Critical Care - Science topic

How is the administration of vasopressors andinotropes optimized in critical care settings?

We are inviting researchers and scholars to collaborate on a comprehensive narrative review focused on Critical Care. The aim and outlines will be shared with the selected contributors. We seek contributors who are passionate about Critical Care and can provide valuable insights through their expertise.

Requirements:

To express your interest, please send the following information to Ms. Hana Abukhadijah at HAbukhadijah@hamad.qa

Authorship: Authorship will be offered based on the timely and quality contribution of the collaborators.

We look forward to your participation in this exciting project and hope to produce a high-impact review that contributes significantly to the field of CC.

Best regards,

Abdulqadir

How does hyponatremia develop in the critical care setting, and what are its clinical manifestations?

How does continuous re-evaluation of monitoring techniques contribute to patient management in critical care settings?

The title that i need to do in my study is Perceived Barrier toward Medication Errors Reporting among nurses in Critical Care setting.

How does the role of anaesthesiologists extend beyond anaesthesia administration to encompass pain management and critical care services?The role of anaesthesiologists extends far beyond the administration of anesthesia to encompass a wide range of services, including pain management and critical care.

It's important to note that the decision to initiate ECMO therapy is made on a case-by-case basis, considering factors such as the severity of illness, the potential for recovery, and the resources available. A multidisciplinary team, including critical care physicians, ECMO specialists, and respiratory therapists, typically evaluates each patient to determine the appropriateness of ECMO therapy.

Epidemiology of infectious diseases

How many days Arctic sun can be used to maintain temperature?

Head injury protocol can be disconnected abruptly? If not, what criteria can be used to taper and disconnect the protocol.

Hi everyone,

ICU nursing staffing's impact on patient (and other) outcomes is well documented in the literature. Nonetheless, methods (e.g. Nursing activities score) have been criticized during the last decade for not including several aspects of the nurse's work besides bedside duties.

Currently, which would be the most valid approach /tool to objectively estimate nursing staffing?

For the acute resuscitation of adults with COVID-19 and shock, the current recommendations are suggesting, using buffered/balanced crystalloids over unbalanced crystalloids.

The purpose of this discussion is address the need for guidance on fluid resuscitation among severe COVID-19 patients and shock management in resource-limited settings

Is it a routine in your intensive care unit to perform ultrasound-guided central venous catheterization?

ICU patients who are receiving invasive mechanical ventilation and noninvasive ventilation often require sedation and analgesia. COVID-19 pneumonia / ARDS induced acute respiratory failure patients are not indifferent in this aspect. Sometimes, it also feels that these patients need more sedation, even on NIV. I shall be delighted to know the sedation practices, drugs, single or combinations you are using in your set-up.

Which methods does they suggest to ease the burden and stress as a teamwork?

My above publications are already published on line at bsccmjournal.org and at banglajol.info/index.php/BCCJ

Apparently bacterial superinfection translates into worse outcome when a patient is tested positive with SARS-CoV-2 and has developed symptoms. This is especially worrisome as the acquisition of any bacterial superinfection seems to be of higher likeliness in critical ill patients according to the few studies addressing the matter so far. Even more so, when we learn, that patients had acquired a bacterial superinfection despite being prescribed antibiotic prophylaxis with the onset of symptoms! We can also learn from actual data, that bacterial superinfections, occurring under prescription of empiric antibiotic medication, had a higher association with fatal outcome. The findings suggest, that patients had acquired or were colonized with a multi-resistant strain during or even prior to their hospital stay. In current publications addressing the matter, however we learn that only about 30% of the strains where resistant to the antimicrobial therapy administered. We therefore must take into consideration that there is a lack of accumulation of MIC of the antimicrobial in the respective tissue during the course of the illness in the 70% of patients, that had acquired a bacterial superinfection with normal susceptibility of the pathogen to the prescribed antimicrobial. This very scenario is held accountable for the development of resistance mechanisms in endemic pathogens. This might display a potential explanation for the selection of multi-resistant pathogens in the course of SARS-CoV-1. However, the course of SARS-CoV-1 was well controllable at that time. We are facing a different scenario in this ongoing pandemic. Whereas IFR and CFR in COVID-19 remain single digit, the wide use of empiric antibiotic prophylaxis might shift morbidity and mortality by promoting bacterial resistance to other dimensions for all of us in the long run.

Dear critical care enthusiasts

Thank you. Regards Dr Mohd Saif Khan, MD, DNB, Postdoctoral fellowship in critical care (JIPMER), DM critical care medicine (TMH Mumbai), MNAMS Associate Professor Dept. of Critical Care Medicine Trauma Centre and Central Emergency Rajendra Institute of Medical Sciences Ranchi-834009, Jharkhand, India

Excess deaths occur when the capacity to deliver critical care to patients with Covid-19 is exceeded (i.e. those who require organ support do not receive it). This is happening around the world now. The media has sensationalised discussions on numbers of ventilators and the availability of ICU beds. Unfortunately, the capacity to deliver healthcare is in fact most limited by human resources. Furthermore those healthcare professionals on the frontline are at greatest risk of contracting the virus.

To improve patient outcomes during the ongoing Covid-19 pandemic; the capacity of healthcare systems to prevent, detect and treat acute respiratory illnesses must be increased. This requires an increase in the number of staff who can do this. The fundamental question is: how can this be achieved now?

Online educational materials have been developed to train healthcare professionals in the basic principles of intensive care. However, this does not help people at the bedside faced with a crashing patient. I believe that familiarisation of staff with the use of systematic checklist proformas for the assessment of critically ill patients (see review above) can increase the capacity of healthcare systems to deliver critical care.

Does anyone have any other ideas? Please share them.

Thank you.

what types of physical therapy protocols are used in the long term acute/critical care setting?

53 Y Female was exposed to boiled water which fall on her abdomen. She left the burn untreated and scab formation occurred. TBSA expected 1-4% , probably superficial partial thickness burn. How would you manage this burn? Peel the scab and create a moist wound environment? Or what procedures would you follow now after the scab has formed?

I am looking for an author to write a chapter for a book I am editing. The chapter is about ethnographic research into critical care. Are you interested in writing this chapter or do you know someone who may be interested?

I'm looking for some inspiration around methods for measuring usability of a bedside testing device in critical care. Any tools and ideas would be great.

Here is a question for everyone that I am currently stumped on:

Its related to the work I am doing to implement CCOT at SPH. The CCOT literature uses a variety of measures and it gets a little confusing:

· Code blue (all types) per 1000 admissions or per 1000 discharges

· Cardiac Arrest (only code blue with CPR) per 1000 admissions or per 1000 discharges

· Code blue or Cardiac arrest excluding critical care areas (i.e., ED, ICU, CCU, CSICU, OR/PACU) per 1000 admissions or discharges

I looked through CIHI and it does not look like they have any stats on in-hospital cardiac arrest rates that I could find. We keep track of code blue data, but I don’t think it is reported to any external organizations. The UK and Australia have done rapid response systems for far longer, but I haven’t come across any official standardized metrics or definitions of what is considered good, bad or ugly in the way of targets.

Thoughts?

Thanks in advance for any assistance you can offer.

Vini

I am begin work on a doctoral project related to nursing perceptions of critical care nutrition and attempting to identify the theoretical framework I will use to guide my study. I am currently leaning towards the health belief model, but am open to other ideas and suggestions.

Thank you.

What can we do to make our students more careful when it comes to basic and core subjects in Nursing? What can we do to enrich students' experience in the clinical settings to become more conducive and achieve the learning objectives? What can we do to make our students become more sensitive to patient needs, the implicit as well explicit ones?

Dear Colleagues

I would like to share with my experience and see whether you similar or different experiences. Firstly, I have a very strong clinical orientation, especially in different critical care units. I still entertain myself with nurses at the clinical setting by asking and working with patients during my work day as a course coordinator to the clinical courses. I have many issues with the opportunities provided to our students to learn by observing and by participating, under guidance, in the process of caring for patients. Often, I experience very disappointing moments in my life, I rarely experience somewhere else, when I ask students about very simple, basic knowledge of anatomy, physiology, pathophysiology, and pharmacology. Students do not have answers. I know for sure these topics have been elaborately explained to them by either me or my colleagues, in this this course or in that. But the result is usually the same; Sir, these topics have not been explained to us, you know". Well, indeed, I know that they were not honest, or perhaps they forgot. Hope to get some response.

Cheers, Lourance

A large number of studies have reported that MEWS is an effective tool for predicting in-hospital mortality. However, there are variations in cut-off point (for mortality prediction). There are studies that consider MEWS ≥ 6, others that mention MEWS ≥ 4 as a risk factor for mortality. What cut-off value do you consider?

Beyond the events on October 16th, 1846 ("Ether Day"), which stories are worth to be recognised about the history of Anesthesiology? Which are the most impressive, curious, or funny things we should remember?

In your point of view, which are the most important points we should discuss concerning intubation / airway management in trauma patients with unstable c-spine fracture?

The Health Technology Assessment (HTA) unit of the CHU de Québec – Université Laval is currently working to get data on integrated early rehabilitation interventions in pediatric intensive care unit.

We define «integrated early rehabilitation interventions» as physical, functional, nutritional, psychological, communicational, social or spiritual rehabilitation activities initiated during the first days of admission of a patient in the pediatric intensive care unit and delivered by each professional according to an intervention plan that has been developed beforehand as a team by these same professionals.

Is anyone in monitoring of oximetry tissue  Rigional except pulse oximetry

My topics and questions are only in the early stages and haphazard. It will be a literature review. So far I am thinking of the effects of sedation breaks in adult ICU patients. Early mobilisation, the psychology effects on long term ICU patients, Are the medical profession overdosing patients who are sedated with opioids/ maybe over use of opioids in the sedated patients. Trying to get an idea of where to go what topic Il get the most information on and develop a question.

I am conducting a study evaluating risk for pressure injuries among critical care patients. I have EHR data pertaining to moisture, nursing skin assessments, body temperature, and also medical devices for surgical critical care patients. I would like to find a way to indirectly assess micro-climate.

I was wondering if any of you are aware of any sepsis pertinent severity score, not APCHE or SOFA?

Inflammatory mediators promote insulin resistance, suggesting perhaps that critical care patients may exhibit hyperinsulinemia. However, I have great difficulty finding an article referring to serum insulin levels (there is an overabundance of publications on hyperglycaemia and insulin resistance but not insulin).

I would very much appreciate it if anyone can refer me to a manuscript making reference on insulin levels in any severe inflammatory setting (burns, sepsis, trauma, and surgery… any context where a strong inflammatory response is solicited).

Note: hyperglycaemia is often treated with intensive insulin therapy –it would be super if the study refer to untreated patients.

Dear colleagues,

Health professionals face difficult decisions in emergency medicine and trauma and critical care and deal with uncertainty. Sophisticated decision making tools could help reduce uncertainty and doubt and speed up decision making.

Would a decision assisting tool be helpful in EM and Critical Care, that based on "big data"  predicts potential diagnoses, outcomes and events and makes management suggestions to the team ?

What are your thoughts?

Risk factors for CRBSI are well documented but I´m looking for a sort of screening tool in ICU pacientes with CVC.

What is your daily routine?

vaECMO in cardiogenic shock results in competing flows (ECMO vs. heart) and can impose increased afterload on the left ventricle. How can hazardous elevation of LA-pressures be anticipated and handled under peripheral vaECMO.

I am looking for any research comparing patient-focused outcomes between ALS-level care and prehospital critical care for OHCA.

I want a tool to measure communication difficulty for a ventilated patient

Do you have any publications/books where I can find the information about duration of a single respiratory rehabilitation intervention on a mechanically ventilated patient in Intensive Care Unit? 

What is the real risk of cardiac tamponade?

Intraoperative awareness may lead to catastrophic psychologic sequelae (1), a fact motibating anesthesiologists to use neuromonitoring in oder to prevent awareness during operation. In the "B-Aware" trial, awareness associated with a BIS-guided protocol in patients at high risk of awareness occurred substantially less frequently than did awareness events in the control group (2). However, neuromonitoring on the basis of the bispectral index (BIS)-monitoring is mostly used for anesthesia induced by propofol and evidence for the safe prevention of awareness in patients monitored with BIS during narcosis induced by volatile anesthetics is limited.

1. Lennmarken C, Sydsjo G: Psychological consequences of awareness and their treatment. Best Pract Res Clin Anaesthesiol 2007; 21:357– 67

2. Myles PS, Leslie K, McNeil J, Forbes A, Chan MT: Bispectral index monitoring to prevent awareness during anaesthesia: The B-Aware randomised controlled trial. Lancet 2004; 363: 1757– 63

The image becomes visible after opening the question. The ensuing discussion provides the interesting bottleneck of this problem though. Any help would be much appreciated.

PS. the last sentence on the image is irrelevant and should have been cropped. 

Can any intensivist in Europe who has adopted CoBaTriCe program explain to me how trainees are evaluated and who are the evaluators?

What this articles addresses, e.g., the differential diagnosis of CAPS, is something I brought up a long time ago, especially at the Galveston APS meeting a few years ago. In this regard, when talking about the longstanding CAPS registry, how do we know if all those patients actually had CAPS versus some of the other entities, e.g., HU syndrome, TTP, underlying infections, malignancies, HIT, etc? Antiphospholipid antibodies have been reported in the presence of infection, and I can easily imagine a patient in a critical care unit developing septic shock with positive antiphospholipid antibodies, not necessarily having CAPS in this setting.

Atropine is of no use to stimulate breathing in cholinergic crisis, and mechanical ventilation is the only option. What potential therapeutic agents can be designed to reverse this phase in critical care practice? 

Recently this article was published in Critical Care:

It included risk factors for VTE specific for ICU patients (such as sedation and vasopressors). table 3

My question, if we are to include these risk factors in a VTE risk assessment score, how many points each should be accounted for?

There are some exclusions from ICU mortality rate, like the age, burn cases, etc.

Are there any others? Please provide a link to evidence.

When I calculate crude mortality rate in ICU the formula is:

total deaths / total discharges in the same period, but some exclude ( as far as I know ) DNAR cases from the numerator, are there any other exclusions.

Are there any Critical Care documents EWS, Evaluation and Daily entry charts available in the public domain for use in Africa

There is much discussion on this field, glutamine is recommended when critically ill patients need parenteral nutrition. We agree with this recommendation and use glutamine in our patients when parenteral nutrition is indicated.

My experience is that APPs can provide quality care to the majority of critically ill patients.  By incorporating Physician Assistants (PA) and Nurse Practitioners (NP) with telemedicine capabilities, I feel critical care can be greatly improved in smaller, rural hospitals.

Thoughts?

I Work with trauma patients. If anyone knows specific material for such patients you helps even more. Thanks in advanced. 

What is the best option: human fibrinogen or cryoprecipitate?

In relation to critical care.

I am currently interviewing SCI patients for my research study and some report the lack of mouthcare in critical care as being particularly upsetting. This should be provided routinely as part of a daily care bundle, however these patients have had to ask for it - despite being non-verbal at that time due tracheostomy/vent.

I'd like to find out about practices elsewhere.

It is very interesting which vein is the most popular in your institution.

I utilize Gambro Prismaflex system - Prismocitrate 18/0 (CVVHDF).

Could you be so kind as to send me such a protocol?

Protocols or guidelines for whom it can be used, any exclusion criteria, guidelines for the use of hypothermia blanket and how/when to rewarm.

I am currently editing a book about critical care nursing.

Do you think that this technique is superior to CVVHF?

I have Sp02% and Fi02%, and I want to calculate a Pa02/Fi02 quotient. Is it possible to calculate a Pa02 from Sp02%? If yes, does anyone have any reliable formulas?

Why not use a MULTIVIB mattress for transferring sound stimuli to these patients?

It can transfer music as well at VAT stimuli, and will aid the process of ventilation significantly.

Olav Skille

GDT has been shown to improve perioperative morbidity asociated to perioperative medicine, but could plethysmographic curve variation (POP variation) become a rutinary valid parameter in this case?

What is the real risk of central vein stenosis after short term renal replacement therapy in a critical care unit?

I am considering to start an animal study on TCD and zero flow pressure but I have no experience on TCD in species other than humans.

Currently working on publishing my study in to the outcomes of critically-ill elderly patients admitted to intensive care.

Our team suspects that IV amiodarone acute hepatotoxicity does not really exist. We think that the "hepatotoxicity" we can find after the administration of IV amiodarone is more a hypoxic hepatitis related to hemodynamic instability or arterial hypoxemia. Amiodarone just favours the hypoxic hepatitis in case of hypotension during its administration. Something possible due to the solubilizer polysorbate 80. We would like to know your point of view specially related to the cardiac surgery postoperative patient.

It is not infrequent to see chest tubes lying in odd, albeit dangerous positions in critically ill patients when they are imaged (CT scans). What are the factors responsible for malpositioning of chest tubes and what effect this has on the patient course? What is the incidence of such occurrences?

We have a clinical problem with a patient with GBS treated promptly with IVIGS. The EMG examination talks about acute motor sensory axonal polineuropathy (AMSAN) with deteriorating clinical course from the first EMG examination. Now the patient is on mechanical ventilation and has no acute infections. At the moment, they have disautonomy and tetraparesia. 21 days ago they received 2 gr/kg in five days of IVIGS. What would you do now?

Nothing,

A second course of IVIGS,

Plasmapheresis?

The nature to which the problem to be looked at within the given area of ICU is what constraints if any contribute to an untimely admission. As this is an area which locally has not been identified as having collected data on the timely admission to ICU, it was an area which needed to be investigated.

A 82 years old patient undergone to cephalum pancreatectomy developed a biliary fistula with high flow (> 1000 ml/day through drainages) in third postoperative day. After 24 hours hypernatremia (162 mEq/L) appeared. Cardiovascular hepatic and renal function was preserved. There were not signs or symptoms of infection.

A 40-year old Filipino man, known to have hypertension for 4 years was admitted to our hospital with severe headache and left sided dense hemiplegia, CT finding was consistent with hemorrhagic stroke. On the tenth day of admission he developed shortness of breath of sudden onset with a significant drop in oxygen saturation. CT angiogram showed saddle pulmonary embolism.

Is the term ALI is really obsolete after emergence of the new Berlin definition of ARDS ? Whats is the actual purpose of such a definition?

In patients with cardiac arrest from accidental hypothermia patients should be transported during ongoing CPR to a hospital with ability to perform "bypass" rewarming.

Most in-hospital deaths in this group is probably because rewarming does not lead to spontaneous circulation, but data is scarce. However, patients may also die after successful rewarming with return of circulation. We have experienced death several days later from sudden development of cerebral oedema and tamponade. This has led us to question the common practice of rapid rewarming to normothermia and extubation.

Should we expand our ICU treatment by controlling the temperature for 2-3 days, aiming for temperature target 34-35 oC and sedation/controlled ventilation before "waking" up? Should we increase the level of neuromonitoring as a routine in the ICU in such patients?

What are your experiences (if any) and views?

We have one completed retrospective data collection and analysis on particular Health indication. Now wanted to published it in index journal.The scientific and ethical approval already has been taken. Can anyone guide me step by step to approach to draft synopsis and research paper/ article. You may provide format if any . It would be great support for me.

Major trauma patients in ICU often require aggressive fluid management. However overzealous crystalloids/blood transfusions have associated problems. Central venous pressures and arterial line waveform are not always helpful in determining need for fluids. What is your experience regarding use of Ultrasound/Echocardiographic imaging of IVC diameter changes in assessing fluid needs of these patients.

Attached is a link to online pdf of the article "Barbier C et. al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med (2004) 30:1740–1746".