocardiograms performed (moderate certainty). POCUSguided resuscitation probably reduces 28-day mortality (relative risk [RR] 0.88; 95% CI, 0.78-0.99), the duration of vasoactive medication (mean difference -0.73 d; 95% CI, -1.16 to -0.30), and the need for renal replacement therapy (RRT) (RR 0.80; 95% CI, 0.63-1.02) (low to moderate certainty evidence), and lactate clearance (high certainty evidence). POCUS-guided resuscitation may results in little to no difference in ICU or hospital admissions, ICU and hospital length of stay, and the need for mechanical ventilation (MV) (low to moderate certainty evidence). There is an uncertain effect on the risk of acute kidney injury and the duration of MV or RRT (very low certainty evidence). CONCLUSIONS: POCUS-guided resuscitation in shock may yield important patient and health system benefits. Due to lack of sufficient evidence, we were unable to explore how the thresholds of operator competency, frequency, and timing of POCUS scans impact patient outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Despite the large burden of critically ill patients in developing countries, mechanical ventilation (MV) is scarce in these low-resource settings. In the absence of data, issues like costs and lack of training are often felt to outweigh the benefits of potential MV implementation in such places. We aimed to investigate the impact and feasibility of MV in a surgical ICU in West Africa. DESIGN: This is a 7-month retrospective observational study (from October 25, 2022, to May 25, 2023), covering all patients consecutively admitted to ICU. SETTING: The NGO EMERGENCY's hospital in Goderich, Freetown, Sierra Leone. The hospital is a referral center for acute care surgery. PATIENTS: Critical patients admitted to the hospital's ICU. INTERVENTIONS: Following brief, practical training of the nursing staff, one basic mechanical ventilator was installed at the hospital's ICU, under the supervision of two intensivists. Only patients with a body weight of over 15 kg and who met the "extreme criteria" for MV received this life-saving therapy. MEASUREMENTS AND MAIN RESULTS: Of the 195 files of patients admitted to ICU during the study period, 162 were analyzed. The median age was 16 (interquartile range 7-27) and 48.1% of the population were under 14 years. The most common cause of admission was trauma (58.6%), followed by acute abdomen (33.3%), caustic soda ingestion (6.2%), and burns (1.9%). Of the overall population, 26 patients (16%) underwent MV (88.5% trauma cases vs. 11.5% acute abdomen). Median time on MV was 24 hours (12-64). The mortality rate in the MV group was 30.8% (8/26), while in the overall study population, it was 11.7% (19/162). One potentially life-threatening event of tube obstruction was handled appropriately. CONCLUSIONS: This study strongly supports the implementation of MV in lowresource settings. In our experience, the consistent benefit of reduced mortality among critical patients largely outweighs the associated challenges. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients. DATA SOURCES: We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024. STUDY SELECTION: We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation. DATA EXTRACTION: Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945). DATA SYNTHESIS: We included 20 RCTs (n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL. CONCLUSIONS: In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality. [ABSTRACT FROM AUTHOR]

Background: Early initiation of targeted antibiotic therapy is important to achieve the best patient outcomes in intubated patients with pneumonia in the intensive care unit (ICU). This study aimed to investigate the applicability of multiplex polymerase chain reaction (PCR) in an ICU by comparing the test results to the results of conventional microbiological methods to assess the possible impact on antibiotic therapy. Method: This retrospective study investigated adult patients with pneumonia on mechanical ventilation in the ICU. Tracheal aspirates were collected within 24h after intubation and the initiation of mechanical ventilation. Samples were initially tested by conventional microbiological methods and subsequently re‐evaluated with rapid multiplex PCR on stored samples. Concordance between the two methods was assessed. An intensivist and a microbiologist retrospectively reviewed the patients' electronic health records for relevant clinical details to evaluate the potential impact of multiplex PCR results on antibiotic therapy. Results: In this study, 76 patients were enrolled and 55 (72.4%) tested positive for 95 pathogens using multiplex PCR, while conventional microbiological methods identified 40 pathogens in 32 (42.2%) patients. Concordance between the two methods was observed in 42 (55.3%) patients. Multiplex PCR detected 39 additional pathogens in 31 (40.7%) patients. Retrospective analysis indicated potential antibiotic de‐escalation in 35 (46.1%) patients and escalation in 4 (5.3%) patients. Multiplex PCR significantly reduced the turnaround time for test results. Conclusion: In ICU patients with suspected pneumonia, multiplex PCR identified a higher number of pathogens compared to CMM. A retrospective assessment indicates that the use of multiplex PCR could potentially have prompted the de‐escalation of antibiotic therapy in nearly half of the patients. Therefore, multiplex PCR may serve as a supplement to CMM in guiding antibiotic stewardship. [ABSTRACT FROM AUTHOR]