共找到 20 条结果
OBJECTIVE: To provide guidelines for admission, discharge, and triage of adult patients to the intensive care unit (ICU), based on expert opinion and the relevant literature. DATA SOURCES: Publications relevant to the admission, discharge, and triage of patients to the ICU were obtained from the medical literature. STUDY SELECTION: Not applicable. DATA EXTRACTION: Articles were reviewed and the relevant information extracted for analysis by an expert panel. DATA SYNTHESIS: The articles were reviewed and graded levels of recommendation made based on a rating system described in the text. CONCLUSIONS: Although little scientifically rigorous data exist validating the criteria for admission, discharge, and triage of adult patients to the ICU, current literature and expert opinion support guidelines to streamline the admission, discharge, and triage process.
Patients with voice, airway, and swallowing disorders are susceptible to psychological distress, loss of identity, and lack of agency. Trauma-informed care offers a framework for promoting safety, trust, empowerment, and collaboration, yet its relevance to laryngology nursing practice has not been systematically synthesized. To map and synthesize existing literature relevant to trauma-informed care in laryngology, with a specific focus on nursing practice across voice, airway, and swallowing care pathways. A scoping review was conducted in accordance with PRISMA-ScR guidelines. Searches of PubMed/MEDLINE, CINAHL, PsycINFO, and Scopus identified peer-reviewed English-language publications from January 2021 through December 2025. Reference lists of included studies and key reviews were hand searched to identify highly relevant trauma-informed laryngology publications from 2020. Eligible studies examined laryngology-related populations, reported patient- or caregiver-centered psychosocial or experiential outcomes, and demonstrated conceptual alignment with trauma-informed care principles, even when not explicitly labeled as such. Data were charted descriptively across care contexts, outcome domains, and alignment with the six Substance Abuse and Mental Health Services Administration trauma-informed care principles. Eighteen studies met inclusion criteria. Studies spanned acute, outpatient, and survivorship settings and addressed tracheostomy, laryngectomy, airway disorders, voice disorders, and dysphagia. Across studies, psychological distress, communication impairment, and perceived loss of control consistently co-occurred as an interrelated vulnerability cluster. All studies demonstrated implicit alignment with one or more trauma-informed care principles, most commonly safety and empowerment, voice, and choice. Peer support and cultural, historical, and gender considerations were less frequently addressed. Caregiver burden and identity disruption were prominent yet under-measured domains, particularly in survivorship contexts. The literature on trauma-informed care in laryngology spans multiple domains of otolaryngology, including voice, airway, and swallowing care. However, current evidence is insufficient to determine the efficacy of trauma-informed interventions in this context. Future work should evaluate the implementation and effectiveness of trauma-informed approaches across these areas of laryngologic practice.
BackgroundOut-of-hospital cardiac arrest (OHCA) is associated with high morbidity and mortality, often requiring complex decision-making in the intensive care unit (ICU). Palliative care may facilitate goal-aligned care but remains underutilized in this population.ObjectiveTo evaluate the impact of palliative care consultation on end-of-life decision-making and clinical outcomes in ICU patients following OHCA.MethodsWe conducted a mixed retrospective-prospective cohort study of 61 retrospective and 40 prospective adult patients admitted to the ICU after OHCA at a tertiary academic center. Patients were grouped by palliative care consultation. Primary outcomes were in-hospital mortality and ICU and hospital length of stay. Secondary outcomes included the proportion of patients with code status change, the timing of code status changes and withdrawal of life-sustaining treatment from ICU admission in both groups, and withdrawal of life-sustaining treatment. Illness severity was assessed using the Sequential Organ Failure Assessment (SOFA) score at ICU admission and at 72 hours.ResultsAmong 101 patients admitted after OHCA, 34 (33.7%) received a palliative care consultation. In-hospital mortality was higher among patients who received palliative care consultation than among those who did not (79.4% vs 41.8%; P = 0.0003). SOFA scores at ICU admission and at 72 hours were similar between patients seen by palliative care and those not seen by palliative care (P = 0.72 and P = 0.27, respectively). All patients who received a palliative care consultation (100%) had a change in code status during hospitalization, compared to 32.8% of those who did not (P < 0.0001). The time from ICU admission to withdrawal of life-sustaining treatment was significantly longer in the palliative care group (6.0 vs 3.0 days, P = 0.016), while the time to code status change was similar between groups (P = 0.415). There were no significant differences in ICU or hospital length of stay, or use of vasopressors, mechanical ventilation, or continuous renal replacement therapy. Among patients who received palliative care consultation, the most common interventions included goals-of-care clarification (85.3%), symptom management, and spiritual or emotional support.ConclusionIn ICU patients following OHCA, palliative care consultation was associated with higher in-hospital mortality despite similar baseline characteristics, illness severity by SOFA score, and treatment intensity, likely reflecting preferential consultation in patients with greater clinical complexity rather than a causal relationship. Palliative care consultation was strongly associated with goals-of-care redirection and a more deliberate process of end-of-life decision-making.
The artificial intelligence (AI) literacy of intensive care nurses and their behaviors in interacting with AI is crucial for evaluating the impact of AI on patient care and treatment. The aim of this study is to determine the AI literacy levels of intensive care nurses, their attitudes toward AI technologies, and the factors associated with these attitudes. The sample for this cross-sectional study consisted of 280 nurses working in the intensive care units of two hospitals. Data were collected face-to-face using a Personal Information Form, an Artificial Intelligence Literacy Scale (AILS), and an Artificial Intelligence Attitude Scale (AIAS-4). Descriptive statistics, Pearson correlation, independent samples t-test, one-way ANOVA, and multiple linear regression analyses were used to analyze the data. The mean age of the participants was 33.47 ± 7.12. 63.9% of the nurses were female, 48.9% were married, and 72.1% had a bachelor's degree or higher. The vast majority of nurses (96.4%) had not received any training in AI, and 50% had no experience in this field. The mean AIAS-4 score of intensive care nurses was 6.26 ± 2.74 (min = 1, max = 10) and the mean AILS score was 39.87 ± 6.69 (min = 16, max = 60). The results indicated a strong, positive, and statistically significant correlation between AIAS-4 and AILS (r = 0.72, p < 0.05). Among the variables included in the model, AILS score, age, gender, marital status, and education level were found to be statistically significant predictors (p < 0.05), explaining 64% of the variance (Adj. R2 = 0.640; F = 100.383; p < 0.001). In conclusion, the regression model revealed that age was a significant predictor, and individuals aged 36 and over had more negative attitudes toward AI technologies. In contrast, higher levels of AI literacy, male gender, being single, and having a bachelor's degree or higher were found to be significant positive predictors of attitudes toward AI technologies. It is recommended that practice-based training programs emphasizing clinical benefits, aimed at improving AI literacy and attitudes toward AI technologies among intensive care nurses, be expanded.
Sedation is a fundamental component of critical care and requires regular, accurate assessment to support its safe titration and minimise harm. International guidelines and local policy at the Wythenshawe Hospital's Cardiothoracic Critical Care Unit mandate hourly documentation of the Richmond Agitation-Sedation Scale (RASS). This audit evaluated adherence to these standards and explored factors associated with documentation completeness and assessment accuracy. A prospective, cross-sectional audit of bedside RASS assessment was conducted without prior notification. Nursing RASS scores were compared with expert auditor ratings. Data were collected using an anonymous, secure, auditor-completed online survey. Statistical analysis examined the relationship between documentation completion and RASS accuracy. Seventy-six nursing assessments were included. Most nurses were Band 5, with a median of 3.5 years of experience. Patients were predominantly male, mechanically ventilated and receiving sedation. Overall, 75% of nurse RASS assessments (n = 57) were accurate; however, only 33% (n = 25) were documented hourly as required by policy. Greater nursing experience was associated with improved accuracy in RASS. Deeper sedation was associated with lower agreement between nurse and expert assessments. Higher self-reported confidence was associated with poorer completion of documentation. Most discrepancies were small, with nurse and expert ratings differing by one RASS point. This audit identified important gaps in the accuracy and documentation of nurse-led RASS assessment in a cardiothoracic critical care setting. The findings suggest that perceived familiarity and confidence may not be sufficient to ensure accurate and consistently documented sedation assessment. Suboptimal RASS documentation and scoring accuracy may limit reliable titration of sedation in critically ill patients and reduce the effectiveness of protocolised sedation strategies. These findings support targeted staff education, reinforcement of standardised assessment processes and improvements in documentation systems to strengthen sedation monitoring and patient safety.
The transition from intensive care units to general wards is a critical and stressful phase in patient recovery, often associated with adverse psychological and clinical outcomes. Relocation Stress Syndrome (RSS) is a recognized condition resulting from this transition, highlighting the need for valid and culturally adapted assessment tools to accurately measure patient stress and guide nursing interventions. This methodological study was conducted to adapt and validate the Persian version of the Relocation Stress Syndrome Scale-Short Form (RSSS-SF). The final Persian version was administered to 155 patients who had been transferred from intensive care units (ICUs) to general wards in Tehran hospitals. Data were analyzed using IBM SPSS 29 and AMOS 24.Item-total correlations, Cronbach's alpha coefficients, and exploratory factor analysis (EFA) were conducted to examine internal consistency and factor structure. Confirmatory factor analysis (CFA) was subsequently performed to test the goodness-of-fit of the model. Model fit indices (χ²/df, CFI, GFI, AGFI, IFI, and RMSEA) and reliability coefficients were evaluated according to standard psychometric criteria. Exploratory factor analysis supported a three-factor structure for the Persian version of the RSSS-SF, explaining 57.97% of the total variance. The Kaiser-Meyer-Olkin value (0.74) and Bartlett's test of sphericity (χ² = 419.33, p < .001) confirmed sampling adequacy. Confirmatory factor analysis demonstrated acceptable model fit (χ²/df = 2.13, CFI = 0.91, RMSEA = 0.07). The overall internal consistency of the scale was acceptable. (Cronbach's α = 0.83). In summary, the Persian version of the RSSS-SF demonstrated satisfactory validity and reliability, generally supporting the factorial structure of the original instrument. The scale is a practical and culturally appropriate tool for assessing relocation stress among Iranian ICU patients and can facilitate the development of patient-centered, family-integrated nursing strategies to improve post-transfer adaptation and recovery. This study was approved by the Research Ethics Committee of the Tehran University of Medical Sciences, School of Nursing and Midwifery (Ethics Code: IR.TUMS.FNM.REC.1404.026). All participants were fully informed regarding the study objectives and procedures, and written informed consent was obtained prior to participation. Participation was voluntary, and confidentiality and anonymity of the collected data were assured. The study adhered to the principles of the Declaration of Helsinki. Not applicable. Data collection for this study was conducted between June 2025 and November 2025. All 155 participants completed the Persian short-form RSSS during the study period.
Survivors of critical illness and their caregivers often experience a complex constellation of sequelae in the aftermath of their recovery, termed post-intensive care syndrome (PICS) and PICS-Family (PICS-F), respectively. These can have a dire impact on patients and families, and thus require coordinated rehabilitative efforts. However, optimal modes of providing support services remain unclear, with traditional clinic-based strategies showing mixed results. This scoping review aimed to summarize the feasibility and effectiveness of nonclinic-based follow-up and rehabilitation strategies for adult survivors of critical illness and their caregivers. Databases were searched on July 8, 2025, and included Cochrane, Embase, PubMed, and Web of Science. Studies reporting interventions and follow-up options for adult survivors of critical illness requiring ICU stay and targeting PICS and PICS-F were included. Studies examining interventions in the outpatient clinic or ICU settings exclusively were excluded. Two team members used Covidence to screen all the deduplicated citations, with a third team member acting as a tiebreaker. The studies included were reviewed in full to extract general data, the studied syndrome (PICS, PICS-F, or both), component of PICS studied, study population, study objectives, methods, inclusion and exclusion criteria, intervention details, general results, and study conclusions. We screened 8608 studies; 45 studies met criteria and were included in this review. Most (64%) focused on the physical and psychological sequelae of PICS. Interventions varied widely, by setting, duration, and approach. Outcome measures were heterogeneous, limiting comparisons. Most studies evaluated the feasibility of interventions and not effectiveness. Only six articles targeted PICS-F exclusively. This scoping review summarizes the status of different nonclinic-based follow-up and rehabilitation strategies for adult ICU survivors. Future research focused on studies that evaluate effectiveness of these strategies in mitigating the burden of PICS and PICS-F, especially within the cognitive domain, is likely to improve aftercare for both patients and their families.
Due to lack of human, physical, and infrastructural resources, most critically ill children in Honduras are cared for by general pediatricians outside of pediatric intensive care units, stressing the need to address the education of this critical group. To understand the educational needs of pediatric trainees in Honduras related to the care of critically ill children, and the impact of the local context to inform future curriculum development. We conducted a needs assessment with a sequential explanatory mixed methods design from 2023 to 2025. Participants included pediatric residents, graduates, and faculty of the 2 pediatric residency programs. Data on essential critical care knowledge and skills, educational needs, and educational strategies was collected through electronic surveys and semistructured virtual interviews. Quantitative data were analyzed using descriptive statistics, and qualitative data, with rapid matrix analysis. Forty-five of 96 (47%) residents and 47 of 91 (52%) pediatricians completed the survey; 5 graduates participated in subsequent interviews. Only 69% of graduating residents (11 of 16) and attendings (33 of 48) felt moderately to extremely confident assessing critically ill children. Both surveyed groups considered all preidentified critical care diagnoses extremely important in their education, yet frequency of treatment, confidence with management, and degree of training were variable. Perceived confidence was dependent on knowledge, skills, available resources, and ability to adapt to constraints. Experiential and self-directed learning are key strategies in their education. Our findings revealed that teaching that builds adaptive expertise and self-directed learning skills is essential for pediatric trainees in Honduras.
Preclinical identification of the underlying causes in emergency patients with predominant disability (D)-problem is often unreliable, leading to misallocation and capacity issues in intensive care and stroke units. To address these challenges, the management of these patients, including acute stroke care, is increasingly shifting to emergency departments or emergency centers. This results in a higher proportion of patients with D‑problems requiring immediate evaluation within the framework of a non-traumatological resuscitation room; however, a standardized care concept for this patient group in the non-traumatological resuscitation room is lacking. To optimize time-critical acute care for emergency patients with predominant D‑problems in the non-traumatological resuscitation room, the "neurological emergency receiving team" (NERT) was established at the University Emergency Department of the University Hospital Freiburg. The NERT concept aims to enable rapid and systematic evaluation and treatment of patients with acute focal neurological deficits and/or unexplained impairment of consciousness through predefined diagnostic and therapeutic pathways. A specialized team was formed comprising experts from neurology, emergency medicine and emergency nursing. In close collaboration with (neuro)radiologists experienced in emergency diagnostics, the team provides acute in-hospital care for this time-sensitive patient population. This article describes the team's composition, responsibilities, and workflow within the NERT concept. The NERT concept enables rapid and standardized management of patients with predominant D‑problems. Interdisciplinary and interprofessional collaboration improves the time to diagnosis and initiation of treatment while reducing the risk of misallocation. The NERT concept represents a feasible model for delivering efficient and high-quality emergency care to patients with D‑problems in the non-traumatological resuscitation room. HINTERGRUND: Die präklinische Zuordnung der Ursachen bei Notfallpatient*innen mit führenden D(Disability)-Problemen ist oft unzuverlässig, was zu Fehlbelegungen und Kapazitätsproblemen auf Intensivstationen und Stroke Units führt. Um diesen Problemen zu begegnen, erfolgt die Versorgung dieser Patient*innen inklusive der Schlaganfallakutversorgung zunehmend in zentralen Notaufnahmen oder Notfallzentren. Dies führt auch zu einem höheren Anteil von Patient*innen mit D‑Problemen mit Schockraumindikation. Es fehlt jedoch ein Konzept zur standardisierten Versorgung dieser Patient*innengruppe im nichttraumatologischen Schockraum. Um die zeitkritische Akutversorgung bei Notfallpatient*innen mit führendem D‑Problem im Rahmen des nichttraumatologischen Schockraumkonzepts zu optimieren, wurde am Universitäts-Notfallzentrum des Universitätsklinikums Freiburg das „Neurological Emergency Receiving Team“ (NERT) etabliert. Ziel des NERT-Konzepts ist es, Patient*innen mit akuten fokal-neurologischen Defiziten und/oder einer unklaren Vigilanzminderung rasch und standardisiert mit festgelegten diagnostischen und therapeutischen Pfaden zu versorgen. Es wurde ein spezialisiertes Team aus den Fachbereichen Neurologie, klinische Akut- und Notfallmedizin und Notfallpflege gebildet, welches zusammen mit in der Notfalldiagnostik erfahrenen (Neuro‑)Radiologen die innerklinische Akutversorgung dieser zeitkritischen Patient*innengruppe übernimmt. Die vorliegende Arbeit beschreibt Zusammensetzung, Aufgaben und Abläufe des NERT-Konzepts. Das NERT gewährleistet eine schnelle und standardisierte Versorgung der Patient*innen mit führendem D‑Problem. Die interdisziplinäre und interprofessionelle Zusammenarbeit optimiert die Zeit bis zur Diagnose und Therapieeinleitung und minimiert das Risiko von Fehlbelegungen. Das NERT-Konzept zeigt eine Möglichkeit, wie im nichttraumatologischen Schockraum die Akutversorgung von Patient*innen mit D‑Problem schnell und qualitativ hochwertig ablaufen kann.
The Emergency Critical Care Program (ECCP) utilizes an ECC attending with dual board certification in Emergency Medicine and Critical Care Medicine providing longitudinal care for MICU patients in the ED after initial resuscitation by the ED team during ECCP hours (2 pm to midnight, weekdays). It is unclear which admission diagnoses of critically ill ED patients are most responsive to the ECCP regarding timely ED downgrades to mitigate ICU overcrowding. This single-center retrospective cohort study included adult ED patients with initial admission orders to the MICU or ECC service between 2015 and 2019. Our primary outcome was the proportion of patients who received a transfer order to a non-ICU service within six hours of their critical care admission order while still in the ED ("Early ED Downgrades"), stratified by admission diagnosis category and adjusted by illness severity. A difference-in-differences analysis compared the change in proportion of "Early ED Downgrades" between the preintervention period (2015-2017) and the intervention period (2017-2019) relative to non-ECCP hours. Our cohort included 1882 patients (mean age 63 years, 53.2% male). The ECCP was associated with a 19.0% (95% CI, 13.0% - 25.0%) increase in severity-adjusted Early ED Downgrades. By diagnosis, significant increases were seen in Respiratory (22.9%; 95% CI, 11.0% - 34.9%), Sepsis (14.2%; 95% CI, 3.0% - 25.5%), and Renal (43.0%; 95% CI, 7.4% - 78.5%) categories. No increases in mortality or transfers to the MICU within 24 h of the downgrades were observed. The ECCP significantly increased Early ED Downgrades, particularly for Respiratory, Sepsis and Renal diagnosis categories, optimizing ICU resources without compromising patient safety.
Near-death experiences occur in approximately 15% of intensive care unit survivors. Despite their profound impact on post-intensive care syndrome and long-term psychological recovery, near-death experiences remain under-addressed in clinical settings. To systematically map and synthesize evidence regarding the subjective experiences, influencing factors, assessment tools, and prognostic impacts of near-death experiences in adult intensive care unit patients, aiming to provide a comprehensive overview and solid reference for clinical identification and future research. Scoping review. Guided by a scoping review framework, a systematic literature search was conducted across PubMed, Embase, Web of Science, CINAHL, the Cochrane Library, PsycINFO, China National Knowledge Infrastructure, Wanfang Database, and VIP Database, from database inception to April 17, 2026. Data from the included literature were subsequently extracted and synthesized. Seven included studies (five prospective cohorts, one qualitative, one mixed-methods) revealed that adult intensive care unit patients experience multidimensional near-death experiences (cognitive, affective, supernatural, and transcendental). The Greyson near-death experience scale is the primary, albeit limited, assessment tool. Prognostically, near-death experiences produce vivid, stable long-term memories and elevate spiritual needs; however, their impacts on psychosocial states and death attitudes remain heterogeneous. The near-death experiences of adult intensive care unit survivors constitute a unique and multidimensional subjective experience, the understanding of which requires both optimized assessment tools and a deeper integration of neurobiological and psychological frameworks. While increased religious interest and memory stability are evident, the persistent contradictions in psychosocial outcomes suggest that specific disease trajectories and cultural factors play a critical moderating role. Within clinical intensive care unit practice, it is paramount to promptly identify near-death experiences by evaluating patients' multifaceted subjective experiences and providing proactive, effective support, as this plays a critical role in facilitating psychological recovery and improving long-term prognosis.
The mortality rate among patients in the intensive care units (ICUs) with severe community-acquired pneumonia (CAP) is high. Identification of severe CAP early in the course and transferring to appropriate setting seem favorable. This study aimed to identify clinical characteristics and the risk factors associated with mortality of severe CAP in the ICU (ICU-CAP). A multi-center, prospective study was conducted at 11 teaching hospitals in China from December 2017 to October 2021. Patients who met the inclusion criteria were assigned to the ICU group and the non-ICU group according to whether they were admitted to the ICU. A total of 170 patients with severe CAP were included, 111 patients were admitted to the ICU and 59 patients were admitted to the ward. Among patients in the ICU, 91.9% of patients were with respiratory failure, 65.8% of patients with consciousness disturbance, 23.4% were in shock state, and 73.0% (81/111) of patients had at least one comorbidity. In-hospital mortality for ICU-CAP was 34.2% (38/111), 28-day mortality was 27.9% (31/111), and 7-day mortality was 10.8% (12/111). Mortality in patients with pneumonia severity index class V (PSI-V) was 40.0% (18/45), mortality in patients with invasive mechanical ventilation was 40.2% (33/82). In the ICU subgroup, invasive mechanical ventilation [odds ratio (OR) =3.35; 95% confidence interval (CI): 1.14-9.81; P=0.02] and age ≥60 years (OR =2.64; 95% CI: 1.07-6.53; P=0.03) were independently associated with in-hospital mortality. In this multicenter prospective cohort, severe CAP patients admitted to the ICU exhibited substantial disease severity, with high rates of treatment failure and mortality. Invasive mechanical ventilation and age ≥60 years were associated with in-hospital mortality in the ICU subgroup.
This review examines the importance of optimizing protein delivery during and in the convalescence of critical illness, with a focus on the challenges associated with individual protein dosing strategies. Muscle mass depletion often begins within the first days of intensive care unit (ICU) admission, emphasizing the need for adequate protein intake. However, many ICU patients fail to meet recommended targets. Large-scale studies have shown mixed results on high-protein intake, with some suggesting no added benefit or even harm in certain groups. This review highlights the need for individualized protein dosing guided by phenotyping and endotyping and discusses the challenges in assessing body composition, illustrated by a case study. The potential role of biomarkers in optimizing protein dosing is also explored, alongside factors that hinder adequate protein intake. Further research is needed to determine the optimal protein strategy for critically ill patients, with a focus on enhancing functional outcomes and quality of life, particularly for survivors who face long-term physical and cognitive challenges. Future guidelines should incorporate individualized approaches, leveraging emerging technologies and patient-centred data to tailor protein delivery and enhance recovery outcomes.
This scientific review explores the intricate bidirectional relationship (crosstalk) between thyroid dysfunction and kidney dysfunction within the context of the intensive care unit (ICU). We discuss how critical illness and acute kidney injury (AKI) lead to thyroid dysregulation, specifically focusing on the high prevalence of non-thyroidal illness syndrome (NTIS) and low triiodothyronine (T3) levels in patients with renal impairment. Mechanisms such as altered deiodinase activity and selenium deficiency are highlighted. The article elucidates the impact of thyroid hormones on renal physiology: hypothyroidism is associated with reduced renal blood flow and glomerular filtration rate (GFR), potentially delaying AKI recovery, while hyperthyroidism induces glomerular hyperfiltration. Furthermore, we address the complexities introduced by renal replacement therapy (RRT), which can alter thyroid hormone kinetics. Recognizing this reciprocal interplay is crucial for intensivists to accurately interpret thyroid function tests and manage renal complications in critically ill patients.
The World Health Organization recommends surveillance, including audits with case reviews of severe maternal morbidities such as eclampsia, to improve obstetric outcomes. We aimed to audit eclampsia and to identify learning opportunities in eclampsia care in Norway. Our study population included all women discharged with a diagnosis of eclampsia (ICD-10: O15) and with a documented generalized seizure in medical records at two university hospitals in Norway from 2013 to 2022. An eclampsia working group developed a digital eclampsia case report form for gathering clinical information from medical records. Based on a structured summary of information from the digital case report form, the group reviewed the care for women with eclampsia. Each case was discussed and reviewed according to the clinical guidelines by the group. Learning opportunities to improve care were identified and classified according to whether they contributed to the outcome. Among 93 139 deliveries, 22 women with an initial eclampsia diagnosis were identified (2.4 per 10 000). Subsequent clinical information identified an alternative probable etiology of seizures in five women. None of the 22 women received magnesium sulfate prior to the seizure, and cerebral imaging was performed in 11 of 22 women. In 18 women, learning opportunities were identified, and for eight women, a different management could potentially have prevented eclampsia. The eclampsia working group identified learning opportunities related to underuse of magnesium sulfate prophylaxis when indicated, inadequate management of hypertension both before and after eclamptic seizure, underuse of cerebral imaging as a diagnostic tool, and lack of follow-up consultation with an obstetrician in women diagnosed with eclampsia. Learning opportunities were found in 18 of 22 women, and improvements in care could potentially have changed the outcome for eight of the women. This audit highlights the importance of differential diagnostic consideration for seizures in pregnant and postpartum women, the use of prophylactic magnesium sulfate when indicated, and the diagnosis and management of hypertension in pregnancy. Eclampsia audits should be incorporated into national routine surveillance and learning systems to improve obstetric care.
Approximately 125,000 school-age children are admitted to pediatric intensive care units (PICUs) in the United States annually. These children are at risk for post-intensive care syndrome in pediatrics (PICS-p) as they reintegrate into their communities. School nurses are uniquely positioned to care for children recovering from critical illness, yet little is known about their comfort and knowledge in post-PICU care. We conducted an online survey of United States-based school nurses. Surveying school nurse demographics, clinical characteristics of the children they cared for, post-PICU clinical information received, and their comfort and knowledge of caring for children post-PICU. Seventy-nine (N = 79) school nurses completed the survey. More than half of nurses (54%) cared for a child who was hospitalized in the PICU during the prior academic year. Over a third (35%) did not receive any discharge summary/written instructions, and only 21% spoke with the child's medical provider before returning to school. While most felt comfortable caring for a recovering child, less than 5% were aware of PICS-p. Most school nurses (91%) expressed interest in learning more about PICS-p, specifically the framework (81%), which includes physical, cognitive, social, emotional, and family impact domains, and screening of at-risk children (53%). Most school nurses are unfamiliar with PICS-p. There are opportunities to improve processes to ensure school nurses receive adequate discharge information and education on PICS-p. Increased awareness regarding PICS-p and its recovery implications may improve school nurses ability to support children upon return to school following PICU hospitalization.
The prognostic value of the modified Nutrition Risk in the Critically Ill (mNUTRIC) score in patients with severe and critical Coronavirus disease 2019 (COVID-19) remains insufficiently defined. This study aimed to assess the predictive performance of the mNUTRIC score for in-hospital mortality in patients with severe and critical COVID-19 admitted to the intensive care unit. We conducted a retrospective cohort study including 355 critically ill patients with severe and critical COVID-19 admitted to a university-affiliated hospital in Vietnam. The mNUTRIC score was calculated using the first available clinical and laboratory values recorded within the first 24 hours of intensive care unit admission. The primary outcome was in-hospital mortality. Associations between the mNUTRIC score and mortality were assessed using multivariable logistic regression. Predictive performance was evaluated using the area under the receiver operating characteristic curve (AUC). Overall in-hospital mortality was 36.1%. High nutritional risk, defined as an mNUTRIC score ≥5, was identified in 29.6% of patients. In multivariable analysis, the mNUTRIC score remained independently associated with in-hospital mortality (adjusted odds ratio 1.58, 95% confidence interval 1.24-2.02; P < .001). The mNUTRIC score demonstrated moderate discriminative performance for predicting in-hospital mortality, with an AUC of 0.750 (95% confidence interval 0.698-0.803; P < .001). At the optimal cutoff value of ≥4.5, the sensitivity and specificity for predicting in-hospital mortality were 54.7% and 84.6%, respectively. In critically ill patients with severe and critical COVID-19, the mNUTRIC score was associated with in-hospital mortality and demonstrated moderate prognostic performance. Given the retrospective design, these findings should be interpreted with caution and warrant further prospective validation.
Candidemia is a life-threatening invasive fungal infection, particularly in patients admitted to intensive care units (ICUs). Epidemiology of candidemia and antifungal resistance have been significantly affected in COVID-19 pandemic. We analysed candidemia cases in neonatal, paediatric, and adult ICUs at Hippokration General Hospital in Thessaloniki, Greece (site 1) and Kayseri City Training and Research Hospital in Kayseri, Türkiye (site 2) from January 2020 to December 2023. Epidemiology, species distribution, and antifungal susceptibility of cases were compared. A total of 388 patients from site 1 and 379 patients from site 2 were included. A significant increase in the incidence of candidemia was observed in both hospitals during the COVID-19 pandemic. Candida parapsilosis was the most common species in all ICUs at Site 1, while Candida albicans was predominant at Site 2. C. parapsilosis became the most frequent species at Site 2 after 2021. C. glabrata was isolated more frequently in Site 1, whereas C. tropicalis was more frequently isolated in Site 2. A total of 14 C. auris strains were isolated, 13 of which were at the site 1. Over 90% of C. albicans strains were fluconazole-sensitive, but resistance was high in C. parapsilosis strains (47% at the site 1 and 40% at the site 2). C. parapsilosis and C. albicans remained the most common species, but their distributions varied between the two locations and over time. The high fluconazole resistance in C. parapsilosis causes a significant challenge for treatment. These findings highlight the necessity of continuous epidemiological surveillance to ensure appropriate antifungal treatment in different geographical regions.
Objectives: To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005. Design: Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland). Setting: Nonfederal, acute care hospitals with critical care medicine beds in the United States. Subjects: None. Interventions: None. Measurements and Main Results: We analyzed hospital and critical care medicine beds, bed types, days, occupancy rates, payer mix (Medicare and Medicaid), and costs. Critical care medicine costs were compared with national cost indexes. Between 2000 and 2005, the total number of U.S. hospitals with critical care medicine beds decreased by 12.2% (from 3,586 to 3,150). Although the number of hospital beds decreased by 4.2% (from 655,785 to 628,409), both hospital days and occupancy rates increased by 5.1% (from 145.1 to 152.5 million) and 13.7% (from 59% to 67%), respectively. Critical care medicine beds increased by 6.5% (from 88,252 to 93,955), days by 10.6% (from 21.0 to 23.2 million), and occupancy rates by 4.5% (from 65% to 68%). The majority (90%) of critical care medicine beds were classified as intensive care, premature/neonatal, and coronary care unit beds. The percentage of critical care medicine days used by Medicare decreased by 3.8% (from 37.9% to 36.5%) compared with an increase of 15.5% (from 14.5% to 16.8%) by Medicaid. From 2000 to 2005, critical care medicine costs per day increased by 30.4% (from $2698 to $3518). Although annual critical care medicine costs increased by 44.2% (from $56.6 to $81.7 billion), the proportion of hospital costs and national health expenditures allocated to critical care medicine decreased by 1.6% and 1.8%, respectively. However, the proportion of the gross domestic product used by critical care medicine increased by 13.7%. In 2005, critical care medicine costs represented 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product. Conclusions: Critical care medicine continues to grow in a shrinking U.S. hospital system. The critical care medicine payer mix is evolving, with Medicaid increasing in its percentage of critical care medicine use. Critical care medicine is more cost controlled than other healthcare indexes, but is still using an increasing percentage of the gross domestic product. Our updated and comprehensive critical care medicine use and cost analysis provides a contemporary benchmark for the strategic planning of critical care medicine services within the U.S. healthcare system.
Critical illness often causes prolonged weakness, possibly due to impaired skeletal muscle regeneration, but the timing and nature of satellite cell (SC) dysfunction remain unclear. We aimed to determine whether SC depletion and dysfunction are detectable early after intensive care unit admission and describe their pathophysiological nature. In this prospective single-centre observational cohort study, mechanically ventilated adults underwent paired vastus lateralis biopsies within 72 h of ICU admission and again after 7 and 180 days. Isolated satellite cells were studied for proliferation, differentiation and fusion, mitochondrial morphology, respiratory function, substrate oxidation, and selected signalling proteins. We enrolled 20 healthy control subjects and 33 ICU patients. Twenty three ICU patients survived to day 7 with a repeat biopsy. During 7 days in ICU, the patient developed profound weakness (MRC score 16 [0-32]) and insulin resistance (whole body glucose disposal 4.0 [3.5-5.1] versus 13.8 [8.8-16.1] mg/kg/min in controls). Satellite cell number per fibre was similar in controls and patients at admission (0.106 [0.085-0.129] vs. 0.098 [0.056-0.125]) and after 7 days (0.084 [0.066-0.117]; paired p = 0.784). SC proliferation was lower in older patients (ρ=-0.68 and - 0.49) and associated with lower muscle strength (ρ = 0.55 and 0.62). Myogenic differentiation was transiently impaired at day 0 (fusion index 68.9% [66.3-71.7] vs. 74.0% [70.3-77.1] in controls; p = 0.029). Satellite cell bioenergetics and substrate preferences were broadly preserved. In contrast, a more fragmented mitochondrial phenotype was associated with lower proliferation, lower respiratory performance, and worse muscle strength (ρ≈-0.6 to -0.8), whereas more interconnected morphology was associated with better function (ρ ≈ 0.6-0.7). Out of 10 ICU survivors at day 180, only 7 attended follow up. In those, impaired SF-36 physical score (62.5 [55.0 to 75.0]) and SC proliferation capacity (~50 %), contrasted with improved insulin sensitivity and SC number per fiber (~71 % and ~95% of control values, respectively). Critical illness was associated with disturbed satellite cell regenerative programming and altered mitochondrial remodelling rather than early depletion of the satellite cell pool or overt bioenergetic failure. Age was a stronger predictor of early satellite cell dysfunction than disease severity. ClinicalTrials.gov, NCT05671614. Registered 4 January 2023.