Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Platelet function in essential thrombocythemia

Introduction: The most crucial component of all diagnostic criteria for essential thrombocythemia (ET) has been the exclusion of reactive thrombocytosis (RT). Our aim was to evaluate the diagnostic performance of the PFA-100 collagen-epinephrine (CEPI) cartridge test and epinephrine-induced aggregometry individually, but mainly combined, in the differentiation of ET from RT.Materials and Methods: 26 patients with ET and 25 with RT were studied. Platelet function was analyzed by the PFA-100 and by light transmission aggregometry with epinephrine and ADP. The JAK2 mutational status was identified and hematological parameters, plasma von Willebrand factor antigen and activity levels were also assessed.Results: The sensitivity (Se), specificity (Sp), positive predictive value (PPV), and the negative predictive value (NPV) of PFA-100 CEPI vs epinephrine-induced aggregometry in the differentiation of ET from RT were estimated as follows: Se (%): 79 vs 85, Sp (%): 92 vs 96, PPV (%): 88 vs 96, NPV (%): 85 vs 86, respectively. When both of these methods were combined, a lower sensitivity of 68%, but a specificity of 100% was attained. The PPV observed with this double abnormal combination was 100% and the NPV 81%. Lastly, when we assessed the abnormality for either CEPI CT or epinephrine-induced aggregometry, the sensitivity was 100%, the specificity 88%, PPV 86% and NPV 100%. Thus, an abnormal combination was strongly suggestive of ET, while normal results with both methods excluded ET.Conclusions: If our results are replicated by further studies, these two methods could be used very effectively as adjunct markers in the differentiation between ET and RT.Εισαγωγή: Η Ιδιοπαθής Θρομβοκυτταραιμία, που συγκαταλέγεται στα Ph-Μυελοϋπερπλαστικά Νεοπλάσματα, χαρακτηρίζεται από υπερπλασία της μεγακαρυοκυτταρικής σειράς στο μυελό των οστών, αύξηση του αριθμού των αιμοπεταλίων και λειτουργικές διαταραχές αυτών, ενώ η κλινική πορεία των ασθενών επιπλέκεται από θρομβωτικά και αιμορραγικά επεισόδια. Κύριο στοιχείο της διάγνωσης της Ιδιοπαθούς Θρομβοκυτταραιμίας αποτελεί ο αποκλεισμός της αντιδραστικής θρομβοκυττάρωσης. Διαταραχές της λειτουργικότητας των αιμοπεταλίων μπορεί να εκτιμηθούν με την θολοσιμετρική συσσώρευση καθώς και με τον αναλυτή της λειτουργικότητας των αιμοπεταλίων PFA (Platelet Function Analyzer)-100.Σκοπός: Να εξετασθεί αν το PFA-100 και η θολοσιμετρική συσσώρευση αιμοπεταλίων μπορούν, μεμονωμένα ή σε συνδυασμό, να συμβάλουν στη διαφορική διάγνωση ανάμεσα στην Ιδιοπαθή Θρομβοκυτταραιμία και την αντιδραστική θρομβοκυττάρωση. Μεθοδολογία: Μελετήθηκαν 26 ασθενείς με Ιδιοπαθή Θρομβοκυτταραιμία και 25 ασθενείς με αντιδραστική θρομβοκυττάρωση. Η διάγνωση της Ιδιοπαθούς Θρομβοκυτταραιμίας βασίστηκε στα ανανεωμένα κριτήρια του Παγκόσμιου Οργανισμού Υγείας του 2008 για την κατάταξη των μυελοειδών νεοπλασμάτων. Για τη διάγνωση της αντιδραστικής θρομβοκυττάρωσης αποκλείστηκε η Ιδιοπαθής Θρομβοκυτταραιμία και προσδιορίστηκε το υποκείμενο νόσημα. Η λειτουργικότητα των αιμοπεταλίων μελετήθηκε με τον αναλυτή PFA-100 με τις φύσιγγες κολλαγόνου-επινεφρίνης και κολλαγόνου-ADP και τη δοκιμασία συσσώρευσης αιμοπεταλίων με διεγέρτες επινεφρίνη και ADP. Επιπρόσθετα, πραγματοποιήθηκε γενική εξέταση αίματος με τον αναλυτή Sysmex XE-2100, ενώ προσδιορίστηκε η αντιγονικότητα και η δραστικότητα του παράγοντα von Willebrand. Αναζητήθηκε επίσης η μετάλλαξη V617F του γονιδίου JAK2. Αποτελέσματα: Για την διαφορική διάγνωση της Ιδιοπαθούς Θρομβοκυτταραιμίας από την αντιδραστική θρομβοκυττάρωση, το PFA-100 με τη φύσιγγα κολλαγόνου-επινεφρίνης και η δοκιμασία συσσώρευσης των αιμοπεταλίων με την προσθήκη επινεφρίνης υπολογίστηκε ότι είχαν ευαισθησία (%): 79 και 85, ειδικότητα (%): 92 και 96, θετική προγνωστική αξία (%): 88 και 96, αρνητική προγνωστική αξία (%): 85 και 86, αντίστοιχα. Όταν οι δύο αυτές μέθοδοι συνδυάστηκαν έτσι ώστε να απαιτείται παθολογική τιμή και στις δύο δοκιμασίες για τη διάγνωση της Ιδιοπαθούς Θρομβοκυτταραιμίας, επιτεύχθηκε χαμηλότερη ευαισθησία στο 68%, αλλά η ειδικότητα αυξήθηκε στο 100%. Επίσης, η θετική και αρνητική προγνωστική αξία του συνδυασμού ήταν 100% και 81%, αντίστοιχα. Τέλος, όταν για τη διάγνωση της Ιδιοπαθούς Θρομβοκυτταραιμίας απαιτούνταν παθολογική τιμή είτε στο PFA-100 με τη φύσιγγα κολλαγόνου-επινεφρίνης, είτε στην συσσώρευση με επινεφρίνη, ο συνδυασμός είχε ευαισθησία 100%, ειδικότητα 88%, θετική προγνωστική αξία 86% και αρνητική προγνωστική αξία 100%. Κατά συνέπεια, ο συνδυασμός παθολογικών τιμών και στις δύο δοκιμασίες οδηγεί στην διάγνωση της Ιδιοπαθούς Θρομβοκυτταραιμίας, ενώ φυσιολογικές τιμές και στις δύο μεθόδους αποκλείουν την Ιδιοπαθή Θρομβοκυτταραιμία.Συμπεράσματα: Αν τα παραπάνω αποτελέσματα επιβεβαιωθούν από περαιτέρω μελέτες, αυτές οι δύο μέθοδοι θα μπορούσαν να χρησιμοποιηθούν στην διαφορική διάγνωση μεταξύ Ιδιοπαθούς Θρομβοκυτταραιμίας και αντιδραστικής θρομβοκυττάρωσης

Cooking in progress: Evolution and diversity of cooking pottery in prehistoric Northern Greece and Bulgaria

International audienc

Treatments for intracranial hypertension in acute brain-injured patients: grading, timing, and association with outcome. Data from the SYNAPSE-ICU study

Purpose: Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with six months mortality and neurological outcome. Methods: A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. Results: 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p < 0.001), with less cardiovascular pre-injury comorbidities (859 (44%) vs 90 (31.4%), p < 0.001), with more episodes of neuroworsening (160 (56.1%) vs 653 (33.3%), p < 0.001), and were more frequently monitored with an ICP device (221 (74.9%) vs 1037 (51.2%), p < 0.001). Considerable variability in the frequency of use and type of eTIL adopted was observed between centres and countries. At six months, patients who received no-basic TIL had an increased risk of mortality (Hazard ratio, HR = 1.612, 95% Confidence Interval, CI = 1.243-2.091, p < 0.001) compared to patients who received eTIL. No difference was observed when comparing mild-moderate TIL with eTIL (HR = 1.017, 95% CI = 0.823-1.257, p = 0.873). No significant association between the use of TIL and neurological outcome was observed. Conclusions: During the first week of ICU admission, therapies to control high ICP are frequently used, especially mild-moderate TIL. In selected patients, the use of aggressive strategies can have a beneficial effect on six months mortality but not on neurological outcome

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

International audienceBackground: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society