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Introduction: The association between obesity and outcome in critical illness is unclear. Since the amount of visceral adipose tissue(VAT) rather than BMI mediates the health effects of obesity we aimed to investigate the association between visceral obesity, BMI and 90-day mortality in critically ill patients. Method: In 555 critically ill patients (68% male), the VAT Index(VATI) was measured using Computed Tomography scans on the level of vertebra L3. The association between visceral obesity, BMI and 90-day mortality was investigated using univariable and multivariable analyses, correcting for age, sex, APACHE II score, sarcopenia and muscle quality. Results: Visceral obesity was present in 48.1% of the patients and its prevalence was similar in males and females. Mortality was similar amongst patients with and without visceral obesity (27.7% vs 24.0%, p = 0.31). The corrected odds ratio of 90-day mortality for visceral obesity was 0.667 (95%CI 0.424–1.049, p = 0.080). Using normal BMI as reference, the corrected odds ratio for overweight was 0.721 (95%CI 0.447–1.164 p = 0.181) and for obesity 0.462 (95%CI 0.208–1.027, p = 0.058). Conclusion: No significant association of visceral obesity and BMI with 90-day mortality was observed in critically ill patients, although obesity and visceral obesity tended to be associated with improved 90-day mortality.

BACKGROUND: Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population.METHODS: A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective.RESULTS: Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day.CONCLUSIONS: Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.

Einleitung: Die Beurteilung von Schmerzen und die darauf basierende optimale individuelle Analgetikadosierung ist insbesondere bei beatmeten Intensivpatienten, die aufgrund einer qualitativen oder quantitativen Bewusstseinsstörung nicht in der Lage zur Selbsteinschätzung ihrer Schmerzen sind, schwierig. Daher untersuchten wir im Rahmen dieser Studie unterschiedliche Methoden zur Vorhersage schmerzassoziierter Reaktionen solcher Intensivpatienten auf in der klinischen Routine stattfindende Schmerzreize. Methoden: In dieser nicht-interventionellen Beobachtungsstudie wurden die Daten von 130 beatmeten Intensivpatienten ausgewertet, bei denen vor den beiden Routinemaßnahmen endotracheales Absaugen und Wechsel der Lagerungsposition die Schwelle des Nozizeptiven Flexorenreflexes (NFRT), die Werte der klinischen Scores Behavio-ral Pain Scale (BPS) und Richmond Agitation-Sedation Scale (RASS), sowie die Laufraten von Sufentanil und Propofol erhoben wurden. Anhand der Flächen unter den Receiver-Operating-Characteristic-Kurven (AUROC) wurde untersucht, ob diese fünf Prädiktoren in der Lage sind, schmerzassoziierte klinische Reaktionen vorherzusagen. Ergebnisse: Bei der klinischen Routinemaßnahme Absaugen können schmerzassoziierte Reaktionen statistisch signifikant durch die Prädiktoren NFRT (AUROC 0,68), Sufentanil (AUROC 0,75), RASS (AUROC 0,74) und BPS (AUROC 0,64) vorhergesagt werden. Bei der Routinemaßnahme Lagerung hingegen können diese Reaktionen durch die Prädiktoren Sufentanil (AUROC 0,69), Propofol (AUROC 0,70), RASS (AUROC 0,89) und BPS (AUROC 0,74) statistisch signifikant vorhergesagt werden. Fazit: Für die klinische Routine kann insbesondere die einfach zugängliche Sufentanil-Laufrate zur Vorhersage schmerzassoziierter Reaktionen verwendet werden. Bei Patienten, die kein kontinuierliches Sufentanil erhalten, kann die vor einer Maßnahme erhobene BPS genutzt werden. Die Propofol-Laufrate sowie der RASS scheinen sich hingegen, wie erwartbar, eher zur Einschätzung des Sedierungs- als des Analgesieniveaus von Patienten zu eignen. Als zusätzliches Nebenergebnis unterstützen unsere Daten die Annahme, dass es sich beim endotrachealen Absaugen um einen Reiz mit einem stärkeren nozizeptiven Anteil handelt, wohingegen ein Wechsel der Lagerungsposition eher einen unspezifischen Stressreiz darstellt., Introduction: It is particularly difficult to assess the level of pain and to optimize individ-ual analgesic dosing in ventilated intensive care patients that are unable to self-report their pain due to qualitative or quantitative disturbances of consciousness. Therefore, in this study, we investigated several methods to predict pain-associated responses to pain stimuli that occur in clinical routine in such intensive care patients. Methods: In this noninterventional observational study, data was analyzed from 130 ventilated intensive care patients. Before the two routine procedures of endotracheal suctioning and turning, we collected data for the threshold of the nociceptive flexion reflex (NFRT) as well as the values of the clinical scores Behavioral Pain Scale (BPS) and Richmond Agitation-Sedation Scale (RASS). Additionally, the dose rates of sufen-tanil and propofol were captured. The areas under the receiver operating characteristic (AUROC) curves were used to examine whether these five predictors were able to predict pain-associated clinical responses. Results: For the routine clinical procedure of endotracheal suctioning, the NFRT (AUROC 0.68), the sufentanil dose rate (AUROC 0.75), the RASS (AUROC 0.74), and the BPS (AUROC 0.64) predict pain-associated reactions statistically significantly. In contrast, for the routine procedure of turning, pain-associated reactions are statistically significantly predicted by the sufentanil dose rate (AUROC 0.69), the propofol dose rate (AUROC 0.70), the RASS (AUROC 0.89), and the BPS (AUROC 0.74). Conclusion: Primarily, the easily accessible parameter of the current sufentanil drug dose rate can be used to predict pain-associated responses in routine clinical practice. In patients not receiving continuous sufentanil, the BPS recorded before an interven-tion can be used. In contrast to these measures, as it can be expected, the propofol drug dose rate and the RASS seem to assess the level of sedation rather than the level of analgesia. And on a side note, our results support the assumption that endotracheal suctioning is a stronger nociceptive stimulus in comparison to turning, which seems a rather unspecific stress stimulus.

Background It remains controversial whether critical illness-related hyperglycemia should be treated or not, since randomized controlled trials (RCTs) have shown context-dependent outcome effects. Whereas pioneer RCTs found improved outcome by normalizing blood glucose in patients receiving early parenteral nutrition (PN), a multicenter RCT revealed increased mortality in patients not receiving early PN. Although withholding early PN has become the feeding standard, the multicenter RCT showing harm by tight glucose control in this context has been criticized for its potentially unreliable glucose control protocol. We hypothesize that tight glucose control is effective and safe using a validated protocol in adult critically ill patients not receiving early PN. Methods The TGC-fast study is an investigator-initiated, multicenter RCT. Patients unable to eat, with need for arterial and central venous line and without therapy restriction, are randomized upon ICU admission to tight (80–110 mg/dl) or liberal glucose control (only initiating insulin when hyperglycemia >215 mg/dl, and then targeting 180–215 mg/dl). Glucose measurements are performed on arterial blood by a blood gas analyzer, and if needed, insulin is only administered continuously through a central venous line. If the arterial line is no longer needed, glucose is measured on capillary blood. In the intervention group, tight control is guided by the validated LOGIC-Insulin software. In the control arm, a software alert is used to maximize protocol compliance. The intervention is continued until ICU discharge, until the patient is able to eat or no longer in need of a central venous line, whatever comes first. The study is powered to detect, with at least 80% power and a 5% alpha error rate, a 1-day difference in ICU dependency (primary endpoint), and a 1.5% increase in hospital mortality (safety endpoint), for which 9230 patients need to be included. Secondary endpoints include acute and long-term morbidity and mortality, and healthcare costs. Biological samples are collected to study potential mechanisms of organ protection. Discussion The ideal glucose target for critically ill patients remains debated. The trial will inform physicians on the optimal glucose control strategy in adult critically ill patients not receiving early PN. Trial registration ClinicalTrials.gov NCT03665207. Registered on 11 September 2018.

Aim and objective The aim of the study was to investigate how the sleep improvement interventions developed for the wards were associated with patients' sleep. The objective was to promote patients' sleep. Background The quality of sleep is vital for patients' health and recovery from illness. However, patients generally sleep poorly during hospitalisation. Sleep-disturbing factors are connected to the hospital environment, patients' physical illness, emotional state and the activities of the staff. Many sleep-disturbing factors can be influenced by appropriate nursing interventions. Design A two-group intervention study including the development of nursing interventions aimed at supporting patients' sleep. One group received a sleep promotion intervention and the other received standard care. Both groups evaluated their sleep in the morning. Methods A survey of participants' sleep evaluations was collected with the five-item Richards-Campbell Sleep Questionnaire. The data were analysed statistically. The STROBE checklist was used to report the study. Results From the participants' perspective, sleep was better in the intervention group, even though statistically significantly only among men. The pain intensity correlated with sleep quality. The number of patients in the room or whether participants had had an operation had no effect on their sleep evaluations. Conclusions Interventions targeted at supporting and promoting the sleep quality of hospital inpatients may be effective. They should be developed in collaboration with patients and nurses. Several nursing interventions can be proposed to promote better sleep among patients; however, more research is needed to confirm the results. Sleep promotion should include both standardised protocols and individualised sleep support. Relevance to clinical practice Investing in nursing interventions to promote patients' sleep is important. Patients' individual sleep-related needs should be part of their care plan. Training programmes that support nurses' knowledge and skills of patients' sleep promotion should be part of nursing education in healthcare organisations.

BackgroundSequential Organ Failure Assessment (SOFA) is a practical and widely used method to describe and quantify the presence and severity of organ system dysfunctions and failures. Some proposals suggest that SOFA could be employed as an endpoint in interventional trials. To justify this, all SOFA components should have comparable weights as organ dysfunction measures. In this study we aimed to investigate whether the associations of different SOFA components with in-hospital mortality are comparable.MethodsWe performed a study based on nationwide register data on adult patients admitted to 26 Finnish intensive care units (ICUs) during 2012−2015. We determined the SOFA score as the maximum score in the first 24 hours after ICU admission. We defined organ failure as an organ-specific SOFA score of three or higher. We evaluated the association of different SOFA component scores with mortality using multivariable logistic regression analysis. ResultsOur study population comprised 63,756 ICU patients. Overall hospital mortality was 10.7%. In-hospital mortality was 22.5% for patients with respiratory failure, 34.8% for those with coagulation failure, 40.1% for those with hepatic failure, 14.9% for those with cardiovascular failure, 26.9% for those with neurologic failure and 34.6% for the patients with renal failure. The age-adjusted odds ratio for in-hospital death was 2.41 [95% confidence interval (CI) 2.27-2.56] for respiratory failure, 4.04 (95% CI 3.57-4.57) for coagulation failure, 4.24 (95% CI 3.47-5.17), for hepatic failure, 1.57 (95% CI 1.47-1.67) for cardiovascular failure, 5.00 (95% CI 4.71-5.30) for neurologic failure, and 4.93 (95% CI 4.58-5.32) for renal failure. Organ failure combinations including cardiovascular failure were associated with lower mortality than other organ failure combinations.ConclusionsAll SOFA components are associated with mortality, but their weights are not comparable. High cardiovascular SOFA scores do not imply an equally high risk as high scores of other components.

BackgroundPainful procedures in early life cause acute pain and can alter pain processing at a spinal level lasting into adulthood. Current methods of analgesia seem unable to prevent both acute and long-term hypersensitivity associated with neonatal pain. The current study aims to prevent acute and long-term hypersensitivity associated with neonatal procedural pain using methadone analgesia in rat pups.MethodsSprague–Dawley rat pups received either methadone (1 mg/kg) or saline prior to repetitive needle pricks into the left hind paw from the day of birth (postnatal day (P)0) to P7. Control littermates received a tactile stimulus. Mechanical sensitivity was assessed during the neonatal period (P0–P7), from weaning to adulthood (3–7 weeks) and following surgical re-injury of the same dermatome in adulthood.ResultsMethadone administration completely reversed acute hypersensitivity from P0 to P7. In addition, neonatal methadone analgesia prevented prolonged hypersensitivity after re-injury in adulthood, without affecting sensitivity from weaning to adulthood.ConclusionsThe current study shows that neonatal methadone analgesia can attenuate acute as well as long-term hypersensitivity associated with neonatal procedural pain in a rat model.ImpactMethadone treatment attenuates acute and long-term hypersensitivity associated with neonatal pain in a rat model.Clinical effectiveness studies are urgently warranted to assess acute and long-term analgesic effectivity of methadone.

Palliative care focuses on symptom management, discussion of treatment and care decisions, network organization, and support of the family. As part of the advance care planning (ACP) process, staff nurses in the acute care setting are often involved in all of the above areas. It is yet unclear what nurses' roles and responsibilities are and what skills are needed in the ACP process. The themes that staff nurses and advanced practice registered nurses (APRNs) discuss in relationship to ACP are manifold. This scoping review demonstrates that staff nurses' core role is advocating for the wishes and values of patients with any life-limiting disease. Staff nurses also serve as facilitators, educators, and advocates to help start ACP conversations and ease patients' transitions between settings based on well-discussed decisions. To be able to engage in ACP discussions, APRNs must have excellent communication skills. Continuous training to improve these skills is mandatory. In the future, clarifying the contribution of staff nurses and APRNs in the ACP process in relation to other members of the interprofessional team can lay the groundwork for improved interprofessional collaboration.

There are an increasing number of children who are dependent on medical technology to sustain their lives. Although significant research on this issue is taking place, the terminology used is variable and the concept of technology dependence is ill-defined. A systematic concept analysis was conducted examining the attributes, antecedents, and consequences of the concept of technology dependent, as portrayed in the literature. We found that this concept refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide ranging sequelae for the child and family, and health and social care delivery.Conclusion: The term technology dependent is increasingly redundant. It objectifies a heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways.What is Known:center dot There are an increasing number of children who require medical technology to sustain their life, commonly referred to as technology dependent. This concept analysis critically analyses the relevance of the term technology dependent which is in use for over 30 years.What is New:center dot Technology dependency refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide-ranging sequelae for the child and family, and health and social care delivery.center dot The paper shows that the term technology dependent is generally portrayed in the literature in a problem-focused manner.center dot This term is increasingly redundant and does not serve the heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. More appropriate child-centred terminology will be determined within the TechChild project.

Objectives: 1) To investigate the current practice in point-of-care ultrasound use in PICUs across Europe; 2) to understand the barriers for point-of-care ultrasound implementation in the clinical practice; 3) to identify existing point-of-care ultrasound training programs; and 4) to assess training needs.Design: Cross-sectional electronic survey.Subjects: Medical directors of European PICUs.Measurements and Main Results: The response rate was 42.3%; 142 of the 336 invited PICU medical directors from 26 European countries completed the survey. The clinicians in almost all the PICUs across Europe were reported to use point-of-care ultrasound in some form. A significant variation in the clinical practice according to the patient characteristics and presence of a fellowship training program was observed. PICUs with cardiosurgical patients reported using point-of-care ultrasound significantly more often than others. Ultrasound-guided vascular access was the most common point-of-care ultrasound indication, except in PICUs providing joint care for neonates and children. Units with a fellowship training program reported an increased use of point-of-care ultrasound for hemodynamic evaluation, during resuscitation and a positive impact on collaboration with imaging specialties. Although no barrier was deemed substantial to impede point-of-care ultrasound implementation, a number of potential hindrances to its implementation were reported-such as lack of formal training curriculum, collaborative learning opportunities, and quality assurance processes. Bedside informal teaching in point-of-care ultrasound was reported the most common method to acquire point-of-care ultrasound skills.Conclusions: Point-of-care ultrasound is being used extensively across heterogeneously organized PICU settings in Europe. However, there remains a significant variation in the clinical practice across the units. Clear needs for improved point-of-care ultrasound training programs and clinical governance structure were identified. Evidence-based point-of-care ultrasound guidelines, structured training programs dedicated to neonatal and pediatric intensive care settings, and educational research in point-of-care ultrasound use may help in strengthening clinical governance, making clinical practice uniform and enhancing quality assurance.

Determination of accurate diagnosis and prognosis for patients suspected of circulatory shock is essential for optimal decision-making. Numerous techniques are available, and each has its specific indications and value.

Purpose of review To appraise the basic and more advanced methods available for hemodynamic monitoring, and describe the definitions and criteria for the use of hemodynamic variables. Recent findings The hemodynamic assessment in critically ill patients suspected of circulatory shock follows a step-by-step algorithm to help determine diagnosis and prognosis. Determination of accurate diagnosis and prognosis in turn is crucial for clinical decision-making. Basic monitoring involving clinical examination in combination with hemodynamic variables obtained with an arterial catheter and a central venous catheter may be sufficient for the majority of patients with circulatory shock. In case of uncertainty of the underlying cause or to guide treatment in severe shock may require additional advanced hemodynamic technologies, and each is utilized for different indications and has specific limitations. Future developments include refining the clinical examination and performing studies that demonstrate better patient outcomes by targeting hemodynamic variables using advanced hemodynamic monitoring. Summary Determination of accurate diagnosis and prognosis for patients suspected of circulatory shock is essential for optimal decision-making. Numerous techniques are available, and each has its specific indications and value.

Background health-related quality of life (HRQoL) is an important patient-centred outcome in patients surviving ICU admission for COVID-19. It is currently not clear which domains of the HRQoL are most affected. Objective to quantify HRQoL in order to identify areas of interventions. Design prospective observation study. Setting admissions to European ICUs between March 2020 and February 2021. Subjects patients aged 70 years or older admitted with COVID-19 disease. Methods collected determinants include SOFA-score, Clinical Frailty Scale (CFS), number and timing of ICU procedures and limitation of care, Katz Activities of Daily Living (ADL) dependence score. HRQoL was assessed at 3 months after ICU admission with the Euro-QoL-5D-5L questionnaire. An outcome of ≥4 on any of Euro-QoL-5D-5L domains was considered unfavourable. Results in total 3,140 patients from 14 European countries were included in this study. Three months after inclusion, 1,224 patients (39.0%) were alive and the EQ-5D-5L from was obtained. The CFS was associated with an increased odds ratio for an unfavourable HRQoL outcome after 3 months; OR 1.15 (95% confidence interval (CI): 0.71–1.87) for CFS 2 to OR 4.33 (95% CI: 1.57–11.9) for CFS ≧ 7. The Katz ADL was not statistically significantly associated with HRQoL after 3 months. Conclusions in critically ill old intensive care patients suffering from COVID-19, the CFS is associated with the subjectively perceived quality of life. The CFS on admission can be used to inform patients and relatives on the risk of an unfavourable qualitative outcome if such patients survive.

Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research.

Background Clinical equipoise exists regarding intravenous (IV) fluid volumes in sepsis. The Conservative vs. Liberal Approach to fluid therapy of Septic Shock in Intensive Care (CLASSIC) trial investigates the effect of restricted vs. standard IV fluid therapy in 1554 adult intensive care unit patients with septic shock. Methods This protocol describes secondary Bayesian analyses of the primary outcome (90-day all-cause mortality) and three secondary outcomes at day 90. We will analyse all binary outcomes with adjusted Bayesian logistic regressions and present results as conditional relative risks and risk differences with 95% credibility intervals (CrIs). The secondary count outcome will be analysed using adjusted Bayesian linear regression with results summarised as conditional mean differences and ratios of means with 95% Crls. We will use weakly informative priors for the primary analyses, and sceptical and evidence-based priors in the sensitivity analyses. Exact probabilities will be presented for any benefit/harm, clinically important benefit/harm and no clinically important difference. We will assess whether heterogeneity of treatment effects on mortality is present using Bayesian hierarchical models in subgroups and on the continuous scale using models with interactions according to five baseline variables assessing the overall severity of illness and the degree of circulatory and renal impairment. Discussion The outlined analyses will supplement the primary analysis of the CLASSIC trial by describing probabilities of beneficial and harmful effects and evaluating heterogeneity of treatment effects in a framework that may be easier to interpret for researchers and clinicians.

Background: Intensified treatment protocols have improved survival of pediatric oncology patients. However, these treatment protocols are associated with increased treatment-related morbidity requiring admission to pediatric intensive care unit (PICU). We aimed to describe the organizational characteristics and processes of care for this patient group across PICUs in Europe. Methods: A web-based survey was sent to PICU directors or representative physicians between February and June 2021. Results: Responses were obtained from 77 PICUs of 12 European countries. Organizational characteristics were similar across the different countries of Europe. The median number of PICU beds was 12 (IQR 8-16). The majority of the PICUs was staffed by pediatric intensivists and had a 24/7 intensivist coverage. Most PICUs had a nurse-to-patient ratio of 1:1 or 1:2. The median numbers of yearly planned and unplanned PICU admissions of pediatric cancer patients were 20 (IQR 10-45) and 10 (IQR 10-30, respectively. Oncology specific practices within PICU were less common in participating centres. This included implementation of oncology protocols in PICU (30%), daily rounds of PICU physicians on the wards (13%), joint mortality and morbidity meetings or complex patients’ discussions (30% and 40%, respectively) and participation of parents during clinical rounds (40%). Conclusion: Our survey provides an overview on the delivery of critical care for oncology patients in PICU across European countries. Multidisciplinary care for these vulnerable and challenging patients remains complex and challenging. Future studies need to determine the effects of differences in PICU organization and processes of care on patients’ outcome.

As global demographics change, ageing is a global phenomenon which is increasingly of interest in our modern and rapidly changing society. Thus, the application of proper prognostic indices in clinical decisions regarding mortality prediction has assumed a significant importance for personalized risk management (i.e., identifying patients who are at high or low risk of death) and to help ensure effective healthcare services to patients. Consequently, prognostic modelling expressed as all-cause mortality prediction is an important step for effective patient management. Machine learning has the potential to transform prognostic modelling. In this paper, results on the development of machine learning models for all-cause mortality prediction in a cohort of healthy older adults are reported. The models are based on features covering anthropometric variables, physical and lab examinations, questionnaires, and lifestyles, as well as wearable data collected in free-living settings, obtained for the “Healthy Ageing Initiative” study conducted on 2291 recruited participants. Several machine learning techniques including feature engineering, feature selection, data augmentation and resampling were investigated for this purpose. A detailed empirical comparison of the impact of the different techniques is presented and discussed. The achieved performances were also compared with a standard epidemiological model. This investigation showed that, for the dataset under consideration, the best results were achieved with Random UnderSampling in conjunction with Random Forest (either with or without probability calibration). However, while including probability calibration slightly reduced the average performance, it increased the model robustness, as indicated by the lower 95% confidence intervals. The analysis showed that machine learning models could provide comparable results to standard epidemiological models while being completely data-driven and disease-agnostic, thus demonstrating the opportunity for building machine learning models on health records data for research and clinical practice. However, further testing is required to significantly improve the model performance and its robustness.

Objectives Intravenous medication delivery is a complex process that poses systemic risks of errors. The objective of our study was to identify systemic defenses that can prevent in-hospital intravenous (IV) medication errors. Methods A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the Grading of Recommendations Assessment, Development and Evaluation system, and the evidence was analyzed using qualitative content analysis. Results Forty-six studies from 11 countries were included in the analysis. We identified systemic defenses related to administration (n = 24 studies), prescribing (n = 8), preparation (n = 6), treatment monitoring (n = 2), and dispensing (n = 1). In addition, 5 studies explored defenses related to multiple stages of the drug delivery process. Systemic defenses including features of closed-loop medication management systems appeared in 61% of the studies, with smart pumps being the defense most widely studied (24%). The evidence quality of the included articles was limited, as 83% were graded as low quality, 13% were of moderate quality, and only 4% were of high quality. Conclusions In-hospital IV medication processes are developing toward closed-loop medication management systems. Our study provides health care organizations with preliminary knowledge about systemic defenses that can prevent IV medication errors, but more rigorous evidence is needed. There is a need for further studies to explore combinations of different systemic defenses and their effectiveness in error prevention throughout the drug delivery process.

Background Prognostic assessments of the mortality of critically ill patients are frequently performed in daily clinical practice and provide prognostic guidance in treatment decisions. In contrast to several sophisticated tools, prognostic estimations made by healthcare providers are always available and accessible, are performed daily, and might have an additive value to guide clinical decision-making. The aim of this study was to evaluate the accuracy of students’, nurses’, and physicians’ estimations and the association of their combined estimations with in-hospital mortality and 6-month follow-up. Methods The Simple Observational Critical Care Studies is a prospective observational single-center study in a tertiary teaching hospital in the Netherlands. All patients acutely admitted to the intensive care unit were included. Within 3 h of admission to the intensive care unit, a medical or nursing student, a nurse, and a physician independently predicted in-hospital and 6-month mortality. Logistic regression was used to assess the associations between predictions and the actual outcome; the area under the receiver operating characteristics (AUROC) was calculated to estimate the discriminative accuracy of the students, nurses, and physicians. Results In 827 out of 1,010 patients, in-hospital mortality rates were predicted to be 11%, 15%, and 17% by medical students, nurses, and physicians, respectively. The estimations of students, nurses, and physicians were all associated with in-hospital mortality (OR 5.8, 95% CI [3.7, 9.2], OR 4.7, 95% CI [3.0, 7.3], and OR 7.7 95% CI [4.7, 12.8], respectively). Discriminative accuracy was moderate for all students, nurses, and physicians (between 0.58 and 0.68). When more estimations were of non-survival, the odds of non-survival increased (OR 2.4 95% CI [1.9, 3.1]) per additional estimate, AUROC 0.70 (0.65, 0.76). For 6-month mortality predictions, similar results were observed. Conclusions Based on the initial examination, students, nurses, and physicians can only moderately predict in-hospital and 6-month mortality in critically ill patients. Combined estimations led to more accurate predictions and may serve as an example of the benefit of multidisciplinary clinical care and future research efforts.

ImportanceWhether selective decontamination of the digestive tract (SDD) reduces mortality in critically ill patients remains uncertain.ObjectiveTo determine whether SDD reduces in-hospital mortality in critically ill adults.Design, Setting, and ParticipantsA cluster, crossover, randomized clinical trial that recruited 5982 mechanically ventilated adults from 19 intensive care units (ICUs) in Australia between April 2018 and May 2021 (final follow-up, August 2021). A contemporaneous ecological assessment recruited 8599 patients from participating ICUs between May 2017 and August 2021.InterventionsICUs were randomly assigned to adopt or not adopt a SDD strategy for 2 alternating 12-month periods, separated by a 3-month interperiod gap. Patients in the SDD group (n = 2791) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191) received standard care.Main Outcomes and MeasuresThe primary outcome was in-hospital mortality within 90 days. There were 8 secondary outcomes, including the proportion of patients with new positive blood cultures, antibiotic-resistant organisms (AROs), and Clostridioides difficile infections. For the ecological assessment, a noninferiority margin of 2% was prespecified for 3 outcomes including new cultures of AROs.ResultsOf 5982 patients (mean age, 58.3 years; 36.8% women) enrolled from 19 ICUs, all patients completed the trial. There were 753/2791 (27.0%) and 928/3191 (29.1%) in-hospital deaths in the SDD and standard care groups, respectively (mean difference, −1.7% [95% CI, −4.8% to 1.3%]; odds ratio, 0.91 [95% CI, 0.82-1.02]; P = .12). Of 8 prespecified secondary outcomes, 6 showed no significant differences. In the SDD vs standard care groups, 23.1% vs 34.6% had new ARO cultures (absolute difference, −11.0%; 95% CI, −14.7% to −7.3%), 5.6% vs 8.1% had new positive blood cultures (absolute difference, −1.95%; 95% CI, −3.5% to −0.4%), and 0.5% vs 0.9% had new C difficile infections (absolute difference, −0.24%; 95% CI, −0.6% to 0.1%). In 8599 patients enrolled in the ecological assessment, use of SDD was not shown to be noninferior with regard to the change in the proportion of patients who developed new AROs (−3.3% vs −1.59%; mean difference, −1.71% [1-sided 97.5% CI, −∞ to 4.31%] and 0.88% vs 0.55%; mean difference, −0.32% [1-sided 97.5% CI, −∞ to 5.47%]) in the first and second periods, respectively.Conclusions and RelevanceAmong critically ill patients receiving mechanical ventilation, SDD, compared with standard care without SDD, did not significantly reduce in-hospital mortality. However, the confidence interval around the effect estimate includes a clinically important benefit.Trial RegistrationClinicalTrials.gov Identifier: NCT02389036

Purpose: Whether positive fluid balance among patients with acute kidney injury (AKI) stems from decreased urine output, overzealous fluid administration, or both is poorly characterized. Materials and methods: This was a post hoc analysis of the prospective multicenter observational Finnish Acute Kidney Injury study including 824 AKI and 1162 non-AKI critically ill patients. Results: We matched 616 AKI (diagnosed during the three first intensive care unit (ICU) days) and non-AKI patients using propensity score. During the three first ICU days, AKI patients received median [IQR] of 11.4 L [8.0 & ndash;15.2]L fluids and non-AKI patients 10.2 L [7.5 & ndash;13.7]L, p < 0.001 while the fluid output among AKI patients was 4.7 L [3.0 & ndash;7.2]L and among non-AKI patients 5.8 L [4.1 & ndash;8.0]L, p < 0.001. In AKI patients, the median [IQR] cumulative fluid balance was 2.5 L [& minus;0.2 & ndash;6.0]L compared to 0.9 L [& minus;1.4 & ndash;3.6]L among non-AKI patients, p < 0.001. Among the 824 AKI patients, smaller volumes of fluid input with a multivariable OR of 0.90 (0.88 & ndash;0.93) and better fluid output (multivariable OR 1.12 (1.07 & ndash;1.18)) associated with enhanced change of resolution of AKI. Conclusions: AKI patients received more fluids albeit having lower fluid output compared to matched critically ill non-AKI patients. Smaller volumes of fluid input and higher fluid output were associated with better AKI recovery. (c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Background The Clinical Frailty Scale (CFS) is frequently used to measure frailty in critically ill adults. There is wide variation in the approach to analysing the relationship between the CFS score and mortality after admission to the ICU. This study aimed to evaluate the influence of modelling approach on the association between the CFS score and short-term mortality and quantify the prognostic value of frailty in this context. Methods We analysed data from two multicentre prospective cohort studies which enrolled intensive care unit patients ≥ 80 years old in 26 countries. The primary outcome was mortality within 30-days from admission to the ICU. Logistic regression models for both ICU and 30-day mortality included the CFS score as either a categorical, continuous or dichotomous variable and were adjusted for patient’s age, sex, reason for admission to the ICU, and admission Sequential Organ Failure Assessment score. Results The median age in the sample of 7487 consecutive patients was 84 years (IQR 81–87). The highest fraction of new prognostic information from frailty in the context of 30-day mortality was observed when the CFS score was treated as either a categorical variable using all original levels of frailty or a nonlinear continuous variable and was equal to 9% using these modelling approaches (p p Conclusion Knowledge about a patient’s frailty status adds a substantial amount of new prognostic information at the moment of admission to the ICU. Arbitrary simplification of the CFS score into fewer groups than originally intended leads to a loss of information and should be avoided. Trial registration NCT03134807 (VIP1), NCT03370692 (VIP2)

Background Heterogeneous respiratory system static compliance (CRS) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous small-case series or studies conducted at a national level. Methods We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe CRS—calculated as: tidal volume/[airway plateau pressure-positive end-expiratory pressure (PEEP)]—and its association with ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide. Results We studied 745 patients from 22 countries, who required admission to the ICU and MV from January 14 to December 31, 2020, and presented at least one value of CRS within the first seven days of MV. Median (IQR) age was 62 (52–71), patients were predominantly males (68%) and from Europe/North and South America (88%). CRS, within 48 h from endotracheal intubation, was available in 649 patients and was neither associated with the duration from onset of symptoms to commencement of MV (p = 0.417) nor with PaO2/FiO2 (p = 0.100). Females presented lower CRS than males (95% CI of CRS difference between females-males: − 11.8 to − 7.4 mL/cmH2O p CRS was marginal (p = 0.139). Ventilatory management varied across CRS range, resulting in a significant association between CRS and driving pressure (estimated decrease − 0.31 cmH2O/L per mL/cmH20 of CRS, 95% CI − 0.48 to − 0.14, p CRS (+ 10 mL/cm H2O) was only associated with being discharge from the ICU within 28 days (HR 1.14, 95% CI 1.02–1.28, p = 0.018). Conclusions This multicentre report provides a comprehensive account of CRS in COVID-19 patients on MV. CRS measured within 48 h from commencement of MV has marginal predictive value for 28-day mortality, but was associated with being discharged from ICU within the same period. Trial documentation: Available at https://www.covid-critical.com/study. Trial registration: ACTRN12620000421932.

Aim To investigate the effect of a musical intervention on neonatal stress response to venepuncture as measured by salivary cortisol levels and pain profile scores. Methods In a randomised control crossover trial, participants were randomised to both a control arm (sucrose) and intervention arm (sucrose and music) for routine venepuncture procedures. Salivary swabs were collected at baseline, 20 minutes post-venepuncture and 4 hours post-venepuncture. Pain levels were assessed using the Premature Infant Pain Profile (PIPP). A total of 16 preterm neonates participated in both arms to complete the study. Results Cortisol values were elevated at all timepoints in the intervention arm (baseline, 20 minutes, and 4 hours post-procedure) but not significantly so (P = .056, P = .3, and P = .575, respectively). Median change in cortisol values from baseline was +128.48 pg/mL (-47.66 to 517.02) at 20 minutes and +393.52 pg/mL (47.88-1221.34) at 4 hours post-procedure in the control arm compared to -69.564 pg/mL (-860.96 to 397.289) and +100.48 pg/mL (-560.46 to 842.99) at 20 minutes and 4 hours post-procedure in the intervention arm. There was no statistically significant difference observed between groups (P = .311 at 20 minutes, and P = .203 at 4 hours post-procedure). PIPP scores were not significantly different between study arms. Conclusion Our findings did not support the additional benefit of music intervention on neonatal stress response to venepuncture in preterm infants.

Objectives: Risks of random type I and II errors are associated with false positive and false negative findings. In conventional metaanalyses, the risks of random errors are insufficiently evaluated. Many meta-analyses, which appear conclusive, might, in fact, be inconclusive because of risks of random errors. We hypothesize that, for interventions in critical care, false positive and false negative findings frequently become apparent when accounting for the risks of random error. We aim to investigate to which extent apparently conclusive conventional meta-analyses remain conclusive when adjusting statistical significance levels and confidence intervals considering sparse data and repeated testing through Trial Sequential Analysis (TSA).Methods: We searched The Cochrane Library, MEDLINE, and EMBASE for reviews of interventions in critical care. We used TSA with the relative risk reduction from the estimated meta-analyzed intervention effects adjusted for heterogeneity based on the observed diversity. We report proportions of meta-analyses and potential inconclusive findings of positive, neutral, and negative conclusions based on conventional naive meta-analyses, which use an alpha of 5% and 95% confidence intervals. In TSA-controlled meta-analyses showing a beneficial or harmful intervention effect, we assessed the risk of bias by six Cochrane domains.Results: A total of 464 reviews containing 1,080 meta-analyses of (co-)primary outcomes were analyzed. From the 266 conventional meta-analyses suggesting a beneficial effect, 133 (50%) were true positive and 133 (50%) were potentially false positive according to TSA. From the 755 conventional meta-analyses suggesting a neutral effect, there were 214 (28%) true neutral and 541 (72%) were potentially false neutral according to TSA. From the 59 conventional meta-analyses suggesting a harmful effect, 17 (29%) were true negative and 42 (71%) were potentially false negative according to TSA. When the true beneficial and true harmful meta-analyses according to TSA were evaluated for risk of bias, new TSAs conducted on only trials with overall low risk of bias showed only firm evidence of a beneficial effect on one outcome and a harmful effect on one outcome.Conclusions: Of all meta-analyses in critical care, a large proportion may reach false conclusions because of unknown risks of random type I or type II errors. Future critical care meta-analyses should aim for establishing an effect of interventions accounting for risks of bias and random errors. (C) 2019 Elsevier Inc. All rights reserved.

Contains fulltext : 218566pub.pdf (Publisher’s version ) (Closed access) Contains fulltext : 218566pos.pdf (Author’s version postprint ) (Open Access) BACKGROUND: Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study. METHODS: We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality. RESULTS: We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47). CONCLUSION: PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.

PURPOSE: To provide a practical overview of the management of the potential organ donor in the intensive care unit. METHODS: Seven areas of donor management were considered for this review: hemodynamic management; fluids and electrolytes; respiratory management; endocrine management; temperature management; anaemia and coagulation; infection management. For each subchapter, a narrative review was conducted. RESULTS AND CONCLUSIONS: Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations, or extrapolations from general ICU management strategies, and not on evidence from randomized controlled trials. The cardiorespiratory management of brain-dead donors is very similar to the management of critically ill patients, and the same applies to the management of anaemia and coagulation. Central diabetes insipidus is of particular concern, and should be diagnosed based on clinical criteria. Depending on the degree of vasopressor dependency, it can be treated with intermittent desmopressin or continuous vasopressin, intravenously. Temperature management of the donor is an area of uncertainty, but it appears reasonable to strive for a core temperature of > 35 °C. The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. Although the rate of infection transmission from donor to receptor is low, certain infections are still a formal contraindication to organ donation. However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely. ispartof: INTENSIVE CARE MEDICINE vol:45 issue:3 pages:343-353 ispartof: location:United States status: published

PURPOSE: Guideline adherence for the management of a donor after brain death (DBD) is largely unknown. This study aimed to perform an importance-performance analysis of prioritized key interventions (KIs) by linking guideline adherence rates to expert consensus ratings for the management of a DBD. MATERIALS AND METHODS: This observational, cross-sectional multicenter study was performed in 21 Belgian ICUs. A retrospective review of patient records of adult utilized DBDs between 2013 and 2016 used 67 KIs to describe adherence to guidelines. RESULTS: A total of 296 patients were included. Thirty-five of 67 KIs had a high level of adherence congruent to a high expert panel rating of importance. Nineteen of 67 KIs had a low level of adherence in spite of a high level of importance according to expert consensus. However, inadequate documentation proved an important issue, hampering true guideline adherence assessment. Adherence ranged between 3 and 100% for single KI items and on average, patients received 72% of the integrated expert panel recommended care set. CONCLUSIONS: Guideline adherence to an expert panel predefined care set in DBD donor management proved moderate leaving substantial room for improvement. An importance-performance analysis can be used to improve implementation and documentation of guidelines. ispartof: JOURNAL OF CRITICAL CARE vol:49 pages:56-63 ispartof: location:United States status: published

Objectives: Prolonged emergency department to ICU waiting time may delay intensive care treatment, which could negatively affect patient outcomes. The aim of this study was to investigate whether emergency department to ICU time is associated with hospital mortality. Design, Setting, and Patients: We conducted a retrospective observational cohort study using data from the Dutch quality registry National Intensive Care Evaluation. Adult patients admitted to the ICU directly from the emergency department in six university hospitals, between 2009 and 2016, were included. Using a logistic regression model, we investigated the crude and adjusted (for disease severity; Acute Physiology and Chronic Health Evaluation IV probability) odds ratios of emergency department to ICU time on mortality. In addition, we assessed whether the Acute Physiology and Chronic Health Evaluation IV probability modified the effect of emergency department to ICU time on mortality. Secondary outcomes were ICU, 30-day, and 90-day mortality. Interventions: None. Measurements and Main Results: A total of 14,788 patients were included. The median emergency department to ICU time was 2.0 hours (interquartile range, 1.3-3.3 hr). Emergency department to ICU time was correlated to adjusted hospital mortality (p 3.7 hr), both compared with the reference category ( 2.4 hr) is associated with increased hospital mortality after ICU admission, mainly driven by patients who had a higher Acute Physiology and Chronic Health Evaluation IV probability. We hereby provide evidence that rapid admission of the most critically ill patients to the ICU might reduce hospital mortality.

Objective: To investigate experienced and preferred prenatal counseling among parents of extremely premature babies.Methods: A Dutch nationwide, multicenter, cross-sectional study using an online survey. Surveys were sent to all parents of extremely premature babies born between 2010 and 2013 at 24(+0/7)-24(+)(6/7) weeks of gestation.Results: Sixty-one out of 229 surveys were returned. A minority (14%) had no counseling conversation. Conversations were done more often by neonatologists (90%) than by obstetricians (39%) and in 37% by both these experts. Supportive material was rarely used (19%). Mortality (92%) and short-term morbidity (88%) were discussed the most, and more frequently than long-term morbidity (65%), practical items (63%) and delivery mode (52%). Most decisions on active care or palliative comfort care were perceived as decisions by doctor and parents together (61%). 80% felt they were involved in decision-making. The preferred way of involvement in decision-making varied among parents.Conclusion: The vast majority of parents were counseled: mostly by neonatologists, and mainly about mortality and short-term morbidity. Parents wanted to be involved in the decision-making process but differed on the preferred extent of involvement.Practice implications Understanding of shared decision-making may contribute to meet the various preferences of parents. (C) 2018 Elsevier B.V. All rights reserved.

Objective: Resilience associated with empathy and increases nurses’ job satisfaction and reduces burnout. This study aimed to determine the relationship between resilience and empathic tendencies of nurses working in the psychiatry service. Methods: This study is descriptive and correlational. The study was conducted with 101 nurses working in a psychiatric state hospital between May 2017 and June 2017. Study data were collected using an information form, Resilience Scale for Adults, and Empathic Tendency Scale. Statistical analysis was conducted using frequency, mean, and Pearson’s and Spearmen’s correlation analyses. Results: Nurses’ resilience and empathic tendencies were above the median (126.8416.09) and 70.037.89), respectively. A highly linear relationship was found between resilience and social resources subscales. A positive, weak-moderate level, linear relationship was found between the scores of resilience and empathic tendency scales. A linear relationship was found between empathic tendency and perception of future, social competence, and social resources. No linear relationship was found between structured style, perception of self, or family cohesion. Multiple linear regression analysis found that the social competence subscale was the variable that predicted the Empathic Tendency Scale score. Conclusion: The study detected that nurses with higher social support were more resilient, and social competence, a subscale of resilience, was effective in the nurses’ empathic tendencies. It is recommended to improve nurses’ social competences and support systems through practices that will improve the quality of the interaction between the patient and nurse, and nurses’ empathy and resilience, which have significant effects on the patients’ recovery time.

IntroductionHospitalised paediatric oncology patients are at risk to develop acute complications. Early identification of clinical deterioration enabling adequate escalation of care remains challenging. Various Paediatric Early Warning Systems (PEWSs) have been evaluated, also in paediatric oncology patients but mostly in retrospective or case–control study designs. This study protocol encompasses the first prospective cohort with the aim of evaluating the predictive performance of a modified Bedside PEWS score for non-elective paediatric intensive care unit (PICU) admission or cardiopulmonary resuscitation in hospitalised paediatric oncology patients.Methods and analysisA prospective cohort study will be conducted at the 80-bed Dutch paediatric oncology hospital, where all national paediatric oncology care has been centralised, directly connected to a shared 22-bed PICU. All patients between 1 February 2019 and 1 February 2021 admitted to the inpatient nursing wards, aged 0–18 years, with an International Classification of Diseases for Oncology (ICD-O) diagnosis of paediatric malignancy will be eligible. A Cox proportional hazard regression model will be used to estimate the association between the modified Bedside PEWS and time to non-elective PICU transfer or cardiopulmonary arrest. Predictive performance (discrimination and calibration) will be assessed internally using resampling validation. To account for multiple occurrences of the event of interest within each patient, the unit of study is a single uninterrupted ward admission (a clinical episode).Ethics and disseminationThe study protocol has been approved by the institutional ethical review board of our hospital (MEC protocol number 16-572/C). We adapted our enrolment procedure to General Data Protection Regulation compliance. Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.Trial registration numberNetherlands Trial Registry (NL8957).

Objectives To evaluate occurrence and risk factors for pneumonia in patients with deep odontogenic infection (OI). Materials and methods All patients treated for deep OIs and requiring intensive care and mechanical ventilation were included. The outcome variable was diagnosis of nosocomial pneumonia. Primary predictor variables were re-intubation and duration of mechanical ventilation. The secondary predictor variable was length of hospital stay (LOHS). The explanatory variables were gender, age, current smoking, current heavy alcohol and/or drug use, diabetes, and chronic pulmonary disease. Results Ninety-two patients were included in the analyses. Pneumonia was detected in 14 patients (15%). It was diagnosed on postoperative day 2 to 6 (median 3 days, mean 3 days) after primary infection care. Duration of mechanical ventilation (p = 0.028) and LOHS (p = 0.002) correlated significantly with occurrence of pneumonia. In addition, re-intubation (p = 0.004) was found to be significantly associated with pneumonia; however, pneumonia was detected in 75% of these patients prior to re-intubation. Two patients (2%) died during intensive care unit stay, and both had diagnosed nosocomial pneumonia. Smoking correlated significantly with pneumonia (p = 0.011). Conclusion Secondary pneumonia due to deep OI is associated with prolonged hospital care and can predict the risk of death. Duration of mechanical ventilation should be reduced with prompt and adequate OI treatment, whenever possible. Smokers with deep OI have a significantly higher risk than non-smokers of developing pneumonia. Clinical relevance Nosocomial pneumonia is a considerable problem in OI patients with lengthy mechanical ventilation. Prompt and comprehensive OI care is required to reduce these risk factors.

ObjectivesWe conducted a systematic literature review and meta-analysis of observational studies to investigate the association between diabetes, hypertension, body mass index (BMI) or smoking with the risk of death in patients with COVID-19 and to estimate the proportion of deaths attributable to these conditions.MethodsRelevant observational studies were identified by searches in the PubMed, Cochrane library and Embase databases through 14 November 2020. Random-effects models were used to estimate summary relative risks (SRRs) and 95% CIs. Certainty of evidence was assessed using the Cochrane methods and the Grading of Recommendations, Assessment, Development and Evaluations framework.ResultsA total of 186 studies representing 210 447 deaths among 1 304 587 patients with COVID-19 were included in this analysis. The SRR for death in patients with COVID-19 was 1.54 (95% CI 1.44 to 1.64, I2=92%, n=145, low certainty) for diabetes and 1.42 (95% CI 1.30 to 1.54, I2=90%, n=127, low certainty) for hypertension compared with patients without each of these comorbidities. Regarding obesity, the SSR was 1.45 (95% CI 1.31 to 1.61, I2=91%, n=54, high certainty) for patients with BMI ≥30 kg/m2compared with those with BMI 2and 1.12 (95% CI 1.07 to 1.17, I2=68%, n=25) per 5 kg/m2increase in BMI. There was evidence of a J-shaped non-linear dose–response relationship between BMI and mortality from COVID-19, with the nadir of the curve at a BMI of around 22–24, and a 1.5–2-fold increase in COVID-19 mortality with extreme obesity (BMI of 40–45). The SRR was 1.28 (95% CI 1.17 to 1.40, I2=74%, n=28, low certainty) for ever, 1.29 (95% CI 1.03 to 1.62, I2=84%, n=19) for current and 1.25 (95% CI 1.11 to 1.42, I2=75%, n=14) for former smokers compared with never smokers. The absolute risk of COVID-19 death was increased by 14%, 11%, 12% and 7% for diabetes, hypertension, obesity and smoking, respectively. The proportion of deaths attributable to diabetes, hypertension, obesity and smoking was 8%, 7%, 11% and 2%, respectively.ConclusionOur findings suggest that diabetes, hypertension, obesity and smoking were associated with higher COVID-19 mortality, contributing to nearly 30% of COVID-19 deaths.Trial registration numberCRD42020218115.

Purpose To describe nurse anesthetists’ experiences using smart glasses to monitor patients’ vital signs during anesthesia care. Methods Data was collected through individual semi-structured interviews with seven nurse anesthetists who had used smart glasses, with a customized application for monitoring vital signs, during clinical anesthesia care. Data was analyzed using thematic content analysis. Results An overarching theme became evident during analysis; Facing and embracing responsibility. Being a nurse anesthetist entails a great responsibility, and the participants demonstrated that they shouldered this responsibility with pride. The theme was divided in two sub-themes. The first of these, A new way of working, comprised the categories Adoption and Utility. This involved incorporating smart glasses into existing routines in order to provide safe anesthesia care. The second sub-theme, Encountering side effects, consisted of the categories Obstacles and Personal affect. This sub-theme concerned the possibility to use smart glasses as intended, as well as the affect on nurse anesthetists as users. Conclusion Smart glasses improved access to vital signs and enabled continuous monitoring regardless of location. Continued development and improvement, both in terms of the application software and the hardware, are necessary for smart glasses to meet nurse anesthetists’ needs in clinical practice. Copyright: CC BY 4.0© 2021 Romare et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Coronavirus disease-2019 (COVID-19) has very high rates of hospital-related transmission among healthcare workers (HCWs), mandating the need for careful intensive care unit (ICU) designing, optimization of staff resources, implementation of vigorous infection control practices, environmental disinfection, meticulous sample collection, and criteria for staff quarantine. Most of the ICUs are not designed to deal with airborne viral infections and require redesigning for the safety of HCWs and patients. Infection control practices related to the prevention of spread of COVD-19 are unique and are well described. The training of staff on infection control practices reduces the infection rate among HCWs significantly. Adequate staffing not only helps in infection control but also prevents burnout of the staff. In case of infection to HCW, the staff must be assessed systematically, and institute's infection control committee should guide for isolation period as well as return to work based upon standard recommendations. This article focuses on infection control and prevention measures required in ICU during the COVID-19 pandemic. How to cite this article: Sharma J, Nasa P, Reddy KS, Kuragayala SD, Sahi S, Gopal P, et al. Infection Prevention and Control for ICU during COVID-19 Pandemic: Position Paper of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(Suppl 5):S280–S289.

Objective Delayed response to clinical deterioration as a result of intermittent vital sign monitoring is a cause of preventable morbidity and mortality. This review focuses on the clinical impact of multi-parameter continuous non-invasive monitoring of vital signs (CoNiM) in non-intensive care unit patients. Design Systematic review and meta-analysis of primary studies. Embase, MEDLINE, HMIC, PsycINFO and Cochrane were searched from April 1964 to 18 June 2019 with no language restriction. Setting The search was limited to hospitalised, non-intensive care unit adult patients who had two or more vital signs continuously monitored. Participants All primary studies that evaluated the clinical impact of using multi-parameter CoNiM in adult hospital wards outside of the intensive care unit. Main outcome measures Clinical impact of multi-parameter CoNiM. Results This systematic review identified 14 relevant studies from 3846 search results. Five studies were classified as Group A – associations found between measured vital signs and clinical parameters. Nine studies were classified as Group B – comparison between clinical outcomes of patients with and without multi-parameter CoNiM. Vital signs data from CoNiM were found to associate with type of presenting complaint, level of renal function and incidence of major clinical events. CoNiM also assisted in diagnosis by differentiating between patients with acute heart failure, stroke and sepsis (with sub-clustering of septic patients). In the meta-analysis, patients on multi-parameter CoNiM had a 39% decrease in risk of mortality (risk ratio [RR] 0.61; 95% confidence interval [95% CI] 0.39, 0.95) when compared to patients with regular intermittent monitoring. There was a trend of reduced intensive care unit transfer (RR 0.86; 95% CI 0.67, 1.11) and reduced rapid response team activation (RR 0.61; 95% CI 0.26–1.43). A trend towards reduced hospital length of stay was also found using weighted mean difference (WMD –3.32 days; 95% CI -8.82–2.19 days). Conclusion There is evidence of clinical benefit in implementing CoNiM in non-intensive care unit patients. This review supports the use of multi-parameter CoNiM outside of intensive care unit with further large-scale RCTs required to further affirm clinical impact.