Tag Archives: Quality and Patient Safety

Examining Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest is a major public health problem affecting over 300,000 persons in the United States each year. Therefore, Wang et al set out to determine if arterial oxygen and carbon dioxide abnormalities in the first 24 hours after return of spontaneous circulation are associated with increased mortality in adult out-of-hospital cardiac arrest.

They found that in the first 24 hours after return of spontaneous circulation, post-arrest
oxygen and carbon dioxide tension abnormalities are associated with increased out-of-hospital cardiac arrest mortality.

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Optimal Position for Intubation

Hypoxemia is the most common complication during endotracheal intubation of critically ill adults. Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation, but has never been studied outside of the operating room. Therefore, Semler et al conducted a multicenter, randomized trial comparing the ramped position with the sniffing position among 260 adults undergoing endotracheal intubation by pulmonary and critical care medicine fellows in four intensive care units between July 22, 2015, and July 19, 2016.

They found that the ramped position did not improve oxygenation during endotracheal intubation of critically ill adults compared with the sniffing position.

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mRNA Expression of CD74 and IL10

Intensive care unit-acquired infections (IAIs) result in increased hospital and intensive care unit stay, costs and mortality. To date, no biomarker has shown sufficient evidence and ease of application in clinical routine for the identification of patients at risk of IAI. Therefore, Peronnet et al evaluated the association of the systemic mRNA expression of two host response biomarkers, CD74 and IL10, with IAI occurrence in a large cohort of intensive care unit patients.

Their results suggest that two immune biomarkers, CD74 and IL10, could be relevant tools for the identification of IAI risk in intensive care unit patients.

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Examining Stress Ulcer Prophylaxis

A decreased frequency of upper gastrointestinal bleeding and a possible association of proton pump inhibitor use with Clostridium difficile and ventilator-associated pneumonia have raised concerns recently. The Reevaluating the Inhibition of Stress Erosions (REVISE) Pilot Trial determined the feasibility of undertaking a larger trial investigating the efficacy and safety of withholding proton pump inhibitors in critically ill patients.

The results support the feasibility of a larger trial to evaluate the safety of withholding stress ulcer prophylaxis.

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Examining Very Short Antibiotic Courses

Many patients started on antibiotics for possible ventilator-associated pneumonia (VAP) do not have pneumonia. Patients with minimal and stable ventilator settings may be suitable candidates for early antibiotic discontinuation. Therefore, Klompas et al set out to compare outcomes amongst patients with suspected VAP but minimal and stable ventilator settings treated with one to three versus more than three days of antibiotics.

Very short antibiotic courses (one to three days) were associated with outcomes similar to longer courses (more than three days) in patients with suspected VAP but minimal and stable ventilator settings.

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Assessing Impact of Conservative vs. Conventional Oxygen Therapy

Among critically ill patients, is a conservative oxygenation strategy aimed to maintain arterial saturation within physiologic limits more beneficial than a conventional strategy? Girardis et al set out to answer this question.

They found that among critically ill intensive care unit patients with a length of stay of 72 hours or longer, a conservative protocol for oxygen therapy may be beneficial; however, because the trial they initiated was terminated early, these findings must be considered preliminary.

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Intensive BP Lowering in Patients with Acute Cerebral Hemorrhage

Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage. Qureshi et al therefore randomly assigned eligible participants with intracerebral hemorrhage and a Glasgow Coma Scale score of five or more to a systolic blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction.

They found that the treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg.

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Expediting Transfer of Patients with Time-Sensitive Critical Illness

Time-sensitive, critical surgical illnesses require care at specialized centers. Trauma systems facilitate patient transport to designated trauma centers, but formal systems for nontraumatic critical illness do not exist. Scalea et al created the critical care resuscitation unit to expedite transfers of adult critically ill patients with time-sensitive conditions to a quaternary academic medical center, hypothesizing that this would decrease time to transfer, increase transfer volume, and improve outcomes.

They found that the critical care resuscitation unit dramatically increased the volume of critically ill surgical patients. It decreased transfer times, increased volume, and, for those who required urgent operation, decreased time from initial referral to the operating room.

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The Predictive Power of Mitochondrial DNA and Toll-Like Receptor-9

Cell injury and death leads to the release of intracellular molecules called damage-associated molecular patterns (DAMPs)—mitochondrial DNA (mtDNA) is one of these DAMPs. Krychtiuk et al set out to analyze whether levels of mtDNA are associated with 30-day survival and whether this predictive value is modified by the expression of its receptor (toll-like receptor-9).

They found that circulating levels of mtDNA at intensive care unit admission predict mortality in critically ill patients. This association was in particular present in patients with elevated toll-like receptor-9 expression.

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Intravascular Complications of Central Venous Catheterization by Insertion Site

Three anatomical sites are commonly used to insert central venous catheters, but insertion at each site has the potential for major complications. In a multicenter trial, Parienti et al randomly assigned nontunneled central venous catheterization in patients in the adult intensive care unit to the subclavian, jugular, or femoral vein (in a 1:1:1 ratio if all three insertion sites were suitable [three-choice scheme] and in a 1:1 ratio if two sites were suitable [two-choice scheme]). The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep-vein thrombosis.

In this trial, subclavian vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular vein or femoral vein catheterization.

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The Effect of Universal Glove and Gown Use on Adverse Events in ICU Patients

Among the many attempts to decrease the rate of healthcare-associated infections is the implementation of specific contact precautions (gloves and gown for entry into rooms of patients colonized or infected with antibiotic-resistant bacteria) and universal precautions (gloves and gown for entry into every room) in the intensive care unit. However, the benefits of these precautions are unclear. Croft et al examined whether the use of universal precautions increased the rate of adverse events compared to usual care (gloving and gowning for only those patients on contact precautions).

They found that universal glove and gown use did not have an impact on the overall rate of adverse events, including subtypes of infectious, noninfectious, preventable, or severe adverse events.

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The Efficacy of a Two-Tier Rapid Response System

Rapid response systems (RRSs) have been implemented to facilitate the early recognition and treatment of deteriorating ward patients. Evidence of their effectiveness is conflicting, but recent reviews suggest RRS utilization improves patient safety. Aneman et al recently assessed the clinical attributes and outcomes of patients admitted to the ICU of Liverpool Hospital both before and after implementation of a two-tier RRS. In this system, the clinical team responds to less serious first-tier criteria, and the RRS is activated when the patient meets more serious second-tier criteria.

The authors found that ICU mortality rates were significantly lower after two-tier implementation, as compared to mortality rates under the preexisting one-tier RRS. Although this study’s applicability is limited by its retrospective design, implementing a two-tier system seemingly improves patient outcomes.

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Delirium Detection Using EEG

Delirium is a significant and prevalent problem among patients in the intensive care unit, but many clinicians struggle to diagnose it. Van der Kooi et al set out to determine the electrode derivation and electroencephalography (EEG) characteristic that have the best capability to distinguish patients with delirium from those without it.

The authors found that with two electrodes and 60 seconds of EEG data, delirium can be discriminated from nondelirium under certain circumstances. This intriguing study is important in that it highlights the possible technological direction in which delirium detection may be headed.

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Benefits of the ABCDE Bundle in ICU Patients

The Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle has been proposed as a strategy to reduce delirium, liberate patients from the ventilator and improve outcomes for intensive care unit (ICU) patients. Balas and colleagues conducted a prospective before-after study at a tertiary medical center to determine the safety and impact of the ABCDE bundle implementation for ICU patients.

They found that critically ill patients managed with the ABCDE bundle spent more days breathing without assistance and experienced less delirium than patients treated with usual care. Some of the limitations of this study are the small sample size and the inclusion of nonventilated and oncology/hematology patients. Although the patient population was small, it represented a heterogeneous population, with more than 40% of patients having had surgery.  Ultimately, multicomponent ventilator liberation and “animation” strategies such as the ABCDE bundle are likely to become an integral component of ICU care if the safety and effectiveness demonstrated in this study can be reproduced.

To learn more about reducing delirium and improving care for ICU patients, visit www.iculiberation.org.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.