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Aim: To describe the time between external ventricular drain (EVD) implantation and mobilization in neurosurgery intensive care unit (ICU) patients with EVDs. Due to increased intracranial pressure, neurosurgery patients with external ventricular drain (EVD) who are admitted to the ICU frequently remain at rest, resulting in prolonged ICU and hospital length of stay (LOS), mechanical ventilator (MV) duration, and other adverse effects., Material and Methods: A retrospective descriptive study was conducted on 131 neurosurgery patients admitted to the ICU with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) who underwent EVD. Time of mobilization, level of mobilization, ICU and hospital LOS, MV duration, and other factors were evaluated for patients who met the inclusion criteria., Results: Of the 131 patients, 67 survived, and 61 began to mobilize in varying degrees of dangling (26.22%), standing (44.26%), and walking (29.5%). The mean number of days between EVD implantation and mobilization was 10.15. According to the findings, the mean ICU-LOS in patients was 14.56 days, the MV duration was 7.13 days, the time of ICU discharge from EVD removal was 7.08 days, and the hospital-LOS was 16.98 days. In addition, seven patients (10.44%) developed DVT, and three developed PE (4.47%)., Conclusion: Prolonged immobility in patients with EVD is associated with negative outcomes such as PE and DVT, as well as an increase in MV duration, ICU-LOS, and hospital-LOS. Therefore, designing an appropriate and standard mobilization protocol and training nursing staff to assist patients in safely mobilizing can significantly reduce the complications above, reduce postoperative care, and empower patients.

Background and Objectives: Carotid-cavernous fistulas (CCFs) represent a group of rare, abnormal arteriovenous communications between the carotid arterial system and the cavernous sinuses (CS). CCFs often produce ophthalmologic symptoms related to increased CS pressures and retrograde venous drainage of the eye. Although endovascular occlusion remains the preferred treatment for symptomatic or high-risk CCFs, most of the data for these lesions is limited to small, single-center series. As such, we performed a systematic review and meta-analysis evaluating endovascular occlusions of CCFs to determine any differences in clinical outcomes based on presentation, fistula type, and treatment paradigm., Method: A retrospective review of all studies discussing the endovascular treatment of CCFs published through March 2023 was conducted using PubMed, Scopus, Web of Science, and Embase databases. A total of 36 studies were included in the meta-analysis. Data from the selected articles were extracted and analyzed using Stata software version 14., Results: 1494 patients were included. 55.08% were female and the mean age of the cohort was 48.10 years. A total number of 1516 fistulas underwent endovascular treatment, 48.05% of which were direct and 51.95% of which were indirect. 87.17% of CCFs were secondary to a known trauma while 10.18% were spontaneous. The most common presenting symptoms were 89% exophthalmos (95% CI: 78.0-100.0; I 2  = 75.7%), 84% chemosis (95% CI: 79.0-88.0; I 2  = 91.6%), 79% proptosis (95% CI: 72.0-86.0; I 2  = 91.8%), 75.0% bruits (95% CI: 67.0-82.0; I 2  = 90.7%), 56% diplopia (95% CI: 42.0-71.0; I 2  = 92.3%), 49% cranial nerve palsy (95% CI: 32.0-66.0; I 2  = 95.1%), 39% visual decline (95% CI: 32.0-45.0; I 2  = 71.4%), 32% tinnitus (95% CI: 6.0-58.0; I 2  = 96.7%), 29% elevated intraocular pain (95% CI: 22.0-36.0; I 2  = 0.0%), 31% orbital or pre-orbital pain (95% CI: 14.0-48.0; I 2  = 89.9%) and 24% headache (95% CI: 13.0-34.0; I 2  = 74.98%). Coils, balloons, and stents were the three most used embolization methods respectively. Immediate complete occlusion of the fistula was seen in 68% of cases and complete remission was seen in 82%. Recurrence of CCF occurred in only 35% of the patients. Cranial nerve paralysis after treatment was observed in 7% of the cases., Conclusions: Exophthalmos, Chemosis, proptosis, bruits, cranial nerve palsy, diplopia, orbital and periorbital pain, tinnitus, elevated intraocular pressure, visual decline and headache are the most common clinical manifestations of CCFs. The majority of endovascular treatments involved coiling, balloons and onyx and a high percentage of CCF patients experienced complete remission with the improvement of their clinical symptoms., Competing Interests: None., (© 2023 Published by Elsevier Inc.)

One of the main objectives in neurosurgical procedures is the prevention of cerebral ischemia and hypoxia leading to secondary brain injury. Different methods for early detection of intraoperative cerebral ischemia and hypoxia have been used. Near-infrared spectroscopy (NIRS) is a simple, non-invasive method for monitoring cerebral oxygenation increasingly used today. The aim of this study was to systematically review the brain monitoring with NIRS in neurosurgery. The search process resulted in the detection of 324 articles using valid keywords on the electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Subsequently, the full texts of 34 studies were reviewed, and finally 11 articles (seven prospective studies, three retrospective studies, and one randomized controlled trial) published from 2005 to 2020 were identified as eligible for systematic review. Meta-analysis was not possible due to high heterogeneity in neurological and neurosurgical conditions of patients, expression of different clinical outcomes, and different standard reference tests in the studies reviewed. The results showed that NIRS is a non-invasive cerebral oximetry that provides continuous and measurable cerebral oxygenation information and can be used in a variety of clinical settings., Competing Interests: Conflict of Interests: The authors declared no conflict of interest., (Copyright © 2022, Author(s).)

Aims: Survival rates after in-hospital cardiac arrest remain very low. Although there is evidence that the use of audiovisual feedback devices can improve compression components, there are no data on patient survival. Therefore, we conducted this study to analyse the survival rate of patients with in-hospital cardiac arrest after discharge from the intensive care unit., Methods and Results: This study was a secondary analysis of a prospective, randomized, controlled, parallel study of patients who received either standard manual chest compression or a real-time feedback device. Parametric and semi-parametric models were fitted to the data. Different survival time of length of stay was investigated by univariate and multiple analyses. Pearson's correlation between length of stay and hospital length of stay was obtained. A total of 900 patients with a mean survival time of 35 days were included. Intervention was associated with a higher length of stay. Relative time was significant in adjusted fitted log-normal regression for intervention group, female gender, and cardiopulmonary resuscitation in the night shift. A positive correlation between length of stay and hospital length of stay was found., Conclusions: Implementation of feedback device improved survival and length of stay. Cardiopulmonary resuscitation performance during the night shift decreased the survival time, which could be due to the inexperienced staff available outside working hours., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

This study assesses the impact of religiosity on delirium severity and patient outcomes among Shi'a Muslim intensive care unit (ICU) patients. We conducted a prospective observational cohort study in 21 ICUs from 6 Iranian academic medical centers. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU) tool. Eligible patients were intubated, receiving mechanical ventilation (MV) for ≥ 48 h. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. A total of 4200 patients were enrolled. Patient religiosity was categorized as more (40.6%), moderate (42.3%), or less (17.1%) based on responses to patient and surrogate questionnaires. The findings suggest that lower pre-illness religiosity may be associated with greater delirium severity, MV duration, and ICU and hospital LOS. The lower mortality in the less religiosity group may be related in part to a greater proportion of female patients, but it remains unclear whether and to what extent greater religiosity impacted treatment decisions by patients and families. Further investigation is needed to validate and clarify the mechanism of the mortality findings.

Background: The rapid shallow breathing index (RSBI) is used clinically to help predict a patient's likelihood of successful liberation from mechanical ventilation (MV). However, the traditional threshold (<105 breaths/min/L) may underperform in patients with chronic obstructive pulmonary disease (COPD). We sought to determine the optimal RSBI threshold for COPD patients to improve the diagnostic accuracy for predicting successful ventilator liberation., Methods: This was a prospective observational multicenter study of COPD patients [according to Global initiative for Chronic Obstructive Lung Disease (GOLD) criteria] admitted to the Medical ICUs of eight academic medical centers. All patients were intubated for hypercapnic respiratory failure and met the American Thoracic Society/European Respiratory Society guidelines to participate in a weaning trial. Ventilator weaning was conducted according to a defined protocol. RSBI was measured through the ventilator after 120 minutes of spontaneous breathing trial (SBT)., Results: Ninety patients were included (39 males and 51 females). Forty-three patients (48%) were successfully extubated whereas 47 patients (52%) failed extubation. Significant differences were observed between groups for duration-of-intubation [duration of intubation (DoI); P<0.0001], spontaneous tidal volume (VT) (P=0.03), and the ratio of dynamic-to-static compliance (P=0.005). The RSBI threshold of ≤85 breaths/min/L performed best: area under curve (AUC) receiver operating characteristic (ROC) curves 0.91, sensitivity 95.6%, specificity 90.4%, positive predictive value (PPV) 95.5%, and negative predictive value (NPV) 90.6%., positive likelihood ratio (LR+) 5.48, negative likelihood ratio (LR-) 0.25, and the diagnostic accuracy 91.7%. In post-ROC analyses, DoI and hospital length-of-stay (LOS) did not impact performance., Conclusions: In COPD patients intubated with hypercapnia, RSBI ≤85 breaths/min/L outperformed the widely used threshold <105 breaths/min/L, yielding a 95.5% probability of extubation success, independent of ventilation duration or hospital LOS., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA)., Methods: We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical-surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge., Results: One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P  < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P  < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones., Conclusion: Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge., Trial Registration: The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016., Competing Interests: The protocol was approved by the investigational review board at Baqiyatallah University of Medical Sciences (IR.BMSU.REC.1394.441), which was accepted by each of the participating medical centers: Baqiyatallah Hospital, Shariati Hospital, Masih Daneshvari Hospital, Loghman Hakim Hospital, Shahid Madani Hospital, Ghaem Hospital, Besat Hospital, and Rouhani Hospital. Consent was required and covered both study participation and publication of findings. Informed consent was required prior to cardiac arrest event and could be provided by the patient, legal guardian, or healthcare surrogate.The informed consent included permission to present and publish de-identified results.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The aim of the present study is to describe how religiosity and spirituality affect the psychiatric morbidity of Muslim intensive care unit (ICU) patients. We conducted a prospective nationwide cross-sectional study of ICU patients discharged from 45 medical centers spanning 31 proivinces in Iran. Adults (age ≥ 18 years) admitted to the ICU and treated with invasive mechanical ventilation were eligible. Nine validated survey tools were administered to detect direct and indirect associations between spiritual health (SH) and depression, anxiety, and post-traumatic disorder. The Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale-Revised (IES-R), Post-Traumatic Stress Syndrome 14 question (PTSS-14) quality-of-life (QoL), and quality of patient to physician or nurse communication (PP-QoC and PN-QoC) scales were modeled through two mediators by structural equation modeling (SEM). Sex, ICU type, LOS, and APACHE II score were added in the independent variable list. 338 eligible patients were discharged from the ICUs during the study period. 56 were excluded (clinical status), and 282 were administered the survey. 278 returned it, with 272 complete and 6 partial responses. SH displayed no direct or indirect association to QoL. SH was indirectly associated with decreased depression and anxiety (B = - 0.081, p < 0.05) via PP-QoC mediator. Both direct and indirect positive associations were observed between SH and IES-R (B = 0.293, p < 0.05; via PP-QoC) and PTSS-14 scores (B = 0.267, p < 0.001; via PP-QoC). Medical ICU location was associated with decreased PTSS-14 scores via the same mediator. In this survey of Muslim ICU patients treated with invasive mechanical ventilation, SH correlated with decreased depression and anxiety, but paradoxically increased post-traumatic stress. The most influential mediator was patient-physician quality-of-communication.

Objective: To determine if non-invasive oxygenation indices, namely peripheral capillary oxygen saturation (S p O 2 )/fraction of inspired oxygen (F i O 2 ) and partial pressure of alveolar oxygen (P A O 2 )/F i O 2 may be used as effective surrogates for the partial pressure of arterial oxygen (P a O 2 )/F i O 2 . Also, to determine the S p O 2 /F i O 2 and P A O 2 /F i O 2 values that correspond to P a O 2 /F i O 2 thresholds for identifying acute respiratory distress syndrome (ARDS) in patients following coronary artery bypass graft (CABG) surgery., Methods: A prospective derivation-validation cohort study in the Open-Heart ICU of an academic teaching hospital. Recorded variables included patient demographics, ventilator settings, chest radiograph results, and S P O 2 , P a O 2 , P A O 2, S a O 2 , and F i O 2 . Linear regression modeling was used to quantify the relationship between indices. Receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of the threshold values., Results: One-hundred seventy-five patients were enrolled in the derivation cohort, and 358 in the validation cohort. The S P O 2 /F i O 2 and P A O 2 /F i O 2 ratios could be predicted well from P a O 2 /F i O 2 , described by the linear regression models S P O 2 /F i O 2  = 71.149 + 0.8PF and P A O 2 /F i O 2  = 38.098 + 2.312PF, respectively. According to the linear regression equation, a P a O 2 /F i O 2 ratio of 300 equaled an S P O 2 /F i O 2 ratio of 311 (R 2 0.857, F 1035.742, < 0.0001) and a P A O 2 /F i O 2 ratio of 732 (R 2 0.576, F 234.887, < 0.0001). The S P O 2 /F i O 2 threshold of 311 had 90% sensitivity, 80% specificity, LR+ 4.50, LR- 0.13, PPV 98, and NPV 42.1 for the diagnosis of mild ARDS. The P A O 2 /F i O 2 threshold of 732 had 86% sensitivity, 90% specificity, LR+ 8.45, LR- 0.16, PPV 98.9, and NPV 36 for the diagnosis of mild ARDS. S P O 2 /F i O 2 had excellent discrimination ability for mild ARDS (AUC ± SE = 0.92 ± 0.017; 95% CI 0.889 to 0.947) as did P A O 2 /F i O 2 (AUC ± SE = 0.915 ± 0.018; 95% CI 0.881 to0.942)., Conclusions: P a O 2 and S a O 2 correlated in the diagnosis of ARDS, with a P a O 2 /F i O 2 of 300 correlating to an S P O 2 / F i O 2 of 311 (Sensitivity 90%, Specificity 80%). The S P O 2 / F i O 2 ratio may allow for early real-time rapid identification of ARDS, while decreasing the cost, phlebotomy, blood loss, pain, skin breaks, and vascular punctures associated with serial arterial blood gas measurements.

Purpose: We investigated the impact of delirium on illness severity, psychological state, and memory in acute respiratory distress syndrome patients with very long ICU stay., Materials and Methods: Prospective cohort study in the medical-surgical ICUs of 2 teaching hospitals. Very long ICU stay (>75days) and prolonged delirium (≥40days) thresholds were determined by ROC analysis. Subjects were ≥18years, full-code, and provided informed consent. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation IV, Simplified Acute Physiology Score-3, and Sequential Organ Failure Assessment scores. Psychological impact was assessed using the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, and the 14-question Post-Traumatic Stress Syndrome (PTSS-14). Memory was assessed using the ICU Memory Tool survey., Results: 181 subjects were included. Illness severity did not correlate with delirium duration. On logistic regression, only PTSS-14<49 correlated with delirium (p=0.001; 95% CI 1.011, 1.041). 49% remembered their ICU stay clearly. 47% had delusional memories, 50% reported intrusive memories, and 44% reported unexplained feelings of panic or apprehension., Conclusion: Delirium was associated with memory impairment and PTSS-14 scores suggestive of PTSD, but not illness severity., (Copyright © 2017. Published by Elsevier Inc.)

Background: Ventilator-Associated Pneumonia (VAP) is an important cause of morbidity and mortality in patients admitted to Intensive Care Unit (ICU). The current study conducted to estimate VAP incidence, attributable mortality and case fatality rate, cost, so related factors can affect the outcome in patients., Materials and Methods: In this descriptive longitudinal study, demographic, clinical and para-clinical data were collected and attributable mortality and case fatality rate was estimated. Multivariable analysis was done to predict the possible risk factors on the outcome of VAP patients. Also, patients' survival curve was plotted based on their length of ICU stay. Finally, the additional cost due to VAP in ICU was estimated., Results: Totally, 8% ICU admissions were affected by VAP and 4% expired during the ICU stay. Further, the attributable mortality rate of VAP was high as compared with standard mortality rate. The most case fatality rate was for Acinetobacter sp. (n=17 60.7%). In multivariable logistic regression analysis, age greater than 40 years, more than 96 hours mechanical ventilation and uncontrolled diabetes mellitus were predictor factors of higher mortality. Inverse association between survival time and ICU length of stay was reported. Finally, the additional cost of VAP was estimated of about 700 US$ per patients., Conclusion: According to the results, strategies to prevent mortality by reducing the duration of ventilation and ICU length of stay should be performed. Also, mandatory fees for the family and the healthcare system should be planned.

Traumatic brain injury (TBI) is a major cause of disability and death globally. Despite significant progress in neuromonitoring and neuroprotection, pharmacological interventions have failed to generate favorable results. We examined the effect of memantine on serum levels of neuron-specific enolase (NSE), a marker of neuronal damage, and the Glasgow Coma Scale (GCS) in patients with moderate TBI. Patients were randomly assigned to the control group (who received standard TBI management) and the treatment group (who, alongside their standard management, received enteral memantine 30 mg twice daily for 7 days). Patients' clinical data, GCS, findings of head computed tomography, and serum NSE levels were collected during the study. Forty-one patients were randomized into the control and treatment groups, 19 and 22 patients respectively. Baseline characteristics and serum NSE levels were not significantly different between the 2 groups. The mean serum NSE levels for the memantine and the control groups on day 3 were 7.95 ± 2.86 and 12.33 ± 7.09 ng/mL, respectively (P = .05), and on day 7 were 5.03 ± 3.25 and 10.04 ± 5.72 ng/mL, respectively (P = .003). The mean GCS on day 3 was 12.3 ± 2.0 and 10.9 ± 1.9 in the memantine and control groups, respectively (P = .03). Serum NSE levels and GCS changes were negatively correlated (r = -0.368, P = .02). Patients with moderate TBI who received memantine had significantly reduced serum NSE levels by day 7 and marked improvement in their GCS scores on day 3 of the study., (© 2017, The American College of Clinical Pharmacology.)

Background: Chest Radiograph accompanied by clinical and laboratory findings are required for diagnosis and follow-up of patients with suspected ventilatorassociated pneumonia (VAP). However, there are no reliable data whether follow-up chest-X-ray (CXR) is needed or not, moreover, when the physicians request CXR and how many times CXR is required. We aimed to determine association of the clinical improvement with resolution of pulmonary infiltrates as well as time of resolution., Materials and Methods: The patients with a diagnosis of VAP based on Clinical Pulmonary Infection Score (CPIS) were enrolled in this study. Clinical evaluation and follow-up were continued and CXR was performed sequentially in two-day intervals until clinical improvement or occurrence of other events including death. Fischer test was used to analyze the association of clinical improvement with radiographic resolution., Results: Out of the seventy -five patients, pneumonia was clinically improved in 48 cases. Mean duration of the clinical improvement was 5.3±4.5 days. Among these patients, pulmonary infiltrations in 44 patients were resolved completely (13.8±5.8 days). Twentyseven patients had no clinical improvement and all of them revealed no infiltration resolution according to the sequential imaging studies. Resolution of radiographic involvement significantly was associated with clinical improvement (p=0.000)., Conclusion: Radiographic resolution occurs in most of patients who survived VAP and there is strong relationship between radiographic resolution and clinical improvement. Moreover, our data revealed that CXR clearance occurred earlier than anticipated previously. Thus, sequential follow-up CXR in VAP had no further clinical value., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

The aim of this study was to evaluate the procalcitonin (PCT) changes in two different high-dose colistin regimens in the treatment of multi-drug resistant MDR gram negative infections in ICU patients. This is a prospective study of adult ICU patients with bacteremia and ventilator associated pneumonia (VAP) caused by MDR gram negative pathogens. Patients were assigned to two colistin administration groups. Group A received 9 and group B received 3 million international units every 24 and 8 h respectively. Baseline characteristics and measurements of PCT concentrations at the start, the 3 rd and the 5 th day of the antibiotic therapy and their trends between the two groups were recorded and compared. of 40 patients enrolled, 34 completed the study protocol, of whom 30 (88.2%) had (VAP) and 4 (11.8%) had bacteremia. There were no statistically significant differences in the baseline characteristics between the two groups. The mean PCT levels in two study groups were; 2.34, 1.24, and 0.95 in group A and 5.89, 1.24 and 0.8 in group B at the baseline, 3 rd and 5 th day of colistin administration respectively (P=0.47). The ICU length of stay (LOS) in days and ICU mortality were; 31.31, 35.3% and 32.06, 22.2% in groups A and B (P=0.39, 0.87), respectively., Conclusion: We did not find any statistically significant differences in the serum PCT levels, ICU LOS or ICU mortality, between the two groups, who received maximum recommended dose of CMS with 2 different intervals of every 8 or 24 h.

Introduction: Deep vein thrombosis (DVT) is a major cause of morbidity and mortality in intensive care unit (ICU) patients despite use of prophylactic anticoagulant therapy. The aim of the present study was to determine the incidence of DVT among medical and surgical ICU patients., Methods: In this cross sectional study, patients older than 18 years who were hospitalized in the ICU of Imam Hossein educational Hospital, Tehran, Iran, for ≥ 2 days, during August 2008 to July 2011 were evaluated regarding DVT incidence. Demographic data, comorbidities, acute physiology and chronic health evaluation (APACHE) II scores, ICU length of stay, type of DVT prophylaxis, and patient outcomes were analyzed using SPSS 19., Results: Out of the 1387 reviewed patient files, 500 (36.04%) patients had been classified as potential DVT cases. DVT occurred in 3.5% of them with the mean age of 60 ± 18 years (62.5% male) and mortality rate of 27.1%. Significant independent risk factors of DVT incidence were age (p = 0.02) and length of ICU stay (p = 0.01)., Conclusion: The results of this study showed the 3.5% incidence of DVT in ICU admitted patients. Longer ICU stay and older age were independent risk factors of DVT development., Competing Interests: None.

Clonidine has sedative and analgesic properties. Randomized studies examining these properties in mechanically ventilated ICU patients are scarce. This study was designed to assess the impact of clonidine on sedative agent use in mechanically ventilated patients. In a prospective, randomized, double blind, placebo-controlled study in a general ICU of a university medical center in Tehran, Iran, 40 patients, over 18 years on mechanical ventilation for 3 days or more randomized into 2 equal groups of clonidine and placebo. Clonidine arm received usual sedation and enteral clonidine 0.1 mg TID and escalated to 0.2 mg TID on the second day if hemodynamics remained stable. Ramsay Sedation Score was used to assess sedation. Opioids and midazolam were used in all patients. 10 patients in clonidine and 3 in placebo arms had history of drug abuse (P = 0.018). The mean of sedatives used in the clonidine/placebo arms (mg/day) were; MED (Morphine Equivalent Dose) 91.4 ± 97.9/112.1 ± 98.8 P=0.39, midazolam 7.1 ± 7.9/8.3 ± 9.2 P=0.66 and propofol 535.8 ± 866.7/139.1 ± 359.9 P=0.125. After adjusting for addiction and propofol, clonidine reduced MED use by 79.6 mg/day (P=0.005) and midazolam by 5.41 mg/day (P = 0.05). Opioids and midazolam need reduced by clonidine co-administration regardless of history of drug abuse. Acceptable side effect profile and the lower cost of clonidine could make it an attractive adjunct to sedative agents in ICU.

Pain in ICU patients should be managed effectively and safely. Fentanyl and Paracetamol are used frequently in ICU. However experience using IV Paracetamol in the setting of critically ill patients is limited. We evaluated the analgesic effect and adverse reactions of intravenous Paracetamol compared to Fentanyl in ICU patients with mild to moderate pain. Forty patients in a general ICU were randomized into two groups of IV Paracetamol and IV Fentanyl in a single blinded fashion. Pain was assessed by Visual Analogue Scale (VAS) before drug administration and six hourly for 48 h of 1 g IV Paracetamol every 6 h for 48 h in the first group and 25 μg Fentanyl intravenously every three hours for 48 h in the second group. Patients were monitored for significant adverse reactions particularly of CNS and hepatic nature. Results showed the age, sex and pain score before analgesia was matched in both groups. Pain scores were similar in both groups at 24 h 2.60 (± 1.2) and 2.40 (± 1.5) and at 48 h 2.25 (± 0.96) and 2.05 (± 1.1) in Paracetamol and Fentanyl groups respectively. Clinical and laboratory adverse reactions were also similar in both groups. The analgesic properties of Paracetamol and Fentanyl were similar in this study. We did not observe any significant adverse effects in the two groups. Clinical and laboratory findings including liver functions remained without any statistically significant difference in two groups. This study demonstrates intravenous Paracetamol may be as safe and effective as Fentanyl in ICU patients with mild to moderate pain.

Unlabelled: Development of antibiotic resistance in Intensive Care Units (ICUs) is a worldwide problem. The purpose of this study was to evaluate the effect of an antibiotic stewardship program (ASP) by carbapenems restriction on gram-negative antimicrobial resistance in ICU. The study was designed in a 21 bedded general ICU of a teaching hospital with two wings (one and two) in Tehran, Iran. Carbapenem prescription in ICU1 was restricted to only the culture proven multi-drug-resistant bacteria with the absence of sensitivity to other antimicrobial agents. Carbapenem had to be prescribed by a trained ICU physician with close consultation with infectious disease specialist and the clinical pharmacist posted in ICU. Post-prescription reviews and de-escalations were carried out by the same team on regular basis. Restriction policy was commenced in January 2011 in ICU1. All documented infections and resistance patterns of isolated pathogens were recorded in both ICUs during two periods of 6 months before and 9 months after restriction policy implementation. During this study bacterial growth was detected in 51.5% of 1601 samples. Carbapenem administration was decreased from 6.86 to 2.75 DDD/100 patients day (60% decreases) pre-restriction and post-restriction respectively. Significant increase in sensitivity of pseudomonas to imipenem was observed in ICU1 comparing with pre-restriction period six months post restriction (p = 0.000). Sensitivity of Klebsiella and Acinetobacter to imipenem did not change significantly during the study period., Conclusion: Our study demonstrated that restriction of carbapenems can increase sensitivity of P. aeroginosa to imipenem.