Current Issue : April - June Volume : 2020 Issue Number : 2 Articles : 6 Articles
Background: Most septic patients managed by critical care response teams (CCRT) are prescribed antimicrobials.\nNevertheless, data evaluating their appropriateness are lacking both locally and internationally. The objective was to\nassess antimicrobial use among septic and non-septic patients managed by CCRT.\nSetting: Case-control design was used to compare septic (cases) and non-septic (controls) CCRT patients at tertiary\ncare setting. The frequency of antimicrobial use was assessed before and after CCRT activation. The appropriateness\nof antimicrobial use was assessed at day four post-CCRT, based on standard recommendations, clinical assessment,\nand culture results.\nMain results: A total of 157 cases and 158 controls were included. The average age was 61.1 ± 20.4 years, and\n54.6% were males, with minor differences between groups. The use of any antimicrobial was 100.0% in cases and\n87.3% in controls (p < 0.001). The use of meropenem (68.2% versus 34.8%, p < 0.001) and vancomycin (56.7% versus\n25.9%, p < 0.001) were markedly higher in cases than controls. The overall appropriateness was significantly lower in\ncases than controls (50.7% versus 59.6%, p = 0.047). Individual appropriateness was lowest with meropenem (16.7%)\nand imipenem (25.0%), and highest with piperacillin/tazobactam (87.1%) and colistin (78.3%). Only 48.5% of\nantimicrobials prescribed by CCRT were de-escalated by a primary team within four days. Individual appropriateness\nand de-escalations were not different between groups.\nConclusions: Empiric use and inadequate de-escalation of broad-spectrum antimicrobials were major causes for\ninappropriate antimicrobial use in CCRT patients. Our findings highlight the necessity of urgent implementation of\nan antimicrobial stewardship program, including training and auditing of antimicrobial prescriptions....
Background: Pain is a common phenomenon among emergency patients which may lead to chronic pain\nconditions and alteration of physiological function. However, it is widely reported that proper pain assessment and\nmanagement, which is often accomplished by adequately trained nurses reduce the suffering of patients. Therefore,\nthe aim of this study was to assess the emergency nurses´ knowledge, attitude and perceived barriers regarding\npain management.\nMethods: A cross-sectional quantitative study design was applied to determine the nurses´ knowledge level,\nattitude and the perceived barriers related to pain management. Hundred twenty-six nurses from the emergency\ndepartments of seven referral hospitals of Eritrea participated in the study. Data were collected in August and\nSeptember 2017. Both descriptive and inferential statistics were used to summarize and elaborate on the results.\nResult: In general, the knowledge level and attitude of the emergency nurses was poor. The participantsâ?? correct\nmean score was 49.5%. Nurses with Bachelorâ??s Degree had significantly higher knowledge and attitude level\ncompared to the nurses at the Diploma and Certificate level of professional preparation (95% CI = 7.1â??16.7 and 9.4â??\n19.1; p < 0.001) respectively. Similarly, nurses who had previous training regarding pain scored significantly higher\nknowledge level compared to those without training (95% CI =1.82â??8.99; p = 0.003). The highest perceived barriers\nto adequate pain management in emergency departments were measured to be overcrowding of the emergency\ndepartment (2.57 ± 1.25), lack of protocols for pain assessment (2.45 ± 1.52), nursing workload (2.44 ± 1.29) and lack\nof pain assessment tools (2.43 ± 1.43). There was no significant difference in perceived barriers among nurses with\ndifferent demographic characteristics.\nConclusion: The emergency nursesâ?? knowledge and attitude regarding pain management were poor. Nurses with\nhigher educational level and nurses with previous training scored significantly higher knowledge level. This\nindicates the need for nursing schools and the ministry of health to work together to educate nurses to a higher\nlevel of preparation for pain assessment and management....
Background: Although mortality due to critical illness has fallen over decades, the number of patients with longterm\nfunctional disabilities has increased, leading to impaired quality of life and significant healthcare costs. As an\nessential part of the multimodal interventions available to improve outcome of critical illness, optimal nutrition\ntherapy should be provided during critical illness, after ICU discharge, and following hospital discharge.\nMethods: This narrative review summarizes the latest scientific insights and guidelines on ICU nutrition delivery.\nPractical guidance is given to provide optimal nutrition therapy during the three phases of the patient journey.\nResults: Based on recent literature and guidelines, gradual progression to caloric and protein targets during the\ninitial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably based on\nindirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia, and when occurring,\ncaloric restriction should be instituted. For proteins, at least 1.3 g of proteins/kg/day should be targeted after the\ninitial phase. During the chronic ICU phase, and after ICU discharge, higher protein/caloric targets should be\nprovided preferably combined with exercise. After ICU discharge, achieving protein targets is more difficult than\nreaching caloric goals, in particular after removal of the feeding tube. After hospital discharge, probably very highdose\nprotein and calorie feeding for prolonged duration is necessary to optimize the outcome. High-protein oral\nnutrition supplements are likely essential in this period. Several pharmacological options are available to combine\nwith nutrition therapy to enhance the anabolic response and stimulate muscle protein synthesis.\nConclusions: During and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to\nreduce the likelihood of the patient to becoming a â??victimâ? of critical illness. Frequently, nutrition targets are not\nachieved in any phase of recovery. Personalized nutrition therapy, while respecting different targets during the\nphases of the patient journey after critical illness, should be prescribed and monitored....
Background: There is little descriptive data on Stenotrophomonas maltophilia hospital-acquired pneumonia (HAP)\nin critically ill patients. The optimal modalities of antimicrobial therapy remain to be determined. Our objective was\nto describe the epidemiology and prognostic factors associated with S. maltophilia pneumonia, focusing on\nantimicrobial therapy.\nMethods: This nationwide retrospective study included all patients admitted to 25 French mixed intensive care\nunits between 2012 and 2017 with hospital-acquired S. maltophilia HAP during intensive care unit stay. Primary\nendpoint was time to in-hospital death. Secondary endpoints included microbiologic effectiveness and\nantimicrobial therapeutic modalities such as delay to appropriate antimicrobial treatment, mono versus\ncombination therapy, and duration of antimicrobial therapy.\nResults: Of the 282 patients included, 84% were intubated at S. maltophilia HAP diagnosis for duration of 11 [5â??18] days.\nThe Simplified Acute Physiology Score II was 47 [36â??63], and the in-hospital mortality was 49.7%. Underlying chronic\npulmonary comorbidities were present in 14.1% of cases. Empirical antimicrobial therapy was considered effective on S.\nmaltophilia according to susceptibility patterns in only 30% of cases. Delay to appropriate antimicrobial treatment had,\nhowever, no significant impact on the primary endpoint. Survival analysis did not show any benefit from combination\nantimicrobial therapy (HR = 1.27, 95%CI [0.88; 1.83], p = 0.20) or prolonged antimicrobial therapy for more than 7 days\n(HR = 1.06, 95%CI [0.6; 1.86], p = 0.84). No differences were noted in in-hospital death irrespective of an appropriate and\ntimely empiric antimicrobial therapy between mono- versus polymicrobial S. maltophilia HAP (p = 0.273). The duration of\nventilation prior to S. maltophilia HAP diagnosis and ICU length of stay were shorter in patients with monomicrobial S.\nmaltophilia HAP (p= 0.031 and p = 0.034 respectively).\nConclusions: S. maltophilia HAP occurred in severe, long-stay intensive care patients who mainly required prolonged\ninvasive ventilation. Empirical antimicrobial therapy was barely effective while antimicrobial treatment modalities had no\nsignificant impact on hospital survival....
Background: Majority burn mortality prognostic scores were developed and validated in western populations. The\nprimary objective of this study was to evaluate and identify possible risk factors which may be used to predict\nburns mortality in a local Malaysian burns intensive care unit. The secondary objective was to validate the five well\nknown burn prognostic scores (Baux score, Abbreviated Burn Severity Index (ABSI) score, Ryan score, Belgium\nOutcome Burn Injury (BOBI) score and revised Baux score) to predict burn mortality prediction.\nMethods: Patients that were treated at the Hospital Sultan Ismailâ??s Burns Intensive Care (BICU) unit for acute burn\ninjuries between 1 January 2010 to 31 December 2017 were included. Risk factors to predict in-patient burn\nmortality were gender, age, mechanism of injury, total body surface area burn (TBSA), inhalational injury,\nmechanical ventilation, presence of tracheotomy, time from of burn injury to BICU admission and initial centre of\nfirst emergency treatment was administered. These variables were analysed using univariate and multivariate\nanalysis for the outcomes of death. All patients were scored retrospectively using the five-burn mortality prognostic\nscores. Predictive ability for burn mortality was analysed using the area under receiver operating curve (AUROC).\nResults: A total of 525 patients (372 males and 153 females) with mean age of 34.5 ± 14.6 years were included.\nThere were 463 survivors and 62 deaths (11.8% mortality rate). The outcome of the primary objective showed that\namongst the burn mortality risk factors that remained after multivariate analysis were older age (p = 0.004), wider\nTBSA burn (p < 0.001) and presence of mechanical ventilation (p < 0.001). Outcome of secondary objective showed\ngood AUROC value for the prediction of burn death for all five burn prediction scores (Baux score; AUROC:0.9, ABSI\nscore; AUROC:0.92, Ryan score; AUROC:0.87, BOBI score; AUROC:0.91 and revised Baux score; AUROC:0.94). The\nrevised Baux score had the best AUROC value of 0.94 to predict burns mortality.\nConclusion: Current study evaluated and identified older age, total body surface area burns, and mechanical\nventilation as significant predictors of burn mortality. In addition, the revised Baux score was the most accurate\nburn mortality risk score to predict mortality in a Malaysian burnâ??s population....
Background: Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction\n(ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different\nrisk factors and different impacts on outcome. This study was designed to (1) describe the respective risk\nfactors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and\nsevere ICU-DD on outcome.\nMethods: Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically\nventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm\ntwitch pressure < 7 cmH2O and ICU-AW was defined as Medical Research Council Score < 48.\nResults: One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age,\nlonger duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of\nMV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p = 0.008), but not ICU-AW, was independently associated\nwith weaning failure (59%). ICU-AW (OR 4.30, p = 0.033), but not severe ICU-DD, was associated with ICU\nmortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW\n(86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%).\nConclusion: Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and\nmortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact....
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