Protocol for a randomised controlled trial of nasal high flow oxygen therapy compared to standard care in patients following cardiac surgery: the HOT-AS study

BackgroundPostoperative respiratory complications following cardiac surgery may increase morbidity, mortality and length of stay. Non-invasive respiratory support therapies can be used prophylactically or curatively to reduce respiratory complications. One system, nasal high flow oxygen therapy, is in use in many intensive care units (ICUs) however there is a lack of information regarding its clinical utility and efficacy.ObjectivesThis paper outlines the study protocol and methodology for a study designed to determine if the prophylactic use of nasal high flow oxygen therapy can improve pulmonary function in patients following cardiac surgery.Methods/designA prospective randomised controlled trial will be conducted of adult patients scheduled for cardiac surgery and admitted to the Cardiothoracic Intensive Care Unit of a tertiary hospital. Study participants will be assigned to receive either nasal high flow or standard oxygen therapy (oxygen therapy at 2–4 L/min via either simple facemask or nasal cannulae) at extubation. The primary outcome measure is improved pulmonary function demonstrated by SpO₂/FiO₂ ratio >445 on post-operative day 3. Secondary outcome measures include atelectasis score on chest X-ray; spirometry; readmission to ICU for respiratory causes; ICU and hospital length of stay; mortality and incidence of respiratory complications at day 28; oxygenation variables; use of adjunctive respiratory support therapies; escalation of respiratory support; adverse events and patient comfort during administration of oxygen therapy.Sample sizeIt was calculated that 340 patients will be required – 170 per arm of study – to give a 90% power to detect a 15% treatment effect.ResultsThis study started recruiting in March 2011. It is anticipated that enrolment will be complete in April 2012 and results available towards the end of 2012.ConclusionThis study will provide evidence of any benefits in the use of prophylactic nasal high flow therapy in post-operative cardiac surgical patients.Trial registrationThis trial is registered with the Australian New Zealand Clinical Trials Registry www.anzctr.org.au (ACTRN12610000973011).     

Safety of physical therapy interventions in critically ill patients: A single-center prospective evaluation of 1110 intensive care unit admissions

Purpose

Critical illness survivors commonly have impaired physical functioning. Physical therapy interventions delivered in the intensive care unit can reduce these impairments, but the safety of such interventions within routine clinical practice requires greater investigation.

Materials and Methods

We conducted a prospective observational study of routine physical therapy from July 2009 through December 2011 in the Johns Hopkins Hospital Medical Intensive Care Unit in Baltimore, MD. The incidence of 12 types of physiological abnormalities and potential safety events associated with physical therapy were monitored and evaluated for any additional treatment, cost, or length of stay.

Results

Of 1787 admissions of at least 24 hours, 1110 (62%) participated in 5267 physical therapy sessions conducted by 10 different physical therapists on 4580 patient-days. A total of 34 (0.6%) sessions had a physiological abnormality or potential safety event, with the most common being arrhythmia (10 occurrences, 0.2%) and mean arterial pressure greater than 140 mm Hg (8 occurrences; 0.2%) and less than 55 mm Hg (5 occurrences; 0.1%). Only 4 occurrences (0.1%) required minimal additional treatment or cost, without additional length of stay.

Conclusions

In this large, single-center study, routine care physical therapy interventions were safe for critically ill patients.     

Adverse events and manual therapy: A systematic review

ObjectiveTo explore the incidence and risk of adverse events with manual therapies.MethodThe main health electronic databases, plus those specific to allied medicine and manual therapy, were searched. Our inclusion criteria were: manual therapies only; administered by regulated therapists; a clearly described intervention; adverse events reported. We performed a meta-analysis using incident estimates of proportions and random effects models.ResultsEight prospective cohort studies and 31 manual therapy RCTs were accepted. The incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was ～41% (CI 95% 17–68%) in the cohort studies and 22% (CI 95% 11.1–36.2%) in the RCTs; for major adverse events ～0.13%. The pooled relative risk (RR) for experiencing adverse events with exercise, or with sham/passive/control interventions compared to manual therapy was similar, but for drug therapies greater (RR 0.05, CI 95% 0.01–0.20) and less with usual care (RR 1.91, CI 95% 1.39–2.64).ConclusionsThe risk of major adverse events with manual therapy is low, but around half manual therapy patients may experience minor to moderate adverse events after treatment. The relative risk of adverse events appears greater with drug therapy but less with usual care.     

Prospective Cohort Study of Patients With Neck Pain in a Manual Therapy Setting: Design and Baseline Measures

ObjectivesThe purpose of this study was to describe the design and baseline measurements of a prospective multicenter cohort study in patients with neck pain treated by Dutch manual therapists. Objectives of the study were to determine which patients seek help from a manual therapist, to describe usual care manual therapy in patients with neck pain, to examine the occurrence of nonserious adverse events after treatment, to describe predictors of adverse events, and to determine whether the occurrence of nonserious adverse events affect outcome after manual therapy care.MethodsDuring a 3-month inclusion period, consecutive patients aged between 18 and 80 years presenting with neck pain in manual therapy practices in The Netherlands were included in the study. Baseline questionnaires included the Numeric Rating Scale, Neck Disability Index (NDI), Neck Bournemouth Questionnaire, Fear Avoidance Beliefs Questionnaire (FABQ), and Patient Expectancy List. Within the treatment episode, manual therapist clinical reasoning and applied interventions were registered and patients reported on adverse events. At the end of the treatment episode and at 12-month follow-up, pain intensity (Numeric Rating Scale), functional outcomes (NDI, Neck Bournemouth Questionnaire), personal factors (FABQ), and global perceived effect were measured.ResultsDuring the 3-month inclusion period, 263 participating manual therapists collected data on 1193 patients with neck pain. Most patients (69.4%) were female. The mean age was 44.7 (±13.7) years. The NDI showed overall mild disability (mean score 26%). Mean scores in pain intensity were moderate (4.8), and there was low risk of prolonged disability owing to personal factors (FABQ).ConclusionThis study provides information on baseline characteristics of patients visiting manual therapists for neck pain. In The Netherlands, patients seeking care of manual therapists are comparable to patients in other countries regarding demographics and neck pain characteristics.     

Clinical course after identification of new-onset atrial fibrillation in critically ill patients: The AFTER-ICU study

PurposeEpidemiological information is lacking after identification of new-onset atrial fibrillation (AF) in critically ill patients. This study aimed to describe the clinical course after the identification of new-onset AF.Materials and methodsThis prospective cohort study enrolled adult patients with new-onset AF in 32 Japanese ICUs during 2017–2018. We collected data on patient comorbidities, physiological information before and at the AF onset, interventions for AF, cardiac rhythm transition, adverse events and in-hospital death and stroke.ResultsWe included 423 new-onset AF patients. At the AF onset, mean arterial pressure decreased and the heart rate increased. Eighty-four patients (20%) spontaneously restored sinus rhythm and 328 patients (78%) received various pharmacological interventions (rate-control drugs, 67%; rhythm-control drugs, 34%). Anticoagulants were administered in 173 patients (40%) and 13 patients (3%) experienced bleeding complications. Twenty-four patients (6%) were still in AF at 168 h after the onset (sustained AF 4%; recurrent AF 2%). The overall hospital mortality was 26% and the incidence of in-hospital stroke was 4.5%.ConclusionsAlthough the proportion of patients with AF continued to decrease with various treatments, these patients had high risk of death. Further research to assess the management of new-onset AF in critically ill patients is warranted.     

Commentary: Kause J et al. (2004). A comparison of antecedents to cardiac arrest, deaths and emergency intensive care admissions in Australia and ANZ, and the UK – the ACADEMIA study

Many patients have physiological deterioration prior to cardiac arrest, death and intensive care unit (ICU) admission that are detected and documented by medical and nursing staff. Appropriate early response to detected deterioration is likely to benefit patients. In a multi‐centre, prospective, observational study over three consecutive days, we studied the incidence of antecedents (serious physiological abnormalities) preceding primary events (defined as in‐hospital deaths, cardiac arrests and unanticipated ICU admissions) in 90 hospitals [69 UK, 19 Australia and two New Zealand (ANZ)]. Sixty‐eight hospitals reported primary events during the 3‐day study period (50 UK, 16 Australia and two ANZ). Data on the availability of ICU/high‐dependency unit (HDU) beds and cardiac arrest teams and medical emergency teams (METs) were also collected. Of 638 primary events, there were 308 (48.3%) deaths, 141 (22.1%) cardiac arrests and 189 (29.6%) unplanned ICU admissions. There were differences in the pattern of primary events between the UK and ANZ (P < 0.001). There were proportionally more deaths in the UK (52.3% versus 35.3%) and a higher number of unplanned ICU admissions in ANZ (47.3% versus 24.2%). Sixty per cent (383) of primary events had a total of 1032 documented antecedents. The most common antecedents were hypotension and a fall in Glasgow Coma Scale. The proportion of ICU/HDU to general hospital beds was greater in ANZ (0.034 versus 0.016, P < 0.001) and METs were more common in ANZ (70.0% versus 27.5%, P = 0.001). The data confirm antecedents are common before death, cardiac arrest and unanticipated ICU admission. The study also shows differences in patterns of primary events, the provision of ICU/HDU beds and resuscitation teams, between the UK and ANZ. Future research, focusing upon the relationship between service provision and the pattern of primary events, is suggested. This abstract was published in Resuscitation, volume 62, Kause J et al., ‘A comparison of antecedents to cardiac arrest, deaths and emergency intensive care admissions in Australia and ANZ, and the UK – the ACADEMIA study.’, pages 275–282. Copyright Elsevier 2004.     

Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit

Objective

Femoral catheters pose a potential barrier to early rehabilitation in the intensive care unit (ICU) due to concerns, such as catheter removal, local trauma, bleeding, and infection. We prospectively evaluated the feasibility and safety of physical therapy (PT) in ICU patients with femoral catheters.

Design, Setting, and Patients

We evaluated consecutive medical ICU patients who received PT with a femoral venous, arterial, or hemodialysis catheter(s) in situ.

Measurements and Main Results

Of 1074 consecutive patients, 239 (22%) received a femoral catheter (81% venous, 29% arterial, 6% hemodialysis; some patients had > 1 catheter). Of those, 101 (42%) received PT interventions, while the catheter was in situ, for a total of 253 sessions over 210 medical ICU (MICU) days. On these 210 MICU days, the highest daily activity level achieved was 49 (23%) standing or walking, 57 (27%) sitting, 25 (12%) supine cycle ergometry, and 79 (38%) in-bed exercises. During 253 PT sessions, there were no catheter-related adverse events giving a 0% event rate (95% upper confidence limit of 2.1% for venous catheters).

Conclusions

Physical therapy interventions in MICU patients with in situ femoral catheters appear to be feasible and safe. The presence of a femoral catheter should not automatically restrict ICU patients to bed rest.     

Exercise is feasible in patients receiving vasoactive medication in a cardiac surgical intensive care unit: A prospective observational study

BackgroundPatients may require vasoactive medication after cardiac surgery. The effect and safety profile of exercise on haemodynamic parameters in these patients is unclear.ObjectivesThe objective of this study was to measure the effect of upright positioning and low-level exercise on haemodynamic parameters in patients after cardiac surgery who were receiving vasoactive therapy and to determine the incidence of adverse events.MethodsThis was a prospective, single-centre, observational study conducted in an adult intensive care unit of a tertiary, cardiothoracic university–affiliated hospital in Australia. The Flotrac-Vigileo™ system was used to measure haemodynamic changes, including cardiac output, cardiac index, and stroke volume. Normally distributed variables are presented as n (%) and mean (standard deviation), and non-normally distributed variables are presented as median [interquartile range].ResultsThere were a total of 20 participants: 16 (80%) male, with a mean age of 65.9 (10.6) years. Upright positioning caused significant increases (p = 0.018) in the mean arterial pressure (MAP), with MAP readings increasing from baseline (supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when back in supine. There were no clinically significant changes in cardiac output, heart rate, stroke volume, or cardiac index with upright positioning. The incidence of adverse events was low (5%). The adverse event was transient hypotension of low severity.ConclusionsLow-level exercise in patients after cardiac surgery receiving vasoactive medication was well tolerated with a low incidence of adverse events and led to significant increases in MAP. Upright positioning and low-level exercise appeared safe and feasible in this patient cohort.     

Identifying Patient Characteristics Associated With the Occurrence of Post Treatment Non-serious Adverse Events After Cervical Spine Manual Therapy Treatment in Patients With Neck Pain

ObjectivesTo compare prevalence rates of serious and non-serious adverse events after manipulation and mobilization and to identify risk factors of serious and non-serious adverse events following 4 types of manual therapy treatment in patients with neck pain.DesignA prospective cohort study in primary care manual therapy practice.ParticipantsPatients with neck pain (N=686) provided data on adverse events after 1014 manipulation treatments, 829 mobilization treatments, 437 combined manipulation and mobilization treatments, and 891 treatments consisting of “other treatment modality”.InterventionsUsual care manual therapy.Main Outcome MeasuresA chi-square test was performed to explore differences in prevalence rates. Logistic regression analysis was performed within the 4 treatment groups. A priori we defined associations between patient-characteristics and adverse events of odds ratio (OR)>2 or OR<0.5 as clinically relevant.ResultsNo serious adverse events, such as cervical artery dissection or stroke, were reported. With regard to non-serious adverse events, we found that these are common after manual therapy treatment: prevalence rates are ranging from 0.3% to 64.7%. We found a statistically significant difference between the 4 types of treatments, detrimental to mobilization treatment. Logistic regression analysis resulted in 3 main predictors related to non-serious adverse events after manual therapy treatment: smoking (OR ranges from 2.10 [95% confidence interval [CI] 1.37-3.11] to 3.33 [95% CI 1.83-5.93]), the presence of comorbidity (OR ranges from 2.32 [95% CI 1.22-4.44] to 3.88 [95% CI 1.62-9.26]), and female sex (OR ranges from 0.22 [95% CI 0.11-0.46] to 0.49 [95% CI 0.28-0.86]).ConclusionThere is a significant difference in the occurrence of non-serious adverse events after mobilization compared with manipulation or a combination of manipulation and mobilization. Non-serious adverse events in manual therapy practice are common and are associated with smoking and the presence of comorbidity. In addition, women are more likely to report non-serious adverse events.     

Effectiveness of nonpharmacological interventions to prevent adverse events in the intensive care unit: A review of systematic reviews

BackgroundDifferent types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence.ObjectivesThe objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit.MethodsA review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study’s quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events.ResultsThirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion.ConclusionsSome nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.     

Feasibility and safety of in-bed cycling for physical rehabilitation in the intensive care unit

PurposeThe purpose was to evaluate the feasibility and safety of in-bed cycle ergometry as part of routine intensive care unit (ICU) physical therapist (PT) practice.Materials and methodsBetween July 1, 2010, and December 31, 2011, we prospectively identified all patients admitted to a 16-bed medical ICU receiving cycling by a PT, prospectively collected data on 12 different potential safety events, and retrospectively conducted a chart review to obtain specific details of each cycling session.ResultsSix hundred eighty-eight patients received PT interventions, and 181 (26%) received a total of 541 cycling sessions (median [interquartile range {IQR}] cycling sessions per patient, 2 [1-4]). Patients’ mean (SD) age was 57 (17) years, and 103 (57%) were male. The median (IQR) time from medical ICU admission to first PT intervention and first cycling session was 2 (1-4) and 4 (2-6) days, respectively, with a median (IQR) cycling session duration of 25 (18-30) minutes. On cycling days, the proportion of patients receiving mechanical ventilation, vasopressor infusions, and continuous renal replacement therapy was 80%, 8%, and 7%, respectively. A single safety event occurred, yielding a 0.2% event rate (95% upper confidence limit, 1.0%).ConclusionsUse of in-bed cycling as part of routine PT interventions in ICU patients is feasible and appears safe. Further study of the potential benefits of early in-bed cycling is needed.     

Deep Natural Language Processing Identifies Variation in Care Preference Documentation

ContextDocumentation of care preferences within 48 hours of admission to an intensive care unit (ICU) is a National Quality Forum-endorsed quality metric for older adults. Care preferences are poorly captured by administrative data.ObjectivesUsing deep natural language processing, our aim was to determine the rate of care preference documentation in free-text notes and to assess associated patient factors.MethodsRetrospective review of notes by clinicians using a deep natural language processing to identify care preference documentation, including goals-of-care and treatment limitations, within 48 hours of ICU admission within five ICUs (medical, cardiac, surgery, trauma surgery, and cardiac surgery) for adults 75 years and older. Covariates included demographics, ICU type, sequential organ failure assessment score, and need for mechanical ventilation.ResultsDeep natural language processing reviewed 11,575 clinician notes for 1350 ICU admissions. Median patient age was 84.0 years (interquartile range 78.0–88.4). Overall, 64.7% had documentation of care preferences. Patients with documentation were older (85 vs. 83 years; P < 0.001) and more often female (53.8% vs. 43.4%; P < 0.001). In adjusted analysis, rates of care preference documentation were higher for older patients, females, nonelective admissions, and admissions to the medical vs. the cardiac or surgical ICUs (all P ≤ 0.01).ConclusionCare preference documentation within 48 hours was absent in more than one-third of ICU admissions among patients aged 75 years and older and was more likely to occur in medical vs. cardiac or surgical ICUs.     

Epidemiology and outcomes of invasive mechanical ventilation without ICU admission in acute care hospitals in Texas: A population-based cohort study

PurposeThe high ICU bed capacity in the United States (US) allows ICU care of patients requiring invasive mechanical ventilation (IMV), absent public health crisis. The use of IMV without ICU admission (non-ICU) in acute care hospitals in the US and its impact on patients' outcomes were not examined.MethodsA retrospective cohort study was performed using statewide inpatient data in Texas to identify hospitalizations aged ≥18 years receiving IMV in acute care hospitals with ICU care capability during January 2014 through September 2015. Use of non-ICU IMV, patient characteristics, and hospital mortality were examined.ResultsAmong 136,728 IMV hospitalizations, 4531 (3.3%) were non-ICU. As compared to ICU admissions, non-ICU IMV hospitalizations were younger (age 18–44 years: 24.9% vs. 17.2%), with lower burden of major comorbidities (no major comorbidity: 24.7% vs. 14.5%), and lower occurrence of non-respiratory organ failures (no non-respiratory organ failure: 32.7% vs. 19.8%). Risk-adjusted hospital mortality of non-ICU vs. ICU IMV hospitalizations was 48.7% (95% CI 48.1–49.4) and 29.9% (95% CI 29.8–30.0), respectively.ConclusionsNon-ICU IMV was provided in 1 in 30 IMV hospitalizations in acute care hospitals. Although non-ICU IMV hospitalizations were younger and healthier than those admitted to ICU, their hospital mortality was markedly higher.     

Postoperative antithrombin levels and outcome in cardiac operations

OBJECTIVE: During cardiac operations with cardiopulmonary bypass surgery, antithrombin is consumed and low levels of antithrombin activity are commonly observed at admission to the intensive care unit (ICU). This study investigates the association between antithrombin activity at admission to the ICU (ICU-antithrombin activity) and various outcome variables. DESIGN: The authors conducted a prospective, observational cohort study. SETTING: The study was conducted at a university hospital. PATIENTS: The study consisted of 647 consecutive patients who had undergone cardiac surgery with cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: ICU-antithrombin activity significantly (p < .001) decreased with respect to preoperative values. As seen with univariate analysis, low levels of ICU-antithrombin activity were significantly associated with higher blood loss, prolonged mechanical ventilation time and ICU stay, a higher incidence of allogeneic blood products use, surgical reexploration, low cardiac output syndrome, adverse neurologic events, thromboembolic events, renal dysfunction, and hospital mortality. When corrected for the other explanatory variables, low levels of ICU-antithrombin activity remained independently associated with a prolonged ICU stay (p = .003) and with a higher incidence of surgical reexploration (p = .023), adverse neurologic events (p = .001), and thromboembolic events (p = .036). An ICU-antithrombin activity value of <58% was found to be predictive of prolonged ICU stay, with a sensitivity of 67% and a specificity of 83%. CONCLUSIONS: Low levels of ICU-antithrombin activity are associated with a poor outcome in cardiac surgery; ICU-antithrombin activity is predictive of prolonged ICU stay.     

Severity of illness and risk of readmission to intensive care: A meta-analysis

BackgroundAlmost one in every 10 patients who survive intensive care will be readmitted to the intensive care unit (ICU) during the same hospitalisation. The association between increasing severity of illness (widely calculated in ICU patients) with risk of readmission to ICU has not been systematically summarized.ObjectiveThe meta-analysis was designed to combine information from published studies to assess the relationship between severity of illness in ICU patients and the risk of readmission to ICU during the same hospitalisation.Data sourcesStudies were identified by searching MEDLINE (1966 to August 2008), EMBASE (1980–2008), and CINAHL (1982 to August 2008).Review methodsStudies included only adult populations, readmissions to ICU during the same hospitalisation and reports of valid severity of illness index.ResultsEleven studies (totaling 220 000 patients) were included in the meta-analysis. Severity of illness (APACHE II, APACHE III, SAPS and SAPS II) measured at the time of ICU admission or discharge, was higher in patients readmitted to the ICU during the same hospitalisation compared to patients not-readmitted (both p-values < 0.001). The risk of readmission to ICU increased by 43% with each standard deviation increase in severity of illness score (regardless if measured on admission to, or discharge from the ICU) (odds ratio (OR) = 1.43, 95% confidence interval (CI) = 1.3–1.6).ConclusionsA relationship between increasing intensive care severity of illness and risk of readmission to ICU was found. The effect was the same regardless of the time of measurement of severity of illness (at admission to ICU or the time of discharge from ICU). However, further research is required to develop more comprehensive tools to identify patients at risk of readmission to ICU to allow the targeted interventions, such as ICU-outreach to follow-up these patients to minimize adverse events.     

A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom--the ACADEMIA study

Many patients have physiological deterioration prior to cardiac arrest, death and intensive care unit (ICU) admission, that are detected and documented by medical and nursing staff. Appropriate early response to detected deterioration is likely to benefit patients. In a multi-centre, prospective, observational study over three consecutive days, we studied the incidence of antecedents (serious physiological abnormalities) preceding primary events (defined as in-hospital deaths, cardiac arrests, and unanticipated ICU admissions) in 90 hospitals (69 United Kingdom [UK]; 19 Australia and 2 New Zealand [ANZ]). 68 hospitals reported primary events during the three-day study period (50 United Kingdom, 16 Australia and 2 New Zealand). Data on the availability of ICU/HDU beds and cardiac arrest teams and Medical Emergency Teams were also collected. Of 638 primary events, there were 308 (48.3%) deaths, 141 (22.1%) cardiac arrests, and 189 (29.6%) unplanned ICU admissions. There were differences in the pattern of primary events between the UK and ANZ (P < 0.001). There were proportionally more deaths in the UK (52.3% versus 35.3%) and a higher number of unplanned ICU admissions in ANZ (47.3% versus 24.2%). Sixty percent (383) of primary events had a total of 1032 documented antecedents. The most common antecedents were hypotension and a fall in Glasgow Coma Scale. The proportion of ICU/HDU to general hospital beds was greater in ANZ (0.034 versus 0.016, P < 0.001) and medical emergency teams were more common in ANZ (70.0% versus 27.5%, P = 0.001). The data confirm antecedents are common before death, cardiac arrest, and unanticipated ICU admission. The study also shows differences in patterns of primary events, the provision of ICU/HDU beds and resuscitation teams, between the UK and ANZ. Future research, focusing upon the relationship between service provision and the pattern of primary events, is suggested.     

Vasopressin in vasoplegic shock: A systematic review

BACKGROUNDVasoplegic shock is a challenging complication of cardiac surgery and is often resistant to conventional therapies for shock. Norepinephrine and epinephrine are standards of care for vasoplegic shock, but vasopressin has increasingly been used as a primary pressor in vasoplegic shock because of its unique pharmacology and lack of inotropic activity. It remains unclear whether vasopressin has distinct benefits over standard of care for patients with vasoplegic shock. AIMTo summarize the available literature evaluating vasopressin vs non-vasopressin alternatives on the clinical and patient-centered outcomes of vasoplegic shock in adult intensive care unit (ICU) patients.METHODSThis was a systematic review of vasopressin in adults (≥ 18 years) with vasoplegic shock after cardiac surgery. Randomized controlled trials, prospective cohorts, and retrospective cohorts comparing vasopressin to norepinephrine, epinephrine, methylene blue, hydroxocobalamin, or other pressors were included. The primary outcomes of interest were 30-d mortality, atrial/ventricular arrhythmias, stroke, ICU length of stay, duration of vasopressor therapy, incidence of acute kidney injury stage II-III, and mechanical ventilation for greater than 48 h.RESULTSA total of 1161 studies were screened for inclusion with 3 meeting inclusion criteria with a total of 708 patients. Two studies were randomized controlled trials and one was a retrospective cohort study. Primary outcomes of 30-d mortality, stroke, ventricular arrhythmias, and duration of mechanical ventilation were similar between groups. Conflicting results were observed for acute kidney injury stage II-III, atrial arrhythmias, duration of vasopressors, and ICU length of stay with higher certainty of evidence in favor of vasopressin serving a protective role for these outcomes.CONCLUSIONVasopressin was not found to be superior to alternative pressor therapy for any of the included outcomes. Results are limited by mixed methodologies, small overall sample size, and heterogenous populations.     

Physical oral care prevents ventilator-associated pneumonia in Vietnam: A prospective interventional study

BackgroundVentilator-associated pneumonia (VAP) has emerged as a critical issue in the intensive care unit (ICU) because of its high burden on patients and medical staff. Here, we examined the potential for reducing VAP incidence through physical oral care interventions without any medication.MethodsThis prospective interventional study compared VAP incidence during an 8-month baseline period (usual oral care) and a 9-month intervention period (physical oral care with sponge brush) among patients who received mechanical ventilation for >48 h in a tertiary care hospital in Vietnam from 2017 to 2019. Physical oral care was provided by general ICU nurses who had been trained by dentists and infection control nurses. VAP was diagnosed using the Clinical Pulmonary Infection Score.ResultsIn total, 423 patients were enrolled in the baseline group and 454 patients were enrolled in the intervention group; 303 and 300 patients, respectively, were included in the analysis. Two hundred thirty-eight VAP episodes were identified: 135 (44.6%) during the baseline period and 103 (34.3%) during the intervention period. Univariate analysis revealed significant reduction of VAP occurrence in the intervention period (odds ratio = 0.65; 95% confidence interval = 0.47–0.90; P = 0.010). The incidences of VAP per 1000 ventilator-days were 63.4 (135/2128) during the baseline period and 48.4 (103/2128) during the intervention period (P = 0.038).ConclusionsPhysical oral care without any medication (e.g., chlorhexidine) reduced VAP incidence in the ICU. This method could be used to reduce VAP incidence, particularly in countries with limited medical resources.